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Robotic Assisted Laparoscopic Surgery

Robotic Assisted Laparoscopic Surgery

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The da Vinci Surgical System is the only FDA Approved Technology available that can provide the surgeon with the range of motion, fine tissue manipulation capability and 3-D visualization characteristic of open surgery, while simultaneously allowing the surgeon to work through tiny incisions typical of laparoscopic surgery.

The da Vinci System has three main parts: the console, where the surgeon sits to operate the robot; the patient side cart, which is positioned over the operating table and contains the arms that hold the instruments; and a third cart which provides a view of the surgery for the other doctors and nurses in the room. When the surgeon looks into the console, he sees a three-dimensional view of the patient’s internal organs and the surgical instruments, similar to what he would see in an open operation.

Unlike an open operation, the camera can magnify the image, creating better visualization. The arms of the robot on are controlled by the surgeon using hand controls. Perhaps the largest advantage of the robot is in the design of the instruments. Unlike most laparoscopic instruments (which can only move in certain directions) the da Vinci’s instruments are wristed. The surgeon can manipulate the instruments in multiple directions, giving the surgeon freedom similar to that of an open platform.

There are limitations to robotic surgery. Unlike an open operation, the surgeon cannot feel the organs. When using the instruments to touch the organs, there is no tactile feedback, so surgeons must be extra vigilant about where each instrument is, in order to avoid damage to the organs. Finally, the da Vinci requires use of instruments that are manufactured only by Intuitive Surgical, Inc. If a procedure requires an instrument that is not currently available through the manufacturer, that part of the procedure must be completed laparoscopically.

Robotic surgeries have led to less invasive cancer surgeries with decreased pain and faster recovery times for patients. Because of the reduced size of the incisions, hospital stays are often shorter, with some patients even able to go home the next day.

During robotic surgery, several instruments, including a camera called a laparoscope, are inserted into the patient’s abdomen through small incisions. These instruments include scissors, graspers, and other instruments modeled after the typical instruments used in traditional open procedures.

Robotic surgery can help surgeons overcome many of the challenges presented by the open or laparoscopic surgery. We have one of the largest
experience with comprehensive robotic surgery in treating invasive bladder cancers with total bladder removal and urinary diversions (also known as Radical Cystectomy).

is a leader in applying the robotic-assisted da Vinci S Surgical System to combine extremely precise movements with three-dimensional imaging to achieve excellent surgical results.

Potential benefits of Robotic surgeries include:

  • Less blood loss, pain and visible incisions
  • Shorter hospital stays and recovery time
  • Fewer post-operative complications
  • Quicker return to normal activities

Dr. Keel discusses the advantages of robotic surgery over traditional open surgery.

Lapaoscopy

What is Laparoscopic Surgery?
Laparoscopy is a technique for performing major abdominal surgery through several tiny (0.5 to 1 cm) incisions, instead of the large, 12 inch incisions that have been used in the past. Laparoscopy involves a high resolution video camera so organs such as kidneys, adrenals, prostate, and ureters can be visualized with a 1-cm telescope, and manipulated with instruments through these small, 0.5 to 1 cm incisions on the abdomen. Because of their small size, these incisions produce much less discomfort after laparoscopy than the scar associated with large incisions required for open surgery. With laparoscopy, the need for pain medication, the length of hospital stay, and the recovery time are greatly reduced. Laparoscopic surgery requires general anesthesia. Although laparoscopic surgery is easier on the patient than open surgery, it requires great skill and technique which require specialized training.

Laparoscopy is established in the mainstream of urologic surgery. Indeed, it is becoming increasingly clear that almost all aspects of retroperitoneal surgery, be it kidney, ureter, adrenal gland, prostate, or lymph nodes, can now be achieved laparoscopically with far less injury and pain to the patient. Minimally invasive surgery is superseding open surgery at major medical centers throughout the world. In the new millennium, the old craft of open, large incision surgery has an ever-diminishing role in the treatment of urologic disease.

Benefits of Laparoscopic Surgery
Several documented benefits in comparison with traditional open surgery have been demonstrated including:
• Less postoperative pain
• Less blood loss
• Shorter hospital stay
• Favorable cosmetic result / smaller scars
• Earlier return to work and normal daily activities
Laparoscopic surgery cannot be performed if you have:
• Uncorrectable coagulopathy
• Intestinal obstruction
• Abdominal wall infection
• Suspected malignant ascites
Also, relative contraindications include morbid obesity, extensive prior abdominal or pelvic surgery, ascites, pregnancy, severe chronic obstructive pulmonary disease (COPD), and severe cardiac arrhythmias or heart disease.

Complications
Complications are decreased in experienced surgeons who perform laparoscopy on a routine basis. The estimated complication rate of laparoscopic surgery is less than 5%. The associated mortality rate is about 0.3% and conversion rate was 1-5%. Risks of surgery include bleeding, infection, injury to adjacent organ such as liver, bowel, spleen or pancreas, as well as possible conversion to open surgery. Most intraoperative complications (2.5%) are vascular and bowel injuries, while postoperative complications (3%) were predominantly blood clots and wound infections. Conversion to open surgery might be necessary to safely complete the planned procedure, which occurs < 5% in experienced hands.

Laparoscopic Nephrectomy

What Is Laparoscopic Nephrectomy?
Nephrectomy (removal of the kidney) is indicated in patients with an irreversibly damaged, non functioning kidney as well as in situations of kidney masses which are presumptive renal cell carcinoma, or kidney cancer. The procedure of traditional open nephrectomy usually involves a large incision, about 1 foot in length, sometimes requiring removal of a rib. The result of open surgery is pain and numbness over the affected side, which further interferes with normal respiratory movement and can prolong recovery. Laparoscopic nephrectomy is a standard of care. This surgery is performed via 3-4 small incisions (0.5 to 1cm in size) and has a significant number of benefits to the patient including decreased pain, shorter hospitalization (about 2 days), less blood loss, lower requirements for pain medication, reduced convalescence, and a more rapid return to full activity. Laparoscopic nephrectomies have been performed for over a decade, and data has shown this procedure to produce cancer control identical to that of open radical/total nephrectomy. At this time, laparoscopic radical/total nephrectomy for the treatment of renal tumors is a standard of care.

Pre-admission
Within 1 week prior to your surgery, you will be scheduled for pre-admission testing. These tests generally consist of a complete blood count, electrolyte panel, urinalysis, urine culture, chest x-ray and, when indicated, an electrocardiogram. Before the procedure, you will require medical clearance from your primary care physician. If you do not have an internist, you may request one or your urologist will recommend one.

Operative Phase
The evening before your surgery, you will not be permitted to eat or drink after midnight. This ensures that no food is in your stomach prior to induction of anesthesia. Before your procedure, an anesthesiologist will see you. You will be given medication which will decrease anxiety and induce relaxation and, once you are in the operating room, you will then be given general anesthesia. This medication is given by the anesthesiologist who will be at the head of the table. This medication will prevent you from feeling any pain during surgery and make you unaware of what is going on around you at this time. The procedure is then performed by the surgical team. It will be necessary for you to have a bladder catheter inserted to help measure urine output during the operative and postoperative periods as well as assist your urination after the procedure. The operative position will be a modified lateral position with the affected site upright 45degrees. Three 0.5 to 1cm small skin incisions will be created as shown in the following figure. The entire surgery will be performed through these incisions. After the operation, the affected kidney will be extracted either intact or morcellated, or fragmented into pieces after being placed in a special specimen bag. The wounds will be closed and covered by tapes. There is no need for removal of any stitch in the future.

Postoperative Phase
After the procedure is completed, you will be placed back on the OR stretcher with total help from the surgical team and wheeled into the recovery room where you will be monitored by the recovery room nurses. They will check your blood pressure, pulse, respirations, temperature and drainage from your tubes. When you are completely awakened from anesthesia, you will return to your room and the floor nurses will then take care of you. You may still be drowsy from the anesthesia, but as this begins to wear off, you might experience some discomfort where the surgery took place. You will be given an injection of pain medication upon request and the effectiveness of the medication will be monitored. If it is not strong enough for the pain you are experiencing, it may be increased according to your doctor’s orders. The pain should begin decreasing each day in which case the dosage will be adjusted. The medication will eventually be changed to pills when you are tolerating fluids and food, usually within 4-48 hours. The bladder catheter is always removed on the first postoperative day. A clear liquid diet will be started on the first postoperative day. The admission is usually a period of time between 1 to 3 days. Upon discharge, you will be given printed discharge instructions. Please ask for these before you leave the hospital.

Follow Up
You should make an appointment to see your urologist within 10-14 days following your discharge. The pathologic report will be discussed with you as well as an inspection of your operative wounds. In case of malignant nature of the disease, you should be followed up.  Close surveillance will be performed to detect any possibility of tumor recurrence or metastasis for the malignant diseases in the future.

Partial Nephrectomy

What Is Partial Nephrectomy?
Although radical nephrectomy is a standard surgery for management of renal cell carcinoma, either open or robotic/laparoscopic, nephron sparing surgery has become accepted for selected patients: those with solitary kidney, bilateral renal cell carcinoma or small renal cell carcinoma. Partial nephrectomy is another option of nephron sparing surgery other than laparoscopic

Pre-admission
Within 1 week prior to your surgery, you will be scheduled for pre-admission testing. These tests generally consist of a complete blood count, electrolyte panel, urinalysis, urine culture, chest x-ray and, when indicated, an electrocardiogram. Before the procedure, you will require medical clearance from your primary care physician. If you do not have an internist, you may request one or your urologist will recommend one.

Operative Phase
The evening before your surgery, you will not be permitted to eat or drink after midnight. This ensures that no food is in your stomach prior to induction of anesthesia. Before your procedure, an anesthesiologist will see you. You will be given medication which will decrease anxiety and induce relaxation and, once you are in the operating room, you will then be given general anesthesia. This medication is given by the anesthesiologist who will be at the head of the table. This medication will prevent you from feeling any pain during surgery. The procedure is then performed by the surgical team. It will be necessary for you to have a bladder catheter inserted to facilitate the record of urine output during the operative and postoperative periods as well as assist your urination after the procedure since normal urination may be influenced by the anesthesia. The operative position will be a modified lateral position with the affected site upright. Three 0.5 to 1cm small skin incisions will be created to perform the procedure. After the operation, the partially excised kidney with tumor will be extracted within a specimen bag and a drain tube will be left over your flank. The wounds will be closed and covered by tapes. There is no need for removal of any stitch in the future.

Postoperation
After the procedure is completed, you will be placed back on the OR stretcher with total help from the surgical team and wheeled into the recovery room where you will be monitored by the recovery room nurses. They will check your blood pressure, pulse, respirations, temperature and drainage from your tubes. When you are awake and your condition is stable, you will return to your room and the floor nurses will then take over your care. You may still be drowsy from the anesthesia, but as this begins to wear off, you might experience some discomfort where the incisions. You will be given an injection of pain medication upon request and the effectiveness of the medication will be monitored. If it is not strong enough for the pain you are experiencing, it may be increased according to your doctor’s orders. The pain should begin decreasing each day in which case the dosage will be adjusted. The medication will eventually be changed to pills when you are tolerating fluids and food, usually within 4-48 hours. Getting ready for discharge: You will probably not have any tubes in place when you go home. The urethral catheter is always removed on the first postoperative day. A clear liquid diet will be allowed on the first postoperative day. The draining tube will be removed according to the daily amount and quality of the drained fluid. This will usually on the 2nd to the 4th postoperative day. The total admission days usually are 3 to 4 days. Upon discharge, you will be given printed discharge instructions. Please ask for these before you leave the hospital.

Follow Up
You should make an appointment to see your urologist within 10-14 days following your discharge. The through pathologic report will be discussed with you as well as an inspection of your operative wounds. In case of malignant nature of the disease, you should be followed up for signs of recurrence or 

Radical Prostatectomy

Robotic Radical Prostatectomy
The most important aspect of choosing to undergo treatment of your prostate cancer is to maximize your chances for cure. Present day data from multiple centers around the United States demonstrate that Laparoscopic Assisted Prostatectomy using the daVinci® Robotic Surgical System has the potential to achieve comparable cancer control to open surgical prostatectomy; this is measured by prostate specimen margin free status. It is felt that the six degrees of freedom and 3-D Vision offered by the daVinci® Robotic Surgical System are key in helping to maximize prostate cancer surgical cure.

One of the biggest advantage of the daVinci® Surgical System over pure laparoscopic modalities is the ability to translate and facilitate human wrist movements into laparoscopic instrumentation. Therefore, more difficult segments of the operation are made easier. Many laparoscopic urologists, for example, feel that the reconstructive portion of the operation which entails the vesico-urethral anastomosis (when the bladder is sewn to the urethral after removal of the prostate) is performed with greater ease, quicker, and in a more “water-tight” fashion. As a result, patients have had their catheters and drains removed shortly after the operation.

Laparoscopic Radical Prostatectomy
Radical prostatectomy is indicated in patients with clinically localized prostate cancer and provides the best way to eradicate this disease. Several groups have investigated a laparoscopic technique to reduce the morbidity of conventional prostatectomy and to improve operative precision. Robotic / Laparoscopic radical prostatectomy was first performed in the early 1990s. Recently, improved instrumentation have permitted several centers to refine the technique and reduce operative time.

Open Radical Prostatectomy
Open Radical Prostatectomy (the “old” / “standard” incision) is still utilized today and still works!  Despite what you see or read this is still a valuable tool and may be necessary in patient who have co-morbidities that prevent robotic/laparoscopic surgery, such as severe pulmonary disease.  Outcomes in regards to erectile function and incontinence have not been shown to be inferior.  However, these patients do require a longer recovery and many times require an additional nights stay in the hospital.

Pre-admission
Within 1 week prior to your surgery, you will be scheduled for pre-admission testing. These tests generally consist of a complete blood count, electrolyte panel, urinalysis, urine culture, chest x-ray and, when indicated, an electrocardiogram. Before the procedure, you will require medical clearance from your primary care physician. If you do not have an internist, you may request one or your urologist will recommend one.

Operative Phase
The evening before your surgery, you will not be permitted to eat or drink after midnight. This ensures that no food is in your stomach prior to induction of anesthesia. Before your procedure, an anesthesiologist will see you. You will be given medication which will decrease anxiety and induce relaxation and, once you are in the operating room, you will then be given general anesthesia. This medication is given by the anesthesiologist who will be at the head of the table. This medication will prevent you from feeling any pain during surgery and make you unaware of what is going on around you at this time. The procedure is then performed by the surgical team. It will be necessary for you to have a bladder catheter inserted to facilitate measurement of urine output during the operative period, and allow healing of the connection that is created between the bladder and urethra. The operative position will be in the Lithotomy position. Six 0.5 to 1cm small skin incisions and the entire surgery will be performed through these incisions. During the operation, the prostate, seminal vesicles, and pelvic lymph-nodes will be removed. The incisions will be closed and covered by a dressing.  No sutures will need to be removed.

Postoperative Phase
After the procedure is completed, you will be placed back on the OR stretcher with total help from the surgical team and wheeled into the recovery room where you will be monitored by the recovery room nurses. They will check your blood pressure, pulse, respirations, temperature and drainage from your tubes. When you are awake you will go to your hospital room and the floor nurses will then take over. You may still be drowsy from the anesthesia, but as this begins to wear off, you might experience some discomfort where the manipulation took place. You will be given an injection of pain medication upon request and the effectiveness of the medication will be monitored. If it is not strong enough for the pain you are experiencing, it may be increased according to your doctor’s orders. The pain should begin decreasing each day in which case the dosage will be adjusted. The medication will eventually be changed to pills when you are tolerating fluids and food, usually within 4-48 hours. Getting ready for discharge: A clear liquid diet will be started on the same day as your surgery. The drainage tube will be removed according to the amount of drainage. This will be usually the 1st post-operative day. Total hospital days usually are 1-2 days. Upon discharge, you will be given printed discharge instructions. Please ask for these before you leave the hospital.

Constipation can be a problem following pelvic surgery.  If you have chronic constipation I advise that you begin MiraLax 1 week prior to your procedure, and advise all patients to utilize this as part of a post-operative bowel management program following pelvic surgery.  No suppositories or enemas should be used for 4 weeks following your surgery.

Follow Up
You should make an appointment to see your urologist within 7-10 days following your discharge. Upon your return to our office your catheter will be removed and we will review the results of the final pathology report. An X-ray, called a Cystogram, may be performed prior to removal of your catheter.  If urinary tract infection with fever and chills develops, a possible subsequence of the catheter, you should immediately contact your urologist. After your initial follow up appointment and catheter removal you will follow up at 3 months to review the results of your repeat PSA.  This and the results of your final pathology report will dictate your future treatment and follow up plan.

Pyeloplasty

Many options exist for surgical management of Ureteropelvic junction obstruction, or blockage of the kidney at the level of the ureter. Although open pyeloplasty remains the gold standard for treating ureteropelvic junction obstruction, endopyelotomy and robotic / laparoscopic pyeloplasty have revolutionized the management of upper tract stenosis or blockage. For those cases of recoverable hydronephrosis, secondary to crossing vessels or which have a large redundant renal pelvis, or decreased renal function, robotic / laparoscopic pyeloplasty has shown it has a similar success rate compared with the traditional open approach and a significantly better result than endopyelotomy. Due to the improvements of techniques and instruments, success rates of robotic / laparoscopic pyeloplasty are approaching that of open pyeloplasty with less pain, smaller incisions, shorter hospital stays, and quicker return to function.

Pre-admission
Within 1 week prior to your surgery, you will be scheduled for pre-admission testing. These tests generally consist of a complete blood count, electrolyte panel, urinalysis, urine culture, chest x-ray and, when indicated, an electrocardiogram. Before the procedure, you will require medical clearance from your primary care physician. If you do not have an internist, you may request one or your urologist will recommend one.

Operative Phase
The evening before your surgery, you will not be permitted to eat or drink after midnight. This ensures that no food is in your stomach prior to induction of anesthesia. Before your procedure, an anesthesiologist will see you. You will be given medication which will decrease anxiety and induce relaxation and, once you are in the operating room, you will then be given general anesthesia. This medication is given by the anesthesiologist who will be at the head of the table. This medication will prevent you from feeling any pain during surgery and make you unaware of what is going on around you at this time. The procedure is then performed by the surgical team. It will be necessary for you to have a bladder catheter inserted to facilitate measurement of urine output during the operative and postoperative periods. The operative position will be a modified lateral position with your affected site elevated. Three 0.5 to 1cm small skin incisions will be created as shown in the following figure. The entire surgery will be performed through these incisions. During the operation, the stenotic (narrowed) portion of your ureteropelvic junction will be excised and then the ureter reconnected back to the kidney. A double-J ureteral stent will be placed to allow healing and drainage of urine from the kidney down to the bladder. The scar tissue will be removed completely and a drain left afterwards temporarily. The incisions will be closed and covered by tapes.

Postoperative Phase
After the procedure is completed, you will be placed back on the OR stretcher with total help from the surgical team and wheeled into the recovery room where you will be monitored by the recovery room nurses. They will check your blood pressure, pulse, respirations, temperature and drainage from your tubes. When you are awake you will go to your hospital room and the floor nurses will then take over. You may still be drowsy from the anesthesia, but as this begins to wear off, you might experience some discomfort where the manipulation took place. You will be given an injection of pain medication upon request and the effectiveness of the medication will be monitored. If it is not strong enough for the pain you are experiencing, it may be increased according to your doctor’s orders. The pain should begin decreasing each day in which case the dosage will be adjusted. The medication will eventually be changed to pills when you are tolerating fluids and food, usually within 4-48 hours. Getting ready for discharge: A regular liquid diet will be started on the first postoperative day. The drainage tube will be removed according to the amount of drainage. This will be usually the 1st to 2nd post-operative day. The double-J stent will be left inside your ureter for 4-6 weeks depending on the blockage, and whether there had been previous surgery. Total hospital days usually are 2-3 days. Upon discharge, you will be given printed discharge instructions. Please ask for these before you leave the hospital.

Follow Up
You should make an appointment to see your urologist within 10-14 days following your discharge. With the double-J stent inside your ureter, you might experience some related symptoms like mild flank or groin pain, blood in your urine, urgency and frequency. If urinary tract infection with fever and chills develops, a possible subsequence of the stent, you should immediately contact your urologist. This stent will be removed in the office under local anesthesia 4-6 weeks after the procedure. Six months after the procedure, a repeat renal scan will be performed to see how the ureter has healed.

Nephro-ureterectomy
What Is Laparoscopic Nephroureterectomy?
Surgical treatment of upper tract Urothelial Carcinoma (UC) [sometimes referred to Transitional Cell Carcinoma (TCC)] of the renal pelvis or ureter is nephroureterectomy (removal of kidney and ureter) with excision of a cuff of bladder. The incidence of local recurrence is as high as 40-60%. However, the traditional open nephroureterectomy involves two incisional wounds over the flank and lower quadrant of the abdomen. This guarantees a painful experience and a longer recovery time for the patients. On the contrary, laparoscopic nephroureterectomy has been shown to be associated with reduced perioperative morbidity, a shorter hospital stay, and a reduced requirement for transfusion than open nephroureterectomy, less pain medication requirements and a return to normal activity sooner. Laparoscopic nephroureterectomy is a safe treatment option for patients with upper tract UC. The shorter hospital stay and faster overall recovery are the obvious benefits to the patient.

Pre-admission
Within 1 week prior to your surgery, you will be scheduled for pre-admission testing. These tests generally consist of a complete blood count, electrolyte panel, urinalysis, urine culture, chest x-ray and, when indicated, an electrocardiogram. Before the procedure, you will require medical clearance from your primary care physician, or if you have a history of heart problems, clearance will need to be obtained from your cardiologist. If you do not have an internist, you may request one or your urologist will recommend one.

Operative Phase
The evening before your surgery, you will not be permitted to eat or drink after midnight. This ensures that no food is in your stomach prior to induction of anesthesia. Before your procedure, an anesthesiologist will see you. You will be given medication which will decrease anxiety and induce relaxation and, once you are in the operating room, you will then be given general anesthesia. This medication is given by the anesthesiologist who will be at the head of the table. This medication will prevent you from feeling any pain during surgery and make you unaware of what is going on around you at this time. The procedure is then performed by the surgical team. It will be necessary for you to have a bladder catheter inserted to help measure urine output during the operative and postoperative periods as well as assist measurement of urine output after the procedure. The operative position will be a modified lateral position with the affected site upright 45degrees. Three 0.5 to 1cm small skin incisions will be created as shown in the following figure. The entire surgery will be performed through these incisions. If removal of the whole specimen for the pathologic evaluation is considered, another skin incision about 5-7cm over lower abdominal wall will be created. After the operation, the affected kidney and ureter will be extracted as a whole via a specimen bag and a drain will be left over lower abdomen. The wounds will be closed and covered by tapes. Because absorbable suture is used, there is no need for removal of any stitch in the future.

Postoperative Phase
After the procedure is completed, you will be placed back on the OR stretcher with total help from the surgical team and wheeled into the recovery room where you will be monitored by the recovery room nurses. They will check your blood pressure, pulse, respirations, temperature and drainage from your tubes. When you are completely awakened from anesthesia, you will return to your room and the floor nurses will then take care of you. You may still be drowsy from the anesthesia, but as this begins to wear off, you might experience some discomfort where the surgery took place. You will be given an injection of pain medication upon request and the effectiveness of the medication will be monitored. If it is not strong enough for the pain you are experiencing, it may be increased according to your doctor’s orders. The pain should begin decreasing each day in which case the dosage will be adjusted. The medication will eventually be changed to pills when you are tolerating fluids and food, usually within 4-48 hours. Getting ready for discharge: You may go home with the bladder catheter in order to allow the bladder to heal. This catheter is generally removed 5-7 days after the surgery. A clear liquid diet will be allowed on the first postoperative day. The drain will be removed according to the daily amount and quality of the drained fluid. This will usually prior to discharge. The admission is usually a period of time between 2 to 3 days. Upon discharge, you will be given printed discharge instructions. Please ask for these before you leave the hospital.

Follow Up
You should make an appointment to see your urologist within 10-14 days following your discharge. The pathologic report will be discussed with you as well as an inspection of your operative wounds. Because of the nature of the cancer, a close schedule of surveillance of the bladder and other kidney will need to be performed. Especially since the incidence of future bladder recurrence is as high as 30 – 60%. You should be followed up on a schedule of 3 months, 6 months, 9 months, 1 year for cystoscopy, and then every six months following that, for at least five years. Furthermore, studies including urine cytology evaluation, chest X-ray film, excretory or retrograde urography, CT scan, and blood tests will be arranged as needed.

Adrenalectomy
Robotic Assisted Laparoscopic Inguinal Lymphadectomy
Certain Penile, Vulvar and Skin Cancers such as Melanoma require inguinal lymphadenectomy, the removal of lymphdodes in the groin, as part of their surgical treatment.

In the past this has been treated by large incisions into the groin which required a significantly extended recovery and often is frought with wound complications, scaring and lymphedema.

Recently this diseased has been approached through minimally invasive techniques which have decreased complications, hospital stays, pain and time to full recovery.  Moreover, the risk of disabling lymphedema has greatly decreased.

If you have been diagnosed with one of the above conditions and require treatment surgically.  Please call and schedule a consultation to see if you would be a candidate for a minimally invasive approach.

Robotic Sacrocolpopexy
Pelvic Organ Prolapse
The classic treatment of cystocele or rectocele required large abdominal or vaginal incisions. Newer treatment of cystocele and rectocele involve minimally invasive surgery. While there are still indication for performing these pelvic reconstruction cases vaginally or even with the standard open incision.  Dr. Keel is able to replicate the same procedures with the latest technology utilizing the da Vinci Robot.

Procedure
da Vinci Robotic Cystocele/Rectocele repair is performed with 4-5 tiny incisions, no wider than your thumb. Using the robot, Dr. Keel is able to repair and restore many of the sagging support structures of the pelvic organs.

Mesh, similar to that used to fix hernias, has been shown to markedly improve the repair, and reduce the chance of recurrence of bladder or rectal prolapse.

For some women with more complex reconstructive issues, a combined robotic/vaginal approach may be required to achieve optimal results.

Pre-admission
Within 1 week prior to your surgery, you will be scheduled for pre-admission testing. These tests generally consist of a complete blood count, electrolyte panel, urinalysis, urine culture, chest x-ray and, when indicated, an electrocardiogram. Before the procedure, you will require medical clearance from your primary care physician. If you do not have an internist, you may request one or your urologist will recommend one.

Operative Phase
The evening before your surgery, you will not be permitted to eat or drink after midnight. This ensures that no food is in your stomach prior to induction of anesthesia. Before your procedure, an anesthesiologist will see you. You will be given medication which will decrease anxiety and induce relaxation and, once you are in the operating room, you will then be given general anesthesia. This medication is given by the anesthesiologist who will be at the head of the table. This medication will prevent you from feeling any pain during surgery. The procedure is then performed by the surgical team. It will be necessary for you to have a bladder catheter inserted to facilitate the record of urine output during the operative and postoperative periods as well as assist your urination after the procedure since normal urination may be influenced by the anesthesia. The operative position will be in the Lithotomy postion. Four to five (0.5 to 1cm) small skin incisions will be created to perform the procedure. After the operation you will have a vaginally packing which will be removed in the morning. The wounds will be closed and covered by tapes. There is no need for removal of any stitch in the future.

Post-operation
After the procedure is completed, you will be placed back on the OR stretcher with total help from the surgical team and wheeled into the recovery room where you will be monitored by the recovery room nurses. They will check your blood pressure, pulse, respirations, temperature and drainage from your tubes. When you are awake and your condition is stable, you will return to your room and the floor nurses will then take over your care. You may still be drowsy from the anesthesia, but as this begins to wear off, you might experience some discomfort where the incisions. You will be given an injection of pain medication upon request and the effectiveness of the medication will be monitored. If it is not strong enough for the pain you are experiencing, it may be increased according to your doctor’s orders. The pain should begin decreasing each day in which case the dosage will be adjusted. The medication will eventually be changed to pills when you are tolerating fluids and food, usually within 4-48 hours. Getting ready for discharge: You will probably not have any tubes in place when you go home. The urethral catheter is always removed on the first postoperative day along with the vaginal packing. A clear liquid diet will be allowed on the first day. The total admission days usually are 1 to 2 days. Upon discharge, you will be given printed discharge instructions. Please ask for these before you leave the hospital.

Vaginal spotting may be common, and should gradually decrease after surgery.

No intercourse for six weeks after the procedure.

Constipation can be a problem following pelvic surgery.  If you have chronic constipation I advise that you begin MiraLax 1 week prior to your procedure, and advise all patients to utilize this as part of a post-operative bowel management program following pelvic surgery.  No suppositories or enemas should be used for 4 weeks following your surgery.

Follow Up
You should make an appointment to see me or your gynecologist within 10-14 days following your discharge.  Here we will discuss your progress and expectations.  You should not lift anything >10lbs (or a gallon of milk) for 4-6 weeks following your procedure.  You can usually return to work with about 3 weeks.

Adrenalectomy
What Is Robotic/Laparoscopic Adrenalectomy?
With improvements in diagnosis, precise radiological localization, preoperative medical management, anesthesia, and refined surgical techniques, surgical management of adrenal abnormalities with laparoscopic adrenalectomy is a safe procedure with a predictable outcome. It is now a standard of care. The diagnosis and management of disorders of the adrenal gland are among the most challenging and satisfying aspect of urological practice. Laparoscopic surgery has established a clear benefit to patients with adrenal diseases because of its minimal invasiveness and low morbidity. The role for open surgery is reserved for very large, > 6cm functioning adrenal cancers. Laparoscopic adrenalectomy is the optimal treatment for adrenal masses < 6cm, for both hormonally functioning and nonfunctioning adrenal masses.

Pre-admission
Within 1 week prior to your surgery, you will be scheduled for pre-admission testing. These tests generally consist of a complete blood count, electrolyte panel, urinalysis, urine culture, chest x-ray and, when indicated, an electrocardiogram. In cases of hypertension due to functional adrenal masses, premedication with antihypertensive agents is indicated for two weeks before the procedure. Before the procedure, you will need medical clearance from your primary care physician. If you do not have an internist, you may request one or your urologist will recommend one.

Operative Phase
The evening before your surgery, you will not be permitted to eat or drink after midnight. This ensures that no food is in your stomach prior to induction of anesthesia. The day of your procedure, you will meet the anesthesiologist to discuss the risks and benefits of general anesthesia. You will be given medication which will decrease anxiety and induce relaxation and, once you are in the operating room, you will be given general anesthesia. These medications and anesthesia are given by the anesthesiologist who will be at the head of the table, which will prevent you from feeling any pain during surgery. The procedure is then performed by the surgical team. It will be necessary for you to have a urethral catheter inserted to measure urine output during the operative and postoperative periods as well as assist your urination after the procedure since normal voiding may be influenced by the anesthesia. The operative position will be slightly oblique with the affected site elevated about 45 degrees. Three to four 0.5 to 1cm small skin incisions will be created as demonstrated on the following figure. The complete surgery will be performed through these incisions.After the operation, the affected adrenal gland will be extracted intact within a specimen bag. The wounds will be closed and covered by tapes (steri-strips). Because the stitches used to close the incision are absorbable, there is no need for removal of any stitch in the future. After a week, the tapes will curl up and fall off.

Postoperative Phase
After the procedure is completed, you will be placed back on the OR stretcher with help from the surgical team and wheeled into the recovery room where you will be monitored by the recovery room nurses. They will check your blood pressure, pulse, respirations, temperature and drainage from your tubes. When you are awake and your condition is stable, you will then go to your hospital room and the floor nurses will then take over your care. You may still be drowsy from the anesthesia, but as this begins to wear off, you might experience some discomfort where the manipulation took place. You will be given an injection of pain medication upon request and the effectiveness of the medication will be monitored. If it is not strong enough for the pain you are experiencing, it may be increased according to your doctor’s orders. The pain should decrease each day and prior to discharge, the medication will be changed to pills when you are tolerating fluids and food, usually within 4-48 hours. Getting ready for discharge: You will most likely not have any tube in place when you go home. The urethral catheter is usually removed on the first postoperative day. A clear liquid diet will be allowed on the first postoperative day, and advanced to solid food prior to discharge. The admission is usually a period of 2 days. Upon discharge, you will be given printed discharge instructions. Please ask for these before you leave the hospital. You may shower, go up stairs, and resume light activity upon discharge.

Follow Up
You should make an appointment to see your urologist within 10-14 days following your discharge. The pathologic report will be discussed with you as well as an inspection of your operative sites. In case of malignant nature of the disease, you should be followed up on a schedule of 3 months, 6 months, 1 year, 1 and a half years, 2 years, and so on for at least five years. Studies including Abdominal CT scan, chest X-ray film, and blood tests will be arranged as indicated. In case of functional neoplasm with hypertension, hyperaldosteronism, or Cushing’s disease, the dosage of your preoperative medication might need to be readjusted. You should also follow-up with your internist to adjust any of these medications.

Kidney Stones
Urolithiasis (kidney stones) is a fairly common condition, with a prevalence of 10-15% of the US population. Stones are more common in Caucasians, followed by Hispanics, Asians, and African-Americans. Men are more likely than women to develop stones. Also, patients with a higher body mass index are more likely to form stones. Climate and location can also affect stone risk, with arid and warmer climates having a higher incidence. In the US, the Southeast has the highest incidence of stone formation and is referred to as the “Stone Belt”.

Diagnosis
The classic symptoms of a kidney stone include flank pain that radiates to the groin. This symptom may be referred to as “renal colic” and usually results from obstruction of urine passage from the kidney to the bladder through the ureter. Hematuria, or blood in the urine, may also be present. The pain may be significant enough to cause nausea and vomiting. Concomitant infection in the urinary tract may also be present and may cause a fever. Diagnosing a kidney stone is based on taking a history and performing a physical exam. In addition, lab tests and imaging studies are typically used to confirm the diagnosis. A medical history is obtained to better define the symptoms. Also, a personal history or family history of stones may be a contributing factor. Associated medical conditions that may increase the risk of stone disease may be identified, such as obesity, inflammatory bowel diseases, or recurrent urinary tract infections. Previous surgeries, including previous urinary tract surgery, or bowel surgery, may indicate the presence of stones. A focused physical exam, including vital signs such as temperature and heart rate, is performed. Flank or abdominal tenderness on the affected side is typically identified.

Lab Testing
Further diagnostic strategies include lab tests and imaging studies. A urinalysis is performed in order to identify the presence of blood in the urine (common with stones). The urinalysis may also show signs of infection in the urine. Blood tests are obtained, including complete blood count and a chemistry panel. These are used to assess for the body’s response to infection (if present) as well as to assess the overall kidney function. Occasionally, a stone can obstruct the affected kidney and decrease kidney function, typically seen as a rise in the serum creatinine measurement. Rarely, stones cause acute renal failure. This is usually due to complete obstruction of a solitary kidney or complete obstruction of both kidneys (extremely uncommon).

Imaging
Imaging studies are the mainstay of diagnosis of urolithiasis. Most commonly, a helical computed tomography scan (CT or CAT scan) is used to diagnose kidney stones. These studies can be performed quickly without the need for intravenous contrast material as kidney stones are easily visible as calcifications. These studies provide invaluable information, such as the number, size, and location of stones and the presence of any associated or predisposing anatomical factors. Hydronephrosis, or swelling of the kidney’s collecting system and ureter, may be used to assess for the presence of obstruction in the affected kidney. Other imaging studies used to diagnose kidney stones include intravenous pyelogram (IVP – requires IV contrast), plain abdominal x-rays, or renal ultrasound. These studies are not as accurate in diagnosing the presence of stones.

Prevention
The best treatment for kidney stones is prevention. For the majority of patients suffering a first kidney stone, the main prevention strategy includes hydration. The goal is to produce around 2 liters of urine per day. This can significantly decrease the risk of recurrence. Also, patients may make dietary alterations, such as decreasing salt and protein intake. Patients should normalize their calcium intake. In fact, cutting back significantly on calcium intake may actually increase recurrence risk. For patients suffering more than one stone episode, those with a significant family history, or young patients with stones should undergo further testing. This generally involves a metabolic evaluation and multiple urine studies to determine the underlying cause of stone formation. Following these studies, dietary modifications and/or medications may be used to decrease the risk of further stone formation.

Management
Initial management of kidney stones depends on several factors. These include the size and location of the stone(s), presence or absence of obstruction, presence of a solitary kidney, presence of infection, or other anatomic factors that may affect management. In general, patients with smaller kidney stones (<5mm) are usually managed with analgesics and medical expulsive therapy. This usually involves prescribing medications for pain control and medications that may increase the rate of passage of the stone. Medical expulsive therapy has been shown to be very effective in increasing the rate of stone passage. This is especially true for smaller stones located in the ureter closer to the bladder. For instance, stones less less than 3mm in size have about an 80% chance of passage without intervention and similar stones very close to the bladder have even higher passage rates. Medical expulsive therapy or observation is typically continued for 4-6 weeks, at which time surgical intervention may be considered if the stone has yet to pass.

Surgery
Surgical intervention can be divided into immediate or emergent procedures and more definitive procedures to treat the stone. Immediate intervention is reserved for certain situations that demand decompression of the affected kidney. These situations include the presence of significant infection and/or fever associated with an obstructing stone, blockage of a solitary kidney, blockage of both kidneys, intractable pain uncontrolled by medications, or persistent nausea/vomiting. In these situations, relieving the obstruction involves placement of a ureteral stent or a percutaneous nephrostomy. A ureteral stent is usually placed using a small scope and camera passed through the urethra and into the bladder. A small hollow flexible tube is then passed up the affected ureter to bypass the stone and allow drainage of the obstructed kidney. Alternatively, a percutaneous tube is placed through the back directly into the kidney to allow drainage. If a urinary tract infection is present, antibiotics are then administered.

ESWL – Extracorporeal Shock Wave Lithotripsy
Definitive management of the stone depends on various factors. Several minimally invasive options are available for treatment. Extracorporeal shock wave lithotripsy (ESWL) uses shock waves passed through the skin to fragment the stone. ESWL is most commonly used for proximal ureteral stones and stones within the kidney that are less than around 1.5cm (or 15mm) in size. Typically, a ureteral stent may be placed before performing ESWL for larger stones (>1cm). The fragmented stone is then easily passed in the urine.

Ureteroscopy
Ureteroscopy can be used for stones anywhere in the ureter and some parts of the kideny. This procedure involves the passage of a small scope and camera through the urethra, into the bladder, and up the ureter of the affected side. Once the stone is identified, a laser can be used to fragment the stone or a small basket can be passed through the scope to grasp and remove the stone. Both ESWL and ureteroscopy have similar success rates for stones located in the proximal ureter and kidney. The success rate declines for both modalities as the size of the stone increases to larger than 1.5 cm. Ureteroscopy is typically used for stones located in the mid-portion of the ureter or in the distal ureter.

Percutaneous Nephrolithotomy & Ultrasonic Lithotripsy
Definitive management of larger stones (>2cm) or multiple large stones in a kidney may require more invasive procedures.
Percutaneous removal of stones from the kidney can be used for large stones, especially those located in the lower portion of the kidney. This procedure involves placing a tube directly into the kidney through the back. This percutaneous tract is then dilated to allow passage of a scope with a camera attached. Several devices can then be used to fragment the stones and remove them from the kidney. Typically, these procedures require an overnight stay in the hospital. Very large stones in the kidney may require a combination of procedures, such as percutaneous removal and ESWL. Occasionally, patients with large stones impacted in the ureter or those with anatomic factors associated with stones may require laparoscopic or robotic procedures to remove the stones and correct the associated anatomic anomaly. For example, a patient with a stricture or obstruction between the kidney and the ureter (UPJ obstruction) may undergo repair of the obstruction and removal of the kidney stones using laparoscopic/robotic techniques.

Renal Cyst Management

What is Laparoscopic Surgery?
Simple cysts are the most common lesions of the kidney. The incidence of cysts increases with age. Symptoms are usually caused by the size of the cyst or to its impingement, or mass effect, on adjacent structures such as the ureter or renal parenchyma. Symptomatic, solitary renal cysts can be managed using percutaneous aspiration and injection of sclerosing agents. For patients with recurrent symptomatic cysts, or cysts that are not easily accessed through the percutaneous approach, a laparoscopic technique will help unroof the cyst. If a cyst is suspicious for malignancy, aspiration and biopsy of the cyst wall are indicated.

Pre-admission
Within 1 week prior to your surgery, you will be scheduled for pre-admission testing. These tests generally consist of a complete blood count, electrolyte panel, urinalysis, urine culture, chest x-ray and, when indicated, an electrocardiogram. Before the procedure, you will need medical clearance from your primary care physician. If you do not have an internist, you may request one or your urologist will recommend one.

Operative Phase
The evening before your surgery, you will not be permitted to eat or drink after midnight. This ensures that no food is in your stomach prior to induction of anesthesia. Before your procedure, an anesthesiologist will meet you and discuss the risks and benefits of general anesthesia. You will be given medication which will decrease anxiety and induce relaxation and, once you are in the operating room, you will be given general anesthesia. These medications as well as anesthesia are given by the anesthesiologist who will be at the head of the table. These medications will prevent you from feeling any pain during surgery. The procedure is then performed by the surgical team. It will be necessary for you to have a bladder catheter inserted to measure urine output during the operative and postoperative periods. Normally, this tube will be removed after the operation. The operative position will be slightly oblique with the affected site elevated about 45 degrees. Three 0.5 to 1cm small skin incisions will be created as demonstrated on the following figure. The complete surgery will be performed through these incisions. After the operation, a biopsy of the cystic wall will be taken for pathological evaluation, which normally takes 3-5 days. In select cases, a drainage tube will be left temporarily. The wounds will be closed and covered by tapes. There is no need for removal of any stitch in the future.

Postoperative Phase
After the procedure is completed, you will be placed back on the OR stretcher with total help from the surgical team and wheeled into the recovery room where you will be monitored by the recovery room nurses. They will check your blood pressure, pulse, respirations, temperature and drainage from your tubes. When you are awake and your condition is stable, you will return to your room and the floor nurses will then take over your care. You may still be drowsy from the anesthesia, but as this begins to wear off, you might experience some pain where the manipulation took place. You will be given an injection of pain medication upon request and the effectiveness of the medication will be monitored. If it is not strong enough for the pain you are experiencing, it may be increased according to your doctor’s orders. The pain should begin decreasing each day in which case the dosage will be adjusted. The medication will eventually be changed to pills when you are tolerating fluids and food, usually within 4-24 hours. Getting ready for discharge: You will probably not have any tube in place when you go home. The catheter in your bladder is generally removed on the first postoperative day. A clear liquid diet will be started as well on the first postoperative day. If a drain was left, the tube will be removed according to the daily amount and quality of the drained fluid. The admission is usually a period of 1 to 2 days. Upon discharge, you will be given printed discharge instructions. Please ask for these before you leave the hospital.

Follow Up
You should make an appointment to see your urologist within 10-14 days following your discharge. The pathology report will be discussed with you as well as an exam of your incisions. If the cysts are diagnosed as cancer, you should be followed up on a schedule of 3 months, 6 months, 1 year, 1 and a half years, 2 years, for at least a period of five years. If the cyst disease is benign, you should still have regular checkups for monitoring of blood pressure, kidney function, and recurrence of the cysts.

BPH (Large Prostate)
How is BPH diagnosed?
In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH—ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE),PSA testrectal ultrasoundurine flow study and cystoscopy.

When is surgical treatment suggested as a form of treatment?
When medical therapy fails, surgery is required to remove the obstructing tissue. Surgery is almost always recommended for men who are unable to urinate, have kidney damage, frequent urinary tract infections, significant bleeding or stones in the bladder.
What are the different surgical treatments available?
Removal of the prostate can be accomplished in several different ways. The location of the enlargement within the prostate and the patient’s general health will help the urologist determine which of the three following procedures to use.

Transurethral resection of the prostate (TURP): Transurethral resection is the most common surgery for BPH. In the United States, approximately 150,000 people have TURPs performed each year. This can be done using electric current or with laser light. After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. The removed tissue pieces are carried by the irrigating fluid into the bladder and then flushed out and sent to a pathologist for examination under a microscope. At the end of the procedure, a catheter is placed in the bladder through the penis. The bladder is continuously irrigated with fluid through the catheter in order to monitor bleeding and prevent blood from clotting and obstructing the catheter. Since there are no surgical incisions with this procedure, patients normally stay in the hospital only one to two days. Depending on surgeon preference, the catheter may be removed while the patient is still in the hospital or the patient may be sent home with the catheter in place, attached to a leg bag for convenience and removed several days later as an outpatient procedure.

Minimally Invasive Surgical Treatments
Newer surgical modalities for the treatment of BPH have been aimed at providing a one-time minimally invasive therapy that is associated with fewer complications than TURP.

Laser Enucleation of the Prostate (HoLEP or ThuLEP) or Laser Vaporization
This techniques utilizes laser technology to achieve the same goal as TURP with equal efficacy and improved safety.  Most patients are able to be discharged the same day as their procedure and their catheters are removed the following day.  This is most effective on larger prostates larger than 60 grams.

Prostatectomy:
When a transurethral procedure cannot be done, Robotic or open surgery may be required. Prostatectomy for BPH is also performed for a prostate that is too large to remove through the penis. Other reasons for choosing a prostatectomy include patients with large bladder diverticula, with large bladder stones and those who cannot physically tolerate having their legs placed in stirrups for TURP/TUIP surgery.

Through small incisions, surgeons operate using a robotic platform with 3D-HD vision and miniaturized wristed instruments. Robotic prostatectomy enables surgeons to operate with enhanced visions, precision and control. This is important when it comes to preserving urinary and erectile function.  An incision is made in the abdominal wall from below the belly button to the pubic bone. The prostate gland can then be removed in its entirety through this process.  Postoperative pain is mild to moderate. Patients usually stay in the hospital for 1-2 days and go home with a urinary catheter. In some cases a second catheter draining the bladder through the lower abdominal wall is used.

What can be expected after treatment?
Postoperatively, patients typically experience significant improvement in their symptoms (table 1). As with any operative procedure, complications do exist. Some occur in the early postoperative period (table 2) while others may occur many years later (table 3).

Will surgery for BPH affect my ability to enjoy sex?
Most urologists say that even though it takes a while for sexual function to return fully, most men are able to enjoy sex again. Most experts agree that if you were able to maintain an erection shortly before surgery, you will probably be able to do so after surgery. Most men find little or no difference in the sensation of orgasm although they may find themselves suffering from retrograde ejaculation.

Is BPH a rare condition?
No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?
No, BPH is not cancer and cannot lead to cancer. Still, both problems can happen at the same time. There may not be any symptoms during the early stages of prostate cancer. So whether their prostate is enlarged or not, men should talk to their health care providers about whether prostate cancer screening is right for them.

*This page’s information is courtesy of The Urology Care Foundation with some revisions. 

Urinary Tract Reconstruction
Kidney obstructions can be managed using robotic and laparoscopic surgical techniques. These surgical techniques drastically decrease the size of incision and promote early convalescence and recovery. Dr. Keel and his team is highly experienced in performing complex reconstructive procedures to treat ureteropelvic junction obstruction, management of ureteral strictures using bladder tubular flaps (Boari Flaps) and management of urinary fistulas.  Other modalities such as ileal interposition, urinary diversion and auto-transplant can be used.

Upper Urinary Tract Reconstruction

Lower Urinary Tract Reconstruction

URETHRAL STRICTURE DISEASE
The urethra is an important part of the urinary tract. While it’s primary job in both genders is to pass urine outside the body, this channel also has an important role in ejaculating semen from the reproductive tract of men. Most people will not have any problems with the urethra, but a few of us may experience the discomfort and dysfunction associated with urethral stricture disease. What is this and how can it be treated? The information below should help you talk with your urologist.

What happens under normal conditions?
During urination, the bladder empties through the urethra and out of the body. Urine passes through an opening called the bladder neck into a portion of the urethra surrounded by the prostate, called the prostatic urethra. The next segment of the urethra is called the membranous urethra and it contains a muscle called the external urinary sphincter. This sphincter allows a patient to voluntarily hold urine and to stop during urination. Together, the prostatic urethra and the membranous urethra make up the posterior urethra, and are approximately one to two inches long. The urine then enters the bulbar urethra, followed by the penile urethra. The penile urethra is the segment that runs along the bottom surface of the penis. The exit at the tip of the penis is called the meatus. The bulbar urethra, penile urethra and meatus make up the anterior urethra, which is nine to 10 inches long.

What is a urethral stricture?
A urethral stricture is a scar in or around the urethra, which can block the flow of urine, and is a result of inflammation, injury or infection.

Who is at risk for urethral strictures?
Urethral strictures are more common in men because their urethras are longer than those in women. Thus men’s urethras are more susceptible to disease or injury. A person is rarely born with urethral strictures and women rarely develop urethral strictures.

What are some causes of urethral stricture?
Stricture disease may occur anywhere from the bladder to the tip of the penis. The common causes of stricture are trauma to the urethra and infections such as sexually transmitted disease or damage from instrumentation. However, in most cases, no cause can be identified. Stricture of the posterior urethra is often caused by a urethral injury associated with a pelvic bone fracture (e.g., motor vehicle or industrial accident).

Patients who sustain posterior urethral injuries from pelvic fracture generally suffer a disruption of the urethra, where the urethra is cut and separated. These patients are completely unable to urinate and must have a catheter to realign the urethra. The catheter is placed through the penis up into the bladder to allow urine to drain until a repair can be performed. Trauma such as straddle injuries, direct trauma to the penis and catheterization can result in strictures of the anterior urethra. In adults, urethral strictures may occur after prostate surgery, removal of kidney stones, urinary catheterization or other instrumentation.

In children, urethral strictures most often follow reconstructive surgery for congenital abnormalities of the penis and urethra, cystoscopy and urethral catheter drainage.

What are the symptoms of urethral strictures?
Some symptoms that may be an indication of urethral strictures can include:
• painful urination
• slow urine stream
• decreased urine output
• spraying of the urine stream
• blood in the urine
• abdominal pain
• urethral discharge
• urinary tract infections in men
• infertility

How are urethral strictures diagnosed?
Simply put, the urethra is like a garden hose. When there is a kink or narrowing along the hose, no matter how short or long, flow can be significantly reduced. When a stricture becomes narrow enough to decrease urine flow, the patient will develop symptoms. Frequent urination, urinary tract infections and inflammation or infections of the prostate and scrotal contents (epididymis) may occur. With long-term severe obstruction, damage to the kidneys can occur.

Evaluation of patients with urethral stricture disease includes a physical examination, urethral imaging (X-rays or ultrasound) and sometimes urethroscopy. The retrograde urethrogram is an invaluable test to evaluate and document the stricture and define the stricture recurrence. Combined with antegrade urethrogram, length of the stricture in order to plan surgical correction can be determined. The retrograde urethrogram is performed as an outpatient X-ray procedure and can define indicate the number, position, length and severity of the stricture(s). This study involves insertion of contrast dye (fluid that can be seen on an X-ray) into the urethra at the tip of the penis. No needles or catheters are used. The retrograde urethrogram study allows doctors to see the entire urethra and outlines the area of narrowing at the stricture. Ultrasound is performed by placing a small, pencil-like ultrasound wand on the skin over the stricture to view it and surrounding tissue. Urethroscopy is a procedure where the doctor gently places a small, flexible, lubricated telescope into the urethra and advances it to the stricture. This study permits the doctor to see the urethra between the tip of the penis and the stricture. All of these tests can be performed in an office setting and will allow the urologist to provide treatment recommendations.

In the case of urethral trauma, once emergency treatment has been provided, the evaluation of patients with posterior urethral disruptions involves a retrograde urethrogram, and if a suprapubic catheter is present, injection of contrast dye through this tube at the same time. Contrast injected from below fills the urethra up to the injured area, and contrast injected from above fills the bladder and the urethra down to the stricture. These two films together allow the surgeon to determine the gap between the two ends in order to plan the surgical repair.

How can urethral strictures be prevented?
The most important preventive measure is to avoid injury to the urethra and pelvis. Also, if a patient is performing self-catheterization they should exercise care, to liberally instill lubricating jelly into the urethra, and to use the smallest possible catheter necessary for the shortest period of time.

Acquired strictures may be a result of inflammation caused by sexually transmitted infections (STIs). Although gonorrhea was once the most common cause of inflammatory strictures antibiotic therapy has proven effective in reducing the number of resulting strictures. Chlamydia is now the more common cause, but strictures caused by this infection may be prevented by avoiding contact with infected individuals or by using condoms. When infection does occur, prompt and complete treatment of the STI with appropriate antibiotics will help prevent future problems.

What are some treatment options?
Treatment options for urethral stricture disease are varied and selection depends upon the length, location and degree of scar tissue associated with the stricture. Options include enlarging the stricture by gradual stretching (dilation), cutting the stricture with a laser or knife through a scope (urethrotomy) and surgical removal (excision) of the stricture with reconnection and reconstruction possibly with grafts.

Dilation This is usually performed in the urologist’s office under local anesthetic and involves stretching the stricture using progressively larger dilators called “sounds.” Alternatively, the stricture can be dilated with a special balloon on a catheter. Dilation is rarely a cure and needs to be periodically repeated. If the stricture recurs too rapidly the patient may be taught how to insert a catheter into the urethra periodically to prevent early closure.

Pain, bleeding and infection are the main problems associated with dilation procedures. Occasionally, a “false passage” or second urethral channel may be formed from traumatic passage of the “sound.”

Urethrotomy
This procedure involves use of a specially designed cystoscope that is advanced along the urethra until the stricture is encountered. A knife blade or laser operating from the end of the cystoscope is then used to cut the stricture, creating a gap in the narrowing. A catheter may be placed into the urethra to hold the cleft open for a period of time after the procedure to allow healing in the open position. The suggested length of time for leaving a catheter tube draining after stricture treatment can vary.

Urethral Stent
This procedure involves placement of a metallic stent that has the appearance of a circular chain link fence. The stent is placed into the urethra through the penis using a specially designed cystoscopic insertion tool after the urethra is widened. The stent expands within the widened stricture and prevents the urethra from closing. The lining of the urethra eventually covers the stent, which remains in place permanently. This treatment has the advantage of being “minimally invasive.” However, it is only suited to very select strictures and frequently causes significant swelling around the device. Removal of these devices is very difficult and may result in a more significant stricture.

Open surgical urethral reconstruction
Many different reconstructive procedures have been used to treat strictures, some of which require one or two operations. In all cases, the choice of repair is influenced by the characteristics of the stricture (such as location, length and severity), and no single repair is appropriate for all situations. Open reconstruction of a short urethral stricture may involve surgery to remove the stricture and reconnect the two ends (anastomotic urethroplasty). When the stricture is long and this repair is not possible, tissue can be transferred to enlarge the segment to normal (substitution procedures). Substitution repairs may need to be performed in stages in difficult circumstances.

Anastomotic Procedures
These are usually reserved for short urethral strictures where the urethra can be reconnected after removing the stricture. This procedure involves a cut between the scrotum and rectum. This is usually performed as an outpatient procedure or with a brief hospitalization. A small, soft catheter will be left in the penis for 10 to 21 days and removed after an X-ray is performed to ensure healing of the repair.

Substitution Procedures
• Free Graft Procedures: Longer strictures may be repaired with a free graft procedure to enlarge the urethra. The graft may be skin (usually removed from the shaft of the penis) or buccal mucosa removed from inside the cheek. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.

• Skin Flap Procedures: When a long stricture is associated with severe scarring and a free graft would not survive, flaps of skin can be rotated from the penis to ensure survival of the newly created urethra. These procedures are complex and require a surgeon experienced in plastic surgery techniques. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.

• Staged Procedure: When sufficient local tissue is not available for a skin flap procedure and local tissue factors are not suitable for a free graft, a staged procedure may be required. The first stage in a staged procedure focuses on opening the underside of the urethra to expose the complete length of the stricture. A graft is secured to the edges of the opened urethra and allowed to heal and mature over a period of three months to a year. During that time, patients urinate through a new opening behind the stricture, which in some cases will require the patient to sit down to urinate. The second stage is performed several months after the graft around the urethra has healed and is soft and flexible. At this stage the graft is formed into a tube and the urethra is returned to normal. A small, soft catheter will be left in the penis for 10 to 21 days.

What are the possibilities of recurrence?
Because urethral strictures can recur at any time after surgery, patients should be monitored by an urologist. After removal of the catheter, follow-up of the repair should be performed intermittently with physical examination and X-ray studies being performed as necessary. Sometimes, the doctor will perform urethroscopy to evaluate the repaired area. Some patients will have recurrence of stricture at the site of the prior repair. These are sometimes mild and require no intervention, but if they cause obstruction they can be treated with urethrotomy or dilation. A repeat open surgical repair may be needed for significant recurrent strictures.

Frequently asked questions:
Can urethral strictures be treated with medicine?
No.

What can occur if no treatment is taken?
The patient would have to continue to tolerate problems with urination. Urinary and/or testicular infections and stones can develop. Also, there is a risk that urinary retention may occur which can cause the bladder to enlarge and also lead to kidney problems.

Is there a risk of infecting others with urethral strictures?
Urethral strictures are not contagious but the underlying cause, like an STI, may be contagious.

*This page’s information is courtesy of The Urology Care Foundation with some revisions.

Urethral Stricture Disease
The urethra is an important part of the urinary tract. While it’s primary job in both genders is to pass urine outside the body, this channel also has an important role in ejaculating semen from the reproductive tract of men. Most people will not have any problems with the urethra, but a few of us may experience the discomfort and dysfunction associated with urethral stricture disease. What is this and how can it be treated? The information below should help you talk with your urologist.

What happens under normal conditions?
During urination, the bladder empties through the urethra and out of the body. Urine passes through an opening called the bladder neck into a portion of the urethra surrounded by the prostate, called the prostatic urethra. The next segment of the urethra is called the membranous urethra and it contains a muscle called the external urinary sphincter. This sphincter allows a patient to voluntarily hold urine and to stop during urination. Together, the prostatic urethra and the membranous urethra make up the posterior urethra, and are approximately one to two inches long. The urine then enters the bulbar urethra, followed by the penile urethra. The penile urethra is the segment that runs along the bottom surface of the penis. The exit at the tip of the penis is called the meatus. The bulbar urethra, penile urethra and meatus make up the anterior urethra, which is nine to 10 inches long.

What is a urethral stricture?
A urethral stricture is a scar in or around the urethra, which can block the flow of urine, and is a result of inflammation, injury or infection.

Who is at risk for urethral strictures?
Urethral strictures are more common in men because their urethras are longer than those in women. Thus men’s urethras are more susceptible to disease or injury. A person is rarely born with urethral strictures and women rarely develop urethral strictures.

What are some causes of urethral stricture?
Stricture disease may occur anywhere from the bladder to the tip of the penis. The common causes of stricture are trauma to the urethra and infections such as sexually transmitted disease or damage from instrumentation. However, in most cases, no cause can be identified. Stricture of the posterior urethra is often caused by a urethral injury associated with a pelvic bone fracture (e.g., motor vehicle or industrial accident). Patients who sustain posterior urethral injuries from pelvic fracture generally suffer a disruption of the urethra, where the urethra is cut and separated. These patients are completely unable to urinate and must have a catheter to realign the urethra. The catheter is placed through the penis up into the bladder to allow urine to drain until a repair can be performed. Trauma such as straddle injuries, direct trauma to the penis and catheterization can result in strictures of the anterior urethra. In adults, urethral strictures may occur after prostate surgery, removal of kidney stones, urinary catheterization or other instrumentation. In children, urethral strictures most often follow reconstructive surgery for congenital abnormalities of the penis and urethra, cystoscopy and urethral catheter drainage.

What are the symptoms of urethral strictures?
Some symptoms that may be an indication of urethral strictures can include:
• painful urination
• slow urine stream
• decreased urine output
• spraying of the urine stream
• blood in the urine
• abdominal pain
• urethral discharge
• urinary tract infections in men
• infertility

How are urethral strictures diagnosed?
Simply put, the urethra is like a garden hose. When there is a kink or narrowing along the hose, no matter how short or long, flow can be significantly reduced. When a stricture becomes narrow enough to decrease urine flow, the patient will develop symptoms. Frequent urination, urinary tract infections and inflammation or infections of the prostate and scrotal contents (epididymis) may occur. With long-term severe obstruction, damage to the kidneys can occur.

Evaluation of patients with urethral stricture disease includes a physical examination, urethral imaging (X-rays or ultrasound) and sometimes urethroscopy. The retrograde urethrogram is an invaluable test to evaluate and document the stricture and define the stricture recurrence. Combined with antegrade urethrogram, length of the stricture in order to plan surgical correction can be determined. The retrograde urethrogram is performed as an outpatient X-ray procedure and can define indicate the number, position, length and severity of the stricture(s). This study involves insertion of contrast dye (fluid that can be seen on an X-ray) into the urethra at the tip of the penis. No needles or catheters are used. The retrograde urethrogram study allows doctors to see the entire urethra and outlines the area of narrowing at the stricture.

Ultrasound is performed by placing a small, pencil-like ultrasound wand on the skin over the stricture to view it and surrounding tissue. Urethroscopy is a procedure where the doctor gently places a small, flexible, lubricated telescope into the urethra and advances it to the stricture. This study permits the doctor to see the urethra between the tip of the penis and the stricture. All of these tests can be performed in an office setting and will allow the urologist to provide treatment recommendations.

In the case of urethral trauma, once emergency treatment has been provided, the evaluation of patients with posterior urethral disruptions involves a retrograde urethrogram, and if a suprapubiccatheter is present, injection of contrast dye through this tube at the same time. Contrast injected from below fills the urethra up to the injured area, and contrast injected from above fills the bladder and the urethra down to the stricture. These two films together allow the surgeon to determine the gap between the two ends in order to plan the surgical repair.

How can urethral strictures be prevented?
The most important preventive measure is to avoid injury to the urethra and pelvis. Also, if a patient is performing self-catheterization they should exercise care, to liberally instill lubricating jelly into the urethra, and to use the smallest possible catheter necessary for the shortest period of time.

Acquired strictures may be a result of inflammation caused by sexually transmitted infections (STIs). Although gonorrhea was once the most common cause of inflammatory strictures antibiotic therapy has proven effective in reducing the number of resulting strictures. Chlamydia is now the more common cause, but strictures caused by this infection may be prevented by avoiding contact with infected individuals or by using condoms. When infection does occur, prompt and complete treatment of the STI with appropriate antibiotics will help prevent future problems.

What are some treatment options?
Treatment options for urethral stricture disease are varied and selection depends upon the length, location and degree of scar tissue associated with the stricture. Options include enlarging the stricture by gradual stretching (dilation), cutting the stricture with a laser or knife through a scope (urethrotomy) and surgical removal (excision) of the stricture with reconnection and reconstruction possibly with grafts.

Dilation
This is usually performed in the urologist’s office under local anesthetic and involves stretching the stricture using progressively larger dilators called “sounds.” Alternatively, the stricture can be dilated with a special balloon on a catheter. Dilation is rarely a cure and needs to be periodically repeated. If the stricture recurs too rapidly the patient may be taught how to insert a catheter into the urethra periodically to prevent early closure.

Pain, bleeding and infection are the main problems associated with dilation procedures. Occasionally, a “false passage” or second urethral channel may be formed from traumatic passage of the “sound.”

Urethrotomy
This procedure involves use of a specially designed cystoscope that is advanced along the urethra until the stricture is encountered. A knife blade or laser operating from the end of the cystoscope is then used to cut the stricture, creating a gap in the narrowing. A catheter may be placed into the urethra to hold the cleft open for a period of time after the procedure to allow healing in the open position.

The suggested length of time for leaving a catheter tube draining after stricture treatment can vary.

Urethral Stent
This procedure involves placement of a metallic stent that has the appearance of a circular chain link fence. The stent is placed into the urethra through the penis using a specially designed cystoscopic insertion tool after the urethra is widened. The stent expands within the widened stricture and prevents the urethra from closing. The lining of the urethra eventually covers the stent, which remains in place permanently. This treatment has the advantage of being “minimally invasive.” However, it is only suited to very select strictures and frequently causes significant swelling around the device. Removal of these devices is very difficult and may result in a more significant stricture.

Open surgical urethral reconstruction
Many different reconstructive procedures have been used to treat strictures, some of which require one or two operations. In all cases, the choice of repair is influenced by the characteristics of the stricture (such as location, length and severity), and no single repair is appropriate for all situations. Open reconstruction of a short urethral stricture may involve surgery to remove the stricture and reconnect the two ends (anastomotic urethroplasty). When the stricture is long and this repair is not possible, tissue can be transferred to enlarge the segment to normal (substitution procedures). Substitution repairs may need to be performed in stages in difficult circumstances.

Anastomotic Procedures
These are usually reserved for short urethral strictures where the urethra can be reconnected after removing the stricture. This procedure involves a cut between the scrotum and rectum. This is usually performed as an outpatient procedure or with a brief hospitalization. A small, soft catheter will be left in the penis for 10 to 21 days and removed after an X-ray is performed to ensure healing of the repair.

Substitution Procedures

  • Free Graft Procedures: Longer strictures may be repaired with a free graft procedure to enlarge the urethra. The graft may be skin (usually removed from the shaft of the penis) or buccal mucosa removed from inside the cheek. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.
  • Skin Flap Procedures: When a long stricture is associated with severe scarring and a free graft would not survive, flaps of skin can be rotated from the penis to ensure survival of the newly created urethra. These procedures are complex and require a surgeon experienced in plastic surgery techniques. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.
  • Staged Procedure: When sufficient local tissue is not available for a skin flap procedure and local tissue factors are not suitable for a free graft, a staged procedure may be required. The first stage in a staged procedure focuses on opening the underside of the urethra to expose the complete length of the stricture. A graft is secured to the edges of the opened urethra and allowed to heal and mature over a period of three months to a year. During that time, patients urinate through a new opening behind the stricture, which in some cases will require the patient to sit down to urinate. The second stage is performed several months after the graft around the urethra has healed and is soft and flexible. At this stage the graft is formed into a tube and the urethra is returned to normal. A small, soft catheter will be left in the penis for 10 to 21 days.

What are the possibilities of recurrence?
Because urethral strictures can recur at any time after surgery, patients should be monitored by an urologist. After removal of the catheter, follow-up of the repair should be performed intermittently with physical examination and X-ray studies being performed as necessary. Sometimes, the doctor will perform urethroscopy to evaluate the repaired area. Some patients will have recurrence of stricture at the site of the prior repair. These are sometimes mild and require no intervention, but if they cause obstruction they can be treated with urethrotomy or dilation. A repeat open surgical repair may be needed for significant recurrent strictures.

*Content from this page obtained from Urology Care Foundation

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