In the article entitled, “Self-employed urologists order more imaging” by Lynn Peeples, she discusses Dr Hollingsworth study published in the Journal of Urology. Dr Hollingsworth analyzed over 37 million visits to Urology offices using data from the National Ambulatory Medicare Survey conducted between 2006 to 2008. He found that one in five visits to a urologist ended in an imaging test being done. Urologists that were self-employed ordered more imaging tests than urologists that were employed differently, such as by hospitals. Of note, four or five urologists are self-employed. The most common tests performed were ultrasounds for enlarged prostate, kidney stones, or because of blood in the urine.

One of the suggestions for this increase in imaging ordered by urologists were monetary incentives. Also ordering of these tests did not vary because of age, gender, medicaid eligibility or urologist practice type or location. Other reasons for ordering more imaging by self-employed urologists included patient preference, legal concerns, and medical ambiguity.

Dr Hollingsworth feels that this study has direct relevance to some of the measures being addressed in health care reform in the Affordable Care Act of 2010. I would agree. However, I believe that the other reasons mentioned such as medical-legal concerns and proper testing play a more significant role in the number of imaging tests ordered by urologists. In addition, the hospital-based urologists may be pressured to order less testing that may be necessary to diagnosing the patient. For instance, a patient is referred for blood in the urine and is a smoker. This patient work-up includes imaging studies such as a CAT Scan to properly evaluate the kidneys and ureters. With an ultrasound, the significance of a kidney mass or kidney stone could be missed at a higher rate than with a CAT scan. The ultrasound is cheaper, but in this situation less accurate for evaluation of kidney masses or stones. which are a source of blood in the urine.

I am all for cutting costs, especially in cases of over utilization of imaging or other studies by all physicians, not just urologists. However, I do not believe in reducing costs at the expense of proper diagnosing for patient care. Dr Hollingsworth is correct in stating that the Center for Medicare and Medicaid are being charged with innovations to reimbursement models for physicians according to appropriate utilization (ordering of tests, imaging). But again, we must not loose site of proper care to the patient.

Positive surgical margins are the margins of the specimen, in this case the prostate, that are inked by the doctor called a pathologist.

A positive surgical margin or multiple positive margins implies a higher likelihood of spread of the cancer being found outside of the prostate either at the time of removal or in the future. In other words, the cancer was not contained at the time of removal. Hence, answering the question: “Are positive surgical margins more common after treatment of prostate cancer with Robotic-Assisted Laparoscopic Prostatectomy versus Radical Retropubic Prostatectomy?” is valid.

In the journal, Urology, the november issue Dr Stephen Williams and senior publisher, Dr. Jerome Richie set out to answer this question. The study involved 950 men treated over three years from 2005 to 2008. Men treated with robotic-assisted prostatectomy for prostate cancer are 1.9 times more likely to have a positive surgical margin versus men treated with the traditional open radical prostatectomy.

This is a statistic is worth looking at prior to making a decision on surgical treatment for prostate cancer.

In my opinion, the experience of the urologist performing the  robotic-assisted laparoscopic prostatectomy plays a big role in resulting positive surgical margins after treatment, as well as the size and anatomy of the prostate. Larger prostates may be more difficult to remove at the apex (front) of the prostate.

Her article is very provocative because in the article she outlines uses for iPhones and iPads which could change the way we treat patients. She describes using the iPhone to monitor a heart patient’s blood pressure, pulse, etc. through streaming on these devices. This would allow doctors to have a more precise and live update on his or her patient so as to make change immediately as necessary.

Hence, office visits would change. In other words, instead of coming to the office to be diagnosed and treated accordingly, one would just have his or her doctor communicate to him by streaming on an iPhone or such devices.

Dr. Saxon also mentions that heart conditions, such as congestive heart failure are a major reason for hospitalizations or readmissions to the hospital. The common picture is that the person has an exacerbation of his chronic condition and ends up in the hospital, gets treated and has his medication adjusted, and then discharged home again. Using this scenario, she suggest that if a person’s vital signs could be monitored by sensors from an iPhone for example, then he would know if his medications were handling his heart condition. And if it was not, then the patient could call his physician to intervene and possibly prevent a hospitalization, which is very costly.

She also mentions using these devices to warn patients of counterfeit medical drugs, which is common place, in third world countries and leads to worsening health care for the patient that uses such drugs. iPhones or iPads would allow drug approved labels to be identified and streamed to the patient inorder to protect them from harm. This technology could be used in this way and many other ways to allow physicians to be more effective, efficient, and competent in treating patients. I also believe in theory that this technology used in this way would tremendously decrease healthcare costs globally, not just in America.

This technology used in this fashion could aid in solving the shortage of physicians that we have been experiencing since the baby boomers have come of age in America. With access to more patients based on streaming through these devices, more patients per physician could be cared for competently.

I applaud Dr. Saxon’s pushing the envelope metaphorically speaking, but my concern is approval from the controlling institutions of medicine and the level of benevolence of the creators of this technology. She mentions that it could be done because there are 5 billion people with cell phones now. So this technology should and could be made available to people and countries from all socioeconomic strata. The almighty dollar would have to take a back seat to helping others, which should be done. I believe health is a right not a privilege.

Finally, the details of maintaining patient confidentiality would have to be addressed, but it could be done!

Urology (not neurology) is the study of medicine that deals with handling illnesses related to the kidneys, bladder, prostate (in men), urethra (voiding tube) and ureters (the tubes that drain the kidney into the bladder). Urology deals with male and female issues in these areas mentioned above.

2) What is a bladder spasm?

Bladder spasms are contractions of the bladder that can result in urgency (inability to hold urine), frequency and pain felt after voiding in the bladder or abdomen, or sometimes at the tip of the penis or near the rectum.

3) What is OAB?

Stands for overactive bladder. This results from bladder spasms, which can be caused from caffeine (tea or coffee), acidic foods, or spicy foods. Many times this can be controlled with dietary changes.

4) What is Interstitial cystitis?

This is a diagnosis of exclusion. This means that after every other cause of the persons symptoms are excluded, such as having a recurrent urinary tract infection, a diagnosis of interstitial cystitis is given.

There are no physical signs of interstitial cystitis but there are some associated bladder findings that may be present.

Symptoms include lower abdominal or peri-rectal pain, frequency, urgency, and burning on urination. Sometimes a person also experiences urethral pain, and pain with intercourse or directly after. Interstitial cystitis is also known as painful bladder syndrome. There are many theories as to the cause of this disorder.

One common theory is that the lining of the bladder is decreased or faulty and that the bladder is no longer able to tolerate acidic urine in it. Many of the other theories involves autoimmune processes (protecting cells of the body are fighting the body, in this case your bladder). I have found that many patient have a cross-over of symptoms and generally fall-out as having interstitial cystitis. They often have symptoms related to overactive bladder.

In either case many are cured with diet alone.

There are some effective medicines that are helpful as well. Although some urologists are prescribing anti-depressants to treat this illness, I have not. There are many other side-effects from anti-depressants that would complicate the healing process in my opinion. Besides a definitive, scientific rationale of how anti-depressants work to heal a person with interstitial cystitis has not been given.

5) Why does my bladder leak around the foley catheter?

A foley catheter is placed in many cases for a person who is undergoing surgery or has an inability to void (to urinate). The catheter has a balloon at the end of it which is inflated once the catheter is in place in the bladder. The balloon is then inflated and the catheter is kept in place this way.

Unfortunately the balloon portion of the catheter sits in a portion of the bladder that stimulates it to contract and squeeze out the urine. This can be handled in the case of long-term catheter use with medicines called anti-cholinergics which will decrease these bladder spasms.

Vasectomies are done when a man desires sterilization. It could be that his wife has had difficult pregnancies, and the next one would be a risk to her health or the unborn childs health. For instance, a woman who has had multiple cesearean sections or has had comorbidities (example, diabetes or hypertension) associated with pregnancy. Often the family has decided together that the wife’s child-bearing years are done ( because of advanced age, etc.). A vasectomy is often chosen as opposed to a tubal ligation for the woman, because it involves less risk to the patient and no anesthesia. A woman has to undergo anesthesia and have an abdominal incision in order to ligate the fallopian tubes (through which the ovaries travel for conception to occur). She also has a longer recovery. A vasectomy is performed in my office in 15 minutes, with a quick recovery, and minimally invasive.

There are three types of vasectomies performed. All three methods involve a small incision in the midline of the scrotum below the penis. The traditional method. The scalpel-less or non-scalpel method, and a laser vasectomy.

I perform the traditional method. It includes ligation of the vas deferens with removal of a 3-4mm portion of the vas deferens. This is followed by suturing of the two ends of the vas deferens, and cauterization (heating closed) the opened ends of the tubular structure.

The scalpel-less vasectomy was developed in China in the 1970′s. It involves bringing the vas deferens through a small incision in the scrotum using a clamp made for this type of structure and performing the ligation. I have been taught this method with use of a syringe needle to transect the vas deferens. There can be a higher failure rate with this method. The presumed benefit is less mobilization of the scrotal structures and vas deferens, hence decreased risk of swelling after the procedure.

The laser is a newer method of ligation and burning of the vas deferens inorder to sterilize a man. A small incision is still made in the scrotum to expose the vas deferens. This is a variation of the same theme.

I perform on average 5 vasectomies weekly for the last 6 years. It is covered by almost all insurances at minimal cost to the patient, if any. It takes approximately 15 minutes, and a local anesthetic is used to comfort the patient and prevent any pain. My patients usually take a couple of days off work or have it done on a Friday in order to relax over the weekend. I recommend no strenuous activity or exercise for the first two days after the procedure, so as to prevent potential swelling of the scrotum or testicles. Swelling occurs in less than 0.5% of my patients. The recovery is fast. Other potential risks include infection, which occurs rarely and is treated with antibiotics, and bleeding. Bleeding has not occured in my practice. I make sure patients are off medicines which can cause bleeding, such a ibuprofen or aspirin at least one week prior to the procedure. Sperm granuloma can develop in some men after a vasectomy. It is essentially scar tissue from the vasectomy that feels like a small bump in the scrotum above or around the testicle. It is not cancerous, and rarely causes pain. If pain results, this is handled with ibuprofen or rarely removal.

After a vasectomy, it takes 6-8 weeks of ejaculations or intercourse, in order to become completely sterile. Until this time, a patient is required to use a condom for prevention against impregnating a woman. After the vasectomy, the patient is given a laboratory slip and a sterile cup to collect a sample of semen (the ejaculate fluid) for examination 6-8 weeks later. I always confirm success of the vasectomy with a follow-up sperm count by your local laboratory. There are internet sources which claim 21 ejaculations are sufficient to remove the remaining sperm from the vas deferens after a vasectomy. This may not be true, since men do not all produce the same amount of sperm in the semen.

Myths about vasectomies include: loss of erections, loss of “manhood” (male hormones, testosterone), developing a high-pithced voice, sperm back-up/ build-up (“blue balls”), or vasectomy causing prostate cancer. None of these myths are true.

For more information about vasectomies, contact Dr. Highshaw at (714) 751-0100 or (951) 509-9000.

Depending on the severity of your symptoms, you should immediately see a urologist or go directly to the emergency room for relief. A CT scan of the abdomen and pelvis without contrast is usually ordered. This test gives the highest chance of finding a stone and the location of the stone. Other laboratory findings aid in the diagnosis such as elecrolyte studies and urine analysis.

There are many types of stones. The most common stone is a calcium oxalate stone. These result from not drinking enough water (dehydration), drinking tea, dark sodas(cola), excessive amounts of nuts or a diet prominent in green leafy vegetables. A diet high in sodium or salt also is a cause for Calcium-based stones. In addition family history plays a large role. For instance, if your mother or father has a history of kidney or ureteral stones, then you have a higher likelihood of having stone disease as well.

There are other types of kidney or ureteral stones which occur less frequently. These include calcium phospate stones, uric acid stones ( which can occur in a person with gout, heavy beef eaters), cystine stones, struvite stones (caused by urinary tract infections/bacteria), sodium urate stones, and drug-induced stones ( such as indinavir or triamterene).

Treatments are as follows: Shock wave lithotripsy if the stone is less than 2cm and in the renal pelvis. Some stones in the upper portion of the ureter called the UPJ can be treated with shock wave lithotripsy. Laserlitotripsy is used to break-up and remove stones within the ureter or kidney. Both shock wave lithotripsy and laserlithotripsy are non-invasive or minimally invasive methods of treatment of stone disease. Percutaneous nephrolithotomy is an invasive method for removing large renal stones.

Stones that are 4mm or less are likely to pass 80% of the time. However, passing stones is usually very painful. It has been described by many of my female patients as more painful than natural child birth without the reward of a child. Tamsulosin is a drug used in the treatment of BPH (enlarged prostate) in men. It has been found to increase passage of small stones through the ureter.

There are some myths about stone treatment and management. One common myth is that cranberry juice will help pass or prevent kidney stones. This is not true. There are other concoctions which patients have brought to me, such as a mixture of soda (cola) and lime juice. I have not had any patients who have benefited from this mixture. I have had one patient who passed a small ureteral stone with the aid of a brazilian tea. However, the stone passage was painful.

The best prevention is to drink plenty of water ( 64 ounces/ day or about 2 liters/ day), cut out dark sodas or teas (if prone to stones), and commit to a low sodium diet.

For more information on management and treatment of kidney or ureteral stones, contact Dr. Highshaw at    (714)751-0100 or (951)509-9000.

HIFU was first discovered in the 1950′s and improved as a use for treatment of prostate cancer over the last few decades. HIFU is minimally invasive. It kills prostate cancer cells by thermal ablation. Surgery and radiation is not used to kill the prostate cancer cells. There is no blood loss and no incision! Patients are typically sent home the same day of treatment, and back to regular activity quicker than after surgical management

Cancer free rates are 84% for low-risk prostate cancer patients at 5 years( Uchida et al; Int J Urol 2009). Potency rates (ability to maintain erections) are 75% and incontinence rates ( leakage of urine) are 2%. Except for cancer free rates,these numbers are superior to those found with other treatments of prostate cancer. However, the cancer free rates are comparable to those found for other treatments of prostate cancer.

There are two types of HIFU. One is called Ablatherm (R) and the other is the Sonoblate 500 (R). I have had very good success with the Sonoblate 500 (R). My patients have had quick recoveries, and return to normal function and erections. The advantage of the Sonoblat 500 (R) is that ablation of the prostate cancer cells occur under real-time ultrasonograpy. This means that the device is able to adapt to changes in the postion of the prostate at the time of treatment and that it adjust to the different shapes and sizes of the prostate. The other advantage is a 3mm overlap of treatment, which allows for very specific areas of treatment. Finally, the Sonoblat 500 (R) has a modality which allows it to interpret excellent areas of ablation from those which need to be retreated at the time of the procedure. This allows for optimum cure rates.

Provenge, which is manufactured by the Dendreon Corp., works by stimulating the patients own immune system to fight and kill prostate cancer cells. The white blood cells, which protect one from non-self influences, are removed from the body and sensitized to a prostate cancer protein. These white blood cells are placed back into the patient, which seek-out prostate cancer cells to destroy.

Some of the side effects from taking Provenge include chills, fatigue, fever, back/joint pain, nausea, and headaches. These are considered mild to moderate reactions and account for the majority of the adverse reactions. The more severe reactions to this medication reported are cerebrovascular events such as strokes, which occurred in 3.5% of patients in the study.

Dr. Soloway, professor and chair of urology at the University of Miami Miller School of Medicine, has stated that “There are problems with Provenge”.  “One is that it’s very cumbersome, because patients have to provide their white cells, and I think that’s on a regular basis. And two, it’s likely to be very expensive.”  I would tend to agree. Having said that, Provenge does provide patients with an alternative treatment for prostate cancer, and that is promising.

For more information about  Provenge contact Dr. Highshaw at (714) 751-0100

The symptoms include frequency, urgency, nocturia ( getting up at night to urinate), incomplete emptying, hesistancy, or at worst urinary retention. treatment is recommended if your life is adversely affected by any one or more of these symptoms.

The prostate is a gland found in the pelvis and between one’s bladder, which collects the urine and empties it from the body, and the penis. More accurately, the prostatic urethra is part of the tube running through the prostate which runs out of the penis and completes the emptying of urine. Prostate cancer has not been proven to be related to BPH, although both can occur together in the prostate.

BPH is a clinical diagnosis based on a digital rectal exam and symptoms. Other studies can aid in determining it’s significance or validating the findings. These studies include a post-void residual, which tells one how much urine is left in the bladder after urination. This is a significant finding, which can also be determined with the use of a bladder ultrasound. The reason for the symptoms is due to urinary obstruction from the prostate gland expanding and closing off the prostatic urethra (the tube running through the prostate and draining the bladder).

Treatment is recommended if a person’s quality of life is affected negatively by the symptoms mentioned above. Conservative or medical treatment is usually tried first. These include medicines that increase the flow of urine by opening the channel for urine flow. Other medications include prostate shrinking medicines, which have some affect on relieving symptoms, but require use of 4 to 6 months. If medical treatments fail,then surgical treatments are used. The traditional surgical management has been the TURP (transurethral resection of the prostate). This treatment is minimally invasive and usually leads to a 23 hour stay overnight in the hospital. Another treatment includes laser vaporization of the prostate. The advantage of the laser is less bleeding and the patient can go home the same day. Other treatments include the transurethral incision of the prostate, transurethral microwave therapy of the prostate, electrovaporization of the prostate, and for those with a very large gland, a simple prostatectomy.

For more information concerning BPH contact Dr. Highshaw at (951) 509-9000.