Services

Vasectomy

Vasectomy-Reversal

Prostate Cancer: Screening and Treatment

• daVinci Robotic Prostatectomy
• Perineal Prostatectomy
• Retropubic Prostatectomy
• Hormonal Therapies
• Brachytherapy (Radioactive Seed Implantation)
• Transrectal Ultrasonography
• In-Office Biopsy with Anesthetic Blockade
• Preventative Regimens

Kidney Cancer: Evaluation, Treatment and Surveillance

• da Vinci Robotic Nephrectomy
• da Vinci Robotic Partial Nephrectomy
• Laparoscopic Nephrectomy
• Open Nephrectomy
• Open Partial Nephrectomy

Bladder Cancer: Screening, Evaluation,Treatment and Surveillance

• BLADDER CANCER
  Definition
  Bladder cancer is a malignancy that occurs in the urinary bladder — a balloon-shaped organ in the pelvis that stores urine. Bladder cancer begins most often in the cells that line the inside of the bladder. Bladder cancer typically affects older adults, though it can occur at any age.
  The great majority of bladder cancers are diagnosed at an early stage — when bladder cancer is highly treatable. However, even early-stage bladder cancer is likely to recur. For this reason, bladder cancer survivors often undergo follow-up screening tests for years after treatment
  Symptoms
  Bladder cancer signs and symptoms may include:
  §                          Blood in urine (hematuria) — blood may appear bright red or tea- colored in the urine, or may appear in a microscopic examination of the urine. The blood often is present intermittently
  §                          Frequent urination
  §                          Painful urination
  §                          Urgent urination
  §                          Repeated urinary tract infection
  §                          Abdominal pain
  §                          Back pain
   
  Risk Factors
  §                          Smoking. Bladder cancer occurs most often in cigarette smokers. Smoking increases the risk of bladder cancer by causing harmful chemicals known as carcinogens to accumulate in the urine and dwell in the bladder. These carcinogens may damage the lining of the bladder, eventually resulting in the development of cancer.
  §                          Chemical exposure. Kidneys play a key role in filtering harmful chemicals from the bloodstream and moving them into the urine. Because of this, it's thought that being around certain chemicals may increase the risk of bladder cancer. Chemicals linked to bladder cancer risk include arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products.  
  §                          Chemotherapy and radiation therapy. Treatment with the anti-cancer drugs cyclophosphamide (Cytoxan) and ifosfamide (Ifex) increases risk of bladder cancer. Pelvic radiation therapy for cervical, rectal and prostate cancers is associated with an increased risk of subsequently developing bladder cancer.
  §                          Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as may happen with long-term use of a urinary catheter, increase the risk of a squamous cell bladder cancer.
  §                          Personal or family history of cancer. If you have had bladder cancer once, you are likely to experience a recurrence. Cancer can recur in the kidneys, ureters, urethra or bladder. If one or more of your immediate relatives have a history of bladder cancer, you may have an increased risk of the disease, although it's rare for bladder cancer to run in families. A family history of hereditary nonpolyposis colorectal cancer (HNPCC), sometimes called Lynch syndrome, can increase your risk of cancer in your urinary system, as well as in your colon, uterus, ovaries and other organs.
  §                          Bladder birth defect. Rare birth defects of the bladder can increase your risk of adenocarcinoma of the bladder.
  §                          Age. Older adults are more likely to be diagnosed with bladder cancer. Bladder cancer diagnosis typically occurs in people 65 and older. People younger than 40 rarely get bladder cancer.
  §                          Race. Whites have a greater risk of bladder cancer than do people of other races.
  §                          Sex. Men are more likely to develop bladder cancer than women are.
  Diagnostic Tests
  §                          Using a scope to see inside the bladder. During cystoscopy, the urologist inserts a narrow tube (cystoscope) through the urethra. The flexible cystoscope has a lens and fiber-optic lighting system, allowing the doctor to see the inside of your urethra and bladder. This examination is routinely performed in a specialized procedure room in the urologist’s office. A local/topical anesthetic is typically applied to the urethra to make the examination more comfortable.
  §                          Removing suspicious cells for testing. During a procedure similar to cystoscopy, the doctor removes a small tissue sample (biopsy) for testing. If a larger volume of tissue is removed, the procedure is referred to as transurethral resection of bladder tumor (TURBT). TURBT is usually performed under general anesthesia in a hospital or surgery center.
  §                          Testing your urine for cancer cells. A sample of urine is analyzed under a microscope by a pathologist to check for cancer cells in a procedure called urine cytology.
  §                          Imaging tests. Imaging tests allow non-invasive examination of the urinary tract.  An intravenous pyelogram (IVP) is a type of X-ray imaging test that uses a dye to highlight the kidneys, ureters and bladder. A computerized tomography (CT) scanis a type of imaging test investigates the urinary tract as well as the surrounding tissues.
   
  Bladder cancer stages
  If the presence of bladder has been confirmed by biopsy, additional tests might be necessary to determine the extent, or stage, of the cancer.Staging tests may include:
  §                          CT scan
  §                          Magnetic resonance imaging (MRI)
  §                          Bone scan
  §                          Chest X-ray
  The stages of bladder cancer are:
  §                          Stage Ta. Cancer at this stage involves only the most superficial layer of the bladder's inner lining, called the mucosa.
  §                          CIS (carcinoma in situ): This is a superficial but high-grade variety of bladder cancer. Though initially non-invasive, CIS has a greater tendency to spread.
  §                          Stage T1. Cancer cells have penetrated one layer deeper into the lamina propria.
  §                          Stage T2. At this stage, cancer has invaded the bladder muscle wall.
  §                          Stage T3. The cancer cells have spread through the bladder wall to surrounding tissues.
  §                          Stage T4. By this stage, cancer cells have spread into other neighboring other organs, such as the prostate gland, uterus, or vagina.
  §                          Metastatic Disease. cancer cells have spread through the blood stream and are growing in lymph nodes, liver, lungs, etc
   
   
   
   
  Treatments and drugs
  T
  reatment options for bladder cancer depend on a number of factors, including the type and stage of the cancer as well as a patient’s overall health and treatment preferences.
  Surgical procedures
  §                           Transurethral resection of bladder tumor (TURBT) is the initial treatment of most bladder cancers. During TURBT, the doctor passes an endoscope through the urethra into the bladder. A specialized cutting loop is used to carefully remove the cancer cells as well a margin of underlying bladder muscle. Often, a bladder catheter is placed to keep the bladder decompressed for several days post-operatively. Following this surgery, common symptoms include painful or bloody urination for a few days.
  TURBT is the principal surgical approach for non-invasive bladder cancers (stages Ta, T1, and CIS)
  The surgeons of Central Bucks Urology have performed thousands of these procedures.
  §                          Surgery to remove the tumor and a small portion of the bladder (Partial Cystectomy). During partial cystectomy the surgeon removes only the portion of the bladder that contains cancer cells. This might be an option if the cancer is limited to one area of the bladder that can easily be removed without harming bladder function. Partial cystectomy can be performed by an open surgical approach through an abdominal incision or by a robotic-laparoscopic approach through keyhole incisions. Surgery carries a risk of bleeding and infection. More frequent urination is common after partial cystectomy, since the operation reduces the size of urinary bladder.  
  §                          Surgery to remove the entire bladder (Radical Cystectomy).  A radical cystectomy is an operation to remove the entire bladder, as well as surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy involves removal of the uterus, ovaries and part of the vagina. Similar to partial cystectomy, radical cystectomy can be performed by an open surgical approach through an abdominal incision or by a robotic-laparoscopic approach through keyhole incisions.
  §                          Urinary Diversion
  Immediately after radical cystectomy, the surgeon creates a new route for urine to exit the body, known as a urinary diversion. Several options exist. Which option is best depends on the type of cancer as well as the patient’s health and preferences.
  The simplest type of urinary diversion is a urinary loop or conduit: the ureters are connected to one end of a segment of intestine; the opposite end of intestine is connected to the abdominal wall, creating a stoma, where urine drains into a synthetic pouch (urostomy bag) attached to the abdominal wall.
  A second type of urinary diversion is a cutaneous continent urinary diversion.  A segment of intestine is used to create an internal reservoir to store the urine. The urine is drained several times per day by inserting a flexible catheter through a small abdominal stoma.
  The third type of urinary diversion is a continent neobladder. A segment of intestine is used to create a bladder-like reservoir. This reservoir is attached to the urethra. Many patients with neobladders can urinate fairly normally. Some other patients need to insert a catheter through the urethra to drain the urine from the neobladder bladder.
  The surgeons of Central Bucks Urology have performed hundreds of cystectomies and offer their patients all three types of urinary diversion.
  Immunotherapy
  Immunotherapy works by signaling your body's immune system to help fight cancer cells. Immunotherapy for bladder cancer is administered through the urethra and directly into the bladder (intravesical therapy). 
  The most effective immunotherapy agent is Bacillus Calmette-Guerin (BCG). BCG is a bacterium used in tuberculosis vaccines. BCG can cause bladder irritation and blood in your urine. Some people feel as if they have the flu after treatment with BCG.
  An interferon is a type of cell your body uses to fight infections. A synthetic version of interferon, called interferon alfa, may be used to treat bladder cancer. Interferon alfa is sometimes used in combination with BCG. Interferon alfa can cause flu-like symptoms.
  Immunotherapy can be administered beginning 2-3 weeks after TURBT to reduce the risk that cancer will recur or progress
  Chemotherapy
  Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination. Drugs can be given through a vein in your arm (intravenously), or they can be administered directly to your bladder by passing through your urethra (intravesical therapy).
  Intravesical chemotherapy is used to treat non-invasive bladder cancers. 
  Systemic chemotherapy is used to treat muscle-invasive or metastatic bladder cancers. Chemotherapy may be used to kill cancer cells that might remain after an operation. It may also be used before surgery. In this case, chemotherapy may shrink a tumor enough to allow the surgeon to perform a less invasive surgery. Chemotherapy is sometimes combined with radiation therapy.
  Radiation therapy
  Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy can come from a machine outside your body (external beam radiation) or it can come from a device placed inside your bladder (brachytherapy).
  Radiation therapy may be used before surgery to shrink a tumor so that it can more easily be removed with surgery. Radiation therapy can also be used after surgery to kill cancer cells that might remain. Radiation therapy is sometimes combined with chemotherapy.
   
  Surveillance
  Bladder cancer often recurs. Because of this, bladder cancer survivors undergo follow-up testing for years after successful treatment.
  What types of tests are used to screen for bladder cancer recurrence?
  Cystoscopy, cytology, bladder biopsy and urine-DNA tests are the principal tools used in bladder cancer surveillance.
  How often should you undergo screening for bladder cancer recurrence?
  In general, doctors recommend cystoscopy screening every three months for the first year, every four months during the second year and every six months during the third year after initial diagnosis and treatment.  People with aggressive cancers may undergo more frequent screening. Those with less aggressive cancers may undergo screening tests less often.
  How can you prevent a bladder cancer recurrence?
  Doctors don't yet know a reliable way to prevent bladder cancer recurrence. Talk to your doctor about ways to reduce your risk, such as:
  §                          Stopping smoking. Ask your doctor about strategies to help you quit smoking. Support programs and medications can help.
  §                          Increasing your intake of antioxidant vitamins. Some studies suggest that large amounts of certain vitamins may reduce the risk of recurrent bladder cancer in some people. But not enough study has been done to recommend taking big doses of antioxidants in pill form. In fact, large doses of vitamin supplements could be harmful. A safe way to increase your antioxidant intake is to increase fruits and vegetables in your diet. Talk to your doctor about other ways to get more vitamins.
  Although there's no guaranteed way to prevent bladder cancer, you can take steps to help reduce your risk. For instance:
  §                          Don't smoke. Not smoking means that cancer-causing chemicals in smoke can't collect in your bladder. If you don't smoke, don't start. If you smoke, talk to your doctor about a plan to help you quit. Support groups, medications and other methods may help you quit.
  §                          Take caution with chemicals. If you work with chemicals, follow all safety instructions to avoid exposure.
  §                          Have your well tested for arsenic. If you have your own well, consider having it tested for high levels of arsenic in the water.
  §                          Drink plenty of fluids. Drinking liquids, especially water, dilutes toxic substances that may be concentrated in your urine and flushes them out of your bladder more quickly.
  §                          Eat your fruits and vegetables. Choose a diet rich in a variety of colorful fruits and vegetables. The antioxidants in fruits and vegetables may help reduce your risk of cancer.
  Alternative medicine
  §         No complementary or alternative bladder cancer treatments have been found to cure bladder cancer. But doctors are studying ways to prevent bladder cancer, including some complementary and alternative approaches. If you're worried about your risk of bladder cancer or that your cancer could recur, you may be interested in trying complementary and alternative treatments. Talk to your doctor about your options.
  §         Vitamins
  Fruits and vegetables are the safest way to get your vitamins. Some research suggests larger doses of certain vitamins, such as vitamin E, in pill form may help reduce the risk of bladder cancer. But other studies haven't found this.
  §         More study is needed to understand what dose is safest and most effective. Until then, focus on eating a wide variety of fruits and vegetables that are rich in vitamins. If you're interested in vitamin supplements, ask your doctor about what doses may be reasonable.
  §         Green tea
  Drinking green tea has been linked to many health benefits. But whether it can reduce the risk of bladder cancer isn't clear. Animal studies have shown promise, but studies in humans have been mixed. For example, one study showed that people who drink the most green tea have a reduced risk of bladder cancer, while another study found that drinking green tea over many years increased the risk of bladder cancer. More study is needed to understand whether green tea is helpful or harmful when it comes to preventing bladder cancer.
   
  Minimally-Invasive Endoscopic Surgery
• Outpatient Chemotherapy and Immunotherapy
• da Vinci Robotic Cystectomy
• Open Cystectomy
• Continent Urinary Diversions

Testicular Cancer: Evaluation, Treatment and Surveillance

Female Incontinence: Evaluation and Treatment

• In-Office Urodynamics
• Medical Therapies
• Biofeedback and Physical Therapy
• Contigen   www.bardurological.com
• Transvaginal and Trasobturator Tape Procedure
• Pubovaginal Sling
• Pelvic Reconstruction
• www.womensbladderhealth.com

Kidney Stones: Evaluation and Treatment

• Extracorporeal Sound Wave Lithotripsy (ESWL)
• Endoscopic Laser Lithotripsy
• Endoscopic Laser Lithotripsy
• Percutaneous Nephrostolithotomy
• Metabolic Evaluation of Kidney Stones Causes

BPH: Evaluation and Treatment

• BENIGN PROSTATIC HYPERPLASIA
   
  What is benign prostatic hyperplasia (BPH)?
  Benign prostatic hyperplasia (BPH) is an enlarged prostate gland. The prostate gland surrounds the urethra, the tube that carries urine from the bladder out of the body. As the prostate gets bigger, it may squeeze or partially block the urethra. This blockage often causes problems urinating.
  The prostate gland begins enlarging during puberty and continues throughout a man’s life. Men can begin experiencing urinary symptoms caused by BPH as early as age 40. The older a man gets, the more likely he is to experience BPH-related symptoms. Approximately half of all men older than 75 years old have some symptoms.
  .
  What causes BPH?
  Benign prostatic hyperplasia is a normal part of the aging process in men, caused by changes in hormone balance and in cell growth.
   
  What are the symptoms?
  BPH causes urinary problems such as:
  ·         Trouble getting a urine stream started (hesitancy)
  ·         Trouble stopping (dribbling).
  ·         A weak or slow urine stream.
  ·         A sense of not emptying the bladder (retention)
  ·         Needing to wake up from sleep to urinate (nocturia)
  ·         Having to urinate often (frequency)
  ·         Having to urinate abruptly (urgency)
  ·         Leaking urine (incontinence)
  In some instances, BPH may completely block the urethra, making it impossible or extremely hard to urinate. This problem may cause backed-up urine (urinary retention), leading to bladder infections, bladder stones or kidney damage.
  Erectile dysfunction, orgasmic dysfunction and diminished ejaculatory volume are experienced more often in men who have BPH.
  BPH does not cause prostate cancer.
   
  How is BPH diagnosed?
  Your doctor can diagnose BPH by asking questions about your symptoms and past health and by doing a physical exam. The AUA Symptom Score Index (available at the end of this site) is a questionnaire that determines the severity of symptoms. Initial tests may include a urine test (urinalysis), blood tests (serum creatinine, PSA), and a digital rectal exam. To further evaluate BPH, a transrectal prostate ultrasound can accurately measure the size of the prostate gland and determine its precise shape. Uroflow is a simple test to measure how well the urine flows out. Urodynamics is a more advanced assessment of the bladder’s function. Cystoscopy allows the doctor to directly examine the internal anatomy of the lower genito-urinary tract.
   
   
  When is BPH treated?
  As a general rule, a man doesn’t need treatment for BPH unless the symptoms are consistently bothersome.  There are 5 complications of BPH that mandate treatment:
  1.       Complete urinary retention
  2.       Development of bladder stones
  3.       Recurrent bladder/prostate infections
  4.       Recurrent prostatic bleeding
  5.       Kidney injury due to bladder dysfunction
   
  Treatment Overview
  Benign prostatic hyperplasia (BPH) cannot be cured, so treatment focuses on reducing symptoms. Treatment is based on symptom severity, degree of patient bother, and presence of complications.
   
  Initial treatment
  The American Urological Association (AUA) makes the following treatment recommendations for benign prostatic hyperplasia (BPH) based on the severity of your symptoms.
  ·         Symptoms that are mild or that do not bother you (AUA score of 0 to 7) may be best treated by watchful waiting. This means you may make small changes to your lifestyle to control your symptoms, but you do not take medicines or have surgery. You have regular checkups to be certain your symptoms are not getting worse.
  ·         The treatment of moderate to severe symptoms (AUA score of 8 or more) depends on how much you are bothered by them. If the symptoms are not greatly affecting your quality of life, you may choose watchful waiting or treatment with medicine. If the symptoms are bothersome or you want more aggressive treatment, you may be offered surgery.
  ·         Severe symptoms, such as ongoing inability to urinate, bladder stones, kidney damage, or ongoing blood in your urine, should be treated with surgery.
   
   
  What to Think About
  Unless surgery is required because of a complication, choosing a treatment is largely up to you and your doctor. If complications arise, surgery may be necessary.
  The extent to which treatment improves your symptoms depends partly on how bad your symptoms are and how much you are bothered by them. If you are not bothered by your symptoms before treatment, you are less likely to notice much improvement after treatment.
  Surgery offers the best chance for improving the symptoms but also has the risk of causing other problems. For more information, see the Surgery section of this topic
   
   
  Medications
  Medicines are sometimes used to help relieve bothersome, moderate to severe urination problems caused by benign prostatic hyperplasia (BPH). If you stop using medicine, the symptoms will usually return.
  ·         Alpha-blockers include doxazosin (Cardura) and terazosin (Hytrin), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo). These agents relax the smooth muscle tissue in the prostate and the opening to the bladder. Symptom improvement typically begins within one week. Alpha-blockers do not stop the process of prostate enlargement. Potential side effects include dizziness, nasal stuffiness, fatigue and retrograde ejaculation.
  ·         5-alpha reductase inhibitors, such as dutasteride (Avodart) or finasteride (Proscar), may reduce the size of an enlarged prostate but may take 6 to 9 months to achieve maximal improvement of symptoms. Potential side effects include diminished semen volume and reduced libido (sex drive).
  ·         Using a combination of an alpha-blocker with a 5-alpha reductase inhibitor may symptoms more than either medicine alone.
  Surgery
   
  Most surgeries for BPH are performed endoscopically: the surgical instrument is passed up the urinary opening in the penis to the location of the prostate. This is described as a transurethral surgery
  Transurethral resection of the prostate (TURP). The obstructing portion of the prostate gland is removed endoscopically with an electrocautery cutting instrument. A patient typically is hospitalized for 24-48 hours after this procedure for monitoring of post-operative bleeding. If a man is taking a blood thinner such aspirin, warfarin (Coumadin), or clopidogrel (Plavix), this surgery cannot be safely performed. The surgeons at Central Bucks Urology have collectively performed more than 2,000 of these procedures.
  Transurethral Laser Vaporization of the Prostate. The most commonly used laser is the Greenlight laser. During this procedure the obstructing portion of the prostate gland is vaporized, sealing the blood vessels in the process. A patient typically goes home on the day of the surgery with a bladder catheter maintained overnight. Bleeding is typically minor during and after this procedure. This surgery can be performed even if the patient is on blood-thinners. Go to the following website for more information:        www.greenlighthps.com
  The surgeons at Central Bucks Urology have collectively performed more than 500 of these procedures.
   
  Open Surgery. Typically reserved for very large prostate glands or if bladder stones are also present, this surgery is performed through an abdominal incision. A patient is hospitalized for 3-7 days afterward and has a bladder catheter for 10-14 days. 
   
  A number of office-based, minimally- invasive procedures have been available since the early 1990’s. The effectiveness of these procedures is far inferior to those options listed above. Based upon their strong, collective opinion that these procedures represent decidely inferior options, the surgeons of Central Bucks Urology do not offer nor recommend them. Three examples of such procedures:
  ·         Transurethral microwave therapy (TUMT): microwave energy is used to destroy a portion of the prostate through heating.
  ·         Transurethral needle ablation (TUNA): a heated needle is used to destroy a portion of the prostate.
  ·         Interstitial Laser Coagulation (Indigo Laser): a puncturing laser is used to destroy prostate tissue.
  What to Think About
   
  Medical therapy typically is tried as the first line of treatment. For many men, medical therapy provides satisfactory and durable improvement in their voiding pattern. Medical therapy must be maintained indefinitely to remain effective.
  Surgery is the most reliable way to maximally relieve symptoms. But surgery may not relieve all your symptoms, and it puts a man at risk for certain surgical complications, including infection, bleeding, urinary retention, and urinary incontinence and ejaculation of semen into the bladder instead of out through the penis (retrograde ejaculation).
  Men who have severe symptoms often notice great improvement in the quality of life following surgery. Men whose symptoms are mild may find that surgery does not greatly improve quality of life; men with mild symptoms should think carefully before deciding to have surgery to treat BPH.
  The benefits of surgery typically prove to be life-long.
  Greenlight Laser Prostatectomy   www.Greenlightforbph.com
• Transurethral Resection of the Prostate
• Medical Management

Erectile Dysfunction: Evaluation and Treatment

• Medical Therapies
• Injection Therapies
• Mechanical Devices
• Surgical Treatment - Penile Prostheses

Varicocele: Evaluation and Treatment

• Fertility Assessment
• Varicocele Repair

Urinary Tract Infections: Evaluation and Treatment

Premature Ejaculation: Evaluation and Treatment

Congenital Abnormalities: Evaluation and Treatment

• da Vinci Robotic Pyeloplasty
• Hypospadias Repair
• Circumcision
• Pediatric Hydrocele/Hernia Repair

Robotic Surgery