Services Artificial Urinary Sphincter An artificial urinary sphincter (AUS) is a device surgically implanted into men with significant stress urinary incontinence. The surgery is usually performed in men who have undergone treatment for prostate cancer and have failed other less invasive treatments for their incontinence. AUS is performed in the operating room, takes about an hour to perform and the patient usually stays overnight in the hospital. Most often the device is placed through a couple of small incisions (just above the belt line and one below the scrotum), and the device can be activated a few weeks after the surgery. Most patients will have a dramatic improvement in their stress urinary incontinence. An AUS may need to be replaced or revised after several years. Other complications, such as a patient developing an infection requiring removal of the AUS, are rare. Botox for OAB (Overactive Bladder) Overactive bladder (OAB) syndrome is a condition in which the bladder muscle is unstable, leading to the bothersome sensation of having to urinate very suddenly and frequently, sometimes even causing urinary leakage. When conservative therapies and medications don’t improve symptoms, Botox® injections into the bladder muscle can be the next step in minimally invasive treatment. Botox injections can be done in the operating room under anesthesia, but typically are done in the clinic. Cystoscopy is performed to look inside the bladder, and the Botox medication is injected in multiple locations spread throughout the bladder. This procedure usually takes about 5-10 minutes, and the patient can go home the same day. Most patients will have significant improvements in their OAB symptoms. There is a small risk that the Botox works too well, causing retention of urine, but this is temporary. If the Botox injections are effective at treating your symptoms, it can be repeated up to every 3 months. Cytoscopy Cystoscopy is a procedure performed by an urologist where a small scope is passed through the urethra and into the bladder in order to inspect the inner lining of the bladder. This procedure is usually performed as part of an evaluation of other problems (i.e., hematuria or BPH), but can also be used to treat certain bladder problems. Cystoscopy is usually performed in the office setting where, after local anesthesia, the scope is passed through the body’s natural opening and into the bladder. Sometimes the procedure is performed in order to remove a stent following kidney stone surgery. Most patients will have a sensation of needing to urinate, but this usually will resolve quickly at the end of the procedure. Most patients will have a sense of needing to urinate after the procedure and this quickly resolves. Some patients will see blood in the urine for a few days afterward. Urinary infection or other complications after cystoscopy are rare, and patients should contact their doctor if they are experiencing problems afterward. Extracorporeal Shock Wave Lithotripsy Extracorporeal shock wave lithotripsy (ESWL) is a procedure performed in the operating room to treat kidney stones that are too large to pass on their own. There are many ways to treat stones, and the particular technique depends on the size, location and type of stone. Some stones can be treated by aiming a series of sound waves at the stone, creating tiny fracture lines in the stone and ultimately breaking it into multiple fragments small enough to pass. In the operating room, under general anesthesia, the patient is positioned on a special table and an X-ray is used to target the stone. The sound waves are generated by a special machine called a lithotripter, aimed at the stone and hit the stone several thousand times in order break it into multiple fragments small enough to pass. A stent is not usually placed in the ureter at the same time, but may be placed if needed. Most patients will see some blood in their urine and will pass many small stone or sand-like fragments for a few days afterward. Pain medication is given to take at home in case passing some of the fragments is painful. Sometimes a stone will need to be treated more than once with ESWL in order to fully fragment it. Complications such as significant swelling of the kidney (hematoma) or infection after the procedure are rare. Female Mid-Urethral Sling for Stress Urinary Incontinence Urinary incontinence is the uncontrolled and unwanted leakage of urine. Stress-type incontinence occurs with increased abdominal pressure, such as when you cough, laugh or sneeze, which pushes urine out of the bladder. This leakage is a result of a weak support system for the urethra. There are several treatment options, such as performing Kegel exercises or pelvic floor physical therapy, but for more severe and bothersome leakage, surgical intervention should be considered. A urethral sling is a strip of material, typically an artificial mesh that is fashioned into a hammock to support the urethra. The surgery can be done in an outpatient setting. A small incision is made in the front wall of the vagina, over the middle of the urethra, and the wings of the mesh are inserted behind the pubic bone on both sides of the bladder. This creates a suspended hammock to support the urethra and decrease leakage. Most patients are able to go home without a catheter. The goal of this procedure is to significantly decrease the amount of urine leaked. Possible immediate complications include urinary retention if the sling is placed to tightly or a UTI. In the long term, complications include possible erosion of the mesh in to the urethra, bladder or vagina, but this risk is low. Laser Vaporization of the Prostate As men age, the prostate enlarges and can slow down or block off the outflow of urine from the bladder. This is called benign prostatic hypertrophy (BPH). Medications are usually the first line treatment, but if patients continue to have bothersome symptoms, then there are several surgical options that can be considered. For men with moderately sized prostates, an option is laser vaporization of the prostate. Similar to transurethral resection of the prostrate (TURP), this is a surgery performed in the operating room under anesthesia. A special telescope, called a cystoscope, is placed down the urethra into the bladder. A laser is then used to vaporize, or melt away, the obstructing prostate tissue. In the process, the laser also coagulates, or seals blood vessels, so there is minimal bleeding. After the surgery, a urinary catheter is often left in the bladder overnight and then removed the next day. The benefit of laser vaporization is that there is less bleeding compared to the TURP, and this is an ideal choice for men who need to be on aspirin or other blood thinners. Possible complications may include inadequate removal of prostate tissue or increased urinary urgency and frequency for several weeks after the procedure. MRI of the Prostate Magnetic resonance imaging (MRI) has become a key tool in the evaluation and diagnosis of prostate cancer. A multi-parametric MRI provides better images of the prostate with a variety of techniques, in combination with an advanced MRI machine and software package. A key element of this study is having the images reviewed and interpreted by a radiologist with expertise in prostate MRI. In some cases the MRI is used to evaluate a patient who has lab findings suspicious for prostate cancer and in other cases to provide better staging information for a patient who has already been diagnosed with prostate cancer. The prostate MRI studies at Mission are performed in an Independent Diagnostic Testing Facility (IDTF), specializing in outpatient MR imaging, and offering a low-cost alternative. Studies are reviewed by a board-certified, fellowship-trained radiologist at Mission with expertise in prostate MRI. Prior to the MRI, instructions are given to all patients to help them prepare for the study. Not all patients are able to have an MRI of the prostate, due to other surgeries they may have had in the past (e.g., pacemaker placement), claustrophobia, reactions to IV contrast or kidney problems. Please make the doctors and staff aware if you think any of these issues apply. The results of the study are not immediately available, but an appointment should be scheduled with the provider who ordered the study to review the results. An MRI of the prostate generates hundreds of images, and it takes time for the radiologist to carefully review these and reach a conclusion. MRI Ultrasound Fusion Targeted Prostate Biopsy (UroNav®) An MRI of the prostate can detect areas suspicious for cancer that are not felt on exam or detected on prior biopsy of the prostate. If areas suspicious for prostate cancer are seen on an MRI, then a UroNav® targeted biopsy may be indicated. UroNav® is a technology that takes the images from a prostate MRI and an ultrasound, fusing them together to target specific areas for biopsy. This technology provides a valuable tool in the imaging of the prostate and diagnosis of prostate cancer. The procedure is usually performed in the operating room, but sometimes can be done in a procedure room. The patient is given special instructions to clean out the rectum (using an enema) prior to the procedure, and antibiotics are given before the procedure to reduce the risk of infection. After administration of local anesthetic, an ultrasound probe is inserted into the rectum in order to image the prostate. The images are then processed by the UroNav machine, which has the MRI images preloaded, and a 3D map of the prostate is generated that assists the urologist in targeting the suspicious areas. Targeted biopsies of the prostate are then taken as well as additional samples. The biopsy specimens have to be reviewed by a pathologist, and the results are available about a week after the procedure. Most patients will see some blood in their urine or bowel movements for a few days afterward. Complications such as an infection after the procedure are rare, and patients should contact their doctor at once if they suspect an infection. Penile Implant (Penile Prosthesis) A penile implant or penile prosthesis is a surgery performed for patients with severe erectile dysfunction who have failed other treatments for this condition. For patients that have long-standing medical problems like diabetes or have undergone surgery for prostate cancer, but would like to remain sexually active, a penile implant is a good option. In the operating room, after general anesthesia, a small incision is made in either the scrotum or just above the penis. Surgically a space is developed, the device fitted and then placed. The entire procedure takes about an hour to perform, and patients usually stay in the hospital overnight. The penile implant can’t be used right away, but is typically activated at an office visit about a month after the surgery. Most patients will have some ache, bruising and swelling in the scrotum and penis, which resolves in a few weeks. It would be rare that a patient would develop an infection after the surgery, but occasionally the implant would need to be removed and replaced. Most penile implants will last for more than ten years, but some will need to be replaced sooner. Posterior Tibial Nerve Stimulation When conservative therapies and medications don’t improve OAB symptoms, posterior tibial nerve stimulation (PTNS) can be the next step in noninvasive treatment. PTNS is performed in the clinic, and usually consists of weekly therapy sessions for about 12 weeks. For the treatment, a small acupuncture needle in placed into the skin of the lower ankle close to the posterior tibial nerve, which travels back to the spinal cord, intertwining with nerves for bladder control. The acupuncture needle is stimulated with a soft electrical pulse for about 30 minutes, leading to neuromodulation of the bladder nerves. PTNS can lead to improved symptoms of overactive bladder, but typically takes several sessions before a difference is noticed. The results may last, but sometimes repeat sessions are required every few months to maintain the response. Other than skin irritation, there are minimal side effects to this noninvasive therapy. Prostate Biopsy Prostate biopsy is a procedure performed if there is suspicion of prostate cancer. The decision to obtain a biopsy of the prostate is due to an elevated prostate specific antigen (PSA) or abnormal prostate exam. Prostate biopsy is usually performed in the office setting, but in some cases is done in the hospital operating room. The patient is given special instructions to clean out the rectum (using an enema) prior to the procedure, and antibiotics are given before the procedure to reduce the risk of infection. An ultrasound probe is placed in the rectum to image the prostate and guide where the biopsies are taken from. The biopsy specimens have to be reviewed by a pathologist, and the results are available about a week after the procedure. Most patients will see some blood in their urine or bowel movements for a few days afterward. Complications such as an infection after the procedure are rare, and patients should contact their doctor at once if they suspect an infection. Robotic Prostatectomy for Prostate Cancer For men with prostate cancer, there are multiple options for management and treatment. If the cancer has not spread outside of the prostate, called organ-confined disease, one of the treatment options is surgical removal of the prostate, called a radical prostatectomy. While this used to be an open surgery with a large incision, it is now mostly performed laparoscopically with the da Vinci Robotic System. The robotic prostatectomy is done in the operating room under general anesthesia, and usually takes about 2 hours. Your urologist will place several laparoscopic ports through small incisions in your abdomen and will then sit at a console with 3D visualization while controlling the robotic arms. A 1-2 day hospitalization is expected after the surgery, and a urinary catheter is left in the bladder for 7-10 days to allow for healing. The robotic prostatectomy offers a chance to completely cure prostate cancer, but does have some known side effects. Men will usually have urinary incontinence for several weeks or months after the surgery, and removal of the prostate can decrease the ability to have an erection. Both of these typically improve in time, and there are additional treatments to help if needed. Using the robotic system allows your urologist to more easily save the nerves and blood vessels that help with urination and erection. Sacral Nerve Neuromodulation for OAB When conservative therapies and medications don’t improve OAB symptoms, sacral nerve neuromodulation can be the next step for treatment. This procedure is typically performed in two stages. The first stage can be done in the operating room, but is typically done in the clinic, while the second stage is done in the operating room under anesthesia. During the first stage, a temporary electrode is placed next to the nerves that go to and from the bladder as they exit the spinal cord. This is completed through a small incision in your lower back, and the electrode is then attached to a temporary external battery. If a patient has improvement in their urinary symptoms, then the second stage of the surgery is performed in which the permanent lead and battery are implanted completely underneath the skin. Most patients will have significant improvement in their symptoms of OAB. There is a low risk that the device malfunctions, which would require replacement, or becomes infected, which would require complete removal. The battery can run out depending on how it is used, but usually lasts 3-5 years. SpaceOAR® (Hydrogel for Radiation Therapy) SpaceOAR® hydrogel placement is a procedure to inject a specialized gel between the prostate and the rectum prior to radiation therapy in order to improve the treatment of prostate cancer and decrease the side effects of therapy. The rectum is an organ sensitive to radiation therapy, and by increasing the space between the rectum and the prostate this can decrease the symptoms during treatment that many patients would normally experience. The procedure is usually performed in the operating room, but sometimes can be done in the clinic. After injecting an anesthetic, an ultrasound probe is inserted into the rectum in order to image the prostate. Under ultrasound guidance, with needles passed through the skin, several small gold pellets (fiducial markers) are placed into the prostate to assist in targeting the radiation. A different needle is then passed above the rectum, but just below the prostate and, the SpaceOAR® gel injected. After the procedure, most patients usually can’t feel the gel. The gel remains in place for about three months and is then reabsorbed and excreted by the body. Complications such as an infection after the procedure are rare, and patients should contact their doctor at once if they suspect an infection. Transurethral Resection of the Prostate As men age, the prostate enlarges and can slow down or block off the outflow of urine from the bladder. This is called benign prostatic hypertrophy (BPH). Medications are usually the first line treatment, but if patients continue to have bothersome symptoms, then there are several surgical options that can be considered. For men with large prostates or have failed other treatments, an option is transurethral resection of the prostate (TURP). In the operating room, after general or spinal anesthesia, a special scope called a resectoscope is inserted into the penis to visualize the prostate. A special tool is then used to trim the prostate and then seal any bleeding vessels. The trimmed tissue is then removed, and a catheter is placed through the penis to drain the bladder. The surgery has excellent long-term results, and there are no bandages or incisions. Most patients will spend about a day in the hospital afterward, usually have a catheter for a few days and will see some blood in the urine. Complications such as scar tissue or erectile dysfunction after the procedure are rare. Ureteroscopy for Kidney Stones Kidney stones don’t always require surgical treatments, but if a stone is not able to pass on its own with conservative measures, then there are several treatment options available. Ureteroscopy (URS) is a minimally invasive therapy for kidney stones in the ureter or kidney, and has a high success rate. This surgery is performed in an outpatient operating room and usually requires general anesthesia, but the patient can usually go home the same day. A small telescope is passed through the urethra and bladder and up the ureter. A laser is typically required is break the stone into smaller pieces, which can then be removed with a grasping device if needed. After the stone is broken up, a temporary stent is placed to allow the ureter to heal. Depending on the size and location of the stone, the procedure may take 30 minutes for a small stone or longer than an hour for larger stones. URS is a good treatment option for the vast majority of kidney stones. Risks of the procedure include infection or damage to the bladder or ureter, but the risk is low. Most patients will have some blood in their urine whenever they have a stent in the ureter. The temporary ureteral stent can cause some discomfort in the side and the sensation of having to urinate more often, but these can be treated with medications. Urodynamics Normal urinary bladder function is controlled by a complex system of nerves that cause the bladder to store urine and to empty when needed. When someone has problems with urination, such as in men who have an enlarged prostate or in women having incontinence, we sometimes need more information about the bladder’s function. Urodynamics is a group of tests used to evaluate bladder function. This is done in the urology clinic and is performed by one of our physician assistants. For the test, a special pressure-sensing catheter is placed into the bladder and another is placed into the rectum. These catheters measure bladder and abdominal pressures as the bladder is filled and while the bladder is squeezing during urination. These are measured using a computer system, generating a graph that is evaluated by your urologist. Urodynamics provides more in-depth information about bladder function, which allows the urologist to offer patients the best treatment options based on the results, especially if surgery is being considered. There is a risk of developing a urinary tract infection after the test, but an oral antibiotic is given at the time to prevent this. The test itself can be uncomfortable, and even embarrassing, but it provides the doctor with the information needed to make the right decisions. Urolift® Medications are usually the first line treatment for BPH, but if patients continue to have bothersome symptoms, then there are several surgical options that can be considered. For men with moderately sized prostates, a minimally invasive option is the Urolift® procedure. This is a transurethral procedure that can be done in the operating room under sedation, but typically is done in the clinic. A specialized cystoscope with the Urolift delivery device is inserted down the urethra in the bladder. The Urolift implants are then deployed into the obstructing prostatic lobes to retract them, opening up the urinary channel through the prostate. There is no heating, cutting or removal of prostate tissue. The Urolift is a good option for men who desire a minimally invasive procedure to help them urinate better. There are minimal side effects, but the main risk is that it may not work well, depending on the size of your prostate. Having the Urolift doesn’t prevent you from having a TURP down the road if your symptoms return. Vasectomy The testicles in men produce testosterone and make sperm. The sperm are stored and then transported from the testicles to the penis in a tube called the vas deferens. For men who wish to prevent additional pregnancy, a surgical procedure called a vasectomy can be performed. This is a quick office-based procedure during which small incisions are made in the scrotum, and a small segment of each vas deferens is removed, which prevents sperm from being transported to the penis and ejaculated. While no form of birth control is 100 percent, vasectomy has one of the highest rates of effectiveness. Though a vasectomy can be reversed, it should be viewed as a procedure for permanent birth control and not as temporary birth control. In the procedure room, after administration of a local anesthetic, the vas deferens is isolated and a small opening is made in the skin. A segment of the vas deferens is removed, surgical clips are placed on either end and a small amount of cautery is used to permanently block the vas deferens. This is done on both the right and left side and takes about 30 minutes to complete. Most patients will have some minor swelling and ache that will last several days, which are improved with the use of intermittent ice pack and anti-inflammatory medication. Complications such as significant swelling of the scrotum, bleeding or infection are rare. The aching sensation should resolve in about a week, but very rarely would a patient have persisting scrotal or testicular ache. Patients that have had a vasectomy should continue to use contraception for the next several weeks and it is very important to provide a follow-up semen specimen to the urologist to make sure sperm are no longer present.