Urology Newsletters
MEditorial August 2010
"I Performed a Radical Prostatectomy Yesterday"
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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.
MEditorial July 2010
“Playing Hardball in the Summertime”
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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.
I think the following advice is sound to those who have experienced urolithiasis. First, let’s assess by CT or other x-rays if you still have stones in the kidneys and whether they are worthy of treatment, e.g., if left alone, what is the worst that could happen? I worry more about the patient who has passed a stone or had one removed—and still has 4-5 more stones in each kidney. A high fluid intake helps. Water is great. [There is not a lot of evidence that stone formation is higher in municipalities have a “hard’ water supply.] Since citric acid is one of the best nonspecific inhibitors of the formation of stone crystal s in the urine, a generous intake of fluids with a high citrate/oxalate ratio is quite important. Lemonade seems to fit the bill, although orange juice isn’t bad. Stone formers should drink three full glasses of, e.g., lemonade, daily. How much overall fluid you should drink depends on a lot of factors such as body size, metabolism, activity, and sweat. A good guideline is to drink enough fluid so that your urine ALWAYS appears more a clear than yellow color.
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”!
MEditorial June 2010
“Timidity in the Practice of Medicine”
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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.
MEditorial, May, 2010
“Prostate Cancer and Aging”
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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.
MEditorial April 2010
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“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.
MEditorial March 2010
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"Bladder Cancer"
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.
MEditorial February 2010
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“Red is the Color”
Recall the Beatle’s song “Red is the Color” [“…that will make me blue, in spite of you, it’s true… yes it is.”]. Red is undoubtedly the color of February, with Valentines’ Day, red roses, and American Heart Association Month.
Yellow is the color of urine; and red is abnormal. Even microscopic red (as well as white) blood cells entering the urine from their normal location in blood and bone marrow is abnormal. However, red blood cells in the urine or the condition described as “gross hematuria” (obvious urinary bleeding) does not always equal serious urologic or kidney disease.
It is easier to discover the reason for gross than microscopic blood in the urine. Some studies estimate that fewer than 1/3 of patients with microscopic blood will have a definite attributable cause. Also, most of that 1/3 will be found to have a cause that is not considered to be a major or life-threatening illness.
How do we define “microscopic blood” in the urine? Many feel that greater than 2 red blood cells per high power field (high power magnification under a microscope) warrants further evaluation. Some await the appearance of more microscopic blood. Others simply do a “dipstick” on the urine, e.g., in an office lab-- and feel any “blood pigment” showing up as a reaction on the dipstick is concerning.
In my practice, I seldom see significant urologic or kidney disease in patients with very low amounts of microscopic hematuria. I get more concerned when there are @ least 10 (and sometimes more than 20) RBC’s (red blood cells) per HPF (high power field); or if there is a clear progression in the number of RBC’s on serial urinalyses. I might have a lower threshold for evaluation in patients who are at higher risk for serious pathology; this includes smokers, patients over 40, men greater than women, patients with worrisome family histories, patients with other or past urologic cancers, patients who are symptomatic with pain or significant urinary difficulties, and those with frequent infections, stones, etc. In lower risk patients with scant amounts of microscopic blood, it is not unreasonable simply to get follow-up urinalyses, e.g., three tests over a 3-6 month period, to get a broader perspective as to the level of concern.
A note about specimen collection. Rarely ingestion of certain dyes incl. those occurring in beets and certain laxatives can cause red urine without bleeding. Certain conditions such as vigorous exercise and/or viral illnesses can lead to microscopic hematuria; and these should prompt repeating the specimen days to weeks later. Mid-stream collections should be done in men and women to lessen the chance that mild inflammations, e.g., of the inner foreskin of men or the vagina/labia of women do not lead to a false suspicion that there is actually urinary bleeding. Especially in women and more so when there are white as opposed to red cells in the urine (or a history of treatment of such women for "recurrent infections" based on these results, despite the lack of symptoms), I feel it is important to get one or more catheterized urine specimens. In my practice, >50% of such situations with microscopic (especially white) blood cells in womens’ urine turn out to be nothing, i.e., the catheterized sample shows few if any blood cells.
We should divide urinary bleeding (microscopic or gross) into renal (kidney) causes and urologic causes. The former are really medical conditions not apparent on radiographic studies or endoscopy (looking inside with a lighted instrument) of the urinary tract (usually cystoscopy, i.e., visualizing directly inside the bladder). These conditions often involve the glomeruli, or microscopic filtration apparatus, within the kidney proper. Acute or chronic kidney disease often causes dysmorphic or “warped’ red blood cells microscopically, protein in the urine, clumping of blood cells or "casts” and concurrent findings of hypertension and certain blood abnormalities, e.g., higher blood lipids; or certain urinalysis findings, e.g., inability to either properly dilute or concentrate the urine depending on the hydrational status of the patient. Kidney disease may or may not alter blood filtration (thereby elevating the blood test "creatinine") in the short or long run. IgA nephropathy, a not-uncommon renal disease caused by an exaggerated immune response often occurring in relationship to a respiratory infection, rarely progresses to "renal failure”.
Once we decide a patient needs evaluation of gross or microscopic hematuria, what tests are appropriate? If medical renal disease is likely, tests are usually done under the domain of the person’s primary care doctor or a nephrologist (non-surgical expert on kidney disease). If a urologic cause is sought, the evaluation depends on the level of suspicion for serious disease. For example, screening the upper urinary tracts can be done with ultrasound--but this may miss certain types of kidney tumors and stones—so if these are possible, a CT scan 1st without then sometimes with intravenous dye (CT urogram) may be a better bet. Urine cytology, simply a special urine test sent to a pathologist, can help screen for the more malignant tumors of the bladder and inner urinary lining. Other similar tests on the urine, looking for certain tumor protein markers (e.g., “F.I.S.H.” test), can also be helpful but are expensive and questionably more reliable than cytology. Cystoscopy, usually with a flexible instrument in the office, will detect almost all bladder cancers and can be done under local anesthetic with or without sedation, depending on the circumstance and pain threshold/anxiety level of the individual. Occasionally, blood in the urine requires tests done in the operating room under anesthesia, incl. urinary tract (usually bladder) biopsies, injections of contrast up the ureters (the urinary tubes leading to bladder from kidneys) and ureteropyeloscopy (introducing a very thin rigid or flexible telescopic instrument from bladder toward kidneys).
As stated, although many patients with red urine will NOT be found to have serious disease: some of the “significant” urologic’ illnesses discovered are the following: infections (yes, certain bacteria can make the urinary lining hemorrhage); urinary stones; prostate enlargement; cancers of the bladder and urinary lining of the upper GU tracts; kidney tumors; radiation damage to the bladder; and excessive anticoagulation. The latter is becoming more common, with many (especially elderly) patients on aspirin, Plavix, Coumadin, etc. One cannot assume that gross bleeding occurring on these drugs only represents too much blood thinning—many such patients do have significant urologic pathology “unmasked” or revealed sooner than it otherwise would be, due to the anti-coagulation.
If you have microscopic or gross blood in the urine, do not panic or assume the worse. Stay calm, consult your regular doctor and perhaps a urologist; and go about an evaluation in a logical and systematic fashion. The word “sanguine” which means optimistic, has a linguistic derivation from the root word for bleeding, so remain optimistic.
MEditorial January 2010
Download January MEditorial 2010 - Why Shop Here?
Why Shop Here?
It is the start of a new year. Besides resolutions unlikely to be remembered one month later, some of us have decisions to make about our personal health care and who will provide that to us.
When “shopping” for a doctor (now that you Christmas shopping is complete) , the first question to ask is “why switch”? I have always been an advocate of consistency, of going with a winner, someone who knows you well and has earned your trust. Chose a doctor based on reputation, including his education, experience, longevity in the community, likely desire to continue practicing for a reasonable future period. To others making that recommendation to you, ask “on what basis do you suggest that doctor?” Personality issues and bedside manner, and especially compatibility are all relevant. Logical reasoning, candor, consistency, and excellent technical skills (in the case of a surgical specialist) would also be near the top. You need to see the truthfulness in the doctor’s eyes and expressions; as well as his confidence tainted with a slight degree of cynicism. The latter means the doctor you are choosing is willing to admit not all problems can be solved (@ least perhaps not by him), and that the mysteries of health and disease will survive all of us. Good outcomes cannot be guaranteed, but the range of likely outcomes from diagnostic and therapeutic interventions can and should be discussed.
This leads specifically to several reasons I think you should “shop” here for your urologic care. In stating so, I readily admit we live in a geographic area of great specialists including in my discipline--and in no way does this self-promotion cast dispersions on any of my colleagues/competitors. You “control the wallet” and must decide from whom you are going to “buy”.
#1. I have a wonderful staff. I am proud of my coworkers and how well they run this practice in harmony with my philosophy of patient care. It is almost daily when a patient will tell me “Dr. Freedman, you have the best staff”. I also have longevity and loyalty from them—this suggests their comfort level working here and with the manner in which I do “medical” business. My coworkers are intelligent, logical, articulate, responsive, respectful, and compassionate to you, the patient. By the way, to “roll the credits”, their names are: Karin (office manager), Shannon (front office manager), Chelsey (nurse/back office manager) and Marlene (assistant to Shannon and Karin).
#2. I esteem the health of you, my patients, over ‘the bottom line”. Although we as doctors should run our practices as businesses and we share great concern regarding financial de-valuation of our services by the government and third party payers (insurance companies)—and you should be concerned about this, too-- my decision-making is and always will be based on what is best for you and not what is best for my earnings in a particular week or month. Surgery is advised when I have reason to believe it is the best choice, but I will not force it upon you--and I will be the first to clearly state its limitations. [Note: surgical reimbursements are not what you’d expect; so there may be less monetary motivation than ever before for me to choose a surgical over a less aggressive approach.] You may leave this office without a prescription and without a date for testing or surgery; but that is fine if I am not sure these are necessary or I feel reassurance or giving you time to contemplate all your options is the most appropriate tactic. You will be honestly told whether “newer” technologies are really better than existing ones or perhaps fads; and why I might feel more comfortable with one surgical technique than another, personalized to your situation. I am perfectly comfortable de-bunking myths and half-truths within my specialty and medicine in general.
#3. I listen closely, when you talk. Notice how I take notes. Your medical record here is all electronic and readily transferable when needed. My “electronic” notes are detailed when appropriate and not boilerplate; this reflects the thought I put into each and every encounter. When you, I or another healthcare provider reviews my progress notes, not only will the decision/diagnosis be understood, but the very reasons I came to this and not another conclusion will be apparent. My doubts will also be expressed.
#4. Review my educational experiences and training on this website. Whether or not you will be impressed, remember that all along the way in my career path, I have been tested and risen to the very top; and selected as one physician with great promise and aptitude. In other words, those before you, including great institutions, have done some of the pre-selection. This is far more meaningful than, let’s say, a lay magazine’s list of “The Best Doctors” in an area (how do you suppose those names get published?)
#5. If you do need surgery, I pride myself on being meticulous, and at one both careful and perseverant enough to get the job done. I operate quickly and efficiently. Significant blood loss and trauma to the tissues is avoided. Minimally invasive techniques and small incisions are done whenever possible. Surgical outcomes (by such measures as cancer cure, improvement of urological functions, and lack of complications) are comparable to “the best” including academic institutions. My “radar” is set to “‘sensitive” both in the operating room and as regards postoperative management. My reflexes in detecting anything slightly awry inside your body help me react to see and correct course. For example, it is not unusual for me to convince a patient, after hearing his/her telephone report of “feeling too poorly” to keep his or her appointment, to come in nonetheless-- only to discover a major health threat, such as a pulmonary embolus or sepsis (extensive bacterial infection). Such conditions could have been fatal if not readily detected.
#6. This practice, although always busy, is still small and personalized, with one solo doctor who knows his patients well. I am proud of the loyalty of my patients to me, and they are rewarded in kind. For the rare patient who chooses to leave and seek specialty care elsewhere, there is another who “shopped elsewhere”--only to later come back.
Thank you and have a great 2010!
MEditorial December 2009
Download December MEditorial 2009 - Testis Cancer
Testis Cancer
As a Urologist, I see about 3-5 new cases of testis cancer yearly. This past year has been interesting, in that I have diagnosed more cases than usual (there is data that the incidence of testis cancer is rising); and the average age of men so diagnosed by myself has been in the mid-50’s. It is more typical to see testis cancer in younger men, often late teens to late 30’s.
Many men come in worried that a lump or swelling in the scrotum represents cancer. Fortunately, most of these abnormalities are benign. Tiny nodules, often smaller than a raisin, are oftentimes cysts--and on careful exam, are actually in the appendages/structures next to the testis but not in the testis per se. Benign conditions raising concern for testis cancer include hydroceles (accumulation of fluid around testis within its surrounding membranes); spermatoceles (cysts of the epididymis, the 1st part of the sperm transport duct between testis and vas deferens); varicoceles (engorged, snake-like veins often predominating on the left side); epididymitis, a swelling of the sperm ducts sometimes due to bacterial infection transmitted from the prostate/urinary tract; and nonspecific cysts which may originate in the coatings of the testis.
This brings up a good point. Unlike kidney cancer, which is most often diagnosed “by accident” on an abdominal ultrasound or CT done for unrelated reasons; or bladder cancer, usually diagnosed cystoscopically after the finding of blood in the urine, testis cancer is most often found on self-examination by the man himself. Testis self-exam is a prudent idea, and assumes one is familiar with his testes to begin with, so as to enable detection of a significant difference. I advise once monthly self-exam, preferably with wet/soapy hands in the shower. This setting usually makes an exam more comfortable, especially since the testes hang down more in the warmth of the shower. Since testis cancers grow rapidly, it is not uncommon to notice a hard lump @ least the size of a grape or marble as the 1st sign of disease.
Testis cancer is really not too common. There are about 8000 new cases diagnosed per year in the US with close to 400 (5%) cancer-related deaths. In comparison, there are 190,000 new cases of prostate cancer per year with 27,000 deaths; (14%) and 200,000 new cases of breast cancer per year with about 40,000 deaths (20%).
Testis cancers (most commonly “germ cell tumors” due to their origin from primitive cells that ultimately produce sperms) rarely causes pain, but we sometimes see pain from hemorrhage within certain types of rapidly dividing tumors. Ultrasound of normal-feeling testes, just as screening for testis cancer or trying to relate some type of chronic scrotal pain to a “silent” cancer seldom worthwhile. Ordering an ultrasound for a lump suspicious for testis cancer is not unreasonable but in many cases, not needed.
If testis cancer is suspected, the first step is usually exploration of the testis not through the scrotum but via the groin (corner of lowermost abdomen). When significant doubt is present, an intraoperative ("frozen section") biopsy can be done with the intent of leaving in the testis if the biopsy shows no cancer. Testes so biopsied/left in do hurt more and take their time healing—and rarely end up being removed @ a later time. . More commonly, the testis, along with a significant segment of its spermatic cord, is removed without doing an intraoperative biopsy. About 90- 95% of these hard nodules within the testis will turn out to be cancerous.
Certain types of testis germ cell cancers, usually “non-seminomas” can produce biochemical “markers” in the bloodstream that are traceable and give a good indication of disease control versus progression. Alpha fetoprotein (AFP) and beta-human chorionic gonadotropin (B-HCG) are a few of the common ones. Seminoma, a very common germ cell tumor, rarely if ever produces these substances.
Many men are cured of testis cancer by the testis removal (radical orchiectomy) alone. Besides markers/blood tests, it is common to “stage” the disease, usually following testis removal, with CT scans from the chest to the pelvis. The cancer can then be “stratified”, with higher stages representing higher risk categories for actual or potential disease. More aggressive treatments are aimed at more advanced disease.
For early stage seminomas, there has been a bit of a trend away from radiation to the retroperitoneal lymph nodes (located in back of the intestines), due to potential side effects, concern about secondary malignancies (1.5 to 2X risk compared to these not radiated), and the relatively low (15%) chance of recurrence if the initial metastatic evaluation including CT is negative. Men who do recur can usually be salvaged with radiation and/or chemotherapy. There are also studies indicating that fairly low dose, single agent chemotherapy, e.g., Carboplatinum, may be as good as (or even better than) the routine recommendation to radiate lymph nodes in those choosing treatment of seminoma, beyond orchiectomy.
Non-seminoma germ cell tumors, also known as NSGCT (e.g., embryonal, choriocarcinoma, etc.) may act more aggressively than seminoma. Observation for early disease can be appropriate in those wishing to be spared the side effects of further surgical or chemotherapy. With observation for early stage disease, there is a 25-30% recurrence rate. Additional treatments for suspected or actual spread of NSCCT to lymph nodes or other organs includes removal of lymph nodes (radical retroperitoneal lymphadenectomy) and chemotherapy. For early disease, it seems only two courses of chemotherapy, usually well tolerated and less prone to causing delayed side effects, will increase the long-term cure rate considerably. Lymphadenectomy seems to be slightly falling out of favor, since it is a big operation, to be done by a urologist very experienced in the procedure; and it has risks of intestinal problems, vascular and nerve injuries, ejaculatory dysfunction, and lymphatic leakage. Also, patients found to have malignant nodes by this operation not uncommonly end up needing chemotherapy, anyways. Chemotherapy, especially beyond two courses, can have temporary or permanent potentially serious side effects involving many systems of the body--and just like radiation, carries with it an increased risk of secondary malignancies often occuring within 10 years of initial treatment. However, such chemotherapy is highly effective against these tumors.
Issues of fertility are also of concern to the often youthful testis cancer patient, not only due to internal scatter (to the externally shielded opposite testis) during retroperitoneal radiation and from chemotherapy , but also due to the known a priori association between testis cancer and poor sperm counts. Sperm banking during the course of testis cancer treatment may be advised to the man still wanting to have a family.
The choice of how to deal with testis cancer beyond the simplest uncontroversial treatment (removal of the involved testis) is complex and requires considerable discussion between the patient/family, his urologist, and often one or more oncologists.
The good news is, that even men with advanced disease (e.g., as exemplified by Lance Armstrong) can be cured--and the current overall cure rates are well above 90%.
Have a happy and healthy Holiday Season!
MEditorial November 2009
Health Care Reformatory
Download November 2009 MEditorial "Health Care Reformatory"
Websters’ on-line dictionary defines “reformatory” as: “a penal institution to which especially young or first offenders are committed for training and reformation.” I think it may be appropriate to proverbially send many of those legislating current health care reform to such an institution, since (1) by their inexperience in dealing with the everyday delivery of medical care, they act as though they are young and in some cases, “1st time” offenders; (“they know not of what they speak”) and (2) the “training” and reformation is best done by practitioners of medicine (and that means especially we doctors) and not even by those pseudo-academics in medical schools/organized medicine and economic hierarchical positions, who are the pretenders to such knowledge.
As a doctor who sees and operates on patients, let me take license in giving these politicians a “reprieve” from reformatory school in listing a few “commandments” which would go a long way toward straightening out the inequities and cost overruns of the current (and indeed, proposed) health delivery system.
#1. Medical malpractice reform. It has to be done. Even more important than the cost of high insurance premiums to doctors is the incredible “defensive medicine” waste by seeing the patient as a potential “legal” adversary and couching the medical encounter in uncertainty. Many illnesses are vague and are more symptoms than actual disease--and we as physicians should be able to tell patients if we feel there is no significant illness and avoid ordering tests which usually just confirm the obvious. Patients should be able to purchase short-term “accident” insurance policies before, e.g., an operation, which--if there are serious complications (whether due to poor medical performance, the patient’s underlying condition, or tertiary reasons)--would compensate the patient for calculable damages, lost income, “plus” perhaps a certain percentage of patient’s yearly income as a one-time “equalization” payment. Pre-treatment arbitration agreements and doctor-lay health boards should be established to review “malpractice” cases for their merit and create a hurdle over which lawsuits have to pass. We need to have a “loser pays” litigation system to discourage malpractice suits except where there is a clear vision and general agreement of wrongdoing.
#2 More patient responsibility. This entails lowering patient expectations, not guaranteeing great outcomes from medical treatments, and disentitling patients from wanting or needing expensive tests an experienced doctor feels are unnecessary. Those who demand an MRI for a headache deemed by the doctor to be “innocent” should have high co-pay for this; then, let’s say, in retrospect, the MR does show an unanticipated serious problem, the entire cost of the test would be reimbursed by health insurance. Unquestionably, patients should “face” more the economics of the medical system and the cost of their own care, perhaps with higher deductibles and co-pays, especially for minor illnesses. Again if a “chest cold” turns out to be lung cancer, the patient can be reimbursed retroactively without any party “holding blame”. HSA’s (health savings accounts) should be stressed as a private market solution to cost overruns and lack of personal control over health costs. Patients need to know in some detail their medical history and carry cards (or potentially “thumb” drives or other electronic medical data formats) with them to help us doctors care for them and avoid redundant tests, etc. Some of the privacy laws need to be loosened just enough to allow more unencumbered transfer of data from one facility to another.
#3. Governments’ role: I’d like to see the government only peripherally involved in the management/delivery of healthcare. I agree with some degree of legislation to control excess profits in the insurance industry. Why in the insurance and not other industries? I feel when there is a 3rd party payment system, i.e., health insurance, the “middle man” has too much say over how the healthcare dollar is being spent, what the patient gets for that premium and how much hospitals and doctors get paid. Insurance companies seem minimally covered under anti-trust legislation whereas doctors (solely or in groups) are under the thumb of such laws. Patients, for sure, should not lose their insurance in the middle of treatment for serious illnesses. Perhaps a government option should only be for those with such serious pre-existing illness and relative destitution that forcing insurance of them through the private sector runs up premiums for all others, especially for businesses not able to afford these. By the way, I’d rather see the government pay private insurers for actual policies to cover these high risk individuals than deliver the care by a subsidiary of itself or even formulate a “Medicare-for-all” program.
#4 Providers’ roles. I believe we as doctors and hospitals need to be held to a high standard of ethics, including in the treatments we offer and the billing for these services. There is always low level fraud in the industry, as well as the high profile cases where usually government-run programs, e.g., Medi-Cal (lacking strict oversight) are “ripped-off” of millions of dollars by unscrupulous providers/business charlatans. This is inexcusable and criminal--but perhaps a “reaction formation” to, and product of, years of declining reimbursements. Given such ethical reforms as well as some of the things discussed above, doctors who put in an honest days’ work and use their high skills to the improvement of individuals’ health DO need to be paid quite a bit more than we are getting now. I say this unapologetically. Practicing good medicine is time-consuming and can be draining of one’s physical and emotional faculties. I do not disagree that outcomes (i.e., good results) as well as hard work and good intent need to be part of the equation for physician compensation. We doctors need to take good histories and examine our patients and frankly, put more thought into what we are hearing and seeing. We need to be less reliant on the automatic referral to other doctors or highly technical diagnostic or therapeutic procedures when simpler solutions are proven to be as effective. We need to determine (and we are doing so) how much it is worth to society to employ a newer test or procedure that is, let us say, only 5% more effective but 3 times as costly as something that already exists. Examples in my specialty include alternate mechanical procedures for prostate enlargement; and use of robotics and laparoscopy for prostate cancer surgery.
To help care for truly indigent patients (excluding those financially capable who elect NOT to partake in the private health care system), we need some creative solutions. Let us as doctors and hospitals commit to deliver uncompensated “pro bono” care (to some extent, we already do this) in exchange for not only tax breaks/ business write-offs but also the satisfaction that such care provides. Consider filling some of the gaps in care (including for indigents and those in rural areas) by a corps of foreign-trained physicians who, let’s say, after 2 years of such (government-salaried) service, can then be free, with minimal bureaucracy, to practice where they choose.
There you have it—principles, to be sure, but more straightforward and intellectually “digestible” than the current nearly 2000 page pending “gobbledygook” legislation being rushed toward law without being able to predict its consequences.
MEditorial Octobter 2009
PSA: Cool Your Jets
Download October 2009 Cool Your Jets
PSA (Pacific Southwest Airways) in a way had its “jets cooled’ when, through an acquisition/merger, it was integrated some 20 years ago into US Airways. I flew PSA many times, and perhaps was cheered up (and my mild flying anxiety relieved) by the “smile” painted onto the fuselage below the cockpit windows.
Interestingly (and probably not involving any patent infringement concern over the initials), the blood test PSA (prostate specific antigen) came on the scene clinically, also in the mid- to late 1980’s, just as PSA airlines was “waving goodbye”. Despite complaints about the inaccuracy of this PSA blood test, historically it has helped detect prostate cancers early, and on balance, has saved lives. Before its existence, we would diagnose prostate cancers based on more advanced disease, often discovered by feeling a lump in the prostate gland. Nowadays, prostate cancers are usually diagnosed well before the gland “feels hard”.
The public is now quite knowledgeable that PSA, like a lot of medical tests, is imperfect and leaves a lot to desire. It needs careful interpretation by the physician, whether that be a urologist or primary care doctor. Somewhat newer variations, e.g. “PSA-2” which gives a free/total PSA ratio, is somewhat helpful in determining the need to biopsy and likelihood of cancer--especially in men whose PSA is mildly elevated. We can also tweak the PSA (and likely be more selective about which men undergo biopsy) by looking at such iterations as PSA density (PSA divided by the volume of the gland as measured on prostate ultrasound) and PSA velocity (change of PSA over time).
Newer prostate cancer screening tests in the pipeline, not yet released to us for clinical use, include the “six gene molecular assay” and the “EPCA-2”. The latter, an assay for early prostate cancer antigen, is said to pick up a high percentage of prostate cancers--even in men who have cancer with a normal PSA-- and to be > 90% accurate in predicting that a man whose test is normal does not have prostate cancer. Interestingly, the EPCA blood test is now hung up in litigation, over a claim by a bioengineering firm that the sanguine data presented regarding the accuracy of this test by the primary university investigator was flawed at best--and “intentionally forged” at worst.
I think it is important to have some perspective when looking at PSA results. Unless the PSA is very high, at least teens to >20, it is always best to assess the value in relationship to prior PSA results. Many men have fluctuating PSA’s; and we may find a PSA similarly elevated 5 years ago as it is now. Variation in PSA’s is common; and spontaneous increases and decreases can be associated with prostate inflammation (prostatitis) the symptoms of which may or may not be apparent to the patient. We frequently see men with fluctuating PSA’s whose only sign of low grade prostate inflammation is the presence of an abnormal urinalysis, with white blood cells noted.
Prostate cancer in its usual form is really a chronic disease, and deaths from it within 10-15 years of its discovery are rare. At my hospital, the 10 year mortality rate for localized prostate cancer (including cases post-facto not felt to be cured by surgery or radiation) is zero. This is a good reason for older men (70-75 or older) and any man with a life expectancy limited to less than 10-15 years, to think twice about even having a prostate biopsy for an elevated PSA, let alone undergoing an aggressive intervention aimed at prostate cancer cure. Many prostate cancers I see in the elderly DO act more like a benign disease, do not progress, and are clinically inactive. These patients probably do better and live far healthier and happier for NOT having had their PSA investigated.
There are studies showing that prostate cancers diagnosed too late and not cured will reduce longevity; but the degree of shortening of life span is most concerning to the population under 60. Most of these studies do not show much more than a 5 year difference in life span between those treated/cured and those either not treated or not cured. This applies to prostate cancers felt to have been discovered early --and not to advanced disease (which is a fairly rare initial presentation).
Some informed urologists take the view that most prostate cancers have, time-wise, a wide “window of opportunity” in which to make the diagnosis, e.g., many months to even a few years, without compromising the patient’s health. To the contrary, men with very high PSA’s and the aggressive rarer forms of prostate cancer may succumb to the disease even if it diagnosed by biopsy right away and treated soon thereafter.
One must also factor in the cost/inconvenience and potential risk of prostate biopsies needed to make a definitive diagnosis. For example, rarely, some men will get serious bacterial infections after a biopsy and require hospitalization. In other cases, the biopsy itself may lead to a chronic prostatitis condition whereby even if the man has no symptoms, the PSA may go to a higher level and fluctuate, possibly causing further concern and the recommendation for further biopsies!
Since prostate cancer is mostly slow-growing and consistent with a long life span; and many biopsies especially in the US (where there is a low threshold to do a biopsy) are “negative” or essentially normal, I feel men should “cool their jets” a bit--and not be overly worried about slight increases in PSA’s-- whether these be within the range considered normal for a man’s age or elevated above the norm. Having a somewhat “longer lens” on these PSA results seldom compromises outcome/leads to unnecessary deaths--but it does give the “thinking” urologist better perspective so as to carefully select out those men who really will benefit from biopsy and potential “curative” treatments for prostate cancer.
MEditorial September 2009
COMPLICATIONS
Download September 2009 Complications
Atul Gawande, a General/Endocrine Surgeon @ Brigham and Womens’ Hospital/Harvard Medical School in Boston, has a knack for compelling writing--and has penned several noteworthy books about what it is like to be a surgeon. One could say his works are the “modern” day version of William Nolen’s famous “The Making of a Surgeon”.
“Better”, the (audio)-book of Gawande’s I myself have “listened to”, and his 2002 “Complications” (I have read synopsis and reviews only) were both best-sellers--and are great reads for the physician as well as the layperson.
At UCLA, where I was a Urology resident, I myself wrote a book chapter on ureteral problems in “Complications of Urologic Surgery”. More than 20 years later, the chapter is outdated and the book has fortunately been revised several times. The types of surgeries now done involving the ureter have changed significantly, as have the resultant complications and management of those problems. As an aside, one of the doctor/editors of the book holding my claim to literary fame once said [and I paraphrase]: “Dr. Freedman… if you do not like complications, do not do surgery”. Other aphorisms, albeit trite, include "surgery is not for the weak-hearted”.
We who do surgery know there is always a chance of complications. We want to communicate this possibility in advance to our patient, but in a discrete and reassuring way so as not to dissuade surgery which is necessary and wanted. Surgery, when it goes well, is a powerful remedy for many health problems. In my specialty of urology, surgical treatment of such diverse problems as prostate enlargement, prostate cancer, stones, incontinence, and impotence really do have a major beneficial impact on quality of life and, sometimes, longevity. If one “sees an opening” in terms of the advantage of surgery over, let’s say, medications or observation, one should take advantage of that probability for an excellent outcome. If the advantage is less clear, we need to have more detailed discussion to help the patient wade through the multitude of therapeutic options-if these do exist.
Surgery should be done when the benefits clearly exceed the risks. We as physicians must also judge (as would a financial adviser concerning our retirement assets), the risk aversion of the patient in question, especially when surgery is elective. Some, frankly, do not want to take the chance on a complication and would prefer to bear their symptoms/medical condition, hoping for a “better” procedure in the future. An example is a man suffering severe symptoms from prostate enlargement needing a TURP (transurethral resection) but not accepting the >50% permanent “problem” of retrograde (backwards) ejaculation. Some patients are misled into thinking a newer procedure, e.g., with lasers, microwave, or laparoscopy, are not only devoid of complications but are “guaranteed” to yield an excellent outcome.
The patient’s underlying condition will help guide us in stating the benefit versus risk of surgery. Poor overall medical condition, failed surgeries in the past, radiation damage to tissues, chronic use of blood thinners, interference with normal immune mechanisms by diseases such as diabetes or extensive cancer, or use of certain drugs, may all tilt the balance against the recommendation for surgery. Both the doctor and the patient need to have a specifics goal for the surgery. Is it to cure cancer?; what is the likelihood in this case it will really happen? Is curing the cancer “worth” the risks of permanent disability? Is the surgery in question to eradicate one urinary stone causing symptoms--or all of a patient’s kidney stones? Is it to cure a myriad of urinary symptoms, or focused on just one of a woman’s symptoms, e.g., involuntary loss of urine? Will the patient be satisfied with a “narrow” good outcome--or only if he/she is totally better on all fronts?
We as surgeons must be careful in excluding patients who, for physical or psychological reasons, cannot withstand certain complications. We must always strive, as Dr. Gawande would say to be “better” and learn from past surgical misadventures or complications. We surgeons are, by nature and training, quite more perfectionistic than you could know. The patient, too, has a responsibility in self-screening for surgery, doing his homework on both the procedure and the surgeon, and having the maturity to accept that--despite the best actions and judgment of his surgeon-- things may not all go well. It is my personal observation that, over the past twenty years, such “maturity” has tended to take a back seat to unrealistic expectations and petulance over unintended outcomes.
A reasonable and informed patient is aware that such things as bleeding, infections, poor healing, acute and chronic pain, bodily dysfunction and need for reparative surgery for these complications can and do occur, in the best of hands. Exemplative of these principles, a patient of mine, treated elsewhere for a bad prostate cancer with surgery and then radiation (and still requiring hormonal therapy now for persistent cancer) had severe urinary leakage. After informed consent, including discussion of my concerns about post-radiation tissue alterations, he underwent placement of an artificial urinary sphincter, concurrent with insertion of a penile prosthesis for impotence (complication also variably seen after all treatments for prostate cancer). My surgery was not only technically “perfect” and unremarkable, but there was absolutely no concern after completing this procedure (on my part or his) about postoperative complications. After the sphincter was “activated”, it worked so well that the man could not thank me enough. However, within 3 months of using the device, probably from the poor vascularity of the urethral tissues and their intolerance of a “foreign body” around them, the cuff of the device started to erode into the urethra, necessitating prompt removal of the anti-incontinence prosthesis. He knows we will “try again” in the future--but the task will not be easy.
Whenever a patient of mine has a surgical complication, as a caring and concerned physician, I try never to pass this off as unavoidable or as ”someone else’s fault”. There are always the “could have/should have” and “what if” self-questionings--in silence. However, when all is said and done, despite whatever unhappiness a complication brings to the patient, his loved ones and the doctor, we all need to accept that, let alone surgery, life does not always transpire as predicted, and a dose of philosophical “fate” is needed to help us move on and be “better”.
MEditorial August 2009
"Swollen Glands"
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When I was a kid, my pediatrician, whom frankly I feared (but admired) would often use the term ”swollen glands” to describe what in fact were lymph nodes in the neck acutely enlarged (and sometimes painful) from a sore throat or ear infection.
In referring to one of my favorite body organs, the prostate, some men use the phrase “my [prostate] gland is swollen”. In many cases, what they really mean is that they believe the gland is enlarged (i.e., BPH=benign prostatic hypertrophy). I try to distinguish enlarged as a “permanent” state of affairs (“large spone”) as opposed to “‘swollen” which is more often temporary-- or, “like a sponge taking on water”.
Men can have chronic enlarged prostate-like symptoms without the prostate actually being enlarged--and in fact, without there being any obstruction to the flow of urine whatsoever. Although there are tests which can show this, on occasion, due to poor muscular function of the bladder, in many cases (especially not-too-old men) , we do not understand the mechanism—it may reflect too many (or hyper-excitable) adrenaline nerve endings in the bladder neck and prostate, which when stimulated (e.g., under stress) cause compression of the base of the bladder and urethra by the prostate. Slow flow, pressure, and frequency/excess nocturnal urinating with small voided amounts ensue. These cases may lend themselves to medication treatment, same as true prostate enlargement, mainly “alpha-blockers” [see below].
When a man truly has prostate enlargement, especially if over 40, we may want to test for prostate cancer with a PSA measurement. Assuming no suspicion of prostate cancer, many with a larger-than-normal prostate require no treatment at all. It is my belief that enlargement without symptoms or with minimal/tolerable side effects, can and should be left alone. I myself do not buy the argument that a medicine (Avodart, for example) should be taken now so as to stall further prostate growth, thus obviating symptoms down the road and the need for surgery later and/or complications of BPH.
The symptomatic man should ask himself not only what are the symptoms but whether and to what extent they truly bother him. There are AUA (American Urologic Association) and other known “scoresheets” to rate this numerically. The patient should also decide whether he wants a one-time definitive treatment, such as surgery--which if done properly, will have a 90-95% chance of success and pose a low risk of complications; or a pharmacologic approach, possibly reserving a decision on surgery for a later date.
If someone has mild to moderate bothersome symptoms and is not especially surgically inclined, it is reasonable to see how he responds to medications. The starting point is often alpha-blockers, e.g., Flomax, terazosin, doxazosin, Uroxatral, Rapaflo. These work well--but perhaps not as well as TURP (transurethral resection of prostate). Common side effects, with great inter-personal variance (and hard to predict), include lowering of blood pressure with dizziness, sinus/nasal congestion, and interference with ejaculation. Other drugs, known as 5-alpha reductase inhibitors, work on the hormonal side of BPH and can shrink the prostate, make it softer, thus in the long run (these can take months to work) lessening the pressure of prostate against what we refer to as the “bladder outlet”. Side effects can include breast swelling/tenderness and alterations in sexual function. These drugs which include Proscar (generic=finasteride 5 mg.) and Avodart (no generic available), are usually well tolerated. I myself reserve these medications for men whose glands are indeed quite large, in which case, they may be used in combination with an alpha-blocker. If the gland does indeed “shrink” considerably over time and symptoms improve, we might try the 5-alpha reductase drug alone, leaving out the alpha-blocker. There are certain cases, e.g., recurrent bleeding from prostate enlargement, problems taking alpha-blockers, etc. where I might rely on Avodart or Proscar alone.
Herbal treatments such as Saw Palmetto, various other plant extracts, and minerals e.g. Selenium, may have a placebo effect and therefore benefit some men with symptomatic BPH. In “scientific” trials, these do not seem to objectively help more than “sugar pills”. My opinion is that a lot of money is wasted on such items. One has to know that BPH symptoms often fluctuate over time, with @ least 35-40% of affected men having spontaneous improvement of symptoms. Therefore, one has to be careful in ascribing a trrue benefit to any treatment.
TURP, an operation to “ream out” the central/blocking part of the prostate is safe and highly effective. It is still the “gold standard” for treating bothersome BPH. The operation sculpts out the excess tissue surrounding the part of the urethra passing through the prostate gland. That part of the urethra soon regenerates. Although backwards ejaculation is not uncommon, urinary incontinence (leakage) is rarely seen. Most men who have an electro-resection (traditional) TURP can go home by the day after surgery and wear a catheter for two days or less.
For very large glands needing surgery, simple open prostectomy or prostate adenomectomy, is a “cutting” operation done through a small lower abdominal incision. Although this is more invasive than TURP, it is better to go this route if TURP (due to the shear amount of blocking tissue), would lead to an inadequate resection and later sloughing of “half-dead tissue” with recurrent bleeding episodes. Hospitalization and recovery is longer than with TURP but it may be worth it. Preoperative exam, cystoscopy and sometimes trans-rectal measurement of prostate size, can help us distinguish the minority of BPH patients requiring such an operation.
What about laser TURP? Claims are that the PVP (green light) and diode laser are “better” than a regular electro-resection TURP. It is my feeling that this is not so--and certainly far from proven. There may be slightly less bleeding with laser, but use of these kinds of instruments may “leave behind” irregular tags of partially obstructing tissue which may create a problem needing further treatment later. Rates of urinary leakage and retrograde ejaculation are similar to regular TURP. I, as one urologic surgeon, still like traditional TURP--and most of my patients are happy and do not wish I had used a laser on them. A lot of corporate marketing goes into the perception that “laser is better”.
TURP alternatives include TUMT (microwave) and TUNA (needle ablation) which can be office procedures. I have more experience with TUMT than TUNA. Although there is a convenience factor (and, I will whisper, higher reimbursement, since the doctor--in essence --is compensated for using his office as the “surgery center” for the procedure), I believe these alternatives are in most cases clearly not as beneficial or durable (i.e., long-lasting) as TURP (electroresection or laser). Although studies of TUMT show anywhere from a 50 to 90% improvement rate, I would say in my practice, fewer than 50% of men notice a significant benefit from a microwave treatment. If I have a chance to re-cystoscope patients who have had TUMT, I see minimal tissue is “missing”, compared to a wide open prostatic urethra after TURP. One thing good I can say about TUMT is that most can get through it under local, it is a procedure (since it uses a microwave catheter device and does not involve cutting) which can often be safely done in anti-coagulated men, and there is a lower chance of backwards ejaculation.
There you have my thoughts in a nutshell (probably a walnut shell, the typical size for a normal prostate!). In BPH, you the patient should be in the driver’s seat, since very few such cases develop serious bladder or kidney complications and you should not be “sold” on a procedure/treatment without careful forethought and a good explanation of all reasonable alternatives appropriate to your situation.
MEditorial July 2009
“My Prostate Hurts”
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Pain perceived by men to be coming from their prostate is one of the more common issues seen in a general urologist’s office. The word “prostatitis” is, I feel, used somewhat too loosely to describe many pelvic pain syndromes, the majority of which are not due to inflammation or infection of the prostate.
The prostate, which produces most of the semen, is located at the bottom of the pelvis and rests atop a “carpet” of muscles joining the bones of the pelvis, known as the “pelvic floor”. The pelvic floor, containing nerves running from the spinal cord to the pelvic organs, actually separates the pelvic part of the abdominal cavity (where the “internal” male genital organs reside) from the perineum, the “external” genital location. The rectum is in back of the prostate and the bladder mostly above it. The prostate surrounds the very first part of the urethra (urine tube ultimately exiting penis) as it comes out of the bladder. Chronic enlargements of the prostate thus make it difficult to urinate over the long run. Inflammations or infections (acute “swellings”) can more suddenly make it hard to eliminate urine--and often cause pain, too.
True bacterial infections of the prostate probably arise from pathogenic bacteria within the male urethra; and are not usually sexually transmittable. Some men’s urethras are likely colonized by types of bacteria more likely to cause disease than others’; this, in association with poorly understood (sometimes temporary) immunologic problems, such as underproduction or weak activity of certain classes of immunoglobulins (e.g., IgA), may lead to acute illness. Symptoms include onset, usually over 12-24 hours, of urinary frequency, urgency, burning with urination, pain behind the pubic bone and/or between the rectum and anus (area known as the perineum) ; and in more severe cases, gross blood in the urine and chills/fevers/muscle aches and flu-like feeling. Like any illness, there can be great variability in the manifestations of prostatitis. In mild cases, the disease is easily confused with other conditions (see below). It would be difficult to tell a man that he has prostatitis if one or more of the following (in addition to the symptoms as stated) are not present: abnormal urinalysis often showing white and red blood cells--and sometimes bacteria; tender/boggy* prostate on digital rectal exam; abnormal urine culture, or abnormal blood culture. Cultures take a few days to return from the lab--and treatment may be needed right away, while these are pending. A complete blood count--especially with the white blood count elevated-- is good supportive evidence for an acute bacterial prostate infection. Some men lacking objective evidence are treated with antibiotics just based on the symptoms—improvement on antibiotics in such cases may be “real” or a placebo effect.
*Boggy refers to a mushy feeling and is akin to a sponge full of water as opposed to one squeezed dry.
The term ”chronic prostatitis” again implies inflammation of the organ, often with more low-grade symptoms off-and-on over many months or years. We really do not know if such an entity exists. If it does, it may represent abnormal healing after a bout of acute bacterial prostatitis with permanently unhealthy prostate tissues. This presentation is far less responsive to antibiotic therapy, even though some urologists will try a prolonged course of antibiotics, e.g., 4-12 weeks’ worth. I try to avoid that approach. Remember long-term full-dose antibiotics are associated with potential for significant complications.
Recurrent acute prostatitis is a term mistakenly used interchangeably with chronic prostatitis. Some men do get repeated attacks of (documented) acute bacterial prostatitis. Each episode may warrant antibiotic therapy; and many of these men will benefit from chronic low-dose antibiotics, e.g., 1/3 to 1/4 the therapeutic dose, to prevent episodes presumably until the man’s immune system recalibrates and is able to “defend” the prostate against bacterial invasion. Low dose antibiotic courses may be from 3-6 months; and occasionally, literally, for years.
Other pain syndromes grouped with prostatitis and more likely pelvic floor disorders. The terms “prostatodynia” and “chronic abacterial prostatitis” have mostly been supplanted by the nomenclature of pelvic floor disorder. There may be aberrant neurologic signals emanating to and from the pelvic floor muscles which in turn cause low grade spasms of these muscles: manifestations can overlap prostatitis, but are usually more chronic and milder. Men who have this condition can have some difficulty with urination and defecation--but mostly vague aches in the deep pelvis and perineum, as well as nonspecific pains (without objective findings) in the scrotum. Pelvic floor disorders may linger for years and do not respond to antibiotics. The condition is neither a sign of, nor does it progress to any serious illness. Muscle relaxants do not usually help, since such drugs would not selectively relax only these muscles. Sometimes, as is the case with “chronic” prostatitis, certain other medicines will help: these include alpha-blockers such as Flomax; anti-inflammatory drugs such as Ibuprofen; some antidepressant drugs; and “herbal” type anti-inflammatories/anti-oxidants such as Quercitin. Some physical therapists can help men who do not relax their pelvic floors. InterStim (Medtronics) , an implantable pelvic floor stimulator, may play a role in severe cases--but he evidence is still controversial and the procedure is costly. The “modest” success rate of such a procedure may be more related to “patient selection”, that is, we need get better at separating out someone with a true pelvic floor disorder from those suffering other entities.
There are causes of “referred” pain to the prostate and perineum. Recently a younger man presented to me with these vague symptoms. In getting a CT to look for occult urinary stone disease (one “long shot” cause) , we discovered avascular necrosis of both hips, a rare condition causing pelvic pain (more often “bony” in quality) and often requiring hip replacement surgery.
To diagnose “soreness” in the prostate area, I believe a thorough exam (including digital rectal) is the best way to go. Lab tests (e.g., urinalysis and urine culture) are needed when actual infection is suspected. PSA (blood test for prostate cancer) should be checked as a routine for men in an age/ethnic group susceptible --even though prostate cancer’s symptoms rarely overlap with the others discussed above. If a man has these things done and they are normal, it is relatively unlikely that other more complicated tests, such as cystoscopy, transrectal ultrasound of the prostate, random prostate biopsies, or pelvic CT/MRI will show a significant disease.
The disappointing news is we do not understand well (and therefore have few specific treatments) for men with chronic pelvic pain syndromes. The good news is that most of these conditions, even if not amenable to specific treatments, are not serious--and are not predictive of future prostate cancer, etc.
MEditorial June 2009
“Choose a Good Doctor, not a Procedure”
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This month, I digress from specific Urology topics to address an issue in health care in general.
More and more, our sophisticated patient population, fueled by media doctors and heavy marketing by hospitals and physicians alike, think they know exactly what procedure they need done. Once the decision has been reached, the patient sets out to find a physician who will do the procedure “that way”. Our office is (not infrequently) telephoned by patients not wanting to make an appointment until they are certain we use a specific type of laser, as opposed to wanting to know how experienced I may be in treating his particular condition. Patients and doctors are not always knowledgeable about scientific methodology and therefore have the psychology of believing what they want to hear, as opposed to what is right. “What is right” is often controversial and in the eye of the medical investigator, whose motives in finding one way or the other on the attributes of a newer technology is not always “‘pure”. For example, the procedure that may be less invasive has got to be “better”; or use of lasers, laparoscopes, “no scalpel” techniques for vasectomy, etc., compared with other instruments, is “safer”.
When I was a urology resident over 20 years ago, it was rare to see a scientific paper or lecture presented at a meeting with asterisks after the presenter’s name showing “funding” of his study by a certain medical manufacturer or drug company having a financial interest in the results; now such questionably ethical practices are almost rampant.
Ample studies, especially of newer technologies, show that the experience of the surgeon is more important to the outcome that the exact equipment used in doing the operation. Patients are more apt to be disappointed by the outcome of surgery done with a newer procedure, since they possess falsely elevated expectations of normal function, lack of pain, and quick/complete recovery. A 2008 study @ Duke University Medical Center showed that to be the situation in men choosing robotic over open radical prostatectomy.
Many doctors, e.g., Internists or Family Practitioners who refer their patients to a surgeon or surgical subspecialist (e.g., urologist) have never seen that doctor operate--and may, themselves, have not been in the operating room since medical school. More importantly, they may be unaware of the differences in the quite variable judgment of surgeons not only on what approach to utilize, but also on whom to operate. That would include not only consideration to the patient’s condition and what he can withstand but also, based on the surgeon’s experience, whether the intended procedure will really have a meaningful impact on the patient’s quality of life or longevity.
Respect the surgeon who is up-to-date and knowledgeable of all available procedures in his specialty--and has perhaps tried a new technology and fallen back upon his more trusted instruments. He may know, in his hands (and perhaps even in those of his competitors seeking a marketing advantage), that a more traditional way, perhaps leaving a longer scar or causing manageable temporary pain, is going to get the job done the right way, with your best interests in mind. An obese lady with a kidney cancer and possible involvement of her renal vein and lymph nodes recently accepted my proposal to remove the kidney via a flank incision as opposed to partially laparoscopically. After 1 hour and 15 minutes, we were finished with the surgery, with essentially no blood loss and no operative complications. A laparoscopic approach in her case would have risked poor access due to her size; more chance of major bleeding and injury to nearby normal structures; and lack of proper assessment of the extent of her cancerous pathology. Respect and choose the surgeon who is willing to share with you the shortcomings of any technical procedure and is honest enough even to risk losing you as a patient.
I recall a somewhat humorous encounter at an Orange County Urologic Society meeting over 15 years ago between a visiting lecturer from a prestigious eastern medical school and a cantankerous (although very insightful) local urologist, whom I will call Dr. Head. It involved treating prostate enlargement with a balloon dilational device. It was the Dr. Head’s feeling (proven by studies a few years later to be correct) that the forceful dilation of prostate tissue by a balloon is almost always a temporary fix needing repeat procedures—or, as stated by the local urologist “ a monetary annuity for urologists”. This got a lot of laughter out of the audience--and at the same time a chagrined, disdainful look by the lecturer.
If you choose a surgeon/urologist to treat your condition based on his reputation as an experienced, technically astute and honest professional, you may not be “immunized’ against failure or complications--but chances are, you will be happy with results that meet your realistic expectations—even if it means your sacrificing “control” over the technical details. Medicine seems to one of few professional fields where clients seek such control. I always tell patients that when I board an airplane, I trust and leave the flying up to the crew; and do not wonder about which switches or levers they are using.
Until we have reliable “doctor report cards” allowing you to preview the performance of your physician in many spheres (technique, knowledge, judgment, bedside manner, reliability, communication), “caveat empror”. Buyer beware, or you may choose a procedure but not get a good doctor as part of the package.
MEditorial May 2009
“Stones and Moans”
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Kidney stones (calculi) are a common urologic problem, and have a folklore of their own in terms of victims telling horror stories of great suffering, e.g., “worse than giving birth”. In a future article, I will address some the theories as to why humans get kidney stones. By the way, years ago, I had a veterinarian as a patient, who, as a gift for my care, brought in a bottle (“trophy”) of urinary stones he had removed from several “domesticated” mammals under his care.
Stones can be found anywhere in the urinary tract. Stones that form in the bladder do so for reasons less related to diet and metabolism/genetics, and are usually attributed to poor urinary turnover from the bladder either due to poor bladder muscular function and or chronic obstruction (e.g., from a large prostate). Once kidney stones form, they may or may not make themselves apparent. Often there is no pain, since there is a reasonable amount of space within the kidney--and most renal stones cannot block the calyces, or chambers, inside. It is felt blockage and not “scraping” causes pain, since internal hollow viscera (body tubes such as ureters and intestines) send pain signals to the brain mainly when they are distended, like the inflation of a balloon. Microscopic blood in the urine may be a tip-off to an otherwise asymptomatic kidney stone.
People may pass stones without knowing it or have a brief twinge of pain, not paying much attention to the underlying cause. Smaller stones, 4 mm. and under, are more likely to be associated with this. In fact, we do not understand exactly what triggers a stone to go from the kidney towards the bladder via the ureter (tube that joins the two). We see many individuals who have stable or slowly increasing size/number of calculi without ever having a severe attack of pain (ureteral colic).
Larger stones do tend to get caught, usually at the UPJ (ureteropelvic junction, 1st part of ureter) or the pelvic inlet (where the ureter enters the pelvis from its location in the back of the abdominal cavity) or the UVJ (ureterovesicle junction, lowermost part of ureter at its entrance into bladder).
Pain, nausea, vomiting, blood in the urine and lower urinary tract symptoms (frequency, urgency, “false warnings” to urinate, and burning often at the end of the stream), are common with a stone. An actual fever is less so, and raises the spectrum of pus starting to build up in the kidney. This situation may warrant more urgent intervention.
Many patients with an acute stone episode end up in the ER since they are often moaning and writhing in pain. It has become far more common for patients to have their diagnosis made, pain controlled and discharged home to pass the stone on their own or see a urologist as an outpatient to possibly intervene. Often the 1st colic attack from a given stone is the worst--although certain patients will have a hard time and may end up visiting the ER several times. Hospitalization is usually not required. The fact that an x-rays (e.g., a non-contrast CT of the abdomen and pelvis, the most useful one for stones) shows an obstructed kidney is not, per se, a reason for being placed into the hospital or immediately having intervention.
The size of a ureteral stone and the duration/severity of symptoms are the primary determining factors as to whether something will need to be done. Those calculi over 6 mm. can be pesky and resistant to passage.
The drug tamsulosin ( Flomax), (used for prostate enlargement and voiding dysfunctions), has been demonstrated to help relax the ureter and thus facilitate passage especially of <6 mm. stones. Although Flomax can cause dizziness and needs to be used carefully especially in the elderly and those with certain cardiovascular conditions, it should, I believe, be tried as part of the initial strategy in most “ureteral colic” patients. Adequate pain control, sometimes with non-narcotic drugs such as ketrolac (Toradol), is important as well as is, in selected cases, medicine to alleviate nausea. Antibiotics are seldom needed for a stone attack . Their use really should be restricted. A urine culture (for bacteria) should be sent before antibiotics are taken--even if for a good clinical reason.
Patients passing a stone should strain ALL their urine with a stone strainer or coffee filter to see if something can be recovered since (1) this is as good a proof as any that the episode is over and may avoid unnecessary follow-up x-rays , and (2) sending the stone for analysis is important in predicting future stones and advising patients as to risk factors and possible prevention. Many stones cause off-and-on symptoms-- thus absence of symptoms, even for days and weeks, is not tantamount to the stone having passed.
If a stone is causing severe symptoms, treatments can be broken down into palliative versus therapeutic. Palliation means a procedure to temporarily relieve the obstruction until the stone passes or is treated. This type of intervention can be very helpful for a patient with a stone and fever; or to get an individual back toward normalcy while awaiting a more detailed/involved surgery. Two common relatively simple procedure are (1) “JJ” stent, placed by the urologist--totally stenting or splinting the ureter (entirely inside)--via a cystoscope under anesthesia; and (2) PCN (or percutaneous nephrostomy) tube with possible “antegrade JJ” stent placed by a radiologist under anesthesia or at least under sedation via a tube inserted through the back into the inside of the kidney. A PCN tube is partially external. These types of tubes usually are removed within a matter of weeks.
Therapies for stones seldom involve dissolution (“melting” stone with medicines) since most stones contain calcium and these do not dissolve well. Uric acid stones, a distinct minority of kidney stones, can be dissolve with medicines that alkalinize the urine--but the process is slow, more so for large stones; this strategy would not, in itself, be practical for a highly symptomatic calculus.
Shockwave lithotripsy (ESWL), invented in the early 1980’s, is an incredible technology applicable to stones anywhere in the urinary tract but often used more for calculi within the kidney or upper two thirds of the ureter. Overall success rate in 80-90% and it can be performed more than once to a stone. It is the least invasive modality--but usually still done under general anesthesia . Endoscopic procedures, including ureteroscopic stone removal (often accompanied by holmium laser fragmentation of especially larger stones--or percutaneous stone removal (via a tract placed by a radiologist into the kidney through the back) are excellent minimally invasive procedures used to treat stones felt more suitable by the urologist for these than for ESWL. For example, a stone stuck in the lower ureter or even higher up may lend itself to an easy ureteroscopic (narrow rigid or flexible telescope passed up ureter through urethra/bladder) stone extraction. A large renal “staghorn”-shaped stone, which can fill a good percentage of the “inner tube” of the kidney, may be best treated first with percutaneous debulking--as opposed to ESWL. Open surgery for kidney and ureteral stones, as well as “newer” procedures to approach the ureter through its outside (via the abdominal cavity) using laparoscopes or robotically-controlled laparoscopic instruments, is usually not needed.
When I was in college, one of the “gut” or easy courses, oft’ felt designed to get athletes through to graduation, was nicknamed “Rocks for Jocks”. This basic geology course (I did not take it!) reminds us that the human body can be studied and “mined” for its richness in geology. Urinary stones are a prominent and sometimes quite painful reminder of this.
Dr. Alan Freedman
MEditorial April 2009
“Urinary Tract Infections”
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One of my pet peeves in medicine is the overuse of antibiotics. For my children, fortunately, I have found pediatricians disinclined to give antibiotics for, e.g., upper respiratory infections and fevers unless there are extraordinary circumstances.
One of the most common things we see in urology is urinary tract infections (UTI’s). These take the form of asymptomatic and symptomatic UTI’s. Symptomatic cystitis is one of the most common acute illnesses in women.
Asymptomatic UTI’s are basically abnormal lab tests (urinalyses, urine cultures/urine “C&S’s”) pointing toward infection in a patient who otherwise feels well. That patient may not have symptoms since the infection is minimal and especially if the bacteria is “weak” and does not cause much response from the body. It is that immune response from one’s body to the bacteria that in part, dictates the degree of pain, inflammation, urinary dysfunction, etc. Some patients with neurologic conditions, diabetes and old age may not have typical urinary symptoms with an infection—e.g., their pain fibers and sensation may be altered. “Symptoms”’ in these patients may be fevers, loss of appetite and a vague flu-like illness.
In reviewing the “significance” of asymptomatic infections, the fact that the patient feels well is more important than the lab result. In assessing the lab results, it is known that specimens from women and occasionally from men (especially those uncircumcised) can contain contaminants that result in confusion. In such cases, or when the basic urinalysis is normal despite a urine culture suggesting UTI, I tend to downplay the results. A catheterized urine specimen is a good arbiter of repeated confusion as to whether an individual even has significant abnormalities on urinalyses and/or urine cultures suggesting infection.
I would tend NOT to treat asymptomatic urinary infections (sometimes referred to as asymptomatic bacteriuria) unless that patient is about to have elective urologic surgery or has certain conditions such as “staghorn” stones of the kidney , the prevention of which may depend upon elimination of--and prophylaxis against--even asymptomatic bacteriuria.
Patients with indwelling urinary catheters often have abnormal urine culture results and are told they have infections without any symptoms (and are given antibiotics). Oftentimes, this is misguided. Indiscriminate treatment of these patients with antibiotics greatly enhances the risks of antibiotics, especially the development of more resistant/dangerous bacteria in the urinary tract and elsewhere. Overuse of antibiotics in this population is a major public health threat-- and cause for hospitalizations and serious illnesses.
Symptomatic infections take the form of lower urinary tract irritative symptoms (frequency, urgency, spasms, leakage, pain, bleeding), occasionally upper tract symptoms (flank pain) and may or may not be associated with fevers. Fevers with urinary infections suggest very serious causative bacteria; kidney involvement (men and women); or prostate involvement (acute prostatitis in men).
A symptomatic UTI patient should be treated with antibiotics if he/she is not resolving the issue spontaneously, symptoms are severe/worsening, or they are associated with documented fevers. The body’s immune system, without antibiotics, can handle and dispose of weakly pathogenic bacteria.
Although others may disagree, I feel that a properly obtained (again, occasionally requiring in-and-out catheterization) urine specimen should be sent to a lab for routine urinalysis and urine C&S (culture and sensitivity) BEFORE antibiotics are taken for a suspected symptomatic UTI. By doing so, we the doctors will be more certain when the results come back (often within a few days) this really was a UTI. Note other conditions including urinary stone disease and painful bladder syndrome/interstitial cystitis can simulate UTI symptoms. By seeing the C&S lab report, we can advise on the type of antibiotic and duration of treatment, more so in patients with recurring UTI’s.
Some patients with recurring UTI’s, especially ones associated with fevers and severe illness do need further studies to see if there is a source, such as obstruction of a kidney by a stone, poor bladder emptying, reflux (backwards flow of urine during voiding), etc. However, most patients with uncomplicated UTI’s (and without fevers) do NOT benefit from such costly analyses. Your doctor can determine into what category of “risk” you fit.
Patients, especially women (but men, too), with recurrent lower urinary infections (cystitis or prostatitis) often benefit from treatment with low dose so-called “prophylactic” antibiotics for 6 or more months until the body’s immune system re-calibrates. These immunologic “oversights” are likely due to poorly understood temporary gene malfunction--to which certain people are prone.
I am not a big believer in self-diagnosis and self-treatment of UTI’s--although some doctors allow self-starting of antibiotics for symptoms suggesting cystitis.
Remember, before you take those antibiotics, how sure is the doctor you have a UTI--and how does he/she plan to prove this? Will an adjustment be made to the antibiotics once the lab results are known? How will those results be communicated to you to avoid unnecessary or inappropriate use of antibiotics? Do the risks of antibiotics (dangerous “superinfections”, allergies, gastrointestinal, and occasionally pulmonary, neurologic and hematologic reactions outweigh the benefits?
MEditorial March 2009
Penile Plastics
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Erectile dysfunction (impotence), to a variable degree, is a very common complaint, affecting perhaps 50 % of men in their fifties and going up by 10 % for every decade of life after the fifties. I even see men in their teens and twenties with “ED”--and not all cases are “psychologic”. “Erections not hard enough” for penetration is more commonly seen than complete inability to erect.
The focus on ED over the last 10-15 years has been toward treatment, as opposed to specifically diagnosing a mechanism for impotence. In practice, knowing what may be causing impotence (e.g., atherosclerosis, diabetes, hormonal problems, etc.) does not tend to change the therapy or offer alternative solutions. For example, inadequate compression of the penile veins (so-called “veno-occlusive disease”) may be a common causative factor, especially in younger men with lifelong ED problems. However, vascular surgeries attempted to alter the venous drainage from the penis have not “held up” in the long run--and were mostly abandoned in favor of oral drugs, injections, and implants in the late 1990’s.
Although the usual treatment algorithm for ED is oral drugs (e.g., Viagra, Cialis) 1st; then either a vacuum-erection device or penile injections 2nd; and a penile implant 3rd (as a “last resort”), there is no rule stating this is the only proper sequence. You do have a choice.
Probably 25-30% of men or oral ED drugs have a poor response--and even more have side effects (facial flushing, sinus congestion, headache, belching, back and muscle aches) that dampen enthusiasm for their use. Vacuum-erection devices and cumbersome and often do not effect a rigid erection. Penile injections are effective but awkward to do; and detract from the spontaneity and intimacy of sex. Perhaps 20% of patients have significant achiness in the genitals following an injection; and priapism (considered an emergency), a painful persistent erection with poor oxygenation of the penile tissues and risk of further erectile damage, is an outside risk. Be wary of heavily advertised “pseudo”-medical companies that push penile injections for ED—they tend to obfuscate other reasonable options for ED treatment--and their profitability is based on repeated sales of the grossly marked up injectable medications.
Penile implants (penile prostheses) have been around for almost 40 years; their bioengineering is now better than ever. They are manufactured by two main companies in the US. Both make excellent devices. The implants have plastic coatings, either reinforced silicone or biourethane, and are filled with saline. These cannot leak silicone or anything else potentially toxic into the body. Some of the implants expand both in girth and length, thus making the rigid penis seem as large or larger than when the man was younger. The best systems are inflatable, and have three components, including (1) the two penile cylinders, (2) an easily palpable scrotal control device and (3) a saline-filled reservoir placed deep in the pelvis. Surgery takes about an hour, and most men spend one night in the hospital (rarely go home the same day). About six weeks later after complete healing, the device can be used. Satisfaction rates for men and their sexual partners are upwards of 90%. Most men do not require revision, replacement or removal of their penile prostheses.
A penile implant allows for more spontaneity of sex, as well as multiple coital sessions. Eliminated are side effects of oral drugs; and the problems associated with penile injections and vacuum devices. Complications from an implant including infection, poor fit, and erosion--especially of the cylinders--are rare. Diabetic men, who often need a penile prosthesis, have an acceptably slightly higher complication rate.
My own take is that more men should have penile implants. This is an operation I truly enjoy doing, both from a technical point of view, as well as for the excellent outcomes which I personally see. It is one of those operations to which many men say “no” (without thinking!) in advance; but those who go through with it wonder why they delayed their decision for so long. Men are generally quite happy with these implants and have improved self-esteem. In fact, although men should undoubtedly listen to their wife’s preferences, some spouses will tell their husband “no, it is not important to me”; but having a fully functioning penile prosthesis with rigid erections simulating the man’s former norm is important to his feeling masculine and his emotional health overall. I feel that even an “occasionally”’ used penile prosthesis can improve the status of a marriage negatively impacted by ED.
As opposed to most “plastics” used in surgery, which provide an aesthetic but usually not a functional improvement, penile prostheses are an innovative, safe way to recreate an important function. Their relevance in the treatment of impotence should not be trivialized.
MEditorial February 2009
“Why do I urinate so often?”
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Urination problems, many not requiring surgery or medications, are probably the most common patient issue we hear as urologists. Going to the restroom to urinate “too often”--occasionally with an urgent feeling-- can definitely impair one’s quality of life. More than one trip to the bathroom at night, for many people, is a bother, and can contribute to insomnia and poor daytime performance. There is, however, no “set” definition of what constitutes “too often”—you have to be the judge of what bothers you.
Despite common mythology, many cases of “urinating too often” are not related to problems in the urinary tract. Recall the kidneys filter the blood. The amount of urine produced by otherwise healthy kidneys is related to (1) the amount of volume in the system (a reflection of overall fluid intake) , (2) use of “drugs” that force the kidneys to produce more urine than they otherwise would ( e.g., diuretics such as thiazides and furosemide, caffeine, and alcohol) and (3) certain bodily physiologic functions, to some extent hormonal-- these are involved in regulating how much excess fluid is “squeezed” through the kidneys from the blood into the urine--or recaptured from the kidneys back into the bloodstream for inadequate fluid in the body’s vasculature. The kidneys are truly sophisticated organs and are amazingly efficient at preserving the right amount of fluid for minute-to-minute bodily functions—as well as other functions in eliminating “wastes”. Urinating too often seldom means the kidneys are malfunctioning.
Certain non-urologic disease states such as diabetes mellitus and the far rarer diabetes insipidus can inappropriately cause the kidneys to produce urine far too dilute and voluminous for the amount of fluid in the system, leading to frequent/large urinations, dehydration, and excess thirst. Patients with congestive heart failure may pool fluids outside the vasculature while mobile during the day with low urine production; only to have far greater blood flow to the kidneys and elimination of excess bodily fluids (and therefore frequent voiding) at night.
Keeping a diary of all fluid intake and all urine production (as well as listing use of “drugs” as mentioned above) can help us to determine if your urinary frequency is related to the kidney’s urine production or more likely a problem with the lower urinary tract, especially the bladder (and prostate in men). A diary showing frequent and small voids points us toward problems with the lower urinary tract. Calculating your daily urine production, a high total nocturnal volume of urine compared to (usually much higher) daytime production of urine suggests problems with the way the kidneys are filtering and the signals they are receiving (hormonal and otherwise) at night. For example, it is felt that sleep apnea causes release of a hormone which results in watery/voluminous urine with frequent but large volume/easy voids at night.
For the patient with frequent/small voids, with or without urgency, associated symptoms such as slow flow may point us in the direction of lower urinary obstruction by, e.g., prostate enlargement. A bladder which contracts poorly, sometimes linked to neurologic disease, is another (non-obstructive) cause. Frequency with gross or microscopic blood in the urine could suggest certain prostate diseases or even rarer forms of bladder cancer which infiltrate and stiffen the bladder lining. Frequency with pain are indicators of infection until proven otherwise--but may be from other causes including lower ureteral (originating in the kidney) stones, bladder stones, bladder cancer, and vague types of chronic cystitis such as interstitial cystitis (chronic bladder pain syndrome). Frequency with urgency and low amounts of retained urine in the bladder can sometimes be traced to a common condition now called “overactive bladder”. The need to “go often” is seen in patients whose bladder is neurologically irritable (occasionally in spinal disease and post strokes) and in those who, for whatever reason, have high amounts of residual urine and are “peeing the tip of the iceberg”.
The role of the urologist is to take a good history, do a thorough directed exam, look at the urine, and generate some ideas about the (quite varied) causations of frequent urinating. A “one solution mentality” obviously will miss the mark in most cases. Additional testing, including urine cultures, urine tests for cancer detection, blood tests, cystoscopy (looking inside bladder), non-invasive office bladder scanning, CT scans and urodynamics (physiologic testing of bladder function) may all be needed at times in more difficult cases; but these should not “automatically” be done.
We do, fortunately, have something to offer most patients with these problems so as to reduce ‘bother” and improve quality of life; and on occasion, detect a serious condition. “Urinating too often” is in the mind of the patient--and it is up to the doctor, especially the urologist, to make the mind-body connection.
MEditorial January 2009
“Maximizing the Value of Your Doctor Visit”
Happy new year!
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I will diverge, this January of a new year, away from urologic-specific topics to give you the first of what I hope will be many of my opinions on your health care. I do this not as one who has written treatises on the subject, or is an expert on the economic state of health care in the U.S. However, as a physician who has practiced for over 20 years, I am keenly aware of and interested in what, from the patient’s viewpoint, optimizes health care, especially in the “one-on-one” office visit context.
First, who do you see when you have a problem? In an area such as Newport Beach, where I practice, many patients have several doctors. Unless you are sure what is causing your problem (or are already actively seeing a specialist for a complex matter), it is best to go from the general to the specific, therefore, start with your primary care physician. This could be a Family Doctor, Internist or Pediatrician; or for a perceived emergency, an ER doctor. You are better off seeing someone who will take at least a brief history of the problem and examine you. The inconvenience of getting partially undressed and submitting to a few unpleasantries is more than worth the knowledge gained to help treat you or simply provide reassurance. Those physicians who feel they can properly diagnose “over-the-phone” or by intuitively diagnosing without such basics, are just as likely to be wrong as right. You should not want or need this. Granted time constraints in your doctor’s schedule may not allow an immediate appointment or prolonged office interaction; then you should consider how urgent it is for you to be seen right away, thereby crowding the doctor’s schedule and making your visit more cursory. Try to have some consistency in whom you see, so that the provider gets to know you well. Changing doctors often is usually not a good idea. Misdiagnoses, medical errors, and over-reliance on tests/procedures or prescription of medications occur less frequently when there is such familiarity. Most primary care physicians in this area are very competent, and can easily diagnose and treat you condition without resorting to an outside referral; give them a chance to do so, unless you are convinced the problem is very serious or potentially life-threatening.
Referral to a specialist is within the realm of judgment of the primary care doctor--with associated factors, e.g., “pressure” by the patient, insurance/cost issues. As relates to the primary care doctor, experience, self-confidence and rapport with you, as well as the complexity and urgency of the medical problem and specialist availability will help determine the threshold for referral.
The more specialized the doctor, the more you, the patient, should be armed, by the time of your visit, with helpful information. Unfortunately, the system is imperfect, and communication between doctors is probably not what you envision. Even with the “electronic age” with e-mails, electronic health records, etc., physician conferencing over your care and its coordination may actually be less than it was 30-40 years ago! For example, doctor primary care “A” may refer you to specialist doctor “B”; but not know the exact date of your appointment and therefore, await word from you on forwarding of pertinent records/x-rays, etc. It may be incumbent upon you to give the referring doctor a week’s notice to prepare and send the pertinent records, or have you pick them up. In my practice, I take it upon myself to forward records or make a phone call if I am referring a patient to another specialist. Especially in surgical specialty practices such as mine as a urologist, x-rays and similar studies which may have been done are important. We like to see the x-rays at the time of your visit, as well as review the report. The films from an ultrasound or CT do not automatically arrive in our office. In fact, when you have such a study done, promises by the radiology facility that these will be delivered to the specialist’s office are often not fulfilled. You are better off asking for a copy (often on a CD disc these days) to hand-carry with you to your appointment.
Think about your visit before you come in; this can be a week or a day in advance--or perhaps upon driving to the office. A few brief “mental” or handwritten “talking points” may be helpful, especially if you are anxious or feel you may forget what you wanted to get across. Some things to consider are the precise nature of your problem, how long you have had the symptoms, whether similar issues have occurred in the past and whether these have to some extent been addressed by another doctor. Do you have records of such assessments? What observations have you made about a pain, pattern of bleeding, or dysfunction? For example if you have a pain, is there any activity which makes it better or worse? Did it come on suddenly, gradually, or intermittently? How much of a “bother” is the symptom, e.g., on a “1-10” scale? Exactly where is the pain located; and how large an area does it encompass? If you have trouble urinating, what is the relationship between your fluid intake and or use of diuretics, caffeine and alcohol, to urinary frequency/urgency? Is the urinary problem more that of storage of urine (urgency to urinate, often with decent flow) or emptying of urine (poor/intermittent/hesitant flow, perhaps without an urgent sensation)?
If available (such as on my website), fill out the patient medical information form before the doctor visit. Not only will this save time, it will enable you to recall what conditions you have had in the past, and to collect your thoughts about why you are being seen. If you have more than one problem, prioritize them. There may not be enough time to address all in one visit, but they are worthy raising in the order in which they bother you; on occasion, more than one problem, e.g., urination issues, elevated PSA blood test and finding blood in the urine, may be tied together into a unified diagnosis.
If you are hard-of-hearing, or have poor memory or a language barrier, it is most helpful to bring someone with you to the office visit to facilitate your care. It is better to have discussed the issues in advance with the intermediary, so as to avoid using most of the visit time “translating” all your issues in front of the doctor.
It may be helpful not only to ask questions of the doctor; but repeat back your understanding. For example, you may say, “let me be sure I have this right; you want me to have a CT scan, since you suspect I am passing a kidney stone, and you feel this is the best way to detect it. You will decide how to treat this, depending on the results and how I am doing”. Another example would be, “you believe my PSA elevation warrants further evaluation with an ultrasound and biopsy; that doing a biopsy is safe, but there is always some chance I may have pain, bleeding and/or infection; or that the biopsy will turn out normal, despite there actually being an early cancer in my prostate”. You may also choose to ask what might happen if you do NOT take a prescription/have test done; as well as what to expect if you DO follow the advised course of action. A good example would be to question any doctor on why antibiotics are needed, what are the downside risks, how does the M.D. know (or how can he determine from tests done in advance) there is a bacterial infection; and do the mere presence of bacteria ,e.g., in the urine, present a significant risk requiring antibiotic therapy.
Finally, value the doctor who is not always so sure about the diagnosis. The fact is, many ailments or symptoms are minor, go away by themselves and are not signs of impending health demise. Also, sometimes the physician’s reassurance itself will reset the anxiety level- and have a profoundly positive impact on symptoms not being caused by serious pathology. Third, there is always a “next time”, e.g., a follow-up exam or a second opinion, which may be a better way of proceeding, in some cases, than overutilization of medications (such as antibiotics) or of testing; or zealous insistence on surgery “as soon as possible”.
Resolve to use some of these ideas at your 2009 doctor visits; and see if they do not change your perception of the effectiveness of the encounter!
Alan Freedman, M.D.
January, 2009
MEditorial December 2008
“Here Comes the Rain Again”
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With the rainy season in Southern California approaching, it brings to mind wetness and gloom; features often associated with urinary incontinence (leakage). When I was in my urology residency, there used to be a video series sponsored by one of the pharmaceutical companies titled “Visits in Urology”. One of these featured a visiting professor from Virginia discussing urinary incontinence with the local academic urologist. While looking out the window at a rainy NYC day, the Virginian, in a great southern drawl, said: “Yep, you sure have some wet women here in New York”.
One of my urology professors at UCLA brought a bit of “black humor” but also an admission of truth from his residents, when he would state “Incontinence is worse [for some women] than cancer—it is like a “social” cancer”. He was referring to the embarrassment and social isolation often brought on by lack of bladder confidence.
Female incontinence, as well as male incontinence, can be due to many factors. One solution does not fit all. Sudden leakage may, for example, represent a urinary infection; or retention, when the bladder stops working, pressure build up, and leakage occurs like a “pop-off’ valve.
More commonly, women complain of leakage associated with some form of activity or straining of the abdominal wall muscles. This is called “stress urinary incontinence”. Provocations include coughing, laughing, sneezing, exercising, or sometimes just standing upright. Occasionally there is urge associated with the leakage, especially an immediate feeling of the need to void when getting out of a chair.
Stress incontinence can be diagnosed in the office by taking a good history and doing a basic examination, including looking at the pelvic/vaginal area. Further tests, such as measuring the urinary residual, bladder capacity and pressure; and trying to reproduce the symptoms in the doctor’s office, may also be helpful. Detailed tests such as cystoscopy (looking inside the bladder) or urodynamics (physiologic testing of the voiding cycle) are rarely needed--except in complicated or re-operative cases.
Having been in practice for over 20 years, I have seen surgical treatments for SUI (stress urinary incontinence) come and go. There is, let us say, a lot of creativity in this field of urology. Sometimes, studies show a certain procedure works quite well, but when the women are questioned 5 or 10 years later, most are incontinent again. The trend has been toward less invasive and more effective procedures. There may be nothing wrong with larger operation such as a “Burch” or “Marshall-Marchetti”-- but why have a more disabling/painful procedure, if the same goal can be accomplished through “mini”-incisions. Also, studies have demonstrated that most women with SUI need “support” (like a hammock) underneath the urethra, not just tacking up of the bladder neck or urethra to the pubic bones or muscles.
“Permanent” mesh type slings have generally supplanted the use of biologic materials. The latter could include the patient’s own tissues, or those sterilized from a human cadaveric, porcine (pig) or bovine (cow) source. Prior concerns about placement of synthetic mesh slings between the urethra and vaginal wall, especially risk of infection, erosion and fistula (hole from urinary tract to vagina) have not been statistically substantiated by studies and almost 15 years of experience.
I can take a woman with longstanding SUI and usually in 20-30 minutes, under anesthesia in the operating room, either cure or greatly reduce her leakage—and it appears the short-term results DO hold up “for life”. Even women with one or more prior failed procedures may be reasonable candidates for the sling operation. The procedure can be done with a short (“24 hour”) hospital stay, or as an outpatient. Pain and bleeding are minimal, and one can return to non-strenuous activities in less than a week, sometimes after a few days of recovery. It is a rare to see women with complications requiring, e.g., dividing, loosening or removing of such slings, but in reality, I have seen this occur.
As you can see, the “weather forecast” for women with the most common form of urinary incontinence is improving all the time.
Alan Freedman, M.D.
MEditorial November 2008
Robotic Prostatectomy: Beyond the Advertising
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Advertising from hospitals and in certain cases, by urologists, has helped fuel a boom in robotic prostatectomies for treatment of localized prostate cancer over the last 5 years. In 2008, over 50% of radical prostatectomies in this country will be done laparoscopically, using the DaVinci robot.
As one who has taken a mini-residency and attended several “world congresses” on the subject, I, like you, are amazed at the technology--and how far some of my colleagues are “pushing the envelope” as regards not only prostatectomy, but also other major urologic operations lending themselves to this robotic technology. Patients are often attracted to newer and presumably more precise/less invasive procedures. Some men choose a technology first and a surgeon second; as opposed to doing what I’d consider to be more reasonable. Choose your surgeon 1st—and if he is as good as you think—he will do the procedure using the excellent skills/particular technique he has mastered, with your best possible outcome in mind.
Taking a step back (and accepting some will accuse me of “sour grapes”, since I am not currently using the DaVinci robot), what is the reality? Does this costly piece of technology, at present, really do better in treating your prostate cancer than modern open nerve-sparing prostatectomy?
Patrick Walsh, M.D., the renowned urologic surgeon from Johns Hopkins, one of the pre-eminent medical institutions in this country, sounds a bell of warning. Minimally invasive robotic prostatectomy, as it currently stands, may NOT be better for the patient than an open technique, especially when the latter is performed by a highly skilled urologist. Walsh cites one (2008) series from Harvard, showing a slightly lower risk of overall complications (30-vs-36%) and a shorter hospital stay (often by one day) for robotic-vs.-open cases. Robotic patients however, had different complications, not seen with an open pelvic technique (e.g., intestinal issues and anesthetic problems related to patient positioning for robotic prostatectomy, as well as operative times that can be twice as long as with an open technique) Of more concern in this study, robotic patients were at higher risk for requiring additional treatments to control their cancer, often within the 1st year after surgery, by three-fold as compared to the “open” series. More experienced robotic surgeons had a lower rate of their patients needing additional therapy, but still not as favorable as with the “open” cases. It is generally felt that positive margins (i.e. cancer cells right to or beyond the line of surgical resection), based on the pathologist looking at the prostate after its removal, are more likely to occur with robotically-removed specimens; and even more so if done by urologists who have performed fewer than 100 such surgeries.
I can say personally that the ability to have a wide open surgical field and to directly feel the tissues in question seems to have some advantage, especially where the disease may be a bit more locally aggressive than average. With a small open incision and gentility/caution, the tissues do not seem to react any worse, from my perspective, than in those treated with “less invasive” techniques.
Eventually the technology for robotics will improve and may evolve a mechanism for tactile feedback. For now, however, advertising claims are unquestionably misleading; and there really is no good evidence that, over time, robotic prostatectomies have better functional or cancer outcomes than open nerve-sparing radical prostatectomies.
Alan Freedman, M.D.
