MEditorial October 2013
“Strong to the Finish”
Now that 15 years has elapsed since Viagra came on the market, and the majority of men with ED have hope for good rigid erections, attention has somewhat shifted toward ejaculatory issues. More and more men see me about problems with the “finish” of the sexual act, including “too soon”; “too late or not at all”; or inadequate amount or change in color (often bloody) or consistency.
Ejaculation is a complex function that involves emotions (feeling of intense affection for the partner); neurophysiological reflexes based on adequate sensory input from the genitals to the spinal cord and higher brain centers; hormones; anatomy and alterations thereof; and learned behaviors.
Although ejaculation is one word, the act is comprised of separable physiological events, including (1) emission, during which the semen containing sperm wells up in the part of the urethra passing through the prostate and causes the man’s feeling of “the point of no return”; (2) propulsion, in which the bladder neck, just above the prostatic urethra, closes like the iris of a camera, and muscles in the perineum (area between scrotum and anus) contract rhythmically, forcing semen out through the penis; and (3) orgasm, which is the brain’s interpretation of utter satisfaction in the climax of the sexual act.
The above mentioned components of ejaculation are under identifiable nerve control (for example, sympathetic and parasympathetic pelvic nerves), which differs for each part—partly explaining how a man can experience one or more aspects of “the finish” without one or two of the others.
Adding complexity is the fact that erection and ejaculation can occur independently. Some men after prostate cancer surgery cannot erect well--but can have an orgasm, at the same time not experiencing emission or propulsion of semen. A rigid erection is certainly helpful to effect ejaculation. It is felt that the penis is more pleasantly sensitive when the skin is tight over the shaft (i.e., penis hard); and recruitment of more and more sensitive nerves leads to the spinal reflex translating into emission and propulsion of semen. This explains why Viagra and its relatives can improve (and perhaps even delay) ejaculation, even though these drugs are indicated for poor erections. Men who lose their erection soon after penetration learn to compensate by rushing coitus and thereby ejaculating prematurely.
In certain disease states involving nerve function, there can be impairment of erection and/or the components of ejaculation. Occasionally, one of the 1st signs of diabetes mellitus in a man is diminution of these sexual functions and over time, many diabetics will eventually have problems erecting and ejaculating properly. In spinal cord injuries, depending on the level at which the cord is injured, there may be erections that are not sustained and which the man cannot feel (“reflex erections”), less likely ejaculation, and not infrequently ejaculation-- if it occurs--with few sperms.
Premature or early ejaculation, if present, may be lifelong or acquired. My own observation is that many men who, when younger, have had premature ejaculation, “overcompensate” with behavioral changes as they age, and they control ejaculation “too well” leading to delayed ejaculation. Ejaculation can be looked at as a spectrum from too early to too late [or not at all]. Some investigators have stated the average time between penile penetration and ejaculation is seven minutes. Premature ejaculation has no strict definition, but is in the eyes of the beholders, that is, the man and his partner. If a man climaxes less than one minute after vaginal penetration that could be disappointing for him and/or his partner, but in some cases it’s just fine.
The sex therapists Masters and Johnson in the mid-part of the 20th century popularized behavioral methods to reduce premature ejaculation. This was mainly having the man take himself to the brink of emission (the “inevitability” discussed above) and withdrawing, often squeezing the penis at the end of the shaft to damper the reaction--only to restart the act soon thereafter. Doing this and other mechanical maneuvers, (e.g. withdrawal and gently “pulling down” testes), do tend to retrain and retard the ejaculatory reflex. A corollary is to find a way to desensitize the penis using 1 or 2 condoms; or applying a cream such as EMLA or a spray such as Promescent) to slow down nerve transmission from the penis to the spinal cord. Promescent, worked on by my esteemed colleague Dr. Ron Gilbert [taken from us unexpectedly and tragically earlier this year] may be advantageous as regards absorption BELOW the skin and therefore having less of a tendency to numb the sexual partner.
Many antidepressants (AD), especially selective serotonin reuptake inhibitors in the family of Prozac (SSRI’s), do variably delay ejaculation, and are now a mainstay of treatment of premature ejaculation. A non-SSRI antidepressant, Anapranil, works well and if taken in low doses, by some either “on demand” (1-4 hours before sex) or every other day, has a low side effect profile. Of the SSRI drugs currently marketed, paroxetine (Paxil) has a strong inhibitory effect (for some too strong), whereas the related drug sertraline (Zoloft) seems to have “just the right effect” and is currently my preference for patients seeking a pharmacological solution. I myself have not seen behavioral side effects in men using these drugs to help ejaculation—but low dose and on demand use may be the reason why.
Dapoxetime, a newer SSRI drug around for more than 10 years and already used in many other countries, is going through its final stage of FDA clearance for US release. Its advantage is a quicker both onset of action and elimination from the body—perhaps making it more ideal than its predecessors for improving ejaculation only and minimally behavior/depression.
Prolactin, a hormone secreted by our pituitary, causes milk development in pregnancy--but has a broad role in male sexual dysfunction. Most doctors know that overproduction of prolactin by the pituitary can lead to sexual dysfunction and low sperm counts/infertility. So-called “hyperprolactinemia” can be caused by a benign pituitary tumor producing this substance. A current question is whether prolactin levels can be manipulated within the “normal range”, since it seems that prolactin by its nature tends to retard ejaculation and increase the latency time (time during which man cannot get another erection after orgasm). Studies of a drug called cabergoline (Dostinex), used to treat excesses of prolactin, shows some promise (studies are preliminary--and safety issues need to be addressed) in promoting earlier ejaculation in those who “have trouble pulling the trigger”--and perhaps even the ability for a man to have multiple orgasms.
Of course testosterone plays a role in ejaculation, with too little of it contributing to delay or no ejaculation. Some studies with Dostinex suggest the latter works best when used in conjunction with testosterone supplementation. Thyroxin, an important hormone produced in a familiar gland in the neck, has a definite in sexual function. New onset of delayed ejaculation might warrant a lab check of thyroid function, e.g., to exclude hypothyroidism.
Finally, my tangential departure to discussion of hematospermia, or blood in the ejaculate. The most common (and expected) cause, these days, are prostate biopsies. This bleeding will stop on its own. Most studies suggest hematospermia is benign, i.e., not related to any serious diseases including genitourinary tract cancer; and it often goes away without treatment (is self-limiting). I myself do not feel that hematospermia alone should be treated as a “prostate infection” with antibiotics--but some of my colleagues disagree. I might consider antibiotics if the man also has painful ejaculation, painful urination, urgency with poor flow--and more so, if there are corroborating lab data such as abnormal urinalysis and/or urine (or sometimes semen) culture. In man over 50 (? over 40) with persistent blood the semen, I might go a bit further beyond a GU exam: including prostate ultrasound done transrectally and sometimes a prostate MRI with contrast. When I have ordered these tests, and assuming a normal prostate exam and PSA, I have rarely, if ever, identified a cause that—if treated—will permanently eradicate the bloody semen. For example, on ultrasound, one can see things like calcifications in the prostate or ejaculatory ducts (joining the seminal vesicles and vasa to prostate)--or prostatic cysts or seminal vesicle (semen containers above prostate) dilations. However, these types of abnormalities are seen just as often in men who have never had blood in the semen as opposed to those who have experienced this symptom. I myself believe some men just have very fragile plexuses of veins lining the prostatic ducts (which sometimes are a bit brittle, perhaps related to calcium deposits), through which semen is emitted before propulsion. “Tearing” of such small vessels is the prostate’s equivalent of a benign nosebleed.
From a pragmatic viewpoint, we as urologists are getting better at translating the obscure and complex physiological concepts regarding hormonal and neurobiology of the sexual act into tangible solutions to improve a man’s (and couples') pleasure during coitus.
Sleep is an essential function. Lack of sleep is related to many health issues and may play a role in others. Besides drowsiness and poor performance during the daytime, sleeplessness is likely associated with cardiovascular, immunological and psychiatric stresses. In a broad sense, sleep is needed for repair of bodily functions, even on a molecular basis—lack of reparation may bring on increased risk of infections, malignancy, rapid aging, and premature death. I suspect the immune system is key here; and that good sleep allows a drained immune system to “refresh” for another day of patrolling against microbes, tumor formation, and its own tendency to mistakenly attack “self” tissues.
As a doctor, I do not like being awoken at night, even though it is “part of the job”. Illness does not respect any time boundaries. Many of my patients are awoken at night by the urge to urinate. Most find themselves “walking in their sleep”, until the problem, in some cases, is so extreme that bedside commodes and containers for elimination are necessary.
Frequent urination, day and night, may be the most common complaint we urologists see, (?) after perhaps urinary infections. Men who need to get up more than once at night may see the urologist, more so if there has been a change in this habit, to resolve anxiety over the possibility of “prostate disease”, or bother or both. Most older men may be unaware that their female counterparts, lacking a prostate gland, are often plagued with similar nocturnal issues. I see many men assuming the frequent visits to the bathroom at night must be due to prostate enlargement or so-called BPH (benign prostatic hypertrophy).
It is true that men with BPH often have nocturia (frequent night urination) as a symptom, along with the array of poor stream, post-void dribbling, hesitant urination, and urgency (pressure to go which is out-of-line with eventual flow). We know of all these symptoms, nocturia is the least likely to respond to medical or surgical treatment for prostatic obstruction. Ironically, in elderly men, nocturia is the symptom most likely to predict the need for future TURP (transurethral operation on prostate) from urinary retention (man cannot void, needs a catheter, and then will only respond to a surgical solution).
Why would men with BPH need to go more often at night? It could be that chronic obstruction causes bladder muscle overactivity/bladder muscle thickening and a functional reduction in bladder capacity, making the bladder signal the brain at night even when there is not much urine stored in it. In some cases, a large middle lobe of prostate pushes like a fist upward on the bladder base, again making the bladder seem smaller, at least functionally. In the minority of cases, the BPH patient truly does not empty the bladder fully and has high amount of “residual urine” (is urinating only the “tip of the iceberg”), thus forcing repeat trips to the bathroom with minimal further urine production sent to the bladder from the kidneys.
We need to distinguish, and in a sense “split off”, the term “diuresis” from urinary frequency. Diuresis means the kidneys are producing more volume of urine than normal. More volume received by the bladder means more frequent voiding-in most people this would be represented in large volume, easy urinations. The bladder is performing correctly in this case. Some of the causes of diuresis are excessive fluid intake; intake of chemicals (e.g., caffeine, alcohol, and some heart and blood pressure medicines like Lasix) that prevent the kidneys from concentrating the urine; and medical conditions like poorly controlled diabetes, whereby the high amount of blood sugar cannot be handled/adjusted by the kidneys, causing what is termed an osmotic diuresis (this tends to dehydrate the patient). Certain heart conditions themselves, with poor cardiac pump function, termed congestive heart failure (or cardiomyopathy), can result in edema or swelling in the peripheral tissues and lungs, with a relative decrease in intravascular fluid volume and diminished renal blood flow. A surprising amount of fluid stored in the pelvis and legs can re-enter the bloodstream when lying flat, causing increased renal blood flow, diuresis and increased urination usually at night.
There is intricate hormonal-type messaging in the body that regulates the volume of fluid in the bloodstream, as well as blood pressure. Signaling from the brain to the kidneys in essence tells these remarkable organs whether to preserve or eliminate body water. Any condition that tends to deplete the intravascular volume will cause the pituitary gland (at the base of the brain) to secrete extra ADH (antidiuretic hormone, aka arginine vasopressin). The kidneys are thus “told” by ADH to send water from the urine back into the bloodstream, leading to yellow/concentrated/low volume urine. Those not “sleepwalking” much to the bathroom notice yellow urine upon the 1st morning elimination.
When especially older men and women with excessive nocturia keep a careful tally of their intake and output (we call this a 24 hour “I&O” diary), we often find they are producing too high a percentage of their 24-hour output in the middle of the night. It is normal that less than 25% of the daily urine volume is produced at night. Greater than 33% of the total is certainly abnormal. This form of abnormal diuresis will cause frequent trips to the bathroom at night, male or female, prostatic enlargement or not.
A medicine called DDAVP has been around for a long time. This is also known as desmopressin, a lab-produced relative of the pituitary hormone arginine vasopressin (ADH) discussed above. DDAVP can be in intravenous, intranasal or oral forms; there is now even an oral form that dissolves in the mouth and is absorbed quickly, without the concern for nasal irritation caused by the prior commonly used administrative route. Initially this drug had limited use in treatment of a rare condition caused diabetes insipidus (not regular diabetes), whereby there was inappropriate, sometimes profuse elimination of needed body water due to lack of ADH secretion by the pituitary and in some cases, lack of receptivity of the kidneys to this hormone. In the last 25 years, DDAVP has played an important role in treatment of childhood bedwetting. It even can help some patients who, due to chronic kidney failure, bleed too easily since their platelets (clotting substances produced in the bone marrow) just do not work properly.
Just in the last 5 years, studies have shown that men and women who produce too high a percentage (33+ %) of their urine at night can and often do respond to the drug desmopresin given in relatively low doses. Note women require an even lower dose than men. Men with known BPH and excess nocturia can respond to DDAVP alone or this as an “add-on” drug to other BPH meds such as tamsulosin (same as Flomax, example of an alpha- blocker) and finasteride (same as Proscar, a hormonal drug to shrink the prostate). A good take-home number is that one-third of such patients will have a dramatic reduction in the number of “sleepwalking” bathroom trips to one-half of the prior number. Plan on two interruptions to sleep instead of four. Since DDAVP artificially signals the kidneys to save water for the body, there comes with this a few warnings: limit oral fluid intake, especially with and after dinnertime; do not take this if there are medical conditions whereby one could easily become “water intoxicated’ at night including severe forms of congestive heart failure and some types of chronic kidney disease; and check with lab tests (more so if higher DDAVP doses are needed, as well as in the very elderly) for over dilution by water of the amount of sodium in the blood. So-called hyponatremia (low serum sodium levels) can cause chronic and acute health problems, especially involving the central nervous system.
Getting back to my male patients who are bothered by frequent awakenings to urinate, be assured that medical and surgical treatment of BPH can (an often does) improve the situation, but nocturnal urine production and urination is a subject that cannot be oversimplified—so be happy with improved flow and storage of urine, and “think broadly”, with your doctor, as to all the causes and potential solutions. Better sleep = better quality of life.
“Prostate Cancer, Genetics, and Giving More Accurate Medical Advice”
The Human Genome Project, an incredible scientific feat, characterized the sequences of genes that make us who we are, and has led to discovery of which proteins are coded by which gene sequences. Contrary to prior teachings, the majority of gene sequences does not code for specific proteins, but may be involved more in the regulation of these gene products. This has medical relevance in that changes in or so-called under or over-expression of these proteins can be used as “markers” for certain cancers; and knowledge of the differences between proteins produced by cancerous versus normal cells has and can lead to targeted therapies potentially replacing the current less specific treatments for e.g., advanced prostate cancer. Now that thousands of human genomes have been sequenced, the differences in genomes among humans @ 0.1% is only 10% of the difference between any human and the closest primate relative (chimpanzee).
Genetic testing is increasingly making its way into prostate cancer diagnosis. Although the validity of such tests is known, the exact role in decision-making for the clinician is less obvious. The results will not always change a cancer patient’s decision. There are also high cost issues; and as is typical for any medical testing, false negatives (normal result when there really is something wrong) and false positives (abnormal result when “all is fine”).
I wanted to share with you a few of the “newer” tests; what they measure; and in what clinical decisions regarding prostate cancer they may be of assistance.
We know that prostate biopsies have at least a 10%, and perhaps (in some studies), 20% chance of being falsely negative. That is, a man has prostate cancer but the biopsy does not detect it. Random biopsies, often 12 in number, sample a small percentage of prostate tissue, and can miss a small amount of cancer, more so if there is no lump felt by the urologist and no specific sonographic abnormality at the time of ultrasound-directed biopsy. So the questions are: “can we trust the negative biopsy results?” and "what can be done after a normal biopsy other than close clinical follow-up and perhaps re-biopsy at a later date?” The MATLOC (methylation analysis to locate occult cancer) study, completed last year, demonstrated the utility of looking for excessive (“hyper-“) methylation of certain nucleotides (building blocks of DNA) to predict, from a genetic/biochemical point of view, the probability of actual cancer in a prostate specimen read as negative by the pathologist. To keep it simpler, let us say that methylation is a reaction to add a so-called “methyl” group to a DNA component. Normal methylation is an everyday process and tends to stabilize cell division and differentiation of primitive to more specialized cells. Hypermethylation (and deficient, or hypomethylation) are associated with certain cancer states. When such tests on prostate tissues (even on “old” preserved biopsy specimens) are performed using a commercially available test (Confirm MDx), hypermethylation--as tested on three separate genetic foci--can not only detect which biopsy cores show methylation, but can predict that these hypermethylated cores, with 80% accuracy, are correlated with the next (2nd ) biopsy of the same areas showing prostate cancer. Note that about 95% of positive prostate biopsies will demonstrate the high methylation reaction.
In this era of doubts about the benefit of PSA screening and even about whether low grade (less aggressive-appearing) prostate cancers require treatment, how do we advise men on whether to be placed in an ”observation” or “treatment” category? There are men now in their 50’s, with newly diagnosed prostate cancer, choosing active surveillance, a form of observation that includes no treatment but close clinical follow-up and repeat biopsies. Are all low-grade prostate cancers alike? Is it safe for a man with a Gleason pattern 6 or 7/10 prostate cancer (as determined by the pathological review of the biopsy) to avoid curative treatments, on a bet the cancer will not progress and given the desire to avoid side effects of aggressive prostate cancer treatment? Something called the CCP or cell cycle progression score can be derived by looking at the expression of proteins from 31 genes felt to be important in the proliferation and aggressiveness of prostate cancer cell behavior. These 31 genes are compared to 15 other “housekeeper” genes in the man’s DNA that are not involved in promoting cancer--so as to “normalize” the amount of genetic protein expression from one subject to another. For simplicity, let us say that the CCP score--by itself--seems to predict better than the PSA or Gleason score alone (or the two in combination) the rate of growth/spread of the tumor and indeed, the chance of death from untreated prostate cancer in a 10-year time frame. The commercially available Prolaris Test (Myriad Labs) combines this CCP genetic information with a CAPRA (Cancer of the Prostate Risk Assessment) score, based on non-genetic parameters, to increase the power to differentiate low risk cancers with low potential to do harm--from low risk cancers with higher potential to progress and cause problems. For example, a Prolaris Score of 1.8 for one man with a pre-biopsy single digit PSA, low percentage of biopsy cores involved and no palpable tumor on digital exam may predict a 5% risk of prostate cancer death over 10 years; a similar man with the same clinical pattern and a low Prolaris score of -1.1 will have a 1% ten year mortality risk. One “problem” to be considered in this test is that in general, with Gleason 6/10 prostate cancers, very few men will die of the disease--even if left untreated-- within 10 years of the time of diagnosis of localized disease. However, a man in his 50’s or 60’s, contemplating observation and seeing that his Prolaris score predicts a low, albeit 5x (5% versus 1%) chance of dying of cancer in the first ten years after diagnosis, may conclude that he could indeed eventually die of untreated prostate cancer—therefore may decide on radical surgery or radiotherapy to try to eliminate the cancer.
Just as immunologic staining of cancer tissues for proteins has pushed cancer pathology into a new era of precision and made pathologic diagnoses more certain, so do newer genetic tests (the ones above only being examples) help us as urologists to answer specific questions about an individual's risk from prostate cancer and to give better advise.
Dolly the Sheep, the 1st cloned mammal, was “derived” from a mammary gland cell—therefore appropriately named after a country singer of the same appelation, known to have an abundance of such cells.
Having just seen the news about the 1st “cloned” hamburger (apparently, it did not taste all that great) from cattle muscle cells, it made me think about the issue of cloning Urologists. What organ would give rise to the 1st cloned Urologist? What, therefore, might be his name?
In that regard, cloning would hopefully not make us Urologists all “the same” but would increase our supply in the US to the projected future need. Of all specialties, urology is “the one” where there seems to be an overall shortfall, not just an issue of mismatch in distribution (too many in Beverly Hills and not enough in Arkansas). A University of North Carolina study, quoting the Dept. of HHS, estimate we need to increase our ranks from about 10,000 nationally currently to 16,000 by 2020. More urologists are needed to care for an aging population with more genito-urinary illnesses. A greater than 50% increase in fewer than 10 years is highly unlikely for several reasons. Reductions in Federal Government subsidies of urology residency programs have contributed to at least a freeze if not a contraction in new doctors entering our specialty. The age distribution of currently practicing urologists is among the oldest in surgery-- only thoracic surgeons are “grayer”. About 44% of the urological workforce here is over 55; greater than 7.5% are over 70.
The skewed age distribution in my specialty has good and bad implications. It is only a matter of time before those Urologists who can--due to adequate finances, increased stress and declining health, or fear of what is coming in the form of the “Affordable Care Act”--“put down their cystoscopies” for good. Do patients want older Urologists (assuming patients have a choice)? Probably depends on how the doctor comes across, as opposed to his/her absolute date of birth. Older doctors do have wisdom (which beats book knowledge any day). Those with steady hands still offer the patient great technical skills; and even if they may not be “up-to-date” on the latest robotic approach to surgery, they can share with their patients an honest perspective on whether the benefits of newer technologies are really justified by their expense.
When I was in residency at MGH and UCLA, women were just starting to come on board into my specialty. Now, about 25% of the Urology residency slots are filled with women--who now comprise 50% of US medical students. Women are great as urologists, and not just for female patients. I have enjoyed tremendously working with my female colleagues. There are some realities, including data suggesting, for lifestyle necessity reasons, women doctors overall work 10-15% fewer hours per week than their male counterparts (I think that attests to their wisdom in pursuing a “balanced life”). Women doctors may be more “biased” towards working for a large group (or be employees thereof) to avail themselves to part-time or flexible hours. In some cases, women urologists may have their practices “crowded” with female patients--thus making it harder to see a broader spectrum of urological problems.
In Great Britain, there is one urologist per 100,000 population versus a ratio in the US of 1:30,000. This means a longer wait to see a “Brit” specialist; many months, as opposed to weeks before elective urological surgery; “lower level” providers (aka “physician extenders”) like nurse practitioners doing procedures such as cystoscopies and prostate biopsies and overseeing shockwave lithotripsy stone treatments; and overall low utilization of resources and less intense care. The same trends are seen on a geographic basis in the US, where the chance of having, e.g., a TURP (operation to relive prostate obstruction), is far higher where there is a high density of Urologists as opposed to lesser-served areas. Perhaps surprising to some, the “outcomes” in terms of patient health is not necessarily better where there is “too much” as opposed to [what is perceived as] “too little” care.
When I visit my dentist, his hygienist seems to do most of the work. He comes in for the last few minutes, does a brief oral inspection, and leaves--always with a smile, of course. I myself could not see taking this approach to patient care, since I feel patients come to a Urology office to see a Urologist. However, I suspect in the future of physician shortages, more and more M.D.’s will model themselves after dentists and their way of practicing. As a corollary, for years now, I am seeing a trend of lower level healthcare workers assessing and referring patients directly to me without the primary care doctor ever seeing that individual. “It’s a Urological problem; go see the Urologist”, she said.
There is a contrary theory that leads to the conclusion we do not need to “clone Urologists”. The practice environment for all doctors, let along Urologists, has deteriorated. The urologists are really there—they are just “hiding”. When a major surgery, such as removal of the bladder and rerouting of the urinary tract [to cure bladder cancer] is reimbursed at less than 25% of the rates that were paid over 20 years ago, there is a problem. Does such a complex surgery taking 5 hours with limitless patient follow-up (at least the 1st three months of which is not compensated beyond the payment for the surgery) and a significant risk of at least mild to moderate postoperative complications warrant an $8000-10,000 or a $2500 reimbursement? Why do economical “forces” make me sometimes pay more for a visit to the auto mechanic than I get paid (before overhead and taxes) for a major surgery--which can improve the quality of life, or in some cases, save a life? So when Urologists’ services are undercompensated and their efforts underappreciated (e.g., by government regulators, insurance companies, politicians refusing to address malpractice reform, and, yes, sometimes patients), there may be no motivation to work harder, see that extra patient, do that difficult surgery. Right now, urologists, inherently highly skilled to solve problems in the operating room, have a money-time incentive to stay in their office and see patients [as does an Internal Medicine doctor]. By the same token, perhaps those policy makers who want to increase the numbers of US Urologists unwittingly are creating a relative oversupply of urologists who will capitulate to lower reimbursements which would the Feds and Insurance companies quite content. Another factor is that in a crowded field of Urologists such as where I practice, there are fewer barriers to referring a patient with a minor Urological complaint that might be easily handled by a primary care provider elsewhere. Urologists should practice specialty medicine and surgery of the genitourinary tract, i.e., do those things of which other doctors are less capable.
Both of the above perspectives have validity; I myself gravitate toward the second camp, i.e., that “money talks”--and most urologists I know will see more patients, take on more difficult surgical cases, and perhaps extend their working career into their 70’s if the kind of work we do is placed into the proper remunerative perspective. Let's think about rewarding those urologists who currently have "boots on the ground"; and talk about "cloning" our species at some later time.
"Is Surgery Necessary?"
Not many of my patients ask me “is my surgery necessary?”, since by the time surgery is contemplated/planned by me, a thorough evaluation has been done, alternatives have been discussed, and a benefit-to-risk assessment for that individual patient has transpired.
Just as with non-surgical forms of medical treatment, as well as diagnostic tests, it is not only permissible but also advisable for the patient to have a goal in mind. Is the goal psychological peace-of-mind from excluding major illness? Is it improvement in symptoms (“palliation”)? Is it cure from a potentially lethal disease or at least prolongation of life? Do you care to share “what your goals are” with the doctor?
Let’s use prostate surgery as an example. Surgery for benign prostate hypertrophy (BPH)—usually in the form of transurethral resection of the prostate (TURP)—should rarely be done for peace-of-mind as regards prostate cancer. We should know in advance that prostate cancer, if suspected, has been excluded by a biopsy. Alternatively, cancer may not need to be diagnosed, because given the man’s age and/or co-existing health conditions, the chance of an incidentally discovered prostate cancer (in the pathologist’s report on the resected tissues) having an adverse effect on health or longevity is low. BPH surgery is usually done to palliate chronic symptoms of poor bladder function due to an obstructed prostate. Most of my TURP patients have already been on and failed medication therapy and have a realistic understanding of what can and cannot be achieved. In some cases, TURP could be an intervention to cure a disease/prolong life, especially if the degree of prostatism is such that it has caused reversible renal failure.
The wise patient should not only ask “what will happen if I undergo this surgery?”, but also, “what will happen if I do not have this surgery?” The 2nd question probably speaks more than the 1st to the issue of necessity. In the example of the TURP above, failure to have the surgery will mean continuation or usually a slow progression of the same bothersome symptoms. It would be statistically rare that taking a pass on such surgery would imperil kidney function or lead to catastrophic illness.
TURP surgery is quite safe, so that even a man in suboptimal health can be considered a candidate as an alternative, let’s say, to living with bothersome symptoms or having an indwelling bladder tube. Sometimes, a TURP can improve non-urological health. For example, a man with cardiac disease could benefit from fewer trips to the bathroom at night/more sleep, secondarily more daytime energy, and decreased anxiety about urinary flow, frequency, and urgency.
One of my maxims to patients is “not everything that is abnormal in the body needs to be treated”. The following is illustrative. Men with certain benign scrotal conditions such as hydrocele, spermatocele and varicocele may seek surgery. In the back (or forefront) of their minds, they may be thinking “this is cancer” but that issue can be dispensed of rather quickly, by physical exam and occasionally ultrasound. If the scrotal condition causes discomfort, there may be justification for surgery; but one would need to know that occasionally, scrotal surgery, even without complications, could increase discomfort. A varicocele in a teenager could cause fertility problems in the future, but since most men with varicoceles can impregnate their wives, is it really prudent to subject a youth who has not “proven” his infertility to an operation? Studies that try to predict which teenagers with varicocele will have fertility issues are not very definitive; and it’s not clear that an operation done “years in advance” is more beneficial to sperm counts than if done once the fertility problem is certain. Most of these benign conditions will not “get worse” or lead to more serious problems.
In my earlier career, I would operate on anyone with a bladder tumor. My goal was to eradicate it; in some cases to stop gross bleeding; and to diagnose more malicious invasive bladder cancers that could metastasize/cause death, and which might need removal of the bladder (cystectomy) to cure. Now I am more willing to “watch” certain smaller bladder tumors that are not bleeding and which, by sight inspection, are clearly not invasive. Experience gives me the confidence to avoid surgery in these situations, since the patients are often older and may experience more problems from being in the hospital or surgery center/ undergoing a general anesthetic and an invasive procedure than they would from the tumor alone.
Another example with bladder cancer may be whether to perform a large surgery (cystectomy) on a patient who has muscle-invasive bladder cancer, where the best chance of cure is with an operation. Failure-to-cure in this situation will likely be lethal. Therefore, I may want to “lower my threshold” and convince a medically higher risk patient to have the 4-5 hour surgery, provided his Internist and Cardiologist feel he is likely to survive not only the surgery, but typical complications seen postoperatively. I would also want to discuss the main alternative to radical surgery, so-called bladder salvage (combined radiation and chemotherapy), which is really not as effective in curing the cancer and, when all is said and done, may be just as rough a ride, or more so, than major pelvic surgery.
In my experience, surgery is necessary if
One final thought about surgery. I always consider the psycho-social context of the patient considering surgery. Experience tells me that the anxious patient who has too many pre-operative concerns seem to be at higher risk for complications-- or at least the perception that surgery has not turned out well. In addition, patients who are older and live alone may not be confident of their ability to care for themselves after surgery. They may, in advance, ask for a few extra days in the hospital or transfer to a skilled nursing facility. They may resist discharge from the hospital postoperatively out of unrealistic fears. These situations are a yellow but not a red light to proceeding with an operation. Such patients may need further preoperative counseling and reassurance…but in some cases, cancellation of a non-life saving surgery is the better course of action.
“Hole in the Wall”
“Something there is that doesn’t love a wall, that wants it down…
The body has natural walls that separate neighboring organ systems, so that urine stays in the urinary tract, digested food and fecal matter stay in the gastrointestinal tract, etc. Birds and other lower vertebrates have a cloaca, a common storage organ for both urinary and gastrointestinal elimination products.
An abnormal opening between two organ systems is called a fistula. Rarely are people born with fistulas, e.g., trachea-esophageal fistula. I remember a medical school classmate whose 1st son was born with this condition. The Chief Pediatric Surgeon at the hospital, notified at LAX, heroically cancelled a trip he was about to take. He surgically repaired this hole (allowing liquids to enter the lungs), preventing further aspiration pneumonia and potential death of the newborn.
Most fistulas we see are acquired (as opposed to congenital); and occur spontaneously, due to chronic inflammation in a structure--and breakdown of the wall between it and another organ. The contents of one can then freely enter the other, without barrier. The flow is usually from the higher pressure system to the lower pressure system. A fistula from the colon/ rectum to the bladder/ urethra usually results in fecal matter entering the urinary tract and not the opposite. Pressure waves developed by the colon are considerably higher than those typically seen in the urinary tract.
A second source of fistulas is “iatrogenic” or created--most often inadvertently--by surgery; and rarely by radiation. The usual context is two nearby structures, one of which is intentionally entered as part of an operation, and the other of which is accidentally lacerated. If the accidental laceration is not obvious/goes unnoticed, a fistula will occur. If the problem is recognized and repaired immediately, the chance for a “hole in the wall” is far less. The vagina is routinely and necessarily entered, so as to completely remove the uterus; the top of the vagina is then closed. The nearby bladder (which can be stuck to the cervix and upper vagina in the case of a diseased pelvis), if nicked, can leak urine once the postoperative urinary catheter is removed. This results in an immediate or delayed “vesico-vaginal” fistula. The woman will notice nearly constant urinary incontinence without having to urinate.
A third cause of fistula is trauma, usually penetrating (as opposed to blunt) trauma with a knife--or a gunshot wound--where two nearby organs such as bladder and rectum are both penetrated. This situation would likely be addressed with emergency surgery… but especially due to the blast effect (gunshot) or bacterial contamination (either), chances for healing without a fistula are low, unless there is diversion of urine and/or gastrointestinal contents.
I will follow with some real examples I have personally witnessed:
Some fistulas are avoidable, some are not-- but all are significant health threats and involve complex decision making for the urologist and general surgeon alike. The chance, for example, of having a fistula after gynecological surgery in the US is estimated to be less than 1 in 200-500 (0.2 to 0.5%). Those holes not associated with irradiated or severely infected tissue are more amenable to definitive surgery to restore structure and function of the involved organ systems to normalcy.
"Some Thoughts About Kidney Stones"
Symptomatic kidney stones (urolithiasis) affect perhaps 1 out of 10 people during their lifetime. Once someone has declared him/herself to be a stone former, the recurrence rate is close to 50% within 5 years. Also, not to be discussed in detail in this MEditorial, it is not all that clear that preventative strategies (diet, medications, etc.), beyond increased fluid intake and voluminous urine output, reduce stone formation or symptomatic episodes. This may relate to the concept that stone formation is complex and involves genetics and what I like to call the “black box” of metabolism, i.e., the entire biochemistry of our bodily functions. In some cases, circulatory problems inside the kidney may predispose to stones. Stones can cause severe symptoms; but since they are episodic (most prone patient will have a few in their lifetime), individuals with urolithiasis often do not “comply” with the doctor’s recommendations about lifestyle changes, diet, hydration, and prophylactic medications. The evidence that infrequent stone formers benefit from extensive evaluation for the cause of their stones and subsequent preventative strategies is not as strong as you would think.
I assess a lot of patients with asymptomatic stones, often in the kidneys. Recently I saw a man whose serial CT’s done over a 2 year time period show a greater than 1 cm. ureteral (thin tube between kidney and bladder) stone with hydronephrosis (backup of urine into kidney which affects kidney’s filtration of the blood). That man, despite lack of symptoms, was shown by a nuclear renal function study to already have lost some of the function of that sided kidney—so we are planning to eradicate the stone soon with shockwave lithotripsy, ureteroscopy, or both. In my practice, I tend to have a high threshold for treating asymptomatic stones located in the kidney. Since the minority of stones in the “collecting system” of the kidney causes any blockage to urinary flow, measurable hindrance to kidney function, or infection, they tend not to be associated with pain. Most kidney stones grow slowly, over months if not years. On non-contrast CT, the best radiologic study to assess all urinary stones, one can often see multiple small stones in a patient who is in the process of passing a stone. Fewer than 4 mm. (1/6 of an inch) stones are difficult to eradicate by the three main minimally invasive treatments including extracorporeal shockwave lithotripsy, ureteropyeloscopy, and percutaneous nephrostolithotomy. Large asymptomatic intrarenal stones should be treated, especially if they take on a “staghorn” appearance, since these can cause chronic health problems including serious kidney infections and shrinkage of the kidney. Some studies suggest that, for example, hard-to-treat asymptomatic mid-sized (i.e., around 8-10 mm.) stones in the lower pole of the kidney should be treated, since at least a third of these will cause problems within 5 years of being discovered. This has not been my experience; and those problems cited include such things as pain and transient bleeding that often resolve on their own. Also, stones in the “basement” of the kidney are harder to eradicate than stones in the main “living room” or those “upstairs”. With the great diagnostic and therapeutic tools we urologists possess to treat symptomatic stones, it is certainly questionable as to whether “stones minding their own business” need to be aggressively pursued. One could paraphrase Isaac Newton’s third law of motion, to the tune that for every stone intervention, there is going to be an equal [and opposite] reaction. There is a potential side effect profile associated with stone treatments—including failure to achieve the objective-- that retrospectively, may make the patient suffer more than if he/she had simply been reassured.
Pain (”ureteral colic”) from stones is related to obstruction and less commonly, infection. Pain tends to wax and wane. The very 1st episode of colic, until the stone is gone, besides catching the patient off-guard, is often the worst. If the stone is causing blockage within the kidney or more likely within the confined space of the ureter, pain may continue until the stone passes or is treated by the urologist. Although some attribute pain to the stone progressing toward the bladder, it is probably not the stone moving, in itself, but the spasm and obstruction created in the “new” resting place, that triggers pain. Respites from pain are likely due to relaxation of the spam of the “smooth” muscle encircling the ureter. Giving tamsulosin (Flomax) or similar alpha-blockers may relax this smooth muscle, help alleviate pain, and enhance the stone expulsion rate.
ER doctors often call me about stones. There is a misperception that stones causing hydronephrosis (fluid back-up into a kidney) as noted on CT and ultrasound, are dangerous and require acute hospitalization--if not immediate treatment. This is not so. Symptomatic ureteral stones have at least an 85% chance of being associated with hydronephrosis—it’s almost a guarantee that someone in the ER with severe ureteral colic will have this radiographic finding. At the same time, over 80% of these patients will spontaneously pass their stone--and the odds are significantly increased with the routine use of the drugs tamsulosin and its relatives.
Factors warranting intervention include fevers associated with an obstructing stone, stone size, duration of disability, and intractable symptoms such as pain and nausea--often associated with loss of work. Fevers may indicate accumulation of pus in the blocked kidney, requiring urgent drainage with a tube placed into the kidney (more essential than the immediate treatment of the stone). Stones larger than 6 mm. (1/4 inch) have a significantly lower spontaneous passage rate than those 4 mm or smaller. stones. There are exceptions--and we do see greater than 1-cm. stones pass without too much fanfare. Stones that are impacted in the ureter for a time period of greater than 6 weeks are not likely to pass, even if symptoms are on the wane. I recently had two highly symptomatic individuals with tiny 2-3 mm. stones stuck for 4-6 weeks in the lower ureter. Both were removed by me ureteroscopically. One had a jagged stone, which was “biting” into the lining of his ureter and causing significant ureteral wall swelling (which gave this miniscule stone the “power” of a much larger stone). The other man had what turned out to be child-sized ureteral orifices (“golf hole-like” openings of ureter into bladder), which disabled him from passing his stone.
To speak somewhat in generalities, ureteroscopy is a great treatment for all ureteral stones and some kidney stones. Used with a Holmium laser, the stone-free rate is 90-95% after one treatment, although some patients will need pre-stenting (with a so-called “JJ” stent) and a minority will need a similar stent, for a while, postoperatively. Shockwave lithotripsy has about a 10% lower stone-free rate but is noninvasive and usually does not require a stent. If a ureteral stone is in the lower ureter or requires more immediate “definitive” treatment due to the degree of symptoms, I am more likely to suggest ureteroscopy as a 1st line therapy. Using percutaneous nephrostolithotomy (by “drilling” a less than 1 inch hole under anesthesia through the back skin and muscles into the kidney and thus taking a shorter/direct path to the stone) is appropriate for large kidney stones and sometimes for lower pole stones not treatable with the other modalities; or a situation whereby multiple stones in different parts of the same kidney require eradication under the same setting.
Analogous to the lack of symptoms not equating to stone passage in the case of an untreated episode of colic, remember that the lack of symptoms after a stone treatment is not tantamount to being stone-free. Clinical and radiographic follow-up are needed to detect the as high as 4-5% of treated patients who may have silent hydronephrosis, either from retained stone fragments (seen more after shockwave lithotripsy) or scar narrowing (stricture) of the ureter, especially after a difficult ureteroscopy.
I never like to see any of my patients suffer; stone disease is certainly a memorable event for the patient. Nonetheless, in many cases, a conservative approach of close observation; symptomatic control of pain and nausea; medical expulsive therapy (“MET”) with tamsulosin; and follow-up with ultrasound and plain x-ray and @ times, a repeat low radiation protocol non-contrast CT, is quite reasonable--with the consent of the patient--to avoid unnecessary interventions/costs and the small but omnipresent potential for temporary or more permanent urological complications.
The normal urinary bladder is a most adaptive organ. It has an amazing ability to stretch and fill the fatty pelvic space that surrounds it. It has the quality of compliance, which means it can increase in volume a lot and not increase its pressure. The receptors (sensory nerve endings) in its wall, ultimately connected to the brain, have, under usual conditions, a high threshold for sending a signal that urination is imminent; they remain “silent” most of the time, allowing us to go about our business, or sleep without the inconvenience of finding a restroom. As the bladder expands, its wall gets thinner but has enough elasticity and “substance” that rupture is rarely seen, as it might be in a distended intestine. To some extent, the full bladder will compress the ureters (tubes entering it from kidneys) to slow down its own further expansion with urine. The volitional signal from one’s brain to the bladder to urinate causes variable contraction of the “smooth” muscle tissue spherically encompassing the bladder and relaxation of pelvic floor “skeletal” muscles to allow rapid and complete evacuation. The neurophysiology and complex “integrated circuitry” that balances bladder storage and emptying is not totally understood, although what is known is the basis for drugs that influence and improve bladder function.
When the bladder has to be removed (cystectomy), such as in cases of muscle invasive or less invasive but refractory and/or symptomatic bladder cancers, replacing it in its native location with biological tissues if a far better solution than a urinary ostomy (= urostomy, urine coming into bag on abdominal wall) although not suitable in all situations. Most so-called “neo”-bladders take longer to construct, and add length to an already demanding operation--often done on older patients with significant medical conditions. Patients undergoing the procedure need to have good renal function to avoid the issue of reabsorption, through the lining of the intestinal bladder replacement, of chemical waste products. Pre-existing urinary leakage would be a reason to give 2nd thought. A bladder replacement patient must accept the surgical consequences, in advance, including a high percentage of leakage at night, much lower percentage of leak associated with coughing/laughing/exercising (stress incontinence) during the day, and the possible need to do self-catheterization many times daily, perhaps indefinitely, to mechanically empty the new substitute bladder (50% in women). When the bladder cancer is close to the prostate in men or to the urethra in women, or on the lower back wall of the bladder in women, connecting the intestinal substitute to the urethra may risk having cancer at the surgical margin, and then recurrence of cancer in the pelvis. In women, proximity of the tumor to the vagina may mandate removal of part of the vagina—that will lead to less support of the bladder and likely worse urinary control.
Requirements for a biological bladder substitute include a reservoir that (1) can hold adequate urine, preferably, as the patient recovers, close to 15 oz.; (2) is made of small intestine which works better than other gastrointestinal organs and of which there is enough (usually 17-20 inches required) to “spare”; (3) can be rendered a low pressure storage system, such as is the case with a normal bladder—a surgical technique called “detubularization” accomplishes this by changing the sausage configuration of small intestine into a long vascularized patch of tissue, which is then shaped by several suture lines to resemble the cover of a giant baseball; (4) not too much fat, and stretchability of the broad blood supply (mesentery) of the intestine so that a tension-free suturing (=anastomosis) of the neo-bladder to urethral stump can be accomplished--this will maintain good blood supply to both the neo-bladder and the area of anastomosis and will prevent neo-bladder shrinkage as well as anastomotic leaks of urine into the pelvis and scar tissue narrowing the juncture with urethra; (5) incorporation into the neo-bladder of what is called an afferent limb or a “chimney”-- a piece of the intestine (the “upper part” harvested) remaining tubularized and to which the kidney tubes (ureters) are attached so that reflux or backwards flow of urine won’t occur when the bladder is full.
An intestinal neo-bladder will produce mucus, more of a problem early on postoperatively when the catheter is still in, often for 2-3 weeks; regular or “as needed’ irrigation may be required to maintain proper catheter function. Some patients may need to insert a tube well after the postoperative period to help evacuate mucus that does not easily egress with the urine.
As one who likes the challenges of urinary tract reconstruction and performing this type of “urinary diversion”, I can say that physically and psychologically, the quality of life for the bladder cancer patient is much better than with an ostomy. In addition, I believe that some patients may be willing to “give up” their bladder earlier in their disease, knowing that a bladder substitute is a quite reasonable albeit imperfect treatment alternative. This is important since locally advanced (into fat surrounding bladder) bladder or metastatic (spread to other organs) cancer is not uncommonly lethal, and bladder cancer may be underestimated (understaged) by transurethral biopsies even combined with MR and other imaging. For example, a patient with a high grade (very malignant-appearing) bladder cancer may wish to consider cystectomy/neo-bladder with the 1st episode or certainly recurrence of a T1 tumor (invading into the layer between bladder lining and muscle). Likewise may be someone whose flat cancer, aka carcinoma-in-situ (CIS) or even multiple recurrent superficial cancers become refractory to transurethral therapy and topical treatment, e.g., failure of BCG, instilled into the bladder repetitively, to control the disease.
A few other words about bladder replacement. Some forward thinking researchers, such as Dr. Anthony Atala of Wake-Forest University, have gotten fairly far with partial bladder and urethral replacements by culturing bladder lining and muscle cells outside the body, stimulating these with so-called growth factors, “molding” these cells by using a biological scaffolding in the shape of bladder and implanting these later into the body. Bladders with cancer cannot be the source of these cells. One problematic issue here is how would an entire such bladder replacement get an adequate blood supply to survive, since we are not talking about a transplant, per se, in which the new organ is hooked up to the host’s native blood supply. Such bladder tissue engineering can also be performed with stem cells, not only embryologic sourced ones (the “sociologically controversial” ones) but also adult stem cells and similar cells in the placenta/amniotic fluid of a newborn, which can be harvested, banked and used later for the same individual if the need arises or for a genetically similar person. Stem cells are “pluripotent”, meaning they can be induced into forming the cell lines of any of multiple different bodily organs. There is even some evidence that in the future, non-stem cells could be induced, by genetic manipulation, to de-differentiate, that is, change their purpose and become, for example more, like a bladder than an oral cavity lining cell. The use of “synthetic” bladders, per se, in experimental settings, has met more issues of stone formation, rejection, infection, and poor function.
In bladder replacement, the future is here, and the advances over the last 25 years have taught us that urinary and kidney function can be quite good if the procedure is done competently on the right patient.
“Take a Walk with Me”
Take a walk with me around the hospital. You will notice some interesting trends. On some floors, almost 50% of the patients are “on isolation”. This is to protect transmission of bacteria they harbor to other patients. Those entering the room have to take special precautions such as wearing gowns, gloves, and masks. Although infection control specialists will extol the importance of meticulous hand washing by healthcare workers, it is not dirty hands that landed patients in these rooms. It is undoubtedly the overuse of antibiotics, both in and out of the hospital, that allows for the evolution of new virulent bacterial strains, some of whose names you may have heard: MRSA (methicillin-resistant Staph); VRE (Vancomycin-resistant enterococcus); C. diff. (Clostridium difficile). Such infections are difficult to treat and have a much higher chance of causing serious/life-threatening complications than garden-variety bacteria. My observation and bias is that far too many patients are receiving antibiotics in doctors’ offices, urgent care centers, emergency rooms and by “over-the-phone”. It seems when someone is ill and the doctor “‘can’t figure it out”, a prescription for an antibiotic is the answer--and at least temporarily makes the patient feel that the physician “is doing something for my problem”. When lab tests for bacteria can easily be done before antibiotics are prescribed, such as culturing the urine, this is often overlooked or not done due to “cost” concern. If a bacterial culture is done, patients may be unaware of the need to call the treating doctor in a few days to verify the result; see if antibiotics are really needed and whether a change to a different drug is mandated.
A related problem is the fragmentation of care. When a patient is seen over several weeks/months by a multitude of providers, the chance for error or overtreatment increases. A patient of mine was hospitalized twice in the last month, 1st for “the flu” and pneumonia, receiving antibiotics then. Soon thereafter, he was re-admitted with inability to urinate and chest pain. He was seen by a different hospital doctor. When he experienced urinary bleeding from his catheter after being discharged from the hospital [and he called his primary care doctor], he was treated over the phone for this with antibiotics, without any evidence the bleeding was related to any infection. Later in the week, another ER visit, for a poorly functioning urinary catheter, resulted not only a change in catheter, but also another antibiotic prescription. Unaware of any urine culture result, he remained on what was, in retrospect, an inappropriate antibiotic until yet another ER visit for bladder spasms, when the 2nd ER doctor checked the prior culture, discovered the growth of a fungus in the urine, and switched this man to an antifungal agent.
Patients of mine who have abnormal urinalyses due to recent prostate or bladder surgery, or due to irritation of the urinary lining by stones, are apt to be placed by an urgent care/ER/primary care doctor on antibiotics for this finding—perhaps born out of fear that if antibiotics are not used immediately to “quell” this lab finding, the patient will become horribly ill. The opposite is more likely, i.e., illness from the antibiotic itself, or ultimately ending up on hospital isolation due to chronic overexposure to these drugs.
Walk with me into the hospital ICU’s. Most of the patients are elderly. Statistically, it probably makes sense that older folks, with deteriorating physical condition, will develop more grave conditions needing critical care. Some of these patients have no local family with whom we doctors can discuss the appropriateness of this level and intensity of care. Others have next-of-kin who “want everything done” to try to stop the downward spiral. There is no arbiter of benefit-versus-risk of intensive care. Although the expensive cost of such care in the last stages of life should be an issue, health care providers do not feel comfortable or empowered to discuss such things; and the patient’s family knows “someone else” is paying for it all. Should patients with end-stage cancer or advanced Alzheimer’s, to cite a few examples, where there is no hope of meaningful survival, be placed in an ICU bed? Should they, even though in some cases, a less aggressive but more humane approach may mean death in days to weeks? Should we as doctors always do the “medically correct” thing without acknowledging the context of the patient? Yesterday, I consulted on a critically ill 92 year old lady with urosepsis (systemic manifestations of bacterial infection originating in her urinary tract) likely due to pus being trapped in one kidney behind a ureteral stone. The “correct” medical remedy would be insertion of a “bypass” tube (stent) into the affected kidney to drain the pus, followed perhaps weeks later by some a minimally invasive attempt to eradicate the offending stone. This could temporarily make her better--but it is likely she would continue to be ill and deteriorate toward death. The lady, in her baseline function, cannot move or speak, does not understand her surroundings, punches at healthcare workers trying to help her, and has--what most sensible people would agree--is a miserable quality of life.
When my father, impaired and living in a nursing home for 2 years with complications of brain tumor treatment, suddenly aspirated food and had pneumonia/respiratory arrest, those caring for him overlooked a healthcare “durable power of attorney” not to resuscitate him. He was aggressively treated in the local ER and moved, on a ventilator, to the hospital’s ICU. A chest tube was soon placed for a ventilator-induced lung rupture causing air to compress a lung from the outside. By the time my mom called me, a lot had been done. But we decided to put an end to it. By the next day, dad had these tubes out, and was moved to a hospice room, his pain and breathing issues palliated with narcotics. He died several days later, in dignity. I keep a picture, in my cellphone, of me standing behind his hospital bed; and one can see a sense of serenity, almost a smile on his face, with two days left to go.
Take a walk with me to the clinical wards or the operating room. Patient care and proper utilization of doctors’ time is delayed and sometimes impeded by a growing mountain of federal and state bureaucracy. In the hospital, it is not uncommon for there to be up to 60 minutes between the end of one of my surgeries and the start of the next. We surgeons do not get reimbursed for sitting around--and the hour is insufficient for us to return to get work done in our offices. Similar cases, if done in an ambulatory surgery center, can flow smoothly, with perhaps 15 minutes between cases. Such centers are not, however, as overbearingly regulated as are acute care hospitals. Risk aversion has taken precedence over getting things done in an expeditious and sensible manner. In the operating room, “time outs” are held, before the operation can proceed, to be sure all in the room identify the patient, and know the name/surgical site of the intended procedure. Those announcing the procedure often cannot pronounce the name of the operation, nor do they themselves understand what it is; in fact, the surgeon is often the only one in the room with any relationship to the patient! Look at the hospital nurses’ preoccupation with completing mandated paper and computer forms, documenting everything, perhaps pleasing to government regulators and lawyers, but detracting from their personal interaction with and “getting to know” patients. A recent random audit of the hospital by the federal body that oversees Medicare payments led to a required test to be passed by all physicians, or “face suspension”. The answers were, in essence, to be memorized, since these auditors would be returning and could--at their will--pick any doctor in the hospital hallways and ask him/her to answer a question about his and the hospital’s compliance with a certain “rule”. The questions seemed to strangely obsess over such “urgent” patient care matters as who has the authority to fax patients’ records from one healthcare institution to another; proper unit refrigeration temperature for patients’ food; and how a surgeon should properly bring his own specialized equipment and instruments into the operating room.
Those of us who have been practicing medicine for a long time do not like these trends. It makes us want to not “take a walk around the hospital”. The somewhat oppressive atmosphere (amidst other financial reasons) indirectly explains why hospitals are more and more hiring salaried physicians, who will go along with the new trends in healthcare and unfortunately can be manipulated at the whim of administrators.
“Prostate Biopsy: Emerging Concepts”
Tissue biopsy, reviewed by one or more pathologists, is the standard for diagnosing prostate cancer; nuances within the pathology report can help us advise the patient as to the severity/risk of his cancer and guide the man as to appropriate therapy, side effects thereof, and the chance of cure.
There are some men whom, without biopsy, we know have a 99+% chance of harboring a biologically significant prostate cancer. These individuals are often older and frail, and would not tolerate complications of a biopsy such as bacterial infection invading the bloodstream, without grave illness. They may have hard irregular prostates and high, escalating PSA’s. Such men would not likely be curable with surgery or radiotherapy, but could die of the disease with no intervention. In my practice, I will offer such individuals hormonal therapy, e.g., with leuprolide acetate (depot Lupron) without requiring/abstracting a tissue biopsy first.
The whole issue of which (if any) men should be screened for prostate cancer and who benefits not only in terms of cure but extension of longevity (with hopefully a minimally altered quality of life) has been addressed by me in prior MEditorials and is obviously the subject on never-ending controversy. Let’s just say that men with at least an otherwise (i.e., not considering that the subject may have prostate cancer) 15 year life expectancy--usually healthy men under 70—who have a biopsy showing any Gleason 4 or higher component, may be at risk for prostate-cancer related death; and therefore, be candidates for early treatment aimed at cure. The Gleason score is generated by the pathologist reviewing the processed biopsy cores under microscopic magnification and is comprised of two areas, each “graded” on a 1-5 scale, with “4” or “5” viewed as more aggressive in their cancer behavior. Since you can look at your Gleason score as two “dice” numbered 1 through 5, if one area has Gleason 4, the other rarely would have less than Gleason 3, so the threshold total (on a scale of 10) we are concerned about, usually “7” on a scale of “10”, has been met.
The biopsy procedure, done under ultrasonic guidance, itself has evolved. Most are performed in the urologist's office, but some are done by radiologists and certain men require or benefit from the procedure being done in a surgery center or hospital under general anesthesia. In the office, I, but not all urologists, like to administer sedation to reduce anxiety and discomfort. I myself feel that the more relaxed patient is probably at less risk for post-biopsy pain and other complications like infection. Both topical numbing of the rectum and an initial transrectal prostate nerve block (both with xylocaine) before starting the biopsy help a lot. The number of tissue cores have been increased from what used to be a total of 6 (three per side) now to 10-12; but sometimes more if a large gland itself statistically requires more random sampling. Fewer cores may be needed if there is a discrete target, such as a lump by prostate exam or a nodule of altered echo-density noted during the ultrasonic scan. Prevention of significant infections seems very dependent on adequate rectal cleansing the day before with an enema [and less often with an oral-based bowel prep]. Fluoroquinolone antibiotics (Cipro or Levaquin) are often started the day before, but some practitioners just give a dose before the actual biopsy. I like “the day before and for a few days after” approach. Because of over-exposure of the population-at- large to drugs like Cipro, it is felt that fluoroquinolone-resistant bacteria residing in the rectum may be a reason for post-biopsy fevers/bacterial infections (perhaps 2-4% of all prostate biopsies); therefore, many--including myself--now like to add another antibiotic such as Ceftriaxone (Rocephin) intramuscularly before the procedure begins. The prostate biopsy, including the ultrasound, generally takes 15 minutes to complete.
Men ask me whether other tests especially stand-alone ultrasound or MRI can detect prostate cancer and perhaps eliminate the need for biopsy. A simple answer is “no”--but the results of these radiographic studies, as well as certain lab tests, can at least be suggestive of a prostate cancer, more so if they are abnormal. A more recently available lab test, PCA-3 (prostate cancer antigen-3), measures the amount of PCA-3 DNA (felt to be “overexpressed” by prostate cancer cells) versus PSA DNA, on a urine specimen taken after a somewhat vigorous prostate “massage”. Studies suggest that over 90% of men with prostate cancer have an abnormally high ratio of PCA-3 to PSA in the urine thus obtained. PCA-3 assays now are finding their place in men who have persistently high or rising PSA’s DESPITE their already having had one or more negative biopsies. The results are helpful in advising whether yet another biopsy, perhaps with one of the techniques listed below, is worthwhile.
“Saturation” biopsy technique requires covering the entire gland with geographically closely placed biopsies, including some deeper cores of tissue into the so-called “transitional zone” (TZ) where cancers are less likely to occur than in the “peripheral zone” (PZ). Saturation technique may involve more than twice as many cores as a regular biopsy and may be better suited to a general anesthetic for comfort. Some studies suggest that at least 25% of men with previously negative (non-cancerous) biopsies may indeed have malignancy when more cores are taken.
MR (magnetic resonance) of the prostate with intravenous contrast is a great technology for detecting abnormalities not obvious by either digital rectal exam or ultrasound alone. MR Radiologists look for low magnetic signal intensity as well as “enhancement” by IV contrast material as features suggestive of prostate cancer. There is now computer software that can link (or “fuse”) these abnormal MR findings to an actual ultrasound, so that the information incorporated allows precisely guided biopsies into areas that in reality look normal on ultrasound; but are “virtually” abnormal. Using this technology, biopsies are still done via transrectal ultrasound and not while the patient is inside the MRI machine. Not only has MR-US “fusion” detected more cancers, but getting back to my earlier point, it has much better yield that regular or saturation biopsies on [what appears to be a] normal gland for the more worrisome Gleason 7/10 or higher cancers, and a lower yield for prostate cancers that are felt to be low grade and thus less biologically a threat.
Working with Urology Specialists of Southern California (see my November, 2012 MEditorial), we are establishing a center here in OC to enable MR-US fused biopsies. The technology is expensive and for now, may have to be reserved for those suspected of prostate cancer with previously normal biopsies--or as part of “active surveillance”. i.e., on those men whose choice of “observation” for their diagnosis of prostate cancer could be swayed by a more accurate type of follow-up biopsy indicating a prostate cancer more a threat to longevity.
Most childhood illnesses are in the realm of infections, usually viral, which although sometimes frightening to parents, go away on their own without any major intervention. Fortunately, most pediatricians have an increasingly high threshold for prescribing antibiotics, e.g., for upper respiratory infections, even ear aches, since the developing immune system can usually handle these--and repeated exposure to antibiotics can set the stage for more resilient and dangerous bacterial infections.
“Surgical” type problems occur in a lower ratio to medical diseases in children versus adults. Interestingly, the genitourinary tract, of all bodily systems, may have the highest incidence of congenital disorders, not all of which manifest themselves at birth. Someone may be born with an abnormal kidney with its outflow tube partially blocked (ureteropelvic junction or UPJ obstruction) which never causes symptoms--or perhaps presents itself as a bad kidney infection at age 60.
What determines whether a pediatric urologic problem is noted “early on” depends upon whether it is external, and the degree of functional derangement caused by the “birth defect”.
For example, an undescended testicle (cryptorchidism) is often noted in the newborn nursery. Some of these are only “delayed” in their descent into the scrotal sac, so waiting a year or so for this to happen before surgically intervening is reasonable and may avoid surgery on a young infant. Since the testis develops embryologically in the abdomen near the primordial kidney, it can remain high up behind the intestines or low down in the inguinal area (where it is sometimes associated with a hernia). Surgical approach to relocating the testis in the scrotum depends on location and length of its blood supply--and may lend itself to open as well as laparoscopic repair. Unrecognized undescended testes, especially those that have shrunken, may be better removed. Cryptorchid testes, as well as their descended mates, are at increased risk for later development of testis tumors. Hypospadias, an abnormally located opening of the male urethra (meatus) is less common, but careful inspection of the baby usually demonstrates this. This congenitally “short” urethra can open as far back as the perineum (space behind the scrotal sac) or anywhere between this and the tip of the penis. Clues to hypospadias include a “blind-ending” dimple at the end of the penis, curvature downward (chordee) of the shaft, and excess foreskin on the top versus the bottom—when the latter is observes, neonatal circumcision should not be done, since urethral “extension tubes” made of skin [including foreskin] are not infrequently used to correct this abnormality. ”Intersex” is an even rarer condition, whereby the sex (gender) of the infant is not obvious at birth—the appearance may be that of a small phallic organ, hypospadias, and testicular maldescent. Lab analysis for “X” and “Y” chromosomes, as well as a check for certain adrenal gland hormones (sometimes genetically abnormal) can help clarify the male versus female conundrum, but the “phenotype”, or appearance of these children is so much closer to girls that traditionally, it is far more common to raise these children as girls and reconstruct, at a later age, in the direction of female genitals. Genetic “boys” raised as “phenotypical” girls would not likely have become fertile men, anyways.
Internal urological abnormalities can show themselves in children with recurrent proven urinary infections (often associated with fevers) and sometimes kidney pain. Obstruction, as alluded to above, of the kidney’s drainage tube (ureter) can occur at the top (UPJ) and bottom (UVJ) of the tube. Areas of the ureter that do not propel (“peristalse”) the urine downwards toward the bladder are commonly found near the bladder and may cause what is known as “obstructive megaureter” in which the tube is very widened and tortuous, or snake-like, in its course. Vesico-ureteral reflux, another cause of megaureter, is where the functional “valve” that prevents backflow of urine during voiding is defective. Bi-directional flow of urine widens the diameter of the ureter, and inhibits its ability to drain urine at the same rate it is produced by the kidney. Some cases are mild and straighten themselves out by puberty, perhaps necessitating the use of low dose preventative antibiotics. Others of a major degree need either injection therapy with “Deflux” to strengthen the valve mechanism or open “reimplantation” surgery—otherwise serious infections and loss of the involved kidney may occur.
In an urban environment like LA and OC with children’s hospitals and pediatric urology subspecialists, we who practice general urology still see most of the garden variety of kids’ urological problems. Acute scrotal pain and swelling is always of concern, especially in boys around the time of puberty, and is most often referred to us by the emergency room. The major diagnoses include torsion of the testicle (spermatic cord torsion) in which the cord twists and the blood supply to the testicle is interrupted. This lack of blood flow (ischemia), if it persists more than 6 hours, permanently damages the testicle and may lead to its removal. If left in, the testicle will shrink, may be the source of chronic pain, and some feel leads to impairment of fertility--even if the other testis seems normal. Exam by an experienced ER doctor, pediatrician, family doctor or urologist may be all that is needed; but the diagnosis can be confirmed by a doppler-ultrasound which will show the problem with the blood supply. We urologists can sometimes de-torse, or untwist, the cord in the ER (it may require sedating the boy or giving some local anesthetic into the groin area); but most of these children go to the operating room immediately for assessment, de-torsing, and suturing (“pexy”) of the problematic testis as well as its mate (@ increased risk for same) to the inner membranes of the scrotum to prevent future occurrence. Of the five torsions I have been asked to see over 2-3 years, the 1st two unfortunately resulted in loss of the testicle, since both either presented to the ER late or were overlooked, since the main symptom was abdominal pain--and the testes were apparently not carefully examined. I got to the latter three cases with enough time to restore the blood flow and salvage the testes. Suffice it is to say, prompt diagnosis of this condition is needed and the testicles should be examined in every boy of the appropriate age with non-descript abdominal pain. Other causes of acute scrotal pain include blunt trauma with development of bleeding around the testis or rupture of the testicle; twisting or torsion of tiny embryological remnants of the testis or its sperm duct (epididymis)—these cause less severe pain, no cord twisting/blood flow interruption and will often resolve without surgery; and, rarely, infection with bacteria spread from the bladder or prostate to the epididymis (epididymitis) and viral orchitis (sometimes seen with mumps and adenoviruses involved in respiratory infections).
Less acute, often painless scrotal “fluid” swellings can represent hydroceles. When seen in boys or teenagers, there is a high incidence of what is known as a congenital (groin) hernia, which is a patent (remaining open after birth) body tube, known as the "processus vaginalis”, which joins the peritoneal (abdominal) cavity with the scrotal area. In order to eliminate the patent tube, many of these hydroceles, if they are in need of surgical repair, are approached via the groin and not the scrotum.
Well I’ve covered a lot--and left out some other conditions, notably the issues of circumcision and bedwetting. I’ll try to get to these in a later MEditorial.
I began writing this December edition at the time of the horrendous slaughter of the innocent in Newtown, Ct. The event made me, as most others, contemplate all kinds of issues from mental illness; to social isolation; to gun control and what was meant by the 2nd amenders by “the right to bear arms”; to “good versus evil”; to heroism; and to the special nature and innocence of children themselves.
In dedication of this month’s MEditorial to those of Newtown whose innocence was shattered, I leave you, my readers, with one verse of the haunting but beautiful song by Whitney Houston (another soul lost in 2012), “The Greatest Love”:
“I believe the children are our future
USSC is neither a university nor an LA “pro” football team. The acronym stands for Urology Specialists of Southern California. It is a one-specialty group practice of urology—in existence for over 5 years--whose current members practice from northern LA County to southern Orange County.
I have signed on to become a member of the USSC team effective January 1, 2013.
Although a group practice, the nice thing is that I will remain in my familiar one- doctor office here in Newport Beach; and run things the same way I have for 25 years. I will retain the staff you have gotten to trust. The practice will have my name, but there also be “Inc.” for incorporated. My signage and letterheads will soon have “Member of USSC” affixed to them.
There are no mandates from USSC about how to practice medicine; how many patients to see; or what percentage of patients need labs, radiographic studies, or surgeries. I will continue to offer state-of-the-art, honest, pragmatic and ethical urology.
USSC will oversee the operations of all its divisions/urologists; bill Medicare and insurances under one federal tax ID number (you will see this on your explanation-of-benefits and statements); coordinate medical services coding, billing, and collections; and provide HR benefits to physicians and employees including payroll, pension, health and dental, employment policies, and relevant insurances. Doctor-members of USSC meet on a regular basis to insure the highest quality of urological care across the board and to strive to represent all areas of urology, even somewhat esoteric diseases and therapies, within our very group. If there is anything I cannot do to help you, there is likely to be someone else in USSC who can take on the task. We will use the same electronic health records platform to unify data and treatment; and facilitate (HIPPA- compliant) transfer of medical records. women's health centers for diagnosis and treatment of bladder disorders; men's sexual health centers; a network of physician assistants/nurse practitioners to extend our ability to care for an increasing number of patients needing urologists; and the like. These are all considered an “extension” of office services, albeit geographically disconnected from where we practice. For example, I can do prostate biopsies in my office currently and physically own the machine/store it in my office; I cannot personally own an entire linear accelerator (produces radiation therapy, e.g., to treat prostate cancer), nor would such a piece of equipment fit in my office. Where there is “group” ownership of these ancillary services, we will always present alternatives to you--while assuring that our facilities will be the best and most cost-effective available.
USSC was developed before we even knew of Obamacare; but is poised to deal with exigencies of the “Affordable Care Act” far better than can any urology solo or small group practice. It is fair to say that for someone like me, the “new economics” of medicine--with higher practice costs, more bureaucracy and declining reimbursements--make it not elective, but mandatory to align with a great group of people such those in as USSC. You, my patients, and I, both stand to benefit.
Sitting in the surgeons’ lounge at the hospital, watching one of several cable news stations, I am amazed at the number of commercials exhorting patients to call law firms to explore liability compensation for environmental exposures such as asbestos (linked to a type of lung tumor called mesothelioma); as well as “defective” medical products. Among the latter, at least as viewed from the legal perspective, are certain hip prostheses and various kinds of synthetic mesh used in female reconstructive surgery.
Synthetic mesh for groin (inguinal) hernia repairs (mainly in men) has been used for years with a very low complication rate and increased success compared to non-mesh repairs, especially as regards faster recovery and lower chance of hernia recurrence. Although the mesh material is similar to that used in vaginal reconstructive surgery, it seems that “purpose” and mesh location make for great variance in outcomes.
Two women I saw recently bring the vaginal mesh subject into focus. One, seen as a 2nd opinion, had a robot-assisted hysterectomy and sacrocolpopexy—a surgery to keep the prolapsing vagina from turning inward on itself (literally inverting), by tacking the top of the vagina upwards and posteriorly to the sacral (bony) area at the bottom of the spine. Synthetic mesh, most often made of a safe substance called polypropylene, is used to bridge the gap between the top of vagina and sacrum, since the distance involved is too great in most to allow direct suturing. A piece of mesh, in this case, eroded through the top of the vagina but was causing minimal symptoms to her; and since she was not sexually active, there was not an issue of male partner coital (penile) trauma. One issue that arose was whether to use synthetic or biologic material, at the time of removal of the eroded sacrocolpopexy mesh, for a suburethral sling needed for, unfortunately, the “new onset” of urinary leakage after the hysterectomy/prolapse repair. The implication, as seen by this patient, was erosion at one site would lead to concern of this happening again (were synthetic mesh used) at another site below the vaginal wall.
A second case was a woman with a large cystocele, a type of prolapse [or hernia] of part of the back of the bladder into the space usually separating the vagina from the more anterior bladder. The cystocele (or anterior pelvic organ prolapse abbreviated as “POP”) caused symptoms of vaginal pressure and sense of something “falling out” as well as frequent/urgent/small volume urinations.
POP is a common female urologic/gynecologic problem seen usually with aging-- but sometimes observed in younger women presumably due to childbirth or aberrant genetic tissue quality. This 70-year-old [second] patient had several legitimate concerns. If the cystocele were fixed, would repair of the cystocele, simply by bringing together the, by definition, weak, tissues suffice, or would some additional material be needed to insure a better/more durable repair? Would that material be synthetic or biological? Were it biological, what would be the tissue source? Since larger cystoceles serve, in a sense, as pressure regulators, would any POP repair increase the risk of new onset stress incontinence (leakage with laughing, coughing, sneezing, exercise)?; if likely, should a pre-emptive suburethal sling be placed and if so, how about using synthetic material? Note: it is known that up to 50% of women, especially with larger cystocele repairs, will develop leakage when they had none or minimal before the POP reconstructive operation.
Most of the controversy around using synthetic mesh for female reconstruction, centers on problems seen with POP repair, and far less so with suburethral slings. Complications from synthetic mesh for POP repairs, cited below, have led the FDA to raise the standard for “proof of safety” to the many producers of these POP “kits”; some manufacturers due to decreasing demand/revenues or the potential/actuality of legal actions, have dropped out of this market. Issues of concern include erosion of the synthetic material through the vaginal suture line; extrusion or migration of the mesh through the vaginal wall or worse, into the bladder or urethra; rare fistulae (holes between lower urinary tract and vagina); “blind” needle passage injury to pelvic organs or blood vessels and nerves; mesh infections very difficult to sure with antibiotics alone; and stiffening of the vaginal area with or without nerve injury--causing pain, more so with intercourse.
Repairing the above problems (which granted, occur in a minority of women) can be as easy as application of topical estrogen creams and watchful waiting; to excising a small piece of mesh from the vagina in the office; to a major surgery under anesthesia to remove most or all of the problematic mesh with precise closure of (if available) healthy vaginal wall tissues. Most, but not all, will have as successful outcome. In my practice, the few such cases I have seen lent themselves to simple excision of extruded mesh.
Women who are older and especially those who have thinned out (atrophic) vaginal tissue; and/or who are diabetic or otherwise prone medically to poor healing, or have had prior vaginal reconstructive attempts should be more “on guard” to their doctor’s suggestions of repair using synthetic materials for POP surgery. Biological materials (including patient’s own tissues harvested from elsewhere; or cadaveric and porcine/bovine issues treated to prevent any risk of infection or “rejection” by the body) are a reasonable alternative--with perhaps lesser strength but lower chance of serious complications.
I am not as concerned with using synthetic kits for suburethral slings (i.e., to treat stress incontinence) since these had a great track record BEFORE we started using similar materials for POP repairs. In the many years I have been in practice, there has been an evolution toward these easy-to-use kits, and away from open surgery (good results but a major operation with a few days in the hospital and not suitable to all of the several different mechanisms of stress incontinence); and transvaginal surgery requiring suturing, more bleeding, more pain, and a higher long-term failure rate than simple slings. In the 20 or so year international experience with synthetic anti-incontinence slings, the success rate has exceeded 90%--and may be higher if women are carefully selected so that the operation is “right” for the presenting symptoms and findings. For the woman not wanting a mesh sling or whose complicated history increases risks of synthetic material near her urethra (e.g., need to repair a urethral outpouching or diverticulum), a so-called “PVS” or pubovaginal sling using her own/ “autologous” tissues [harvested form the fascia covering muscles in the lower abdominal wall] and polypropylene sutures and can be substituted. Results are good--but this is a slightly bigger operation that using a synthetic sling kit; healing takes longer; and one could argue that autologous tissue repair will not hold up, in the long run, for the same reasons the incontinence began, i.e., the woman’s tissues involved in support of the mid-urethra are genetically or developmentally defective.
By the way, in the example of 1st patient of mine mentioned above, I did not see a problem in her undergoing a mesh suburethral sling at the same time the scacrocolpopexy mesh was being removed. The sacrocolpopexy mesh erosion does not imply she would have trouble, in general, from mesh. In the 2nd woman, we satisfied her legitimate concerns and did a nice repair using biological material of a porcine origin to reinforce the cystocele closure; and a synthetic suburethral sling to try to avoid new onset stress incontinence.
As in all surgeries, vaginal reconstruction patients deserve appropriate consent about the benefits versus risks of the various options. I, as well as most who delve in these procedures, will do what the woman wants as long as it is within the “wide” range of reasonable options and she feels an “invested partner” in the decision process.
“Advanced Prostate Cancer”
Advanced prostate cancer is defined as a disease that is not curable by conventional localized treatments such as radical (open or robotic) radical prostatectomy or radiation. Disease may extend beyond the prostate as determined by the urologist’s digital rectal exam or by different staging modalities including MR and CT; or may be metastatic, that is, known to have spread to other organ systems, often lymph nodes and bones--and perhaps to yet other organs. These types of cancers are often associated with abnormally high Gleason scores on the biopsy/pathology report. Disease may reoccur, as can be true with most other cancers, after what seemed to be curative therapy. The relapse may sometimes show itself only as a rising PSA; or findings suggesting metastases on bone scan or other radiographic studies. Advanced or metastatic prostate cancer may or may not cause symptoms including in the urinary tract, in the pelvis, blockage of kidney(s) urinary drainage or distant pains (such as in the back and other bones) and generalized “not feeling well” and eventually weight loss, poor appetite and difficulty performing everyday tasks of life—also known as “constitutional symptoms”.
If it can be shown that the recurrence is likely in the pelvis (or in the prostate, if it was irradiated but not removed), sometimes another attempt at “local cure” can be offered. This would be radiation after surgical failure or more rarely, prostate removal after radiation failure (latter a far less successful strategy).
What I would like to focus on are patients who have advanced disease despite the above considerations, who have also failed so-called “hormonal therapy”. The latter has been around for over half a century and was initially in the form of castration (removal of both testes) since most prostate cancers are androgen (hormones like testosterone) sensitive--just as the majority of female breast cancers are sensitive to estrogens. So depriving a prostate cancer of male hormones will get a good response in over 80% of cases. Nowadays, drugs are often used to take the place of either castration or another old-time therapy for prostate cancer, that is, the administration of female hormones. Lupron and other similar long-acting drugs (e.g. Zoladex, Firmaggon, etc.) act through organs at the base of the brain, the hypothalamus and pituitary, to interrupt signaling to the testes to produce testosterone, this achieving a chemical castration. Decreasing testosterone starves and kills off prostate cancer cells. In some cases where it is felt weaker male hormones produced in organs other than the testes (e.g., adrenal glands) need blockade, drugs such as Casodex can be added—these pharmaceuticals act by binding to androgen receptors within the prostate cancer cells.
Men do not die of prostate cancer even with advanced disease, if the cancer is still “hormonally responsive”. Their cancers take a definite turn for the worse when they develop resistance to the basic hormonal control, so-called “hormone-refractory prostate cancer” (HRPC). A rising PSA despite use of e.g., Lupron alone or a combination Lupron-Casodex is a definite harbinger of problems to come. When this occurs, metastases can occur in over a third of patients, even silently, within a few years--even in men who have no symptoms. Some urologists or oncologists will use “secondary” hormonal therapy including cessation of Casodex (if the man is taking this) or use of other steroid drugs such as ketoconazole combined with prednisone.
Further progression of prostate cancer has often been treated with chemotherapy, with the favored current drug being taxotere. As a solo agent, taxotere is more effective than other drugs used in the past, but like many such agents, they can sometimes be poorly tolerated by older men who are frail and have very symptomatic disease such as bone metastases. Taxotere can certainly cause a partial remission (lessening of measurable disease) and can palliate symptoms--but does not cure such unfortunate men. Prolongation of survival versus “placebo” can be measured in months as opposed to years.
There is interest in using taxotere and perhaps newer more specific prostate cancer drugs, recently developed, at an earlier stage of the disease to try to prevent widespread metastases. The more aggressive approach of combining chemotherapy (or “targeted therapy”) with hormonal therapy and either surgery or radiation may have a role in high risk men who have bad (but possibly just localized) prostate cancers at the very get-go. Studies of such multi-modality interventions are not “mature” enough to state there is an advantage versus traditional treatments and “saving the big guns” for relapses.
Newer drugs already available (but expensive!) are targeted at the prostate cancer cells and specifically their hormone (androgen) receptors. As prostate cancer progresses, it genetically may develop more and harder-to-block androgen receptors. Also the so-called Gleason pattern, assigned at the time of prostate biopsy to a newly found cancer, tends to migrate upwards to a higher and more aggressive score if tissue is available for re-biopsy in cases of advanced disease. Zytiga (abiraterone) and “in-the-pipeline” enzalutamide are promising drugs that likely will significantly extend survival even in patients who have progressed after both regular hormonal and chemotherapy.
Provenge is another advance. Although expensive, this therapy is covered by Medicare and many insurance companies and is administered by urologists and medical oncologists. It ise of a vaccinsorts made by exposing the prostate cancer patients T-cells (a form of lymphocyte or white blood cell produced in bone marrow and found in blood) to a mixture of chemical substances in a lab--and then reinfusing the “bolstered” cells back into the patient in several office sessions over a 1-month time period. The substances used in the lab that “arm” the T-cells to immunologically fight prostate cancer cells are so-called antigens found on most prostate cancer cells (prostatic acid phosphatase) and a “mouthful” name for certain white blood cell products--abbreviated GM-CSG (granulocyte/macrophage colony stimulating factor). The long and the short of it is that this “vaccine” treatment seems to prolong survival in men with refractory prostate cancer—and at three years after treatment, many more such patients are alive as compared with men not having received this treatment. It’s still not likely a cure, but something to give a man more quality time. Provenge needs to be given when the hormone-refractory disease 1st appears; the FDA and insurance companies, as well as the producer of this vaccine, require there be some measurable form of disease beyond PSA elevation, e.g., bone metastases—and the patient should not have severely symptomatic prostate cancer, nor shall he have received chemotherapy or be weakened by other therapies recently before the vaccine.
Urologists, by their nature, see a lot of patients with suspected prostate cancer and likely curable malignancies--but far fewer with advanced disease, especially hormone-refractory disease. The newer approaches beyond so-called “cytotoxic chemotherapy” do lend hope to the future for patients whose aggressive brand of prostate cancer will relapse.
“The Red Sea"
The actual Red Sea, between North Africa and the Arabian Peninsula, an extension of the Indian Ocean, has important geopolitical, economic/commercial and religious connotations. The origin of its name is controversial and may be more of a linguistic malapropism. There is a seasonal reddish plant that grows near the water’s surface. As far as I know, its name has nothing to do with blood [or the spilling thereof from those “warring” factions connecting to it historically].
As urologists, we not infrequently encounter “red sea” situations where there is significant bleeding (hemorrhaging) from the urinary tract. Associated with significant bleeding is the formation of clots which are hard to pass, even more so in someone with a narrowed urethra, e.g., prostate obstruction. An emergency (often painful) situation can transpire with the need for transfusion of blood products, cardiovascular instability/shock, urgent surgery, and rarely death.
Bleeding implies open blood vessels. Reasons can include trauma, urinary tract cancer, stones, as well as infections and related inflammations. Abnormal “benign” prostate tissue often has very fragile blood vessels below the surface that can open up with no obvious or minimal provocation [such as sneezing hard or lifting something heavy]. The blood vessels that feed the urinary tract organs can be defective themselves. This can be seen after pelvic radiation, where the small veins in the wall of the bladder become more prominent and fragile (“telangectasias”), and are closer to the surface, which has been thinned out by the radiation treatment, even given years before. Arteriovenous malformations (AVM's) and pseudo-aneurysms (these can be congenital or acquired--and may evolve with certain disease states or after the urologist’s cutting surgery into the kidney or the interventional radiologist passing a tube into the kidney to obtain better urinary drainage) often affecting the kidney, can suddenly open up and hemorrhage. Benign growths in the kidney, called angiomyolipomas, have abnormal blood vessels with poorly formed vascular walls and can bleed significantly into the urinary tract or into the space around the kidney, especially when they reach a size of larger than 2.5 inches.
What should you think about when you see very red urine? Besides the usual admonitions to stay calm, realize that whatever the cause, the gross bleeding may well stop on its own. Some prudent “medical” first aid helpful moves are to rest; avoid straining to have a bowel movement or lifting; make sure your blood pressure is not too high; and [perhaps] most importantly, stop anticoagulant medicines, if you take these. Such drugs include but are not limited to: low-dose (“baby”) and regular aspirin, Plavix, Pradaxa and Coumadin (warfarin). Some feel the ibuprofen and related drugs also have an anticoagulation effect, albeit lesser than the others mentioned. You and your general doctor, internist or cardiologist should have a good reason that you take blood thinners, but staying on these in the face of acute hemorrhage is unwise—and can make urological procedures to stop bleeding more risky and less effective. In most cases, cardiologists are OK with stopping anticoagulants in the face of urinary hemorrhage; and the cardiovascular risk from being off these for a matter of a week or two is low. I think it’s reasonable to stop these right away and at the same time contact the prescribing physician to be sure the reason underlying this temporary change is discussed. Note each anticoagulant medicine has a different time span to be eliminated from the body, to the extent that it will no longer effect the “coagulation cascade”; also some but not all the anticoagulants have what amounts to antidotes that can be effective if used when hemorrhage is significant.
Our approach to stopping bleeding depends on what we think is causing it, the degree of blood loss, whether or not the individual can pass urine, and other factors such as the degree of pain in the bladder and/or kidneys and the patient’s vital signs (stable versus unstable). Placing a urinary catheter in the office or ER can sometimes help--especially if the patient cannot eliminate urine spontaneously or if the hemorrhage is soon after transurethral surgery for bladder cancer or prostate enlargement. Theory here is that the distended bladder “pulls” on the cut surfaces (including lining of the urinary tract and underlying blood vessels), not allowing them to come together and seal off. Placing a urinary catheter and manually irrigating out most if not all clots will often provide relief from bladder distention--if not put an end to the oozing. In general, a bladder catheter placed just for bleeding without bladder distention will not control hemorrhage. A catheter through which blood clots cannot be irrigated (sometimes one of too narrow a caliber) will also be ineffective.
Approaches to major bleeding usually involve a preliminary x-ray of the entire GU tract from kidneys to bladder; a so-called CTU (CT Urogram) is one of the best options. Next would be a cystoscopy (look with ‘scope into bladder). In cases with major bleeding, that is better done in the operating room under anesthesia, so that a more rigid/larger instrument can be comfortably used—that also allows clots likely present in the bladder to be irrigated. Many pathologies that cause hemorrhage can be approached cystoscopically: for example, resection of bleeding prostate tissue or bladder cancer, or laser treatment of a smaller bladder cancer or even a growth in the ureter (tube from bladder to kidney) or the inside membranes of the kidneys themselves.
Open or laparoscopic surgery may be needed to remove part or all of a diseased urinary organ [such as a kidney or the bladder], occasionally on an urgent basis, for life-threatening hemorrhage.
The interventional radiologist is increasingly important in assisting us to control bleeding, since blood vessels can be intentionally occluded from within the vascular system, e.g., bleeding areas from the kidney and bladder can be detected and sealed by placing a catheter by way of a groin artery and aorta into the aortic branches feeding the appropriate part of the urinary tract.
Here are some interesting recent examples, in my practice, of controlling major GU bleeding. An older man bled repeatedly and needed hospitalization for anemia/transfusions secondary to remote prostate cancer radiation and so-called “hemorrhagic radiation cystitis”. He failed multiple attempts to electrically and laser-cauterize bladder vessels with the cystoscope; and well as chemicals such as silver nitrate and potassium aluminum sulfate (alum) instilled into the bladder to nonspecifically cauterize its entire surface. He had 40 "daily" hyperbaric oxygen treatments to help improve the integrity of the bladder damaged by “oxidative stress” (so-called "free radicals") from his curative radiation. I finally asked the Interventional radiologist to do two things: (1) embolize blood vessels leading to that portion of the bladder which was hemorrhaging; and (2) divert the urine away from the bladder using externalized kidney tubes (percutaneous nephrostomies) to “place the bladder at rest”. While the bladder was at rest, receiving very minimal urine from the kidneys, patient had a 2nd course of hyperbaric oxygen which, thus, far has helped tremendously and which I feel will work better in the long haul than the 1st course of HBO--due to the concurrent interventions. Patient’s tubes are all out and he is voiding fine, yellow urine.
Another example of a cross-disciplinary approach follows. A man already with chronic renal failure, on hemodialysis, had major hemorrhaging traced cystoscopically to be coming only from left ureter/kidney. Attempts to visualize/diagnose/treat the offending bleeder were thwarted and unsuccessful, since there was poor visualization of the inside of the kidney with the flexible uretero-pyeloscope (skinny telescopic instrument to look at urinary tract above the bladder). Patient was taken by interventional radiologist to angiography (radiographic study of blood vessels) and had a "selective” left renal angiogram. This showed a previously unknown arteriovenous malformation (a cluster of thin-walled abnormal blood vessels fed by several branch arteries). The radiologist was able to occlude several visibly bleeding vessels with an excellent outcome--this in fact improved renal function, since the left kidney, previously backed up with clots, was now able to function and excrete its load of urine better.
Turning the "red sea” into the “yellow sea” is highly gratifying for me as a urologist. My patients need not worry that their life is in danger, even with the most egregious cases of urinary tract hemorrhage.
“Taking care of the Poor and Uninsured”
The Supreme Court’s decision on the the Affordable Care Act (ACA) has spawned more silly political games as opposed to a deep thoughtfulness of just what should be done to provide some modicum of “health care” for all legal citizens of our country. Is [the “mandate”] a tax? Is it a fine? If it is a tax (since at least one person in a robe “said so”), does that mean that a pledge not to raise taxes on a certain segment of the population has been cast aside? Focusing on side shows and “footnotes” to the greater story is what all politicians and “talking heads” do best.
I, as one doctor, am not sure it’s bad public policy to compel all citizens to carry health insurance. Prospective smaller [insurance] payments are preferable to retrospective large health care costs--absorbed by other patients, doctors, and hospitals for uncompensated care. We cannot be so laissez-faire as a society to leave these choices so “open” that “the whole” suffers, just as do the individuals, by capricious decisions about personal economics. Health is different than consumer goods; even than food or housing.
The larger concerns to me are the ability of our healthcare system to absorb “new“/indigent and underinsured patients; the quality of care [“we want our healthcare”—what does that mean?]; the under capitalization of the system to provide the high tech medicine we all seem to feel we deserve; prospective higher health insurance costs; and related to the latter, under compensation of doctors and other providers--with the tacit inference that we doctors have no “bottom” to what we will accept for our important/highly skilled services.
What else, besides governmental programs and “mandates” to purchase health insurance could be tried so that all are covered? Undoubtedly the cost of care needs to be lowered to address more the sometimes insatiable “demand” side of health care. I doubt the ACA, as structured, would do so. We may have to try a more tiered system, which provides reasonable care to all as a baseline. We should “under” and not “over” promise! Human capital in this instance costs less than machines. More time spent listening to and examining the patient--and less emphasis on laboratory testing, high tech radiographic investigations, or multi-specialty referrals will dramatically cut costs and not necessarily reduce the quality of care. Rewards are needed to incentivize doctors who are experienced and good at this clinical paradigm. Punishments of doctors in terms of litigation for bad outcomes need to be reined in by malpractice reform to protect those who “did their job” by utilizing fewer resources--but nonetheless who practiced evidence-based-medicine and relied on statistical probabilities as opposed to “exceptions to the rule” to treat their patients.
When two treatments are available and similar in outcome, but one costs more than 2-3 times more to deliver than the other, why not go with the less expensive alternative? Take Urology as an example. Is it sacrilegious to suggest that advanced prostate cancer patients be treated with surgical as opposed to medical castration?—the latter, in terms of expensive hormonal drugs, is often given indefinitely, @ a cost surpassing that of a simple surgery after just several long-acting drug doses. How about the relative costs of open versus robotic radical prostatectomy for localized prostate cancer? Is the significantly higher cost of the high-tech latter justified by any major added benefits, in a society bankrupting itself on limitless healthcare, sometimes based more on perceptions than reality?
If we are going to provide health care for all citizens, I feel those who demand more have to pay more. He who goes to the ER and feels (against the advice of doctor) his headache warrants an MRI or urgent neurology consult should be ready to pay a higher percentage of the cost of care. Perhaps if he turns out to be the, let’s say, the 1/10,000 whose life was actually saved by such patient-driven extra interventions, the system can reimburse him with interest.
How about some novel ideas, perhaps to be tested 1st on a pilot basis. Shelve pathetically paying programs for the indigent like Medi-Cal: very few doctors participate. Let any patient (including the poor and underinsured) see the doctor of their choosing, based on availability. Offer federal tax credits for all uncompensated or poorly compensated care—perhaps up to some arbitrary percentage of the doctor’s tax burden. Poor or uninsured patient gets reasonable basic thoughtful no frills care; and the provider can “write off” the, e.g., unpaid $100 office charge, dollar for dollar on his taxes. You can bet doctors would cooperate with this type of “payment” and take such patients into their practice. Perhaps allow such indigent/non-paying patients to “have their day in court” if they feel harmed by medical negligence; but 1st have a panel of medical experts with some respected/rational lay persons allow to “pass through” only the most egregious examples of poor medical care. Consider a reverse service corps comprised of foreign medical school graduates who wish to practice here in the US. Increase their numbers-- and assuming they pass the usual entry exams-- have these physicians serve, salaried for 2 years, those who otherwise cannot be seen by doctors in the private sector. Those foreign doctors who serve and perform to a certain standard then are assimilated into the general medical community. Perhaps hospitalize uninsured patients in underutilized facilities, including, e.g. those under the auspices of the VA; in conjunction, reduce bureaucratic red tape that creates unreasonable autonomy of federal agencies. Is there anything wrong with both insuring good health care for returning veterans and covering health care for those less fortunate, under federally-based programs working together? (By the way, I favor the private sector solution).
Put aside newer schemes to shield the payors of health care (government and insurance companies) from risk. We doctors know all too well past such plans, e.g., capitated HMO’s; as well as newly hatched plans (ACO’s or accountable care organizations) to shift the risk and cost variance of taking care of patients from the payors to the providers. Shifting the financial risk correlates with shift of medicolegal risk. For example, an insurance company would prefer that a doctors’ group (as opposed to the company itself) decide, on both medical and financial considerations, to deny a bone marrow transplant for an advanced cancer patient with a low chance of long-term survival. Transferring risk to the doctors only works with major tort reform.
In proceeding into the murky future of poorly written federal health legislation, let’s be sure our hospitals are solvent and doctors are “happier”/ adequately compensated for their demanding and tireless work; without that, any plan to guarantee “health care for all” in this country will undoubtedly implode.
“PSA Fluctuations: What Goes up May Come Down”
Organized urology is in an uproar. Men and their families are more confused than ever. As referred to in my October 2011 MEditorial (“PSA Redux”), the US Preventive Services Task Force (USPSTF) has now given a final grade of “D” (failing) to PSA as a screening vehicle for prostate cancer. Screening of course implies doing the blood test on men with no prior or current suspicion (e.g., abnormal exam of prostate) of having prostate cancer or even other significant prostate disease. Statistics can be flung all over the place-- but one, from a large screening trial, suggests that over a thousand (perhaps 1400) men may need to be screened for prostate cancer to save one man from dying of the disease. Of these 1400, perhaps 40-50 found to have prostate cancer might not “benefit” in terms of years of life extended by undergoing such aggressive and sometimes harmful (usually but not always curative) treatments as radical prostatectomy and radiation therapy. Furthermore PSA screening creates anxiety over uncertainty—as well as overutilization and the costs of doctor visits; ultrasounds and other radiographic tests; and biopsies which, @ their least, are unpleasant.
What about using PSA results over time as a screening test? It is always a good idea to repeat the PSA and consider the PSA-2 test (free/total ratio) before recommending a biopsy. There are many reasons for PSA fluctuations, some of which are poorly understood. Let’s just say that the PSA going up does not necessarily mean prostate cancer; and it may come down either spontaneously or due to resolution of specific conditions that caused it to elevate in the 1st place.
Prostatitis is an inflammatory condition of the prostate, probably caused by bacteria, but it’s not always evident or identifiable. Inflammation may be present for years or the rest of one’s life, even after all bacteria have been eradicated. In low grade cases of prostatitis, there may be no symptoms at all or perhaps a slight increase in urinary frequency and urge. Tip-offs, besides symptoms of inflamed urination, might include: a past history of urinary infection or prostatitis; the presence of white blood cells or an enzyme called leukocyte esterase on an office or lab urinalysis; or “bogginess” on prostate exam. I liken the latter to the prostate feeling to me like a round sponge filled with water, not yet “squeezed out”. When we look at the “free percentage” of PSA in the blood, there is an overlap (of especially low, i.e.,<10%) percentages both in men with prostatitis and cancer. Significant acute prostatitis, often the symptomatic variety, can cause a rapid increase in PSA: far greater than seen even with a very malignant prostate cancer.
In my practice, I see little harm in giving a course of at least two weeks of an antibiotic, usually so-called fluoroquinolones (Cipro/Levaquin) to those men felt by one or more of the above criteria to have prostatitis as the cause of PSA elevation. Usually the PSA-2 is then repeated one month after finishing antibiotics—I would like to see the PSA be reduced close to the patient’s prior (presumably normal) baseline. Studies are interesting, in that one can expect on average a 25-35% decrease in PSA after treatment for even low grade prostatitis—but a similar % of men with a new PSA elevation NOT treated with antibiotics will fluctuate (downward) in a similar manner! Once down--whether due to prostatitis or not--the PSA may “behave itself” and not rise again.
I would not tend to repeatedly give antibiotics to the man who, once or twice treated with antibiotics, continues to show PSA elevation or worse, PSA “velocity” (steady trending upward over time). This is especially true in the man who has never had symptoms of prostatitis and in whom the only clinical findings are minimal (e.g., an abnormal urinalysis with no bacteria growing on the urine culture). It is conceivable a man might have chronic prostate inflammation concurrent with prostate cancer. Delaying a biopsy too long, in this context, could cause progression of a prostate cancer; also, over-use of antibiotics to treat an asymptomatic or suspected prostatitis may actually increase the risk of a post-biopsy bacterial infection (often with fevers and significant illness), which is increasingly felt caused by fluoroquinolone-resistant bacteria living in the rectum, the pathway by which the prostate biopsy is most commonly done.
What’s interesting, but perplexing, is the following: PSA reduction after antibiotics does not necessarily mean that a biopsy will not show cancer. Conversely, failure of PSA to decline with such antibiotic interventions does not mean there is cancer. In addition Dr. William Catalona, an expert out of Northwestern University, has stated that the chance of finding cancer in men with fluctuating (“flu”) PSA’s is statistically about the same as in men with steadily increasing (“si”) PSA’s. In that study, however, men with fluctuating PSA’s had slightly less aggressive pathologies, i.e., tumors which might not act as aggressively as those “si” patients, whose pathology tended to show a worse/more chaotic malignancy.
Given all of the above, a man in good health with a 15+ year life expectancy whose PSA fluctuations continue (and never normalize) despite suspicion of prostatitis and 1-2 rounds of antibiotic therapy should consider having a biopsy. Of course, with all the controversies over whether the discovery and treatment of prostate cancer saves lives, a detailed informed consent should be given by the urologist before scheduling the biopsy.
For the record, some other things, besides prostatitis, that cause PSA fluctuations include variation between different labs and several different lab methodologies of assessing PSA value (consistency in the lab you choose may be important); day-to-day variation in the prostate gland’s output of PSA, perhaps by up to 15%; ejaculation or vigorous prostate exam (avoid having PSA checked for 24 hours after these); use of finasteride (low dose=Propecia for balding or high dose=Proscar for prostate enlargement) or its “younger cousin” Avodart (dutasteride); and change of seasons. One French study indicated that summer climate is associated with up to a 25 to 35% increase in PSA versus winter climate. Cause and effect are unclear, but it could be anything from dehydration from the heat (with concentration of the blood from which the PSA sample is taken) or hormonal changes in testosterone (increase), Vitamin D3 (increase) or melatonin (decrease) that directly or indirectly influence genetic production of the PSA molecule by the prostate gland.
With a disease like prostate cancer, which is often slow growing and not necessarily a threat to health or longevity, it is wise to “have perspective” and avoid anxiety over individual PSA results without 1st getting a better overview of the big picture.
“Timing is Everything”
“You may delay, but time will not”. Benjamin Franklin.
“Take time to deliberate, but when the time for action arrives, stop thinking and go in”. Napoleon Bonaparte.
The timing of a medical intervention is sometimes as important as the treatment itself. In my surgical specialty, urology, deciding not only IF but WHEN to operate has ramifications for patient outcomes and their safety. It also affects the patient’s psyche, as well as cost of medical care. Distinguishing a true emergency from something less urgent is a part of this decision process.
Truth be told, there is less economic incentive than ever before for surgeons like myself to perform surgery, but there are still those among us who will try to convince a patient that his or her condition, not emergent or life-threatening, needs surgery that day or in the near future. In extreme cases, this plays to the medical naivety of patients; turning a semi-elective surgery into an emergency will not allow time for the patient to deliberate or perhaps obtain a 2nd opinion. Unequivocally, the cost of medical care is considerably higher when delivered on an emergency basis.
In urology, surgical emergencies do occur. Emergencies imply a threat to life or loss of body function [which could be permanent] or significant correctable pain not amenable to optimal pain management. These situations include urinary bleeding to the point the patient needs transfusions, is rapidly becoming anemic, has unstable vital signs from hemorrhage and/or has a bladder full of blood clots which cannot be managed by irrigating through a urinary catheter. Certain types of infections need urgent intervention, sometimes in hours, other times within a day or two. Any “closed space” infection can lead to dissemination of bacteria throughout the body, cardiovascular instability and shock with dysfunction or failure of multiple organ systems. Examples would be spontaneous or postoperative abscesses; or blocked kidneys (often by stones) with chills and fevers. Vascular problems as seen in spermatic cord torsion, usually in children and adolescents (twisting of cord leads to shut-off of arterial flow to testicle) need urgent intervention, since there is a limited time (perhaps 4-6 hours) before which interruption of blood flow will lead to permanent non-function of the organ.
I will give a few examples where the urgency of intervention is less clear. Kidney stones passing into the ureter (tube between each kidney and bladder) can be quite painful and may need surgical intervention even if not causing a serious infection. Although pain can be unbearable, it is often controllable with appropriate narcotic analgesics. Oftentimes (unlike in the past), the patient can go home and try to pass the stone spontaneously, perhaps helped by so-called alpha-blockers (e.g., tamsulosin/Flomax) which can relax the muscular tissue in the ureter allowing it to relax its “grip” on the stone. The 1st attack of pain from a stone is often the worst. Therefore if the stone is not too large, especially under 6 mm. (1/4 inch), it is reasonable to follow the patient with exams and x-rays and allow several weeks, or longer (barring ongoing severe symptoms) for the stone to progress downward and hopefully be eliminated. About 90% of stones under 4 mm. and over 70% of stones between 4 and 6 mm. will pass spontaneously. A urologist could argue that even for the stone likely to pass, pain and loss of work are not worth any delay, and interventions such as ureteroscopic stone removal and shockwave lithotripsy have a high success rate and low chance of causing problems—however, counterarguments include surgical risks, failure of the procedure to eradicate the stone and, of course, the cost issue.
Another contentious example is with urinary retention in men, not infrequently related to chronic prostate enlargement. If the man ends up needing a urinary catheter when he cannot void at all, does this mean it is time for more urgent surgery? Perhaps. However, this is somewhat dependent on how often this event has happened, the severity of antecedent urinary symptoms, whether the man has been tried on drugs to help the bladder compensate for the obstructing prostate, and whether one or more “trials of voiding” are to be offered. The latter simply means removing the catheter and seeing if the urinary retention has resolved spontaneously. In my practice, well over 50% of men needing a catheter for retention will overcome the problem and not require “urgent” surgery—some may need an operation, e.g., transurethral resection of prostate (TURP), at a later date, when they are more (physically and psychologically) ready and accepting of the surgery--and its potential adverse effects. If a man with retention were to say “I do not want this to happen again” and he has a known prostate obstruction and especially pre-existing bothersome urination symptoms, I will probably omit the “trials of voiding” and proceed to scheduling a surgery.
Cancer surgery is another interesting example. As expressed in the wonderful Pulitzer-Prize winning book by Siddharta Mukharhjee “The Emperor of All Maladies: A Biography of Cancer”, the fear factor from the diagnosis of cancer is unrivaled among diseases. Most patients facing this condition want it eradicated right away, hopefully never to resurface. However, in Urology, several cancers we deal with do not necessarily require immediate surgery; and deliberation without undue delay is preferable. Examples of these would include (1) most garden-variety prostate cancers (grow slowly, present low risk of reducing longevity, especially to those diagnosed over 70); (2) small solid kidney masses, usually under 3 cm., which--although they could be cancerous-- would be slow to disseminate to other parts of the body—and the myriad of newer minimally invasive treatment options dictate thoughtfulness, not haste in decisions; (3) most superficial bladder cancers, which do not even necessarily need urgent transurethral resection if they appear [to the experienced urologist] low-grade and are not causing significant bleeding.
On the other end of the spectrum are more aggressive urological tumors which, if still felt to be curable or at least more controllable with surgery, should be dealt with more urgent timing. These include but are not limited to all testicular cancers, large solid renal masses (likely kidney cancer) and high grade/invasive (often into muscle) bladder cancers.
Timing of surgery also relates to the age and condition of the patient. In a non-emergent situation, the urologist should consult with the patient’s other doctor(s) to understand how the surgery (more so should complications ensue) may affect the patient’s other medical conditions; and whether so-called "co-morbidities” will potentially adversely affect the outcome of surgery. Blood thinners such as aspirin, Plavix, Coumadin, and Pradaxa should, if at all possible, be held for the appropriate number of days before any surgery. In the frail or older patient unsuitable for surgery (or if such surgery were deemed too complicated and/or not likely to work), alternatives should be offered, e.g., a chronic bladder tube to be changed on a regular schedule in a man with prostate enlargement who can no longer void spontaneously.
A urologist with a good sense of surgical timing and perspective will do the right thing when the patient is ready; avoid unnecessary delays in treatment; limit pain and suffering; and contribute his or her share to lowering the cost of medical care.
“Got to Go, Got to Go [Urgency, Overactive Bladder and Neurogenic Bladder]”
A few years ago, I temporarily experienced a symptom I not uncommonly evaluate and treat: urinary urgency. Not being a coffee drinker, I was trying an “energy drink” to help with afternoon mental acuity (post lunch “dwindles”). This compound contained some caffeine but also other “herbal” supplements that are felt to improve alertness, memory, and mood; as well as some amino acids and high doses of water soluble vitamins especially vitamins B6 and B12. In this regard, I think the product worked quite well. However, the urge to void it created, 30-45 minutes after consumption, was so strong, that, let’s say, one would not want to be stuck in the left lane of OC/LA rush hour freeway traffic.
Urgency is a strong uncomfortable feeling of the impending urge to urinate, not infrequently accompanied by some volume of leakage. It can occur with or independent of urinary frequency; the mechanisms of these symptoms are not necessarily the same.
I am convinced urgency results from a combination of things. There are specialized sensory nerve endings in the bladder wall. If these are excitable either due to “no known reason” or localized disease (e.g., inflammation from a bladder infection and rarely some “flat” types of bladder cancers) or pathological conditions in the nerve fibers between the bladder wall and the spinal cord, there will be a reduced brain threshold for the sense of urgency. Combine this with diuresis (a rapid production of urine by the kidneys) and you have urgency and urge incontinence (leakage). If the bladder is like a balloon holding water, overdistention occurring over a short period of time--as opposed to a longer time frame--will excessively stimulate even normal nerve receptors in its wall.
What I have described is considered “sensory urge” in contradistinction to other classifications of urgency more commonly seen in patients with true/known neurological disease. Urgency can also be due to lack of “inhibition” of actual bladder muscle (known as “detrusor”) contraction. Normally the brain senses bladder contraction when one voluntarily initiates urination at the “socially correct time”. Let’s say the bladder is receiving inappropriate electrical signals from the brain or spinal cord to contract before it is full and in advance of when one wants to commence the urinary act. The detrusor (bladder muscle) pressure may suddenly rise to the point where the brain senses an impending accident—and even a competent urinary sphincter (control valve) cannot stop the leakage. Complicating this is that certain neurological conditions--especially spinal cord injuries and multiple sclerosis--lead to a discoordination between bladder contraction (inhibitable or un-inhibitable) and pelvic floor (“carpet” of muscles across the bottom of the pelvis with openings for the urinary and rectal sphincters) relaxation. As the bladder pressure rises and urination begins, there is a resistance to flow. This results in urgency with poor flow, sometimes low volumes, and a sense or actuality of poor emptying. Spontaneous (unwanted) bladder overactivity together with lack of pelvic floor relaxation is a more worrisome problem, since this disorder more often leads to urinary infections and potential functional and structural damage to the kidneys (via refluxing of urine backwards to the kidneys, obstruction of the kidneys’ drainage tubes, and stone formation). In addition, some patients with neurogenic bladder disorders have brains that cannot really sense what is going on “below”--so accidents and other problems like infections and urinary retention may go under appreciated.
Most people with urgency and urge incontinence do not have neurological disease or a known “neurogenic” bladder. I do not feel neurologic disease can be inferred by looking at bladder function alone. One has to consider the totality of neurologic symptoms and specific exam findings (as well as adjuvant radiographic and other testing) to diagnose neurological illnesses. On the other hand, bladder problems with storage (urgency is more of a dysfunctional storage problem) and emptying (poor flow, inadequate emptying) are a common byproduct of most neurological diseases including stroke, MS, Parkinson’s, and spinal cord diseases causing paralysis. The term “overactive bladder” was coined perhaps 20 years ago to explain patients having “neurogenic bladder” symptoms without clinically significant neurological disease. Dr. Frank Hinman of San Francisco many decades ago used similar terminology for children with these types of urgency and leakage symptoms--so-called “non-neurogenic neurogenic bladder”.
The most common treatable symptom of overactive bladder (OAB) is urgency. Success of treatments is based on reduction both in urgency and incontinent episodes (frequency of this occurring as well as volume leaked). Basic urologic history and physical is often enough to establish the diagnosis. If neurological disease is not known or unlikely, a normal abdominal and pelvic exam with low residual urine (which can be assessed easily in office with an ultrasound-like device called a bladder scanner) and lack of bladder lining disease--especially infections--is enough for a tentative diagnosis. Sometimes other testing of anatomy including cystoscopy (looking inside bladder) and ultrasound/CT are helpful but are often unnecessary. Functional tests of the bladder’s storage and emptying functions (urodynamics) are sometimes informative but probably--as often as they are employed-- do not change the treatment plan in many cases.
It is still a good idea to approach “benign” urgency with behavioral modifications before resorting to medications. Reducing fluid intake (to that amount needed to quench thirst) and especially eliminating “drugs” (e.g., caffeine, alcohol and diuretics) which cause rapid bladder filling is prudent. Urinating on a regular “timed” basis, i.e., by the clock and not waiting for a late signal to void is, too, beneficial. When this fails, OAB drugs, of which there are many examples (I like some of the newer ones, e.g., Vesicare and Enablex), often help. They do not necessarily need to be taken indefinitely--since the underlying mechanisms for urgency can improve over time, whether due to the medications or independent of them. Dry mouth and constipation are not uncommon side effects seen with this “cholinolytic" class of medications but especially with the newer drugs used at her lowest possible dose, are less of a problem and are usually outweighed by the benefits.
When significant urgency and urge incontinence persist despite the above reasonable remedies, we sometimes have to resort (more so in the “non-neurologic” context) to other treatments considered more avant garde [and perhaps a bit experimental, @ least from the perspective of insurance companies that pay the bill]. I will not go into detail now--but these include pelvic neuromodulatory devices such as “Urgent PC” (non-implantable via lower extremity nerve stimulation); and “InterStim” (implantable) electrical simulation which seems to relax the pelvic floor and thus lead to more coordinated voiding and a reduction, versus placebo, in urgency. Another avenue is injection into the bladder of Botox (similar to that used for facial wrinkles). This often helps--but just as wrinkles slowly reappear, so will the sensory or detrusor instability leading to urge and urge incontinence.
The body is an amazing creation. Normal functions, such as bladder urinary storage without undue awareness, should never be taken for granted.
“Equal Rights: Male Slings”
Stress incontinence (urinary leakage, e.g., with sneezing and exercise) is a common condition, which in women, often arises without any antecedent surgery. Genetic predisposition, childbirth, and deteriorating muscle and tissue tone all play a role. For many years, surgical slings have been available to treat female stress incontinence. Originally, these often were taken from the woman’s own abdominal wall fascia (muscle coating), placed between the urethra and vagina, and sutured into place with “permanent” sutures. Another iteration of “self” slings utilized an island of vaginal tissue separated from the rest and also requiring sutures. These were somewhat supplanted by tissue slings derived from purified cadaveric or animal (pig/cow) sources. Synthetic slings, mainly of polypropylene mesh, are now more commonplace and have had a good track record for 20 years with a 90+ % success rate and very low chances of erosion, infection, or chronic pain; need to remove these is a rare exception.
Men can develop urinary leakage from deterioration of the sphincter’s neuromuscular function and more so if the prostate has undergone surgery, even a transurethral prostatectomy (TURP). More commonly, leakage is seen after radical prostatectomy (open or robotic) performed in an attempt to cure prostate cancer. Quoted incidence of post-radical prostatectomy incontinence is fewer than 4% but one Medicare-commissioned study (it should be said, done over 20 years ago when the open and robotic cancer operations were less technically sophisticated) said that up to 30% of men, more so those older than 70, having radical prostatectomy, complained of SOME degree of even minor leakage.
Until 10 years ago, treatments for this type of leakage, short of placement of an artificial urinary sphincter (AUS), were not all that successful. These included drugs, physical therapy and cystoscopic injections of bulking agents such as collagen into the sphincter area. Men and their urologists often rejected the AUS operation, usually successful, as “overkill”. Furthermore as much of an advance as this prosthesis represents, it does have mechanical/hydraulic parts, can have “engineering” failures in the body, and requires a man capable of manipulating/operating the device. Some men, as they age, frankly become less competent to do so—and they cannot rely on their family members to figure this out and be constantly “available” to them.
AMS (American Medical Systems, Minnesota), a bioengineering leader in the development, among other devices, of innovative treatments for impotence and incontinence, has had male slings in their armamentarium for 10 years. I myself never got used to their InVance Male Sling, which required drilling multiple small screws to anchor a wide pyramidal-shaped piece of compressive mesh over the urethra as it courses in the perineum (space between scrotum and rectum). Their newer AdVance Male Sling, to me, is better and more akin to the female slings. In common with the female slings are the anatomical/surgical approach; use of a narrow ribbon-like piece of polypropylene mesh; lack of need for suturing or bone anchors; and nearly immediate “locking in” of the sling in an immoveable position by the tissue through which it passes. The male sling is a bit more technically challenging than its female counterpart, requires a deeper incision to expose the urethra underneath one of the perineal muscles crossing it and freeing up of the curved part of the perineal (“bulbar”) urethra from a tethering tendon. The male sling both repositions the urethra upwards toward the natural sphincter area--and like the female sling, provides some support.
It takes me 30-45 minutes to do this procedure and many men can go home the same day without wearing a catheter; a small percentage without a catheter may need one subsequently inserted within the 1st 24 hours, for a few days. More prolonged “retention” of urine is uncommon--as is significant bleeding, infection, severe or chronic pain, or erosion of the sling into the urinary tract.
The Advance sling works best when (1) it is done by a technically astute urologist well versed in surgery on this part of the male anatomy; and (2) the “right” patient is selected. I usually decline to do the procedure on men either who have non-bothersome leakage or have major volumes of leakage usually needing diapers as opposed to pads and have "soaking" as opposed to dampness. Men with more than 2-diaper leakage per day should think about an artificial sphincter. Men who have had pelvic radiation (either as a primary or "clean-up" procedure) for prostate cancer may be too technically difficult to get a good result from a male sling (e.g., the sling may not be capable of pulling the urethra upwards). They too may want to consider having an AUS (also of @ least slightly higher failure risk in the post-irradiation setting).
The AdVance sling gives me a great intermediate tool for treating the majority of men who actually have a low degree of embarrassing leakage. Insurances and Medicare cover it; why not consider joining all the women out there with successful outcomes and throw away the pads and diapers for good!
“Some ‘P’s’ associated with the Penis”
The penis is a fascinating organ, an area of concern and sometimes obsession by its owner. The most common issues are those of function, but a surprising number of men express anxiety over its size. If one searches books on the subject of the penis (e.g., on Amazon’s website), one finds that the most requested “literary classics” have titles such as “Huge Penis” or “…The Ultimate Guide for a Longer, Thicker, Stronger Penis”. In this regard, low self-esteem for penile size has spawned a sub-industry in urology with penile enhancement surgery. My viewpoint is that unless the penis is truly very small, most men should steer clear of such remedies, which probably create more of the optical illusion of increased length and girth (especially in the flaccid state)—and which can, on occasion, lead to significant complications including infection, scarring, pain, deformity and even poorer function. It is difficult to make men with a poor “body image” happier with surgeries like this. I will rarely refer a man to certain urologists who--by their extra specialty training-- are capable of doing reasonable penile reconstructive surgery on carefully selected individuals.
I have done three penile surgeries in the last few days, and five in the last few weeks. The most unusual was a total penectomy (removal of the entire penis) for an aggressive penile cancer. Most penile cancers occur in uncircumcised men and are felt to be more [poor] hygiene-related than foreskin-related, per se. In over twenty years of practice, I have only had to remove the penis in three patients. However, other men have had penile malignancies of lower grade, more akin to other “skin cancers”—these could be dealt with by either excision of the abnormal skin or what is referred to in Dermatology as “MOHS surgery”, a type of shaving-of-skin procedure to get down to normal uninvolved tissue. If a lot of skin is actually excised surgically, a skin graft is harvested and sewn into place by the urologist or plastic surgeon.
Abnormalities of potency (impotency) or inability to get or hold an erection are very common and probably increase by 10% per decade of life starting in the 40’s. We do see rare men in their teens and twenties with issues (often giving a history of NEVER getting a rigid erection), some of which are due to physical problems regarding blood flow dynamics in the penis. “Venous leak” impotence refers to the inability to maintain high enough pressures (tantamount to rigidity) during sex—due to abnormal veins that are not occluded by the erecting penis and thus allowing blood to exit the penis too quickly, usually an occurrence not seen until after a man ejaculates. We can diagnose this condition using ultrasonic-type tests, but it is questionable whether surgery to repair the “leaky” veins helps or holds up over time—and many young and older men with this particular condition will benefit from oral drugs.
It is often said that impotency has a physical cause in most cases and that sometimes, impotency can be the first “early warning,” sign of such diseases as diabetes and coronary artery occlusions. I believe this is true. However, whatever the physical “cause”, once a man develops difficulties in this matter, there is always bedroom anxiety and psychological duress that compounds the impotency. In my practice, if I am worried about such “medical condition” associations, I will have the man see his internist/primary care physician about as yet undiagnosed and potentially serious health conditions. I tend to focus on the “practical” of things I know I can do to make the man more potent. Sometimes I will check a testosterone level, but I am not convinced that treatment of a slightly low result will make much of a difference. An extensive “evaluation” with lab and other tests seldom gets the impotent patient to where he wants to be. I have no trouble offering the man with inadequate erections treatment based on his subjective symptoms, something I usually will not do with other urological conditions. Although in the past, various tests of nocturnal erections (a normal event in healthy men) have been used as a proxy for determining physical versus psychological impotence, very few urologists use these anymore. In truth, it is difficult to objectify what is going on in the bedroom!
Oral drugs like Viagra, Levitra, and Cialis (known as phosphodiesterase inhibitors), probably work by affecting a cascade of biochemical events leading to relaxation of the spongy tissues inside the corporeal bodies (paired long tubes inside penis accepting blood during sexual excitement). If the spongy erectile tissue is relaxed and not stiff, the chambers can fill with blood and cause rigidity by expanding against the relatively inflexible firm outer wall of these chambers (tunica albuginea). These drugs help 75% or more of men achieve better erections and have a good safety profile; but should be used in caution in men with serious cardiac disease and cannot be used in those who take nitrates, e.g., nitroglycerine.
Penile self-injections were a mainstay for treatment of impotence until 1998 (the year that Viagra was approved by FDA). A rigid erection lasting up to 60 minutes can be achieved safely in most men if the dose of drug is properly titrated (always start low!). Papaverine was the original drug that gave way to Prostaglandin E-1 (commercial name = Caverject); but now a lot of men have three drug mixes (AKA “triple P”), including the two above penile injection drugs plus Phentolamine.
Aching in the penis, bruising, and scar tissue in the corporeal bodies are the main side effects from penile self-injections--but occasionally one can see a painful prolonged erection lasting well over 4 hours that requires treatment. This condition, called priapism, is also seen in other men not using injections including those with sickle cell disease, other hematologic disorders, and in some cases those on certain psychiatric medicines. Sudafed available over the counter, as well as the prescription drug terbutaline, can terminate an early priapism. A more severe priapism may require (in an emergency room setting) an “antidote” such as diluted phenylephrine injected irrigated into the penis/with irrigation of the blood sludge out of the corporeal bodies; or even an urgent surgery to “shunt” blood away from the engorged penile corporeal bodies, which--in priapism--are not receiving enough oxygen.
Penile prostheses (implants) seem to have had a revival, now that many aging men with increased medical morbidities have developed refractoriness to oral drugs; and either do not respond to penile self-injections or do not want to do them. Bioengineering of both inflatable and rigid implants are better than ever, with a greater than 90% “couple” satisfaction rate. Surgical risks of infection or need to remove/revise the implant are acceptably low. A skilled implanter (such as myself) can usually get you through this with excellent functional and cosmetic results. This is really a good option that should not necessarily be “the impotence treatment of last resort”.
Peyronie’s disease is a condition noted in men of all ages, with a firm plaque involving the erectile tissue. This may come on relatively abruptly and can usually be felt by the patient. It causes curvature or an hourglass deformity with erection. Painful erections may go away as the condition stabilizes. Coital trauma may play a role in this condition--but most men I see with this have not had a major traumatic incident with swelling. Some feel Peyronie’s is an autoimmune disease where the immune system “makes a mistake" and forms antibodies against "self" tissues. Peyronie’s with mild symptoms can and should be watched. For severe symptoms with impotency, a straightening operation with placement of a penile implant may be needed. If potency is preserved and treatment is needed, the use of Vitamin E is often recommended but probably without a sound experimental/clinical basis. Transdermal or injection forms of the cardiovascular drug verapamil can help--but I have not seen great results with this. The drug Trental, also used for some vascular conditions and which has anti-inflammatory properties, is sometimes used; and there are at least anecdotal stories of significant improvement/penile straightening. A vacuum-erection device may play a “non-invasive” role in “physical rehabilitation” of the crooked penis. Surgical straightening procedures can be done for Peyronie’s with intact potency--but these are complex and there is sometimes as trade-off between a straighter penis and less rigidity/decreased sensitivity during sex.
I could go on with the “P’s”; but I think I will yield to your “Q’s”.
“The Heat is On”
I am one whose mood responds well to the Santa Ana winds, which bring warmth and a feeling of comfort amidst drearier January days in Southern California. It is postulated that these and other similar winds (e.g. Siroccos in North Africa) create atmospheric ionization, with the positive and negative ions created having different physiologic and psychological effects. Positively charged ions may influence mood, relaxation and energy via melatonin, a hormone produced in the brain.
Another form of “ionizing radiation” is radiation therapy, which has been used to treat localized prostate cancer for many years. Indeed there has been a revolution in this science, even since I finished medical school. Before the 1980’s external radiation, mainly via photons (atomic particles of light energy)/electrons, were aimed at the area of the prostate but could not be precisely focused so as to avoid injury to surrounding tissues, even the skin. Seed implants, if used, had to be placed via an open incision with surgical exposure of the prostate gland [a bit more of which would have allowed removal of the cancerous gland!].
Side effects of radiation limited the dosage, which in turn led to poorer cancer outcomes than with removal of the gland (radical prostatectomy). Significant gastrointestinal/rectal, as well as urinary side effects were not infrequently seen--and are still seen, more so in our older prostate cancer patients treated well over 20 years ago.
Although there are many types of radiation and sometimes non-electron (i.e., proton) particles used, the net thrust can be summed up as: “increase or boost the radiation dose to the prostate and immediately surrounding tissues to kill all cancer cells and reduce the dose to surrounding tissues, especially rectum and bladder”. The need for this goal led 1st to “conformal external radiation,” with several beams coming at the prostate from different directions, and within the last 15-20 years, IMRT (intensity-modulated radiation therapy). IMRT, as with other external sources, is administered over about 6 weeks to limit the daily dose, but uses a sophisticated system to “shape” the radiation beam to the individualistic anatomy of the prostate by opening and closing tiny windows known as collimators (often using tungsten barriers) thus partly interrupting the beam and deforming it away from normal structures. This technology safely allows a higher radiation dose, often 75-80 Gy, pronounced “gray” (a unit of radiation), lethal to most prostate cancer cells.
Modifications to IMRT systems are based on the premise that the prostate may slightly “move” both within a session and from day-to-day treatments based on degree of rectal and bladder fullness. One would not therefore want the radiation beam to omit treating some prostate tissue or to “get” the innocent bystander contiguous structures. Tomotherapy and “Rapid Arc” are examples of the “IGRT” radiotherapy, IG standing for image-guided, integrating active “real-time” imaging into the treatment protocol [initially calculated by a radiation oncologist and physicist].
Brachytherapy, which can be a stand-alone radiation treatment or used in conjunction with above-stated external sources, implies either (1) permanent seeds giving off slow radiation and implanted into the prostate as an outpatient one-time procedure, or (2) temporary needles allowing conduction of electron beam radiation into the prostate via plastic needles removed right after each session. The needles used in either case to enter the prostate are passed under ultrasonic guidance between the scrotal area and rectum under anesthesia. These treatments, used as sole therapy, probably have as high a cure rate for the typical low grade prostate cancers as IMRT or radical prostatectomy --but are limited by their inability to radiate much beyond the outer capsule of the prostate (a not uncommon area of early local cancer cell penetration); as well as more irritation, and more urinary tract side effects, especially with permanent seeds, to the urethra. On the other hand, for the most part, brachytherapy has fewer rectal side effects vs. external sources.
Proton beam therapy has certain characteristics that make it more targeted to the prostate and not giving off much radiation before either entering or exiting the prostate. It is felt to be an effective and safe form of external radiotherapy. Proton beam facilities are expensive to build and therefore costly to administer; and are geographically limited. There are no clear-cut unbiased “scientifically done” studies to say proton beam is better than IMRT either in terms of cancer outcome or side effects.
Besides avoiding surgery, one benefit to prostate radiation is essentially no urinary leakage--compared to a definite risk with radical (open or robotic) prostatectomy. With surgery, the chance of significant leakage lasting more than 6 months is well under 5%; but anywhere from 10-30% of men experience some, perhaps a minor degree of ongoing incontinence. Urinary side effects, if they do occur during or after radiation, are often graded “more severely bothersome” by men than is incontinence, per se--and can include occasional bleeding, pain, urgency and frequency.
Impotence is common to all treatments for prostate cancer. Preservation of potency is better than ever with both modern radiation therapy and technical refinements in (open and robotic) radical prostatectomy. One should expect a 25% or greater drop-off in erectile rigidity after any of these treatments and possible permanent ED. The worse results are with older men, generally 70+ and/or those with weak erections from the start. Men who choose radiation for their prostate cancer often note good erections initially--with progressive deterioration over 2-3 years; during the same time course after radical prostatectomy, erections may actually improve from at 1st a dismal situation. I myself would not suggest choosing radiation over surgery for potency issues alone.
I think radiation therapy is a good prostate cancer therapeutic option, comparable in outcome but different as regards side effect profile vis-à-vis radical prostatectomy. For early, likely curable prostate cancer, the statistics for freedom from PSA recurrence as well as disease-free survival are similar, likely for 10-15 years after therapy. For locally very aggressive prostate cancer (we urologists can identify that smaller fraction of men), radiation therapy with the addition of hormonal therapy (i.e., “anti-testosterone” drugs) MAY provide better local control of the cancer; but these, unfortunately, are the type of patients who have a higher failure rate with either primary modality of treatment and whose disease may nonetheless progress.
As one urologist with two close blood relatives (one against my advice!) having been treated with external beam radiation therapy, I feel I am open-minded about this approach. All of us who care for men with prostate cancer need to be so and offer choices; while at the same time guiding a patient to the right solution based on his individual situation and needs.
First, let me take this moment to wish all the readers of this website and all my patients a wonderful Holiday Season, including a Merry Christmas and Happy New Year. May 2012 be free of any major health issues for you and your loved ones.
We all know about health care reform, the exploding cost of health care, and the stresses which will be placed by the new legislation, if/when implemented, on the system including for doctors, other practitioners and hospitals by more entrants (patients) into the healthcare arena. The higher burden placed on physicians and lower reimbursement from an under-capitalized system could lead to shorter patient encounters; longer waits; too much reliance on lab tests, x-rays and other diagnostic tests; as well as inaccurate diagnoses made by less-than-experienced practitioners. Specialists could be overwhelmed with patients previously diagnosed by their primary cares in a culture that seeks more and more expertise. This in turn could make, for example, urologists, less available to do what they do best, e.g., complex diagnosis and surgery. Complications of care could multiply.
I am not going to get into the whole topic of tort (and specifically medical malpractice) reform and the politics thereof. Let’s just say that, based on my 25 years of experience, changes in malpractice legislation (even something as simple as “loser pays”) will definitely cut health care costs, keep many physicians from early retirement (and encourage more bright young minds to enter the profession), and allow for “smarter” medicine. Patients need to, if not actually face more of the costs of the medical care they seek, at least be aware of what these are. They need to be given an honest assessment, using the available tools of “evidence based medicine” as to what works and what does not. We need to quote patients the percentages involved in our joint decision making. Once understood (“informed consent”), patients should “live within" the boundaries of their medical choices. For example, what is the chance that a surgery to remove a post-fracture fixation device will really eradicate chronic pain in the leg? In a patient with blood in the urine, what is the chance that adding a CT or CT urogram on top of an already normal kidney ultrasound will show something of significance to the patient’s health; and let’s say there is a 1-2% chance of finding something, is that worth $500 of cost? What are the odds that chemotherapy for lung cancer in an 80 year old patient will truly add significant/quality longevity—or is this just being done to avoid the perception of “giving up on grandpa”?
When patients experience a bad outcome from their medical care, it is easy to look for blame, especially in a society like ours. Most health care interventions derive from perception of illness and a patient seeking help from a doctor. Could it be that a less-than-optimal outcome or a downright complication ensue from the patient’s illness itself; the limitations of medicine/surgery; or mere randomness? Is it permissible to say that any system is imperfect and on rare occasions, accidents will happen?
Besides tort reform, I’d like to see a system where--if compensation for a bad outcomes is needed--it comes more from a “no-fault” logic--except in the most egregious cases of poor medical care [where the case should 1st go to a panel of experts before being referred for legal arbitration, not to a lay jury for judgment].
Some patients are more stoic than others about outcomes of their health problems. To those less so inclined, I have a few suggestions. To those of you old enough to remember, one used to be able to buy a personal liability insurance policy at the airport in the very unlikely event of accidental death or injury resulting from a flight. Most elected not to buy it, and of those who did, very few claims were in need of payment. Why not have patients who are “worried” purchase an inexpensive case-by-case “no-fault” policy before undergoing surgery (or before being diagnosed/treated by their Internist) that will compensate them appropriately, without blaming anyone, should they suffer serious injury/prolonged disability/income loss attributable to the procedure? I do not proclaim to know how much this “policy” should cost as related to the potential award, but somewhere in the realm of $100-$500 before a surgery and $50 to $100 before an illness is diagnosed/treated non-surgically seems reasonable.
Another thought. Most patients are happy with their medical outcomes. I often hear patients tell me, after they see the insurance company’s "explanation of benefits"; that the doctor was clearly underpaid for the benefit derived. Why not try out a pilot program for “voluntary gratuities” i.e., “tips” from happy patients to defray the cost of compensating those rightfully unhappy. Let’ say someone is quite pleased with the outcome of prostate surgery, and they “tip” $250. This can go into an earmarked insurance fund (preferably run privately and not governmentally) to cover awards needed to those truly “damaged”. It could even be arranged that a certain percentage of such gratuity (e.g., 33-50%) could be paid via the fund directly to the treating physician, as an incentive to keep doing a fine job.
I admire plumbers and other tradesmen. My own father was an electrician. These vocations are honorable and, like surgery, their work has definable goals and satisfying solutions. Results are more predictable than in the human body, since the “engineering systems” in buildings are better understood and less open to “randomness”.
I should have learned more from my dad. In a way, I wish our school systems had more vocational tracks for high school students, since it is increasingly unclear all students are suitable for college or “professions”; and likewise, traditional college grads are finding it hard to jump start a career with a liberal arts background and few tangible skills. Also, vocational education ties in with our country’s economic need to have a higher “manufacturing to service industry” ratio. We need our young people to know how to make and fix things.
That much said, we had a plumbing problem in our home. A copper supply pipe broke [“pinhole leak”] in the ceiling over a bathroom, causing water damage behind several walls before we noticed and shut off the main valve. I called a plumber. Now I realize I could have price shopped and perhaps saved 30% or more. A local non-corporate plumber [or handyman] may have been more eager for the work at a reasonable fee. Having to control the situation from afar, “over the phone”, in essence, did not lend itself to getting multiple estimates. For perhaps three hours of work, including tearing out a piece of ceiling, partial pipe replacement (it was in a “difficult area”), and testing the system cost me $1100. A small percentage of this may be reimbursed by my insurance. Obviously the plumber himself likely made less than 25% of this sum. “Should have had [in your house] copper pipe type 'L' instead of the flimsier type 'M' which leaked", said the plumber. [I guess I will ask about that in advance, next time I am about to purchase a builder’s home!]
Now again, plumbing in a near emergency is important and valued, but I ask you, what is its relative value compared to “human plumbing” or the urologic surgery, for example, I do? One could argue that the relative values reflect what the market will bear; and prices adjust according to supply and demand. In medicine this is not true, since patients (the receivers of a “product”) are rarely aware of the price of services they receive and in essence, will take what they want/can get, so long as their out-of-pocket is affordable and minimal. We doctors are mostly paid by insurance companies and the government (Medicare, etc.); and the reimbursements for our services (prices) are basically fixed, with some variance by geographical areas and supply-of-provider issues [were there only one urologist in Newport Beach, he/she would be extremely busy, would not accommodate all kinds of problems and probably disenroll from participating in any contracted payment system].
This leads me to share with you some “EOB’s” or “explanations of benefits” which both patient and doctor receive from payors after a medical service (in this case, surgical) are rendered. These all recent examples in my practice.
A patient with a very large prostate obstruction , failing repeated voiding attempts after going into acute urinary retention despite maximal medication therapy, underwent open surgery done through the bladder [“open prostatectomy”] , to “clean his pipes” of a mass of benign prostate tissue. His retention did nicely resolve after recuperation from the surgery. The 1 hour 15 minute operation--with an extra half-hour writing postoperative orders and speaking with family-- as well as the “all-inclusive” three months (including 2-3 days in the hospital) of postop care at no additional insurance company reimbursement payed our practice $950. With the patient’s copay of $190, this added up to $1140. What I personally “saw” of that $1140, after paying office overhead and income/other taxes, was in the vicinity of $370.
A man with aggressive bladder cancer had me remove his entire bladder and create an ileal conduit (means of removing urine from body via a small intestinal “pipe” to a stomal appliance on the abdominal skin). Surgery took 4.5 hours. He had no major postoperative complications and went home 6 days after surgery; and has done quite well. He is likely cured of a potentially lethal cancer without the need for further oncologic therapies. Insurance payment to me was $2350 with patient’s copay @ $470 for total of $2820. As in the prior example, after “the necessary accounting”, that equated to $910 in my pocket.
Yet another (also grateful) patient had his post-radical prostatectomy/post-irradiation (prostate cancer) urinary leakage immensely helped by my artificial sphincter operation, to put an internally inflatable “cuff” around his urethral “pipe” so as to occlude it until each time he feels the need to void, @ which time he presses a scrotal button to release the cuff’s grip. One hour operation. One day in the hospital, three months “gratis” included postoperative care, no complications. His HMO insurance paid me $950. Patient had no copay requirement. In actuality, money I “took home” from this operation was $310.
The pipes in my home work fine now. Leakage is gone and the homeowner’s insurance company restoration people are there to assess water damage/structural integrity. The patients I mentioned have had their plumbing systems fixed to the best of my ability. They all seem happy. Hey, I do not mind being called a “human plumber” or part of the “stream team”. Not everyone can fix a pipe, toilet or septic tank. Far fewer have the cognitive and technical training, experience, and skills to decide on whether to operate and how; and accomplish this task in generally “risky” patients, efficiently and remarkably few complications. In in all seriousness, what do the medical payments to doctors NOW say about the quality of doctors and their willingness to work hard on behalf of their patients in the FUTURE?
In October, 2009, I wrote a MEditorial on this website [you can find it in the archives] entitled “PSA: Cool your Jets”. In light of the recent US Preventive Services Task Force (USPSTF) data published in the medical journal “Annals of Internal Medicine” and lay citations to the work, I have reviewed my own thoughts from then and wish to update these now. The USPSTF, which not too long ago also had controversial recommendations about mammography in younger women, gave the PSA (prostate specific antigen) test a “D” [as in “bad grade”] rating, based on their review of a huge amount of data and their conclusion that PSA has minimal benefit to the population at large--and risks of assessing any PSA elevation further, as well as treatment, may outweigh any benefits.
If anything, my own experience and the recent data (as well as urology meetings I have attended) make me concur more with the task force and less with some in “organized urology” who will continue to defend PSA screening--perhaps more on an emotional basis for the patients [and, cynically, on an economical basis for themselves and all who can benefit from CaP screening and treatment]. The argument would be something to the effect “If you are the one whose prostate cancer was cured (and “life was saved”) by PSA screening, would there be any doubt in your mind that PSA screening is useful… it’s only an inexpensive blood test”.
Statistics are difficult, confusing, and can be misused to gain advantage. I try to stay away from these in my discussions of urologic evaluations and care with patients. However, I will reiterate two statistics about prostate cancer screening. First, 1400 men will have to be “screened” to identify one life-saving prostate cancer (CaP) treatment. Second, nearly 50 men will need to be treated for their prostate cancer to see one life saved by an aggressive intervention, e.g., surgery or radiotherapy.
We have to be sure we are on the same page. By screening, I mean taking a man in the age range susceptible to prostate cancer who has no symptoms and is seeing me to be “checked for prostate cancer”; or is sent to me with (often an isolated) elevated PSA. It does not include men who have other suspicions for prostate cancer such as those with symptoms referable to the urinary tract or concerning for advanced/metastatic disease, suspicious DRE’s (finger exam of the prostate) or men who have had CaP in the past, whether treated or not.
If it were only a matter of getting a blood test, that might be acceptable. However, these tests have consequences, including biopsies, not infrequently repeated over time, which can harm the prostate and patient, especially creating chronic inflammation, sometimes significant infections, and perhaps a cycle of “bumps” in PSA causing further concern and testing. Anxiety, I feel, is a too-often overlooked issue; and I do wonder whether cancer phobia caused by somewhat inadequate screening tests can lead to physical or emotional illness and even perhaps decrease longevity.
If I were “king” of urology, I would avoid PSA screening without a discussion 1st of the consequences. I’d like to ask the man why he wishes to be screened. Does he understand that a biopsy might need to be done to “find out”--and that side effects could occur and perhaps 10% of biopsies, more so in large prostate glands, are falsely negative (they fail to detect cancer cells that really are there)? Should the biopsy show cancer and more so, if the man is older (we used to say 75+ but now I’d lower that to 65+), does the man know that the natural history of prostate cancer, once diagnosed, is often more like a benign disease which, if at all, progress slowly, and is easily consistent with another 20 years of life even with no treatment? Is he cognizant of the data that CaP is often over treated and therefore one cannot simply justify surgery or radiation complications (impotence, poor bladder control, severe radiation sequelae) based on the argument “it was worth it to have been cured”. [Many do not need to be cured]. I see many older men whose argument to be screened and either followed closely for their PSA or biopsied and even [aggressively] treated is “I do not want to die of prostate cancer”. What they are missing in this logic is that they will die of something, most likely well within the time it would take CaP to bring about their demise. Better to die of some other cancer?; or of a stroke?
Primary care doctors are busy and are trying to handle the multiple medical issues of an aging population. It is easier for them to include a PSA as “screening” in pre-physical comprehensive lab tests than to discuss its (or for that matter, other tests’) utility in a given patient.
I would suggest that if a man wants prostate cancer screening, either the PCP take the time to have the right conversation; or this duty should be relegated to a urologist before that blood test is even drawn.
In my practice, I would try to convince asymptomatic men over 65 NOT to even start with PSA screening; and perhaps to consider no biopsy if the PSA is elevated. PSA’s in such cases can certainly be followed--but the past reliance on PSA velocity (rate of increase in PSA over time) is now also being questioned as to its utility in distinguishing between those who do and do not have CaP. I would likely advise men by their mid-40’s to have ONE screening PSA, since there do appear to be data indicating a very low PSA at this age cohort (usually PSA <1.0) correlates with a minimal chance of developing a clinically significant prostate cancer within 20 years. I would also “screen” patients as well as offer biopsies to men between 50 and 65, but only after a heart-to-heart discussion and informed consent. That advise to have PSA screening and potentially a biopsy would be stronger in higher risk groups including men who are African –American and those with a strong familial (?-hereditary) history-- especially prostate cancers occurring in relatives only in their 50’s.
“On-Call” Follies (aka “The Un-Making of a Surgeon”)
The 1970 very readable memoir by Dr. William Nolen about his surgical training, “The Making of a Surgeon” aptly chronicles the rigors of surgical “apprenticeship”, in a way, the “rites of passage” we in surgery and its subspecialties have been forced to endure as the price to enter the “club”. There are many references in Nolen’s book to the horribly complicated and sick patients; matters of life and death decided by neophyte doctors in their 20’s and early 30’s; long hours, nights and weekends “on-call”; and the military-like chain of command in the maturation process toward becoming a “real” surgeon.
I am not aware of any books about the “unmaking” of a surgeon. However, I suspect the same factors that “make” a surgeon can wear on the individual, no matter how strong the character, and can among other things (inadequate compensation, stress, lack of balance in life, the publics’ unrealistic expectations and their fear of death) can create the spiral toward retirement from the surgical/medical profession (“unmaking” of the surgeon) before one’s time.
Let me share with you the essence of an especially wearying weekend “on-call” for me. We take rotating weekend call to cover other similar specialists’ practice in the same geographic area. There is no set monetary compensation for doing this, and in fact, a lot of the care is “free”. We cannot charge for phone calls (like our lawyer and accountant colleagues) from patients, hospitals, nurses or other doctors. People are free to pick up the phone and page us at will. Many are hoping we can practice good “telephone medicine” (an oxymoron of sorts) and make an intelligent decision on a patient we do not know and have never examined. This recent weekend, I probably fielded at least 50 calls. Most were legitimate in the sense there was a perceived problem, but often times, the caller divulged minimal helpful information--to the point where any decision making was more likely a guess on my part.
One of the calls, from the emergency room of an affiliated hospital was due to the inability to reach the urologist covering that particular hospital. At 11:30 PM on Friday night, for a non-life threatening emergency (urinary bleeding almost certainly due to excessive use of anticoagulation), I was put in the position of “villain” for not immediately agreeing to assume the care for the “MIA” urologist. It required my talking to three different individuals (doctor, PA, charge nurse) in that ER to repeatedly explain what my role would be if the situation deteriorated and really warranted a urologic visit to the bedside of that patient.
Another problem Friday night [which occupied much of the weekend] was a colleague’s patient, who went to an academic center for his kidney cancer surgery; but when he bled three weeks postoperatively from a vascular abnormality at the surgical site, he chose not to go back to the “downtown” hospital, but to come to our hospital. I and our interventional radiologist did a quite capable job of diagnosis and treatment. We see this phenomenon frequently, when we have to care for the complications created elsewhere and by the patient’s personal choice to drive (or even fly) to an outside facility with (usually) an illusion that their care or outcome will be superior.
Several problems I cared for were “iatrogenic”, i.e., in part created by healthcare providers themselves. One was the need to stent a ureter in a patient whose partially blocked kidney became more so after a gynecological procedure. Another was trauma to the urethra from inadvertent inflation of the urinary catheter retention balloon in the urethra (and not, as it should be, in the bladder); followed by a bleeding tear in the bladder after radiologic insertion of a tube into the bladder through the skin. That patient needed an urgent surgery to remove innumerable blood clots from the bladder, cauterize the area of injury, as well as to place an appropriate urethral catheter. [More about him below].
Another emergency was to place a ureteral stent on a lady without insurance who had developed pus in the kidney from an obstructing ureteral stone and was at risk for developing septic shock. Federal and state legislative “unfunded mandates” essentially force us to care for such patients without any guarantee of compensation.
Calls come left and right from the emergency room about issues that could, in a more “civil” setting, be addressed the next day or perhaps in the office. Part of this is really related to the patient: our society seems to have a low threshold for feeling their medical problem (1) is a true emergency (which if not immediately addressed, could cause death) and (2) can really be solved in that setting. Requests are made for us to see patients in the hospital for a consult, interrupting our busy schedule and adding to the cost of healthcare, when an outpatient office visit after discharge from the ER or hospital could suffice; or a simple phone conversation from doctor-to-doctor could clarify the issue.
It is finally Monday morning. I am “off” call for the other doctors; only “on-call” for my own patients. Monday is a typical hectic workday. Monday night, I fall asleep within a second of my head hitting the pillow. Off goes the cellphone/pager @ 4AM. An emergency? No, it was a hospital nurse calling for me to clarify an order (written during daylight hours, Monday morning 20 hours before!) about removal of a patient’s urinary catheter—that very patient who needed emergency surgery over the weekend for the “iatrogenic” problem started on the same hospital floor. After answering the call--and choosing to defer any commentary until I would see the patient early Tuesday morning--I lay half-awake, sleep deprived, another busy day on the horizon.
A glamorous profession, wouldn’t you agree?
“Tubes inside Tubes”
As a medical student, one thing I liked about Urology was the brilliant design of the urinary tract: a “factory” (kidneys) to filter blood into urine; two tubes (ureters) to move the urine to a storage container (bladder); and another tube (urethra) for final elimination.
Disorders of the urinary tract (male and female) involving blockages and diminution of function sometimes require the placement of tubes to facilitate movement of urine to the outside. Obstructions can be between the kidneys and bladder or below the bladder (e.g., prostate) involving the urethra. “Stagnation” of the urine in the kidneys or bladder may not cause any harm--or may result in pain, infection and damage (including renal failure), sometimes permanent. A good urologist can determine whether an ultrasonic or radiographic finding of poor urinary drainage really does need decompression with a tube.
There are many roles for tubes within the body’s urinary tubes and storage containers. Tubes, including catheters and stents, should be used when necessary--but only with good justification and only for a limited amount of time, if the underlying condition is correctable. Tubes, usually made of naturally occurring or synthetic plastic/rubber (e.g., latex and silicone), are never “all good” for the urinary tract and in time, will cause problems, the most common of which is infection. Other complications include episodic bleeding from irritation of the urinary tract lining, pain/spasms, and stone formation. External tubes such as Foley catheters and suprapubic tubes (to drain bladder urine via urethra or through a skin puncture in lower abdomen); as well as percutaneous nephrostomy tubes (placed to drain urine via the back out of a blocked kidney) are universally associated with bacteria in the urine. Such bacteria often cause cloudy and malodorous urine. Some consider this to be infection and in fact, if associated with proven bacterial growth on a urine culture (lab test), this is probably true. However in such cases, if the doctor has a low threshold for treating this with antibiotics, chances are the tradeoff for the patient’s health will be bad—and temporary clearing of the odor will only lead to more serious infections with highly resistant and potentially dangerous bacteria. Lesson is: as long as the tube is in you, put up with minor symptoms and avoid being treated with antibiotics for “low grade” infections.
Acute blockage of the bladder, sometimes related to prostate enlargement in men, is painful and may require a catheter placed in the office or ER. Since temporary does not equate to permanent obstruction, an attempt should be made to get the catheter taken out, usually within a week or so of its being placed, for what is called a “trial of voiding”. During this period of observation, the doctor may prescribe medicines (e.g., alpha-blockers such as tamsulosin or doxazosin) to allow proper bladder function; and the patient keeps an itemized record of all fluid intake and all urine output (“I&O” diary). When I am involved in this, I may have the catheter removed in the morning and ask the patient to return late that same day to see if another catheter is needed. If there continues to be symptomatic urinary retention and surgery is either not an option--or is to be delayed, so-called “intermittent catheterization” can be taught to the patient/family, to be done usually 4x/day (depends a lot on fluid intake). This will effectively empty the bladder and avoid a “foreign body” residing in the urinary tract around-the-clock. If this procedure is done with good technique and without friction (by generous lubrication of each catheter), even if catheters are re-used (“clean” technique), this is generally safer and better in terms of infection versus an indwelling catheter. Patients requiring chronic self-catheterization can often, however, qualify through insurance for use of a new/disposable catheter for each insertion.
Tubes can also decompress the kidneys, if the ureters are occluded from within (far more likely from a ureteral stone than a tumor) or from outside (compression by scar tissue or tumor, especially a urologic or non-urologic cancer spread to pelvic lymph nodes). Back-up of urine into the kidney(s) is called “hydronephrosis”. The best drainage is afforded by internal self-retaining tubes called “double-J” or “JJ” stents. These are placed by us under anesthesia using a cystoscope to visualize the ureteral orifices (look like “golf holes” in the bladder); and navigating the tube beyond the obstruction onto the kidney. Under certain circumstances, our Interventional Radiology colleagues are asked by us to do the same, only via a “percutaneous” access as opposed to through an endoscope in the bladder. An external tube is placed under local anesthetic (sometimes with sedation) into the distended kidney through the skin/muscles of the back--and via this manmade temporary tract, the internal “JJ” stent is placed in an antegrade fashion immediately or after a delay of a few days. The stent would be removed if the underlying process is temporary and/or treatable (stone passes or is removed; ureter and or its kidney removed for ureteral tumor; ureter freed from scar tissue). If the disease process in more serious or not easily corrected, a “JJ” stent is changed by us under anesthesia about every 6 months; failure to do so can lead to brittle/calcified stents that are harder to remove without traumatizing the tissues; and which can even fracture upon “late” removal.
Urinary tubes can sometimes be helpful in other circumstances. Postoperatively for bladder or prostate surgery, an indwelling catheter is often needed until the area is healed enough so that the chance of bleeding (e.g., from over distention of a biopsy site) or leakage of urine outside the bladder is minimized. In some cases of heavy urinary bleeding especially with retained urine, decompression of the bladder can allow the body’s clotting mechanisms to work better. Occasionally with heavy bleeding from the bladder (sometime seen years after radiation to the pelvis e.g. for treatment of prostate cancer), I have asked the interventional radiologist to place external tubes into both kidneys so as to short circuit urine away from the bladder for a period of weeks, thus putting the bladder “to rest” and often allowing the bleeding to stop [without doing anything directly to the bladder]. When we are treating larger stones in the kidneys or ureters, we not infrequently place a “JJ” ureteral stent in advance of or during the definitive procedure (shockwave lithotripsy, ureteroscopic stone removal) to prevent the multitude of fragments generated from acting like “wet mud” and obstructing the ureter—which would cause pain, possible infection, and hospitalization).
It is always prudent to question your doctor about the necessity of a urinary tube; what is its purpose; what are the risks; and under what conditions it will be removed and/or replaced. Tube decompression of the urinary tract is relatively easy-to-do and can be great in relieving symptoms/preventing more serious problems; but should not be viewed as a panacea.
Having had a good vacation, affording me relaxation and time to read, not only do I not have a “medical topic” in mind right now; but I’d like instead to share with you some books you may consider for “summer reading”, should you so choose. If you are like me, and cannot keep your eyes open late at night for a good read, consider an audiobook source. We use Audible.com, a great service for downloading then listening to books (I do in my car) via a number of electronic devices.
You will see my reading biases over the years favor non-fiction and probably biography/history, at that. A few have a medical slant. I will start, however, with one of my favorite non-fiction books. The list could be a lot longer--and the books are in no particular order.
Analogous to the prostate cancer versus breast cancer paradigm, (i.e., prostate cancer Is an “in vogue” malignancy and its treatment options are now as controversial as breast cancer treatments have been for 20 years) is the issue of male hormonal replacement therapy (testosterone, sometimes referred to as “T”) versus female hormones (estrogen).
Whether or not there is a true [male] “andropause”, as there certainly is female menopause, is debatable. Testosterone production, 95% by the testicles and 5% by the adrenal glands (located near the kidneys), seems to surge when men are developing in utero, as a means of “masculinizing” the male brain as well as the developing genitals. Lack of this production--or tissue insensitivity to testosterone--can lead to errors in male genital development (like the urethra not making it to the tip of the penis or the two side of the scrotum having a cleft in between, appearing more like the female labia) and may even play a role in boys having more interest in “girl things”, i.e., playing with dolls.
After birth and until puberty, testosterone production remains dormant, only to surge during adolescence. After age 40, there is a gradual unpredictable decline by decade of life, but not the dramatic cessation as is seen in estrogens at menopause. Men in their 80’s can have normal testosterone levels (as well as good sexual functioning!).
It is even controversial as to what constitutes a “low” testosterone level. Most labs have their default normal levels (usually between about 250 and 800 nanograms per deciliter) set not based on what clinically is an adequate male hormone level--but rather “statistically”—based on what levels are observed in 95% of the population (so-called “confidence interval”). Thus it is possible a man may have signs of inadequate “T” (medically called hypogonadism) and yet fall within the normal blood test range. Since once produced, testosterone appears in the bloodstream in many forms, often attached to “carrier” protein molecules produced by the liver, like albumin and sex hormone binding globulin, it may be more relevant to discuss the concept of ‘free T”, that is the fraction NOT attached to a carrier molecule, since this form seems to be more available to stimulate cells influenced by male hormones.
In clinical practice, there has been an evolution of thought as to what male symptoms are caused by too low a testosterone (or “free T”). It is not too common that poor erections, per se, are explainable by low T although this blood test should be measured in men with impotence, more so those with low sex drive (libido). It is now felt that there are non-sexual symptoms attributable to male hormone imbalance--but since these complaints can be caused by many other problems, and there are risks to being on testosterone replacement therapy (TRT), the correct remedy is not always clear. For example, bone weakening (osteopenia/osteoporosis), lack of physical stamina well as mental concentration, and even depression, could be partly due to hypogonadism and therefore respond nicely to TRT; but other causes of often “vague” symptoms need to be assessed usually by the patient’s Internal Medicine doctor. Note depression itself can cause poor sexual function, and as a corollary, some antidepressants including SSRI drugs related to Prozac can suppress sex drive and responsivity.
I see a lot of men already on TRT, sometimes for years, who have no idea of what abnormal level(s) led to treatment--or even what exactly was the goal of this drug intervention. If I am going to treat a man for hypogonadism, I want to see from the start more than one lab test showing either low total or free testosterone. I want to correlate the low level with the symptoms. I suggest avoiding TRT only to “treat a low lab test”. Pituitary hormones that stimulate testosterone production may need checking, since rarely, the “master” hormonal organ (pituitary, located at the base of the brain) can be deficient, e.g., due to a benign tumor producing prolactin which crowds out the production of LH (luteinizing hormone), a messenger hormone telling the testes to “function better”. It is also important to have a goal in mind, not to simply tell a man he will be on TRT for life--but rather as long as it takes to see if the a patient’s manifestation of hormonal insufficiency is responding appropriately. A six month trial of replacement therapy will help differentiate those whose will benefit from those who won’t. Non-responders should have blood free/total testosterone levels checked on therapy, just to be sure they are being adequately dosed.
Traditionally TRT was done with oral pills or injections. The former had a higher incidence of liver problems and the latter the issue of uneven blood level, high after a shot and low a few weeks later. Some doctors feel the “excess highs” could cause problems, e.g., overstimulation of red blood cell production by bone marrow. More often nowadays, I prescribe a daily transcutaneous form of testosterone applied by the man after drying off from a shower. This provides a steady level of TRT with low side effects. Some men are opting for long-acting testosterone pellets, done in an office injection procedure; such pellets can give off a steady level of testosterone for up to 6 months. The latter get around the issue of “forgetting” to apply the testosterone gel or patches; and avoid the messiness or rash issues.
I feel testosterone replacement should be stopped if it does not help; or if it causes major side effects; or if prostate cancer is suspected/untreated/ persistent after initial cancer treatment. Testosterone is not felt to “cause” prostate cancer even though growth of prostate cancer cells seems often dependent on testosterone; in fact, there is some evidence that [paradoxically] men with chronically low “T” levels may be MORE subject to getting prostate cancer. I would worry about a man with low “T” and a high prostate cancer blood test (PSA). In a man successfully treated for prostate cancer who needs extra testosterone to treat symptoms, TRT is currently felt to be a safe intervention.
Men interested in having children should be aware the TRT can inhibit sperm production, probably by suppressing a pituitary signaling mechanism that allows utilization of intratesticular testosterone by the developing sperm cells. Regular testosterone preparations, well as the far more potent (often illegal) “anabolic steroids” can lead to infertility issues.
In terms of related hormones marketed to men both over the counter and as prescriptions to either help potency, or bathe men in the “fountain of youth”, I neither condone these nor do I prescribe them. I do not have much respect for “hormone mills”, where doctors give men concoctions of hormones to feel better. Some of these drugs include HGH (human growth hormone) and DHEA (a weak cousin of testosterone).
If you or a loved one has concerns about “low T”, ask your doctor--but also do a reality check so as not to overestimate the benefit of TRT, or to look at it as a panacea or the main/ only solution to less-than-optimal health.
Thanks in good part to a healthy 2010-2011 rainy season, the greens of the grass, the horticultural color diversity, and one of my favorites, the fragrance of jasmine, seem especially intense and beautiful this spring: pollination at its best.
I think the analogy of pollination to human reproduction is more appropriate than ever, since our growing knowledge of sperm and egg function, as well as incredible assisted reproductive technologies (abbreviated as “ART”) not infrequently require an intermediary (akin to the pollinating bee) to effect fertilization. Reproduction in humans is not always the same as “successful” [depending on your point of view] sex. Sex is fun; reproduction can be a chore!
Let’s look at the male part of the fertility equation. Sperms are produced by the testicles in an incredibly high quantity, the tens of millions per cc. of semen; but most are “wasted” on the way to fertilize the egg (ovum) usually in the fallopian tube. Production of sperms goes on continuously, sometimes for a man’s whole lifetime, and [as opposed to the limited supply of eggs, petering out toward menopause, in the female] are produced anew to fully develop in a given cycle. The ova on the other hand, exist, a priori, in a state of so-called meiosis, a biologic process in which only one-half of the 46 human chromosomes and one “X” chromosome exist.
Research suggests sperm problems/male infertility are very dependent on genetics and chromosomal function. Men have two “sex” chromosomes, an “X” and a “Y”. The “Y” chromosome has portions of gene sequences that control sperm production. “Deletions” or acquired absence (in the DNA splitting and recombination processes) of some of these gene sequences, may determine a man’s capability of fathering a child, especially in cases where the sperm count is exceptionally low or zero. See more below.
Although most authorities feel a sperm count of below 20 million per cc. is low, this is controversial. Remember fertility is determined by the ability to cause pregnancy, not by a sperm count itself. Some doctors do not consider a man “infertile” unless he and his partner have gone 6-12 months without conception. We do see pregnancies in couples where sperm counts are well below 20 million per cc.; and difficulties conceiving in other couples where the man has more than 100 million sperms per cc. Some other factors that bear on fertilization include the morphology (appearance) of the sperms (can also be genetically-linked), with odd-shaped sperms being ineffective at penetrating the “thick” barriers around the human ovum. Strange-looking sperms do not, however, lead to babies with birth defects. Motility of sperms relates to how fast sperms progress in a forward direction through the cervix after ejaculation. Speed and direction are important here. Furthermore, some fast/normal-appearing sperm seem to lack enzymes needed to penetrate the egg. In other cases, thick cervical mucus (not normal at the time of ovulation) slows down even hearty sperms on their way to the fallopian tube.
There are risk factors for poor sperm counts and function. How these factors interfere with sperm production/function is less than clear but they may work by inducing production of toxic substances in the testis such as “free radicals”. Adverse conditions include presence of a varicocele (varicose veins inside scrotum--usually worse on the left side, since the anatomy/angle of the left vein entering the body from the scrotum is different than the right): history of testis cancer; history of undescended testis at birth; history of testicular torsion—an acute painful twisting of the testicular blood supply, more often seen toward puberty but occasionally seen in younger boys and adults. Varicoceles associated with poor sperm counts/male infertility can be fixed as an outpatient surgery with an anticipated 70% chance of improving the sperm count/motility/morphology and an improved chance (perhaps 1.5 to 2x as high versus NOT fixing the varicocele) of a subsequent pregnancy. Despite all the studies on this controversial issue, we still cannot predict which infertile men with which sized varicosities will benefit (and to what extent) from tying off these abnormal veins--which may act as a "heat sink" raising the relatively low scrotal temperature above that at which sperms can be properly produced.
This leads back to genetics. Further research on the “Y’ chromosome, motivated by the Human Genome Project, will undoubtedly lead to better predictions as regards male fertility and hopefully some treatments to improve sperm counts and function (so-called “seminal parameter”). The available medical therapies right now are limited and often do not help. Men with “untreatable” sperm dysfunction/infertility are often referred nowadays, with their wife, for “couples therapy” to a GYN/Infertility doctor who can often achieve a pregnancy using such reproductive technologies ranging from IUI (in-utero insemination) to IVF (in vitro fertilization, which used to be referred to as “test tube babies”) to ICSI (intra-cytoplasmic sperm injection, where a single sperm can be injected using a piston-like pipette under microscopy into the wife's harvested egg—with the resultant embryo implanted into the wife’s uterus). The sperms used to achieve this can be harvested, even in their “immature” predecessor state, from the testicle in some men with zero sperm counts (no sperm at all in the ejaculate, referred in this instance as “NOA” or non-obstructive azospermia). Open and percutaneous (through the scrotal skin) techniques permit such sperm retrieval. A whole other important issue is whether “ART” will lead to more birth defects including an increase in male infertility in babies so produced. Genetic testing, such as those for certain “Y” chromosomal microdeletions, help predict in which cases such retrieval will likely lead to a pregnancy. Deletions in certain areas of the “Y” sex chromosome called “a” and “b” portend a bad outcome, whereas deletion in the “c” region is more favorable for a pregnancy using assisted reproductive techniques.
My feeling is that for a while, perhaps another decade or so, we as urologists will depend heavily on our GYN/Infertility colleagues to “rescue” infertile couples (by “pollination”) who suffer poor sperm function--but eventually, my specialty will be able to improve sperm production and function directly within a man’s body.
As a urologist/surgical subspecialist, I really enjoy operating on patients, especially when I know in advance that a job well done will be rewarded by a better quality of life or increased life expectancy for my patient.
Another gratifying--although less dramatic--event is experienced almost daily in the office. This involves unraveling and reassembling pieces of a patient’s medical puzzle, using logic and sound medical principles to move toward the right answer. Not necessarily due to mistakes or oversights from other health care providers, many patients have misperceptions about their health and medical care. Frankly, part of the problem is the anxious or poorly prepared patient notgiving a clear/succinct/”prioritized” history of his/her past health or current symptoms; as well as not listening to the doctor or inability ask the right questions.
A “week in the life” of a busy urologist (myself, just this past April 4-9) will illustrate how a bit of “old fashioned medicine” and clear thought applied to a clinical problem without excessive tests or treatments can often clarify misperceptions and help the patient.
Yes, there’s a lot of bad information out there, along with lack of thinking (and sometimes, unfortunately, self-aggrandizing motives) by health care providers--and mistaken beliefs on the part of patients as to the benefits-versus-risks of different diagnostic tests and treatments. Temporarily leaving out of the equation the role of insurance companies, malpractice attorneys and government with its quasi-solutions to the “health care crisis”, clarification of misperceptions by improved patient education and doctor-patient communication will undoubtedly lead to better health care at a lower cost.
“Shrinking the Prostate”
The medication Proscar, now generic as finasteride was initially felt to be a wonder drug. The word with this, as well as the more recently developed Avodart (dutasteride), is that it would reduce the “surgical business” of urologists by reducing greatly the number of operations, especially transurethral resection of the prostate (TURP) for benign enlargement (BPH).
These drugs are engineered specifically to block an enzyme found in “male” cells (abundantly in the prostate) which converts testosterone to dihydrotestosterone (DHT). DHT is far stronger than testosterone in promoting prostate growth. By not effecting blood testosterone levels, these so called 5-ARI drugs have a relatively low incidence of causing impotence (although some men taking these do still complain of reduced libido and sexual function) or other hormonal abnormalities, such as breast swelling/tenderness.
Studies do reveal these drugs modestly reduce the size of the prostate over many months; it can take 6 or more months to detect a clinical difference. Avodart, by blocking two different “types” of the 5-alpha reductase converting enzyme, may “shrink” the prostate faster. Unfortunately, it is difficult to assess the degree of shrinkage unless the man is in a study whereby prostate gland size is measured ‘before” and “after” using, e.g., transrectal ultrasound. The urologist’s finger turns out to be a quite a crude measuring stick; and it is rare to see dramatic changes by simply palpating the gland on rectal exam from year to year. More often, I see a softening of the gland which may mean reduced size or at least less compression of the 1st part of the urethra. More relevant is that reduction in prostate size does not always equate with improvement in voiding, which, after all, is the real goal here. How many men will be happy with chronic use of a drug which may measurably shrink the prostate but not improve flow or reduce frequency/nocturnal urinating/urgency, etc.? There are many theories as to this discrepancy, but I suspect the most likely explanation is muscular damage to the chronically blocked bladder; permanent loss of strength of the bladder may not be significant helped, let’s say, by a 10-25% reduction in prostate size. Also, there are different types of benign tissue comprising what we call BPH and response to these “shrinking” drugs may depend on one’s mix (glandular versus stromal) Excess nerve innervation of the prostate (even in those glands with unimpressive size) may make it more ideal in some cases to avoid these drugs and rely on alpha-blockers (see below) .
Further studies by the drug companies (or in urology clinical trials, sometimes sponsored by the pharmaceutical manufacturers!) point to a lower incidence of acute retention (blockage necessitating at least a temporary catheter) and reduced need, in one’s future, to have a TURP. When one reads between the statistical lines, it is apparent these risk reductions are relatively minor ( perhaps 5-10% of an already low number--since a minority of men with BPH symptoms either go into retention or need/have surgery anyways) , and may not warrant the personal and societal costs of these drugs and the occasionally bothersome side effects.
I see a fair number of men placed on these drugs as 1st line treatment for BPH, even on the basis of sheer enlargement as opposed to symptomatic enlargement. There are many men, prescribed 5 ARI drugs, who have minimally enlarged glands and are far less likely than those with large glands to have a response. The rate of drug discontinuance in these patients is high. I would avoid prescribing these just because a prostate gland feels large to me.
In my practice, I usually use alpha-blockers (e.g., tamsulosin) as 1st line treatment for enlarged prostate symptoms, emphasizing dealing with that which bothers the patient as opposed to the size issue, per se. Alpha-blockers do not shrink the gland--but block nerve impulses and in so doing, relax the pressure of the prostate on that part of the urethra within it. Since I do not like starting two new drugs at once (? which one caused the side effects) , I will wait to see the response to alpha-blockers for at least a month before deciding which patient may benefit, in the long run, from addition of a 5ARI drug. Not as often as I would like, some men in 3-6 months can come off the alpha-blocker and rely solely on the finasteride or Avodart.
As to risk reduction for prostate cancer, studies have been done and are still underway with both of the current 5ARI drugs. As regards Proscar, it did reduce the incidence of prostate cancer by over 15% over a 10-year period of observation; but it seemed to “select out” for patients with more high grade and aggressive prostate tumors. A higher percentage of these tumors, more likely to spread and cause harm, were seen in the finasteride group as opposed to the control/placebo arm of the study. Anything that treats the hormonal component of prostate cancer can, over time, effect “competitive advantage” and growth to those prostate cancer cells not responsive to hormonal manipulation. Since the less aggressive prostate cancers are easier to treat and can take decades to cause death, I myself am NOT advising patients, as of now, to use 5ARI drugs as a form of cancer prevention.
“Crimson is a Red Color/A Doctor’s Report Card”
In February 2010, partly as my ongoing attempt to play on (? with) words, the title of my website “dissertation” was “Red is the Color”, also name of a Beatles’ song I happen to like. Because of Valentine’s Day and the nearly equally traditional American Heart Association “month”, February, at least in this country, is most associated with the color red.
I again, this year, can allude to Crimson, a maroon shade of red, as the reference point to my MEditorial. As well as the color and inoffensive nickname of my undergraduate Alma Mater (not unlike the more athletic Alabama Crimson Tide), Crimson is also the proprietary name of a software available to hospitals, governmental health agencies (e.g., Medicare) and insurance companies; and many feel, in the future, to doctors and most importantly, patients, as a means of grading doctors’ performance in many areas.
Undoubtedly, in the future (no joke: if there are enough doctors left, in light of increasing demands and insufficient funding of the US health care system), there needs to be a better/more objective way for patients to determine who is and who is not a good doctor. Referral from other doctors, friends and relatives is satisfying from the patients’ and doctors’ perspective, but limits the ability to compare the costs and outcomes of medical care. Going online and “Googling” (as you have done to look at my website, thank you) is probably not a good way to rate doctors, due to the statistical invalidity (bordering on nonsense) of most such websites that “grade” doctors; please try to find me one with more than just a few unscreened/unsourced comments--whether laudatory or scathing.
“Crimson” (and, I hear, similar software), around to almost everyone but doctors and patients for several years, has just been released to doctors at my main hospital for their review. There is a lot of data to digest; however, statistical analyses are applied so one may compare himself or herself to other doctors in the same or other specialties--as well as those in other medical institutions--using the program. For example, in quality-of-care, one can see the percent of patients needing readmission within 3 and 30 days of discharge, complications of care (surgery), complications of the patient’s underlying condition, and one doctor’s mortality rate versus “expected” mortality based on the severity of the patient’s condition. There are similar “metrics” under other major headings, e.g., utilization of hospital resources and cost of care, i.e., is one doctor spending too much to obtain similar or even worse results?
As chairman of our urology department at this time, I have had a special briefing on the Crimson methodology; overall I like it--as well as where it could lead us, i.e., in allowing our patients to choose their doctor in the future both on quality and cost. I am hoping for a day when doctors can compete on cost of care to the patient; the patient “sees” and analyzes the cost, and (because it will “have to be”) makes a not insignificant contribution to his or her healthcare expenditure; and that patient knows what to expect for what is being paid.
There are some shortcomings of this, one of the initial attempts at giving doctors report cards. In school, we were graded on the work--including tests--we ourselves took mostly as individuals. Doctors’ work in hospitals is a constant interplay between many human and non-human factors. Even in the human realm, we are interdependent with other doctors, nurses, etc. It is hard for one to have his/her opinion on “how to proceed” with a patient problem dominate those of others. Hospitalized patients tend to have multiple doctor care providers. When something goes awry, sometimes all the players are “lumped together”; or one individual takes heat which should have been doled out, in proportion, to others. One of my colleagues, looking at a Crimson “complication” rating, noted that her “organ laceration” rate was falsely higher than it should have been--after she was called in an emergency as a consultant to REPAIR a bladder laceration sustained during a gynecologist’s surgery on a woman. When I looked at one of the Crimson parameters as to “length of stay” [in the hospital] I noted one of my patients who underwent removal of the bladder (cystectomy) and creation of a new bladder (neobladder) using intestine stayed 11 days, three beyond the hospital’s mean stay for that surgery of 8 days. In dissecting the “whys”, this patient was doing fantastic and was ready to go home at 7 days postoperatively; but stayed an extra 4 days after a plugged urinary bladder catheter went unnoticed overnight, leading to leakage of urine into the surrounding pelvic tissues, excess seepage through the surgical drain, and fever. Thus, in a sense, I got “dinged”, the patient temporarily suffered (he did fine subsequently), and the cost of care went up, due to someone else’s oversight/lack of clinical skill.
In addition, thus far, programs like Crimson do not include outpatient work done either in the hospital or office. In my specialty, much of the work--including urologic surgeries--can be done as an outpatient or with a 23 hour hospital stay. If patients do not have access to this data, can they make a fair judgment when comparing their expectations of care to those needing hospitalization? Also, many outcomes can only be judged over time--well after hospital discharge--and are not currently reflected in "report cards" like Crimson. Examples include long term cancer and functional outcomes (e.g., potency and bladder control) after robotic versus open radical prostatectomy in one institution; and patient satisfaction rates after suburethral slings for female stress incontinence and transurethral prostate resections for symptomatic benign prostatic enlargement.
Let us remain optimistic, however, that Crimson and other such programs will open up avenues by which doctors can improve the quality and outcome of care; and patients can shift toward doctors with the best “mix” of care metrics, whose skills and efficiencies are measurably better than their peers, and, yes--worthy of a higher level of compensation.
Within a two week period around the New Year, I saw 3 new patients with kidney tumors, @ least two of which likely have cancerous tumors. I thought therefore, this would be a timely topic for discussion.
Not all kidney growths are cancers; in fact the majority of "mass" lesions we see on x-rays: incl. CT's (=CAT scans), as well as ultrasounds, are cysts which often do not need treatment, are seldom cancerous--and may not even warrant a prolonged period of observation.
Of the solid masses, there are some benign-acting tumors such as angiomyolipomas and oncocytomas. Size of the mass matters, i.e., the smaller the sold tumor, the less chance it is cancerous; and small tumors, if cancerous, have a low chance of spreading (""metastases"), estimated @ a 1% chance over 3 years' follow-up for tumors under 2.6 cm. in diameter. Larger tumors are more likely to be malignant and are more prone to metastasizing. However, I had a case a few years ago when a difficult-to-remove 20 cm. tumor turned out to be an oncocytoma, which is a "good one" to have.
As regards the size issue, it turns out one of the main reasons for the increased incidence of kidney cancer is the "accidental" finding of small so-called "indeterminate" renal masses on studies such as CT's and ultrasounds often ordered for symptoms (e.g., abdominal pain, having nothing to do with a kidney problem). Urologists are often asked to assess these asymptomatic small masses. One would think that finding solid (possibly cancerous) tumors "early" would improve the overall statistics on cancer survivability, but such "screening" appears not to be achieving this. As stated, the small tumors are occasionally observed or if treated, are usually cured. However, there has also been a trend towards increased numbers of more of the larger/aggressive tumors which can spread either in advance of their discovery or recur after their surgical treatment.
About 3.5% of internal cancers in this country are of renal origin, and kidney malignancies result in about 2.5% of all cancer deaths. Somewhere between 40,000 and 50,000 new cases will be diagnosed in the is country annually---with more than 15,000 deaths anticipated from the disease.
Of the malignant kidney tumors, most, called "renal cell carcinoma" or RCC for short, derive from the "meaty" functioning cortical part of the kidney. These represent 90% of kidney cancers. The 2nd most common type (which I will not discuss here) are transitional cell cancers (TCC), which are really of the same cell origin as bladder cancer--and tend to occur in patients who have had the latter or are @ risk for bladder cancer (smokers commonly). Transitional cell cancers of the kidney originate from the inner lining of the part of the kidney where urine collects before it heads down the ureter to the urinary bladder.
Most RCC's are fairly obvious on CT: moderate to large sold masses often at the periphery of the kidney which enhance after intravenous dye is given: that means the tumor, which usually creates its own blood supply rapidly as it grows, takes up the dye from the circulation similar to the rest of the normal part of the kidney. In such cases a biopsy (which can be done under CT guidance through the skin without spreading tumor) is seldom needed, since the growth should be treated surgically anyways. Biopsying the small more indeterminate masses may be more reasonable with the following caveat; a negative biopsy (no cancer cells seen) may well be "falsely negative', that is, it could underestimate or miss the cancer cells.
Solid indeterminate masses, especially in frailer/older patients, can be watched by serial CT's or ultrasounds--since their growth rate is slow, sometimes only 1/3 to 1/2 cm. annually; and as stated, some of the masses are benign and the chance of <3 cm. tumors spreading is felt to be low. Lesser invasive treatments such as freezing (cyroablation) which can sometimes be done non-operatively by a specialized radiologist, may be an option for treatment. However, this modality is less often to be advised even for small mass in a healthy, "younger" patient, since we do not often know for sure after the treatment if the tumor is completely gone; and studies suggest a slightly higher local recurrence rate when compared to partial removal of the kidney. Retreatment of such recurrences with partial nephrectomy may be very difficult.
Large suspected kidney cancers should be removed. The trend has been to take out part of the kidney including the tumor with a small margin of normal tissue. This gets harder if the mass is very large (over 4-6 cm.) and/or located centrally where major blood vessels enter the kidney. The urologist, should however, discuss with the (suspected) RCC patient the matter of partial nephrectomy (PN); and under what circumstances a total/radical nephrectomy (RN) might be necessary in advance or judged more appropriate during the actual operation.
More and more studies show partial nephrectomy (PN) to be the best treatment for small to moderate sized RCC. Cancer outcomes are as good as for RN--and preservation of more normal kidney tissue generally leads to better health, as the years progress. Whether PN should be done via an open--usually flank--("on the side") incision or laparoscopically without or with the use of robotics is controversial. Your surgeon should discuss those alternatives with you. In their favor, given an experienced laparoscopic urologic surgeon, there may be less postoperative pain and a shorter hospitalization/quicker return to work. However, the operation takes longer (often 2--3X as long) and may incur more bleeding and so-called "warm ischemia" time. That means the main blood supply to the kidney is controlled laparoscopically with small metal clamps in advance of cutting out the tumor to reduce bleeding and to see clearer; in doing so, there may be >30 minutes of no fresh blood flow to the kidney, resulting in a prolonged/slow recovery of that kidney's function. Laproscopic PN may also be associated with more delayed bleeding and urine leakage into the tissues surrounding the cut edge of the kidney.
Treatment for the patient who has had part or all of the kidney removed and yet has "adverse" prognostic factors (predicting recurrence); or for those unfortunate to have demonstrable recurrent or metastatic disease focus not on radiation or traditional chemotherapy--but on "biologic" medications to alter the immune response such as Interleukins (e.g., IL-2) and Interferons. In general, partial responses are not uncommon but complete responses and/or cures are seldomly seen. IL-2, more so the higher dose protocol, can have serious side effects. Better results are now being seen with a group of new chemotherapeutic--like agents, e.g., Sutent, which attacks certain molecular processes felt to promote the growth, invasiveness, and spread of these cancers. Furthermore, drugs such as these can be used sequentially with others of similar ilk, occasionally gaining further @ least partial cancer remission, and they can also be used before or after use of immune modulators e.g., IL-2. Occasionally, selective surgical removal of renal cell cancer metastases will, in fact, allow for recurrent remission from disease. More possibilities for prolonged survival are opening up to patients with aggressive kidney cancers.
Just to review my three patients cited at the start of this MEditorial. One (76 yo) had his tumor found be my on physical exam; it was quite large and impinging close to vital structures--but was safely removed by me in an under 90 minute open surgery with the surgical margins clear of tumor cells. The second patient (56 yo), who presented with generally feeling poorly and some left back ache, had surgery elsewhere last week----her growth was also quite large; and although a laparoscopic approach was being contemplated, I would not doubt if the surgeon had to reconsider mid-stream; and rely on a formal open incision. The third patient, only in his 30's, with an incidentally discovered small <3 cm. tumor, is weighing his options--but I have advised a partial nephrectomy. His prognosis, whether or not this small solid mass turns out cancerous, is really excellent.
“Why do I Examine You?”
A 77 year old man comes in, transferring care from another (retired) urologist regarding prostate enlargement and chronically elevated PSA blood test. On both visits six months apart, I decide to thoroughly examine him, despite the fact that he is really here only to be sure his prostate is “fine”. On the 2nd visit, I discover a large mass in the lateral right upper abdomen (not present the 1st time) —which turns out to be a nearly six inch, but surgically removable and potentially curable kidney cancer.
A 72 year old woman who had her bladder removed elsewhere and got chemotherapy for a pelvic lymph node relapse a year later questions “why do you have to examine me especially ‘there’ [meaning in the pelvic/female area]”?; and adds “my prior doctor has not done any significant exam since after he removed my bladder”. I tell her a similar patient was referred to me with a CT scan following bladder removal not suggesting anything further wrong; however it was clear by a simple pelvic exam using two fingers (and later proven by biopsy) that the cancer had relapsed and was stuck to the vaginal wall.
A 42 year old woman with minimal symptoms keeps having bacterial growth and white blood cells in her urine and has been on 6 courses of antibiotics prescribed by another doctor over the past year. Her lab tests are no better. My examination of her is normal. I decide to catheterize her bladder and compare the result to her office voided urinalysis. The catheterized specimen, unlike the urinated specimen, is normal. Conclusion: many patients, especially women, no matter how hygienic, have bacteria and white blood cells outside the bladder in the vaginal area that “contaminate” a voided urine specimen and lead to incorrect diagnosis and treatment.
Unfortunately, there seems to be a trend in medical care I see practiced of playing up the technological and laboratory/radiographic aspects of diagnosis and downplaying the importance of a good history and physical exam. Now, a majority of patients sent to me say they were not examined or at least “not down there” by the 1st doctor who saw them for a perceived problem. Given, many do still have a yearly “health maintenance” general physical exam. The public is becoming more accepting of shortcuts in their care and the approach of “getting a prescription or having a test ordered” without getting undressed. Some doctors and patients see such things as too time consuming, inconvenient or embarrassing.
Examining a patient helps establish a “bond” and proper professional doctor-patient relationship; and reinforces the notion that a physician is someone who, by training, experience and wisdom, should have access to the body, to examine any and all areas that are appropriate to lead the patient toward better health. Thoroughness of a physician should be judged by how much is learned during the encounter, not so much by how much time was spent or how many x-rays or lab tests (or secondary referrals to other specialists) were ordered.
I learn a lot by taking a succinct but detailed history--and trying to get my patients to think about their symptoms. This helps me judge whether or not there is a serious problem and if that resides within the genitourinary tract. In my years of doing this, a history NOT suggesting significant illness, along with a normal pertinent physical exam goes a LONG way toward a preliminary or final diagnosis of “nothing serious wrong”. If medicine were practiced in a more sane environment in this country, with less “2nd guessing” by others, we could save an incredible amount of money by placing our resources into thoughtful doctors who know how to use the power of history and physical exam to eliminate costly and often unnecessary other testing and referrals.
If I had the time and were not so busy practicing my surgical craft, I would likely offer all new patients a complete history and physical and, patient permitting, examination of the whole body.
Next time you see me or you other doctors, do not desire short cuts in your care. Diagnosis without exam or worse, diagnosis over the phone is a disturbing trend, whereby important illnesses may be missed--and likewise, basically healthy patients will be given, inappropriately, a diagnosis and treatment for a disease that does not exist.
Have a most Happy Holiday season!
“Men Wearing Diapers who Should Not”
Leaking urine (incontinence) is not uncommon in adult men and women; and for a variety of factors, increases with aging. Having to wear pads or diapers is a humiliating problem, replete with low self-esteem/depression/frustration; hygienic issues including skin breakdown and rarely contribution to bedsores; loss of socialization; and cost.
I will limit my discussion this time to incontinent men. There are two general causative factors :(1) aging/neurological issues, and (2) specific urologic conditions and treatments (including surgeries) thereof.
Hyperactivity of the bladder with high bladder pressures (both during filling with and elimination of urine) can overcome even the most competent sphincter (control mechanism) and lead to leakage, sometimes sensed strongly as urge and at other times imperceptible to the man. Especially with neurological (brain, spinal cord and peripheral nerve) diseases, one may not even feel the need to urinate, let alone leakage. Such neurologic diseases include but are not limited to: diabetic neuropathy, multiple sclerosis, stroke, Parkinson’s disease and spinal cord injury. Hyperactivity includes spontaneous unwanted contractions of the bladder--as well as poor “compliance” in which the bladder, like a balloon, becomes more rigid and less stretchable given the same amount and rate of urine entry from the kidneys, where it is produced.
Some neurologic conditions have no affect on bladder pressures, but weaken the pelvic floor musculature--of which the urinary sphincter is an important part. Men have two areas of resistance to leakage: (1) the prostate (if it has not been surgically altered or eliminated) and (2) the “muscle” sphincter as mentioned, an opening in the “multi-ply carpet” of muscles comprising the pelvic floor. For example, neurological weakness of the “lower” muscular sphincter (only part of which a man can voluntarily contracted, thus “stopping” urination on mid-stream) would, if it were known in advance, place the prostate surgical patient at higher risk for prolonged or more severe incontinence.
It should be pointed out that yet other (and variants of the above-mentioned) neurological conditions can increase bladder pressures and simultaneously lessen sphincter “guarding” against leakage; or in an uncoordinated fashion, increase bladder pressure while not reflexively allowing sphincter relaxation—this can increase both incontinence, retention, and proneness to urinary infections.
Radiation to the prostate for cancer seldom reduces the resistance of the sphincter mechanism--but can lead to a stiff poorly compliant bladder as well as chronic irritability and inflammation of the bladder leading to higher urinary storage pressures and thus, a tendency to leak. TURP (transurethral resection of prostate) for enlargement with blockage symptoms rarely damages the sphincteric mechanism but needs to be used cautiously in men with pre-existing bladder instability sometimes manifested by urinary urgency and urge incontinence. Urodynamic testing can sometimes help us to sort out these potential problems in advance. Radical prostatectomy, done robotically or open, has small chance of inducing prolonged and significant incontinence; the overall rate in less the 2-4% and many men will slowly recover their continence function over the 1st postoperative year.
Behavioral modifications can improve male incontinence “at the edges” where leakage is neither profound not especially bothersome. Reducing oral intake, eliminating beverages that promote more urine output (caffeine, alcohol, diuretic drugs) and timed voids (urinating, e.g., every 2 hours especially before leaving the house whether you feel the need to do so or not) can lessen unwanted leakage. Medications (“cholinolytics", e.g., Oxybutinin-ER, Detrol-LA, Vesicare, and Enablex) are more intended for urgency leakage related to high pressure bladders without sphincter weakness. Side effects especially in the elderly can limit their use: these include dry mouth, constipation, and sometimes mental confusion. Physical therapy to the pelvic floor, biofeedback, and neurostimulation (e.g., implantation of an Interstim device) may again help for patients who are refractory to medications germane to the treatment primarily of urge or mixed (combination of urge and stress) incontinence.
Surgical treatment of male incontinence, in which this urologist has a special interest, is ideal for the normal bladder with weak sphincter. Most commonly this results from prostate cancer surgery, but can also be seen rarely after TURPs, as well as from aging and neurologic-related pelvic floor problems. The urologic device company AMS (American Medical Systems) makes two “male” devices for this problem, each with a 90+% satisfaction rate. The male sling (“Advance” sling) , similar to those manufactured by the same and other companies for female stress incontinence, is a permanent ribbon-like mesh placed through the perineum (space between scrotum and rectum) via small incisions. The sling is not placed in direct contact with the urethra and is pulled up snugly, thus upwardly re-positioning the proximal part of urethra below the prostate area, to where the sphincteric mechanism works better. The procedure is done as an outpatient and seldom causes trouble voiding. It is most effective with mild to moderate under 2 pad-per-day leakage (we can discuss in person what that means). For moderate to severe leakage greater than 2 pad-per-day leakage, an artificial sphincter (AUS) made of synthetic materials is a better choice. One or two cuffs are needed and are surgically placed around the urethra. These plastic donut-like devices use saline fluid to compress the urethra; the entire fluid system is a compact hydraulic engineering system for transfer back-and-forth fluid between the cuffs and a reservoir below your pubic bone by way of an easily detectable/self-controllable intrascrotal pump. Rare problems include less-than-optimal function, infection, and early-vs.-delayed erosion of the cuff(s) into the inside of the perineal urethra, necessitating removal and the hope to “try again later". Having had radiation as a primary or secondary treatment of prostate cancer does increase the chance of local complications--but irradiated patients who do not have a high pressure bladder may nonetheless be surgical candidates.
Men who wear diapers should have hope; appropriate treatment depends on careful assessment by a qualified urologist as to the underlying cause, condition of the patient and his tissues and the likely outcomes for various therapies. Come to a good urologist 1st before investing in a company specializing in paper products! “I can’t hold it”, in most cases, should not lead to a life of social isolation and despair.
Permanent male sterilization by vasectomy has an interesting history dating back to the late 19th century. Although nowadays, we know that vasectomy simply interrupts flow of sperm from the testicle to the prostate (where it admixes with the bulk of semen before ejaculation), the procedure was initially characterized, incorrectly, as helpful in shrinking the prostate gland and improving urination. At one time, it was claimed vasectomy might be the “fountain of youth”, and was even performed on Sigmund Freud. Before its value for this purpose was disproven, the Austrian doctor whose faulty notion of physiology led to the procedure’s popularity, was nominated several times for a Nobel Prize! Even as recent as when I was a medical student, vasectomy was performed during transurethral or open prostate enlargement (BPH) surgery to prevent bacterial infection of the other scrotal sperm tube (epididymis); but that use of vasectomy is felt now unnecessary. Men rarely get acute epididymitis, e.g., after so-called TURP. Other uses of vasectomy which have fallen into disrepute include involuntarily sterilization of criminals--especially of sex offenders and of men whose low brain function was felt to disqualify them from reproducing.
Nowadays, vasectomy is popular--but the number of vasectomies in the U.S., about 500,000 plus per year, is not increasing. Even in developed countries such as ours, women undergo tubal ligation, a riskier internal procedure done usually laparoscopically, at a rate up to three times that of vasectomy.
Although vasectomy can be reversed with a success rate above 70%, a man should be certain he has concluded his family before signing on for the procedure. A man can legally choose to have a vasectomy without his wife’s permission. In my practice, I like to know that both partners are in agreement. I also like to see “serious intent”, i.e., the couple is already using significant contraception, signaling their aversion to parenting more children. It is surprising but not that unusual to see a couple using the relatively unreliable techniques of withdrawal or rhythm to prevent pregnancy, who want me to perform vasectomy. There seems to be a mixed message here: “We [the couple] do not want to take adequate precautions but we want you to do a surgical procedure, incurring potential risk”. It seems every year, one such couple in my practice has a new (presumably unwanted) pregnancy while awaiting the actual vasectomy.
Techniques of vasectomy vary as do any urologic or other surgical operation. There really are not good controlled scientific studies suggesting one procedure is either more successful or has more complications than another. Experience of the urologist (number of cases done per year and in his career) is probably the most important factor. Whether a traditional vasectomy or “no scalpel” (NSV) procedure is offered, a minimally traumatic technique--as well as certain precautions to limit the chance of vasectomy failure--are of paramount importance. Some of the latter maneuvers I do include very small puncture incisions, dissection only right over the vas deferens, meticulous control of any oozing, removal of a small piece of vas on each side, use of titanium clips and “hot wire” cauterization of the vassal canals. I employ “no scalpel” instruments but use a slight variation of the “no scalpel” technique, more of a hybrid between this and traditional vasectomy, than the NSV procedure popularized in China and “imported” to the west in the 1980’s.
I must admit I enjoy doing vasectomies, my relatively easy Friday morning surgical equivalent to the dentist’s tooth extraction. The vasectomy procedure takes under 15 minutes and most vasectomies are done in the office under local anesthesia; monitored intravenous “conscious sedation” with a drug like Versed is offered and does help relax the man; getting one’s mind off the operation generally eases pain both during and after the vasectomy. In rare cases, where the anatomy is unfavorable, or there has been prior scrotal surgery, or the man is undergoing a simultaneous other operation, the vasectomy can easily be done under anesthesia in the surgery center or hospital.
Complications can be seen after vasectomy as in any operation; no guarantees should be made. Vasectomy, however, is safe and proven to be effective. Some degree of minor pain and swelling is to be expected. Progressive major swelling with so-called “hematoma” formation probably occurs in 1-2% of cases but it is rare that anything needs to be done about this--since it almost always goes away on its own. Sometimes the dissolvable skin suture is absorbed before the skin is sealed, leading to a small opening with drainage for up to a week; this is not an infection, Actual infections are rare, and except in rare cases where the man has a condition impairing his immune system, preoperative antibiotics are not needed. Chronic intermittent swelling and discomfort often due to “congestion” of the epididymis (coiled sperm duct between testicle and vas) can rarely occur. This is sometimes misdiagnosed as an infection and treated with antibiotics--but true epididymitis should not occur after vasectomy, since the route for spread of bacteria from the prostate back to the epididymis has been surgically interrupted. Spontaneous reversal of the vasectomy on one or both sides in very rare, certainly less than 1 out of 5000 cases and has been reported to occur even years after the vasectomy. Such a reversal could lead to pregnancy. In my practice, I check one semen analysis 8 weeks after the vasectomy, and will do a 2nd if requested; or if the 1st shows (which it occasionally does) a very low number of immobile or dead sperm. The latter may be sequestered in the seminal vesicles (located near the prostate) beyond where the “roadblock” was created; and simply may require more ejaculations to eliminate. Vasectomy does not cause sexual dysfunction. Studies and/or claims suggesting a link between vasectomy and urologic diseases (e.g., prostate cancer) or chronic non-urologic diseases (atherosclerosis, heat attacks, cancers, and dementia) are either statistically flawed or disproven.
It has been my experience that not only are wives very supportive of their man undergoing vasectomy, but the man is “rewarded” in more ways than one by partaking physically in this contraceptive decision. As I tell men, the spontaneity of sex without concern about pregnancy tends to make the act actually more enjoyable.
“Code Yellow: I Cannot Pee”
“Sudden” shut-off of urination is one of the most common emergencies we face as urologists. This very painful situation usually requires urgent placement of a catheter to drain the bladder; this can be a one-time deal or more likely left indwelling (so-called “Foley catheter”). Once the bladder over distends--for whatever reason-- it takes a variable amount of time to recover; some feel overstretching of the bladder is akin to overinflating a balloon, with damage to the small elastic fibers that comprise the balloon, making it flaccid and lose recoil. One difference between the balloon and the bladder is that the latter has living cells which can repair and replace themselves, eventually functioning, in unison, as if nothing ever happened.
Most patients who suddenly “cannot pee” have underlying problems with their bladder function, occasionally with just mild/barely noticeable antecedent symptoms, such as a bit more voiding at night, occasional start-and-stop urinating, and having to go twice to empty the bladder. Many patients with ‘”acute urinary retention” swear to no prior such problems; and never have even thought of visiting a urologist.
With aging, there are progressive but subtle changes in the nerve and muscular function of the bladder (which is mostly a container made of smooth muscle tissue). Minor inapparent malfunctions are increased by stresses placed on these nerves and muscles. An obvious source of nerve impairment is the type of neuropathy often associated with diabetes--but also seen in more “pure” neurologic diseases e.g., multiple sclerosis and spinal cord injury. Chronic overwork of the bladder by having to pass urine beyond an obstruction (BPH or benign prostatic hypertrophy, in men, most commonly) can also “decompensate” the bladder to where its function is marginal, but nonetheless adequate from the patient’s perspective.
Any patient with impairment of nerve and/or muscle function of the bladder is at risk for going into urinary retention. What, then, is the “tipping point”? We do not always know for sure, but any/all of the following, as well as other factors, may play a role: (1) other serious illnesses or major operations--especially on the abdomen--that render a patient relatively immobile and possibly incapable of recruiting lower abdominal wall muscles to “help” the weakened bladder; (2) very high fluid intake, especially intravenous hydration seen in hospitalized individuals; (3) use of lasix or other diuretic medicines that force the kidneys to filter more blood and excrete a high volume of urine, overwhelming partially or completely the impaired bladder’s ability to eliminate; (4) urinary infections, especially bacterial prostatitis in men, causing more swelling and congestion of the gland sitting below the bladder and surrounding the 1st part of the urethra; (5) certain medicines that play havoc with the nerves going to the bladder and bladder outlet, including those that interfere with bladder contractility or those that prevent relaxation of the bladder outlet (bladder neck, and in men, prostate) during the act of urinating; (6) stress brought on by anxiety, prolonged travel, poor sleep, use of certain cold/respiratory medications that cause spasm of the bladder outlet, or exposure to cold weather or water. (7) significant urinary bleeding, resulting in blood clots that literally “clog the drain”.
Some men assume their prostate must have “grown larger” to bring on acute retention. This is rarely the case. Men can have retention without a large prostate; and benign prostatic enlargement may only be chronically creating an adverse climate for the bladder, which puts it “at the brink” of shutting off suddenly. By the way, men with acute retention rarely develop this from known or unknown prostate cancer.
In my experience @ least 50% of men with prostate enlargement and acute retention will “come out of this” on their own, given a few weeks. During this time, some type of tube drainage will be needed, either an indwelling bladder tube or so-called “intermittent” catheterization. Increasing doses of alpha-blocker drugs, such as Tamsulosin (Flomax) or Doxazosin (Cardura) can help acutely. “Prostate shrinking” medicines, e.g., finasteride/Proscar or Avodart will seldom resolve this situation in the short run--but may reduce the chance of this recurring, in the long run. For BPH patients with unresolving retention, a TURP (transurethral resection of prostate) or with very large glands, an open prostatectomy, will solve the problem in 95% of cases, but there is a rare man, often older/more frail with other serious medical problems, who either cannot undergo these procedures or in whom these will not help. So-called “lesser invasive” alternatives to TURP such as microwave (e.g., TUMT) and needle radio-ablative technologies (e.g., TUNA) are simply not as effective as the “gold standard”, TURP.
Women with acute retention often come out of it spontaneously, but may be at risk for increasing such unpleasant episodes in the future. Since urethral blockage is rarely an issue for women--and their bladder outlets do not respond as well to alpha-blocker medications, intermittent self-catheterization may need to be taught to and done by the woman either on an "as needed” or regular basis. Such relatively “newer" technologies such as a sacral neuromodulation with “Interstim” [Medtronics Corporation] require more research to see where they fit in, especially in non-obstructive retention; but I myself have NOT seen many patients benefit from this approach, as high tech as it seems.
Remember "what goes up must come down"; and not all that causes distress in our bodies has a downhill course. If you "cannot pee", give time a chance, before resorting to major interventions, especially surgery.
"I Performed a Radical Prostatectomy Yesterday"
I performed a radical prostatectomy yesterday. This was to treat and hopefully cure a man with seemingly localized prostate cancer. In past years, this would not be a reason for citation or boast. I used to do three or more of these a month. However, given the fact I still do this operation "open" as opposed to robotically, the number of these cases, for me, have become somewhat lower.
By the way, the surgery, done through a 4 inch incision, went terrifically, and took under 2 hours. The anatomical dissection was clean and relatively blood-free; and based on the conduct of the surgery, I anticipate a full recovery, maintenance of bladder control and erections, and cancer cure. The patient could almost go home today-- but he needs a bit more time in the hospital, so tomorrow is more likely. He is pleased.
Over a month ago, I had the chance to discuss the issue of open versus robotic radical prostatectomy with my former, soon-to-retire Chief of Urology (from my residency days). He was quite honest in begrudging the slick "jump quickly on the bandwagon" marketeering of the robot for this use; and the innumerable false claims of its superiority over traditional open technique. He cited some studies pointing to a higher positive margin rate for cancer in robotic cases (more so when the "neophyte" robotic surgeon has an insufficient number of cases under his belt); as well as the drain on time, money, and resources imposed by the newer technique. Some have estimated the actual cost of this surgery to be 2-3 times as high as open radical prostatectomy. The amount of equipment needed is astounding (a large operating room can barely accommodate all that is needed), and the expense of limited reuseable instruments significant. Who will actually be paying for this excess in the brave new world of universally accessible health care?
Some surgeons take greater than one hour just setting up the Da Vinci robot and "docking" it to the laporoscopic sites; the technically astute "open" urologist almost has the prostate out within that time.
There are certain poorly understood issues related to robotic prostatectomy including the long-term effects on the abdominal (peritoneal) cavity of transgressing it with laparoscopic instruments for what is essentially a deep pelvic operation, as well as prolonged over distending the cavity with carbon dioxide gas. Also, some question whether it could be injurious, for example, to the brain, to keep a man for the 3-4 hour duration of a robotic prostatectomy in a steep "Trendelenburg" position to gain better access though the pelvic organs (this means that the operating table is severely tilted so the head is close to the floor and feet high toward the ceiling). "Venous congestion" of the brain may not manifest itself in short-term morbidity, but what about long term effects, e.g. on cognitive function? Look at the degree of facial swelling of most men after the robotic prostatectomy. Roboticists would say there is no problem, but how does anyone really know?
The bottom line is: studies really do NOT demonstrate superiority of robotic prostatectomy over open technique either in cancer control or long-term potency and continence rates. Although I myself picked up an MBA during my educational journey, I am nothing for marketing when compared to those who seem to easily "sell" patients (including many I personally have diagnosed) on Da Vinci prostatectomy. Claims about less pain and quicker recovery (e.g., to return to work) with the robotic technique may statistically have some truth; however, the (usually quite modest) pain after surgery is common to both types of radical prostatectomy and far more related to intolerance of the necessary indwelling urinary catheter as opposed to the difference between one 4 inch incision and five one-half to three-quarter inch puncture incisions.
When I am asked how I want my prostate removed "if and when" the day comes, my answer is "by a competent surgeon who I know to have good judgment and refined technique in the operating room-- and if this turns out to be an 'open' surgeon, I would have absolutely no qualms".
As stated before in many of my writings: "buyer (medical consumer) beware": choose a good surgeon and he will get you through the process using the technique he does well and feels is best for your case.
“Playing Hardball in the Summertime”
Summer here in coastal Southern California is nothing like where I grew up on the east coast. In June and (even this) July in Newport Beach, we are lucky to have a few hours of sunlight in the late afternoon, barely warming the air into the 70’s.
When I become nostalgic about my summers gone by, I think of intense heat, sweating, the beach, transient relief by thunderstorms, and yes, trips to Fenway Park to watch hardball. With this in mind--and the MLB All-Star Game coming back to Anaheim this week, I thought I would share my thoughts on a “human” hardball, of sorts, that is, kidney stones. After all, summer and dehydration drive more patients to ER’s and urologists’ offices with these maladies, which probably affect 5-10% of Americans during their lifetime.
A prior MEditorial (May 2009) addressed the issue of kidney stones (urolithiasis) more from a clinical perspective, including typical symptoms and recommended treatments. I want to focus on the cause of urinary stones. Fact is, as is typical in many avenues of medicine, there is more we don’t than we do know in this regard.
The demographics: men have 2-3 x the incidence of stones compared to women. Caucasians lead other racial groups in this infamous distinction. Hot/humid climates produce more stones. The incidence of kidney stone disease has been slowly increasing, but theories as to “why” vary.
In my judgment, there has to be a predisposition to getting urinary stones. It cannot be diet or low fluid intake alone. Although there are specific known genetic and hereditary causes for urolithiasis, they comprise a small minority of patients. These include disorders such as renal tubular acidosis, hyperoxaluria and cystinuria. Urologists suspect there may be some more powerful (as yet unidentified) single or poly-genetic mutation that places one at risk for urolithiasis-- and that proneness may be transferred into an actuality by dietary and lifestyle choices. How the genetics yields causation is speculative-- it could have to do with hyperabsorption of certain nutrients in the diet, the loss of beneficial substances in excess via the kidney’s filtration system, lack of excretion of inhibitory chemicals into the urine, or some kind of damage to the macroscopic and microscopic parts of the kidney’s filtration or excretion systems. Unproven theories have included poor blood flow to the kidney’s papillae with deposition of small calcium deposits (forming tiny plaques @ and below the lining of the inside of the kidney) onto which stone crystals can gravitate like a magnate.
Two people can have the exact same diet; one never has urolithiasis, the other gets several stone attacks a year.
We can identify several chemical factors in patients who ARE prone to stones including excess amounts of calcium excreted into in the urine, hyperabsorption of oxalates (found in certain foods like beets, spinach, rhubarb, chocolate, cola beverages) from the small intestine and low urinary volume. Much higher concentrations of calcium mated to oxalate can occur in human urine than, for example, in water.
Not knowing exactly what causes kidney stones makes it such that advice on dietary prevention is often aimed only at those who already have suffered. Most stones are made of calcium oxalate (in a monohydrate or dihydrate form). Less common calcium phosphate/carbonate or so-called triple phosphate (“infection") stones; as well as non-calcified uric acid stones follow in prevalence.
In terms of diet, we discussed low oxalates in the diet. The pendulum for limiting calcium in the diet swung away from calcium restriction for quite some time--but now, it appears academic urologic studies suggest that patients with calcium stones SHOULD be restricting not only oxalate but also calcium intake. There is also ample evidence that a low salt diet (low sodium) helps prevent urolithiasis, possibly because sodium drags calcium into the urine with it.
I also tell my stone patients to have a passed or removed stone analyzed—this information is probably better than blood tests or 24-hour collections of urine at assessing risk for stones and for giving advice as to further treatment and/or prevention.
I suspect urinary “hardballs" will always be a fact of life in humans (as well as other animals); but improved treatments as well as better understanding of causation will likely reduce suffering, as time progresses.
So let’s “play ball”!
“Timidity in the Practice of Medicine”
Recently reading a book about the “calm decisiveness” and quick thinking of the admirable US Airways pilot Chesley Sullenberger (landing jet on the Hudson River) made me think of my own profession how “boldly” it handles difficult situations.
Like aviation (the Airbus 320 in the “Hudson” event is said to be semi-robotic and can actually “relieve” the pilot of his need to make certain technical decisions in an urgent situation), medicine and surgery have had great technology, to a certain extent over-glamorized as an “equalizer” among health providers that reduces the individual need (or perhaps desire) to be decisive. Unfortunately, many quite costly technologies have been developed without studies showing they work better than existing less engineering-buffed procedures or that there is anyone out there willing to pay the asking price. In a sense, doctors and nurses have ceded personal involvement in diagnosing and treating conditions to machines that can never take over the human function of assessing the interpersonal variance and complexity of disease. Likewise, insurance companies, hospitals and medical school training programs have introduced concepts such as clinical algorithms and “evidence-based medicine” to create rote care templates (sometimes mutable by the healthcare provider only at a personal cost to that individual!), which allege to be better and safer for the patient. In my opinion, these never come close to the full utility of a well trained and astute doctor/ nurse (especially in a more idealized environment, not currently existing in the US, lacking worry as to “post-facto second guessing”).
Now--if you wish to read on--here are a few examples of what I observe. Primary care doctors, pressed for time and dizzied by an aging overmedicated population with too many problems on their “list”, tend not to want to render a definitive diagnosis or treatment for anything complex--but to defer that to a specialist. Such timidity raises the cost of healthcare, inconveniences patients, in some cases reduces the patient’s respect for his physician, and often accomplishes nothing. Unless serious illness or death is imminent, a good history and physical, basic relevant lab tests and an educated guess (after considering the “horses” and not the zebras”) as to the diagnosis will either be correct or at least “do not harm”. If the problem seems puzzling but not dangerous, how about the "boldness" of just a follow-up visit?
Hospital admission history and physicals for urgent illnesses nicely outline the problem list and symptoms, but it is rare to see a discharge summary which in retrospect captures the exact real reason why the individual became ill; and what could be done to prevent readmission for the same. There always seems to be a list of multiple irresolvable possibilities.
Timidity is also seen where I myself graze, in the land of surgical and medical specialties. Unfortunately, some specialists tend to offer the patient testing only within the realm of what they know best. They figure once they have done everything to rule out disease in their part of the body, let someone else determine what, if any, real disease exists. An example would be a patient with midline upper abdominal pain, who is sent to the urologist when the CT scan suggests a previously unknown low grade right or left kidney blockage (likely congenital and of no clinical import/clearly not causing the person’s pain). That individual then has ordered further CT with contrast, nuclear renogram and possibly endoscopic surgery including a ureteroscopic inspection of the upper ureter, all of which turn out normal and not worthy of further treatment. In the meantime, this patient had acid reflux disease, easily diagnosable perhaps by a primary care physician and most certainly by a gastroenterologist, even without the benefit of extensive testing. Another example would be the gastroenterologist feeling the compulsion to endoscope the upper and lower GI tracts (and perhaps biopsy innocent-appearing tissue abnormalities) for anyone sent him/her with obviously “benign” GI symptoms. “That is what gastroenterologists do”; [they are paid to suspect serious versus minimal disease]. Then, there is the surgeon who is referred a man with a groin hernia present--without symptoms--for months to years. The doctor, thereupon, in a sense, timidly, convinces the patient a hernia repair is best done soon.
Nurses, perhaps by training, personality traits, or deference to the "expertise" of physicians, tend to be timid about saying clearly what they think about a clinical situation. Even those quite experienced may not be able/willing to “go out on a limb" and "boldly” state whether what they are observing in a hospitalized patient seems serious or routine; the decision is placed on the shoulders of the doctor who knows the patient (often at home after hours) or a hospital-based physician, who--albeit he/she is clinically quite competent, does not have familiarity with the patient or treatment of the condition up until that point. In this case, a proper review of the chart and selected exam and some questioning by the nurse of the patient/family, and conferring with the charge nurse, could lead to a more reassuring phone call, the essence of which might be..” your patient has some blood in the urine [postoperatively], but in my experience, this is not unusual after the procedure you performed--and I think it is reasonable you assess this when you make rounds in the morning”.
Out of timidity, many of us in medicine have turned everything into an emergency; emergency room doctors have a low (lower than ever) threshold for advising admission to the hospital, whereas further observation as an outpatient may suffice. Patients cannot seem to leave the emergency room without a prescription, e.g., for antibiotics, even when deep inside the treating physician doubts an infection; and waiting a few days for the laboratory result to come back would not be detrimental. ER discharge notes implying the patient must be seen by a specialist within a day or two are often mere hyperbole, meant to protect the interests of the referring M.D./hospital and not necessarily to lead to better care.
With strength of conviction, and a hands-off approach from lawyers, government, insurance companies, hospitals and the like, I am hopeful we, as healthcare providers, can regain our decisiveness--and in doing so, restore the trust patient should have in our extensive expertise and judgment.
“Prostate Cancer and Aging”
Prostate cancer to men has become since the 1990’s what breast cancer has been to women for decades before: a topic of immense publicity, concern and fear; riddled with controversies about the correct approach and even the myriad of treatments. Research and clinical studies have progressed--but not enough that the treatment options do not still appear, to many men diagnosed with prostate cancer, to be an unbiased “menu” of sorts from which to choose one’s favorite “flavor”.
We are finding prostate cancers in younger men, not infrequently in their 40’s by more aggressively screening with PSA blood tests. Not all treatments are similar or carry with them the same likelihood of cure and freedom from side effects. Not all men are the same. However, In the case of prostate cancer, which is generally a disease of men over 60, there are other important factors bearing on the physician’s and patient’s decision.
Prostate cancer is a very common finding on autopsy studies of men dying over age 70 from other causes. One study done 40 years ago suggested over 2/3 men dying at an older age of unrelated causes had some microscopic cancer within the prostate. Such men may have had to live to over 90 to feel any effects of such cancers.
It is observed that many men over 75 with prostate cancer do not die of the disease, even if left untreated. Part of this has to do with the indolent (“lazy”) growth pattern of prostate cancer, perhaps more so in this age group; as well as “the facts of life”—i.e., other causes of death competing for mortality in older men. If one looks at actuarial data (from life insurance companies), one can easily determine the likelihood of living 5, 10 and 15 years given a certain “starting age”. Because of the nature of most prostate cancers, it may not be necessary to treat prostate cancer in a man whose life expectancy is under 10 (some even say 15) years or whose health precludes the more aggressive interventions of surgery and/or radiotherapy. Once the doctor has decided that prostate cancer is unlikely to be a factor limiting longevity, further conclusions may come forth, including decisions not to do a prostate biopsy (even if cancer is suspected) and even not to check PSA blood tests as prostate cancer screening.
Another thing to consider, especially where treatment is not likely to be needed due to age/infirmity, is the cost in terms of quality-of-life, from aggressive treatments themselves. Studies from UCLA/Rand Corporation have nicely addressed some of these issues. “Bothersome” complications from surgery and/or radiation therapy, like incontinence and radiation cystitis (recurrent bladder hemorrhage) might be more acceptable to the “younger” man who is cured and has 5-10 years added onto his life expectancy, as opposed to someone whose number of years remaining would not be altered, even if cure is obtained.
Biopsies may be required, however, even in older men in whom there is suspicion of an aggressive prostate cancer. Characteristics pointing to this include high PSA’s (usually>20), rapid increase in PSA (where the PSA number doubles more quickly than every 6-8 months), very hard/irregular prostates which are associated with a higher chance of metastases (spread beyond prostate), or known metastatic disease (e.g., a man who presents with severe bone pain and a nuclear bone scan showing tumor in several areas of bone). Such older gentlemen, once diagnosed, would not, in most cases, be suitable for removal of the prostate or local radiotherapy--but might be treated with hormonal modalities such as Lupron, which acts via the pituitary gland on testis function, and indirectly halts or slows down the progression of the cancer. In rare cases where a serious prostate cancer is likely but the infectious, hemorrhagic and/or medical-cardiovascular risks of undertaking a biopsy are high, one can consider hormonal treatment without biopsy proof of cancer.
It is normal for older patients to fight for meaningful longevity and try to prevent diseases which could bring about their demise. However, one should not become overly focused on one disease to be avoided over all others; or falsely assume that a disease process such as prostate cancer, if not discovered/ cured, is tantamount to a terminal sentence.
“In Memoriam: Mel Novegrod, M.D.”
This month’s MEditorial is almost 2 weeks’ late. First there was a brief vacation-- then as usual, return to my medical office busier than ever and begging the question as to whether the vacation was really worthwhile!
Then came the news that broke a lot of hearts. My esteemed friend and urologic colleague, Dr. Mel Novegrod, was on life support after a sudden catastrophic cardiac event, causing an irreversible brain injury. His family took him off the ventilator and Mel passed away on April 6, 2010.
Mel was 68--but he seemed and acted 20 years younger. Despite a history of some heart problems since his 40’s, Mel seemed @ 68 very spry and as energetic as ever. He and I worked together much of the past 20 years, covering patients for each other, assisting in the operating room, and occasionally consulting over difficult cases. Mel was one of the truly nicest people I have ever met. He had a funny sense of humor and went out of his way to help those around him. He made people feel comfortable and was a pacifying influence in the operating room. He was a "can do” individual. No task was too menial; and no time for his involvement in a patient matter was inappropriate. He worked hard, some say too much so for a man of retirement age. He loved what he did and was "atop his game” to the very end.
I can recall Mel carrying a typical list of the 15-20 or so patients he was seeing at Fountain Valley Regional Hospital at a time I could commit the few I myself needed to see to memory. He generously offered to help on surgical cases where he knew, ahead of time, the reimbursement would be minimal, and his time would certainly be remunerated better if he remained in his office.
Mel was beloved by his colleagues, nurses, and patients—and so much so by his wife and two adult children. He loved Marci dearly and was a true “old-fashioned’ romantic. He had a sheepish smirk/smile whenever you greeted him. He would always start by saying, in his Brooklyn accent “Al…how’s the family?” He would tell jokes and stories dating back to his halcyon days as a resident in urology @ Yale/New Haven Hospital. He could barely restrain himself, repeatedly telling the quirky story of his Yale co-resident (now a famous academic urologist), unhappy with the operating room supplies for surgery he was about to perform at a Connecticut community hospital affiliated with Yale, not accepting the apologetic plea “Doctor, we will get it right next time”; in which case, that physician then wryly retorted “Don’t worry—there won’t be a next time; I’m not coming back!” Mel delighted in others’ accomplishments--even those perhaps a bit sordid. He was proud that one of his other Yale associates, later practicing in Virginia, was the surgeon who successfully re-attached the urological organ of John Bobbitt, maimed by his infamous wife Lorraina.
Mel was a superb clinician with common sense and a fund of medical knowledge which served his patient base well. He always took notes on events in the life of his patients so as to refer back to these--and genuinely take an interest in them as humans first, patients second. Dr. Novegrod was humble, knew his limitations, was not afraid to refer out a case to someone else--and was never arrogant. Mel was the type of physician we all (I, too) strive to be; but most will not quite get there.
I and our medical community are deeply pained by the loss of this unforgettable man.
Last month, my article addressed the issue of blood in the urine (“hematuria”). A concerning cause of hematuria is bladder cancer, a variably malignant tumor starting in the lining of the urinary bladder. Probably due to randomness, I have seen more than my share of this disease, just since the start of this year. Cause of bladder cancer is not always known, but cigarette smoking is an unequivocal risk factor; and industrial exposure to certain organic chemicals, including aniline dyes and benzene-derivatives, may play a role.
Bladder cancer is usually detected by cystoscopy (looking inside bladder, usually in the office under local anesthetic, sometimes with sedation); but occasionally, other tests, e.g., CT scanning, ultrasound and advanced urine tests (cytology, BTA, “F.I.S.H.”, etc.) can suggest this disease. TURBT (transurethral resection of bladder tumor) is the hallmark of diagnosis and treatment. This is an operation under anesthesia to “ream out” the growth from within the bladder. Very large tumors may require several sessions--or simply may not be safe to totally remove in this fashion.
Most urologists can tell, by looking at the growth and its characteristics, whether this is a more "serious” form of bladder cancer. Most cases fortunately involve superficial cancer, i.e., not invading into the deeper bladder layers including the lamina propria (just below the lining) or the muscularis (thick muscular layer, located even deeper, in which there are numerous blood vessels and lymphatics allowing tumor cells to spread outside bladder and potentially to lymph nodes and other organs). Characteristics of the more innocuous superficial bladder cancers include small size, papillary appearance (like a polyp or “head of broccoli”), lack of focal thickening of bladder wall or involvement of the area where the ureters (tubes entering bladder from above, conducting urine from kidneys). The latter involvement can actually block the ureters, which would be a concerning finding and would favor the diagnosis of a more aggressive/invasive cancer. Multicentricity, or many growths as opposed to one or two, also raises certain red flags. So would a focal or diffuse velvety-red appearance of the bladder lining (possible “flat” cancer).
Once the tumor is resected, it is sent for pathology, from which we derive a definite diagnosis including the type of tumor (most bladder cancers are "transitional cell carcinomas”, named after the cell of origin) as well as its grade (on a pathologic scale of 1-3 or sometimes 1-4, based on malignant appearance of cells microscopically) and depth of penetration, provided we, as urologists, have done biopsies deep enough into the bladder wall. Only exception to having a pathology report would be if I choose to cauterize or laser an obviously superficial/small/minimally malignant tumor (especially a “repeat offender”) , which I know--by sight--has no change of causing significant problems. In some frail/elderly patients and those on anticoagulants, use of a Holmium or other laser device may be preferable, even though doing such will reduce the accuracy or availability of specific pathologic diagnosis.
Most TURBT’s (except perhaps those done with a laser) require a few days of catheterization to allow more optimal healing of the surgical ulcer site. Failure to leave in a catheter will increase the chance of postop bleeding and inability to urinate-- especially in make patients.
Once we have back the pathology, we can direct further treatment. Most patients have a fairly low grade superfiical pattern which simply can be "watched” with surveillance follow-up office cystoscopies. These tests may occur, e.g., every three months for the 1st two years and barring reoccurrence, every 6 months for out to 5 years--and then yearly. The very minimal low-grade bladder cancers may not need life-long follow-up. More aggressive tumors or repeated episodes of bladder cancer need to be taken more seriously. Removal of the bladder (see below) is always an option to cure such disease and prevent metastases (potentially fatal spread of bladder cancer to other organs). However, intermediate types of bladder cancer including those with more malignant cells or depth of penetration into lamina propria –or another "flat" type of bladder cancer called CIS (carcinoma-in situ) may be managed with BCG. BCG is an altered form of mycobacterium (of which tuberculosis is an example) which when placed into the bladder in a liquid form causes a specific type of immunologic response felt to help the body fight off bladder cancer. BCG treatments are one of our best weapons, short of total bladder removal, against recurrence or even progression of bladder cancer. Studies indicate anywhere from a 50-75% reduction in bladder cancer when BCG is utilized. Side effects, if any, are usually minor and include some pain with urination and bleeding for 1-2 days. More severe side effects from overstimulation of the immune system and rarely absorption of some of the BCG (altered/weakened) bacteria into the bloodstream may make the patient sicker and rarely require hospitalization and anti-tuberculosis antibiotic therapy.
Another "adjuvant" treatment we use to reduce recurrences is a chemotherapeutic agent called Mitomycin-C. This can be used by instillation into the bladder in the office as a series of treatments; but now commonly is placed into the bladder right at the end of the TURBT operation as a solitary treatment, especially in patients with intermediate-risk tumors. It is usually well tolerated and lacks the side effects of the same drug if used intravenously to treat other types of advanced (non-bladder) cancers.
When we talk about worse forms of bladder cancer, we are referring to those where the pathologic features show very malignant cells or deep penetration into the bladder wall. Studies suggest these tumors are genetically altered with lack of cell division regulation--and production of substances that allow invasion through normal barriers and into lymphatic channels and blood vessels. These types of bladder cancer, as well as more intermediate types (such as those involving lamina propria or carcinoma-in-situ) which keep recurring despite TURBT and use of BCG and other adjuvant modalities of treatment are dangerous and are associated with a higher risk of metastases and death from bladder cancer. It is in these cases we must strongly consider removal of the bladder (radical cystectomy). This is done in conjunction with urinary diversion either with an ileal conduit (intestinal urinary tube ending up as a skin stoma) or continent diversion (internal “new" bladder formulated by use of excess intestines). The latter diversion allows one to still urinate, although control may be less than perfect especially at night and urinating may not be quite the same as with a normal bladder.
In some cases of localized but severe bladder cancer where a cystectomy is not wanted by the patient or there is a very high surgical risk, a Medical Oncologist can coordinate “bladder- sparing" therapy usually incorporating chemotherapy and localized bladder radiation—the results of this are controversial and probably, in my mind, not as successful as removal of the bladder.
Failure to intervene with cystectomy at the proper time or delays in diagnosis of a very malignant bladder cancer can have catastrophic consequences. Although some patients with very advanced bladder cancer can be treated with chemotherapy, many will, unfortunately, succumb to the disease.
It appears that the number of annual cases of bladder cancer in the US is increasing, up 50% over a 20 year period since the late 1980’s. Over 75,000 new cases, mostly of the superficial variety, are diagnosed annually, with a 3:1 male predominance.
As you can tell, bladder cancer is actually many diseases. We as urologists have to be very precise in our diagnosis and in advising the best course of action to patients afflicted with this problem.
“Red is the Color”