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Prostate Cancer: Screening and Treatment

 PROSTATE CANCER
Prostate cancer is malignancy of the small, walnut-sized gland that produces semen, the fluid that nourishes and transports sperm. Prostate cancer is one of the most common types of cancer in men, affecting about one in six men in the United States. A diagnosis of prostate cancer can trigger anxiety, not only because prostate cancer can be life-threatening, but also because treatments can cause side effects such as bladder control problems and erectile dysfunction (impotence). Fortunately, both diagnostic methods and treatment techniques for prostate cancer have dramatically improved since the 1980’s.
Prostate cancer usually grows slowly and initially remains confined to the prostate gland. While some types of prostate cancer may need minimal or no treatment, other types are aggressive and can spread quickly. If prostate cancer is detected early — when still confined to the prostate gland — the likelihood of successful treatment is excellent.
Signs & Symptoms
Prostate cancer usually does not produce any noticeable symptoms in its early stages. Consequently, some cases of prostate cancer are not detected until the cancer has spread beyond the prostate. Most often, prostate cancer is first detected during routine screening with a prostate-specific antigen (PSA) test or a digital rectal exam (DRE).
Early signs and symptoms of prostate cancer can include urinary problems, caused when the prostate tumor presses on the bladder or on the tube that carries urine from the bladder (urethra). However, urinary symptoms are much more commonly caused by benign prostate problems, such as an enlarged prostate (benign prostatic hyperplasia) or prostate infections. Less than 5 percent of cases of prostate cancer have urinary problems as the initial symptom. When urinary signs and symptoms do occur, they can include:
„X Trouble urinating
„X Starting and stopping while urinating
„X Decreased force of the urine stream
„X Blood in urine
„X Blood in semen
Prostate cancer that has spread to the lymph nodes in the pelvis may cause:
„X Swelling in the legs
„X Discomfort in the pelvic area
„X Blockage of the ureters (tubes draining urine from kidneys) causing kidney failure
Advanced prostate cancer that has spread to bones can cause:
„X Bone pain that does not go away
„X Bone fractures
„X Compression of the spine

RISK FACTORS FOR DEVELOPING PROSTATE CANCER
„X Age. After age 50 the incidence of prostate cancer increases.
„X Race or ethnicity. For reasons that are not well understood, black men have a higher risk of developing and dying of prostate cancer.
„X Family history. If a man’s father or brother has prostate cancer, his risk of the disease is greater than that of the average man.
„X Diet. A high-fat diet and obesity may increase the risk of prostate cancer. One theory is that fat increases production of the hormone testosterone, which may promote the development of prostate cancer cells. Other dietary factors are under active investigation.
PREVENTION
„X Eat well. High-fat diets have been linked to prostate cancer. Therefore, limiting one’s intake of high-fat foods and emphasizing fruits, vegetables and whole fibers may help reduce risk. Foods rich in lycopene, an antioxidant, also may help lower prostate cancer risk. These foods include raw or cooked tomatoes, tomato products, grapefruit and watermelon. Garlic and some vegetables such as arugula, bok choy, broccoli, Brussels sprouts, cabbage and cauliflower also may help fight cancer.
„X A study has found that supplemental vitamin E and selenium do not reduce the risk of developing prostate cancer.
„X Get regular exercise. Regular exercise can help prevent a heart attack and conditions such as high blood pressure and high cholesterol. When it comes to cancer, the data aren't as clear-cut, but studies do indicate that regular exercise may reduce cancer risk, including prostate cancer. Exercise has been shown to strengthen the immune system, improve circulation and speed digestion — all of which may play a role in cancer prevention. Exercise also helps to prevent obesity, another potential risk factor for some cancers. Regular exercise may also minimize urinary symptoms and reduce the risk of prostate gland enlargement, or benign prostatic hyperplasia (BPH). Men who are physically active usually have less-severe symptoms than do men who get little exercise.
„X Nonsteroidal anti-inflammatory drugs (NSAIDs) might prevent prostate cancer. These drugs include ibuprofen (Advil, Motrin, others) and naproxen (Aleve). NSAIDs inhibit an enzyme called COX-2, which is found in prostate cancer cells. More studies are needed to confirm whether NSAID use actually results in lower rates of prostate cancer or reduced deaths from the disease.
„X 5 Alpha-reductase inhibitors. Research has shown that the drugs dutasteride (Avodart) and finasteride (Proscar) reduce the likelihood of developing prostate. These drugs are currently FDA-approved to control prostate gland enlargement. At this time, these drugs are not routinely prescribed to prevent prostate cancer.

SCREENING & DIAGNOSIS
„X Digital rectal exam (DRE). During a DRE, the doctor inserts a gloved, lubricated finger into the rectum to examine the prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of your gland, more tests likely will be recommended.
„X Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein and analyzed for PSA, a substance that's naturally produced by your prostate gland to help liquefy semen. It's normal for a small amount of PSA to enter your bloodstream. However, if a higher than normal level is found, it may be an indication of prostate infection, inflammation, enlargement or cancer. Screening with PSA and DRE can help identify cancer at an early stage.
„X Transrectal ultrasound. If other tests raise concerns, a transrectal ultrasound might be utilized to further evaluate the prostate gland. A small probe, about the size and shape of a cigar, is inserted into the rectum. The probe uses sound waves to image the prostate gland.
„X Prostate biopsy. If initial test results suggest prostate cancer, prostate biopsy will be recommended. Following application of local anesthesia, the ultrasound probe is inserted into the rectum. Guided by the ultrasound images, a spring-propelled needle is used to retrieve six to twelve thread-like pieces of prostate gland tissue. A pathologist evaluates the samples. The pathologist determines if cancer is present. If cancer is found, the pathologist grades the aggressiveness of the cancer with a Gleason score.
WHAT IF PROSTATE CANCER IS FOUND
Determining how far the cancer has spread
Once a cancer diagnosis has been made, further tests will be obtained to determine if the cancer has spread. Some men don't require additional studies and can directly proceed with treatment based on the characteristics of their tumors and the results of their pre-biopsy PSA tests.
„X Bone scan. A bone scan evaluates the skeleton in order to determine whether cancer has spread to the bone.
„X Computerized tomography (CT) scan. A CT scan attempts to determine if the prostate cancer has spread to the tissues adjacent to the prostate gland, to the pelvic lymph nodes, to other organs or to the skeleton.
„X Magnetic resonance imaging (MRI). An MRI is an alternative to a CT scan.
Prostate Cancer Grading (The Gleason Score)
When a biopsy confirms the presence of cancer, the next step, called grading, is to determine how aggressive the cancer is. The tissue samples are studied, and the cancer cells are compared with healthy prostate cells. The more the cancer cells differ from the healthy cells, the more aggressive the cancer and the more likely it is to spread quickly.
The pathologist identifies the two most aggressive types of cancer cells when assigning a grade. The most common scale used to evaluate prostate cancer cells is called a Gleason score. Based on the microscopic appearance of cells, individual ratings from 1 to 5 are assigned to the two most common cancer patterns identified. These two numbers are then added together to determine your overall score. Scoring can range from 2 (nonaggressive cancer) to 10 (very aggressive cancer).
Staging
After the level of aggressiveness of your prostate cancer is known, the next step, called staging, determines if or how far the cancer has spread. Your cancer is assigned one of four stages, based on how far it has spread:
„X Stage T1. Signifies very early cancer that was suspected by PSA elevation but cannot be felt on finger examination of the prostate.
„X Stage T2. The cancer can be felt, but it remains confined to the prostate gland.
„X Stage T3. The cancer has spread beyond the prostate to the seminal vesicles or other nearby tissues.
„X Stage T4. Cancer has spread to neighboring structures such as the bladder
„X Stage N+. Cancer has spread to regional lymph nodes
„X Stage M+. Cancer has spread distantly (bones, liver).
TREATMENT OPTIONS
Multiple options exist to treat prostate cancer. For some men a combination of treatments — such as surgery followed by radiation or radiation paired with hormone therapy — works best. The treatment that's best for each man depends on several factors. These include how fast the cancer is growing, how much it has spread, a man’s age and life expectancy, as well as the benefits and the potential side effects of the treatment. The most common treatments for prostate cancer include the following:
Watchful waiting/Active Surveillance
Prostate cancer is often diagnosed at a very early stage. This allows some men, particularly those over 70 years old, to choose watchful waiting as a treatment option. In watchful waiting (also known as observation, expectant therapy, deferred therapy or active surveillance), repeat PSA tests, rectal exams and periodic biopsies will be performed to monitor progression of the cancer.
Watchful waiting may be an option if prostate cancer isn't causing symptoms, is expected to grow very slowly, and is small and confined to one area of the prostate. Watchful waiting may be particularly appropriate for those who are elderly, in poor health or both. Many such men will live out their normal life spans without treatment and without the cancer spreading or causing other problems.
Hormone therapy

Prostate cancer cells are fueled by testosterone, the principal male hormone. Testosterone is manufactured mostly by the testicles. The brain sends a signal to the testicles to produce testosterone. By blocking the signal from the brain to the testicles, testosterone production is turned off. With dramatically reduced testosterone levels, prostate cancer cells go into remission.
Drugs commonly used in this type of hormone therapy known as LH-RH agonists, such as leuprolide (Lupron). Such agents are injected into a muscle or under the skin once every three or four months. They can be administered so that they act continuously or intermittently for a defined period or for the rest of a patient’s life, depending on the specific situation.
Other drugs used in hormone therapy block the body's ability to use testosterone, known as anti-androgens. Examples of anti-androgens include bicalutamide (Casodex) and nilutamide (Nilandron). They are oral medications, taken daily. These drugs typically are given along with an LH-RH agonist.
In most men with advanced prostate cancer, hormone treatment is effective in helping both shrink the cancer and slow the growth of tumors. Sometimes doctors use hormone therapy in early-stage cancers to shrink large tumors so that surgery or radiation can remove or destroy them more easily. In some cases, hormone therapy is used in combination with radiation therapy or surgery. After these treatments, the drugs can slow the growth of any stray cancer cells left behind.
Depriving prostate cancer of testosterone usually does not kill all of the cancer cells. Within a few years, some cancer cells again begin to grow even without testosterone. Once this happens, hormone therapy is less effective. When cancer becomes “hormone-resistant¡¨ or “hormone-refractory¡¨, other options such as chemotherapy can be considered.
Side effects of hormone therapy can include:
„X Reduced sex drive
„X Erectile dysfunction
„X Hot flashes
„X Weight gain
„X Reduction in muscle and bone mass
„X Breast enlargement (gynecomastia)
„X Fatigue
„X Increased risk of diabetes or heart disease

External beam radiation therapy (EBRT)/ Intensity-modulated radiation therapy (IMRT)
Radiation treatment uses high-powered X-rays to kill cancer cells. Radiation is effective at destroying cancerous cells, but it can also damage or scar adjacent, healthy tissues.
The first step in radiation therapy is to consult with a radiation oncologist, a physician who treats patients with radiation. Computer-imaging software helps your doctor find the best angles to aim the beams of radiation. Precisely focused radiation kills cancer in the prostate while limiting radiation exposure to surrounding tissues such as the rectum and bladder.
Treatments generally are given five days a week for eight weeks. Each treatment appointment takes approximately 10 minutes. However, much of this is preparation time — radiation is received for only about one minute. No anesthesia is required for external beam radiation, because the treatment cannot be felt at the time of radiation delivery.
A patient is asked to arrive for radiation therapy with a full bladder. This will push most of the bladder out of the path of the radiation beam. A body supporter holds the patient in the same position for each treatment. Small ink tattoos or internal gold markers are used to guide the radiation beam so that it hits the same targets each time. Custom-designed shields help protect nearby normal tissue, such as the bladder, erectile tissues, anus and rectal wall.
Pelvic radiation increases the likelihood of developing either bladder or rectal cancers. Radiation typically cannot be followed by surgery due to the qualitative alteration of the integrity of the tissues of the urinary tract.
Side effects of EBRT/IMRT can include:
„X Urinary problems. Radiation causes inflammation and irritation of the bladder and urethra in the short term. In the long term, the bladder and urethra often lose elasticity and resilience. The most common signs and symptoms are urgency to urinate and frequent urination. These problems usually are temporary and gradually diminish within a few weeks after completing treatment. A minority of patients experience chronic, long-term problems such as incontinence, frequency, nocturia, urgency or episodic blood in the urine. Urge-type urinary incontinence is the most common type of permanent of post-radiation incontinence. Hospitalization and surgery are sometimes required to address these complications.
„X Loose stools, rectal bleeding, discomfort during bowel movements or a sense of needing to have a bowel movement (rectal urgency) occur in some patients. In most cases these problems eventually resolve. Incontinence of stool occasionally occurs. For long-term rectal symptoms, medications can help. Rarely, men develop persistent bleeding or a rectal ulcer after radiation. Surgery may be necessary to alleviate these problems.
„X Sexual side effects. Radiation therapy doesn't usually cause immediate sexual side effects such as erectile dysfunction, but most men who have undergone radiation treatment experience sexual problems within two years of treatment.
Radioactive seed implants (Brachytherapy)
Radioactive seeds implanted into the prostate gained popularity in the 1990’s as a treatment for prostate cancer. The implants, also known as brachytherapy, deliver a higher dose of radiation than do external beams, delivered over the course of several months. The therapy is generally used in men with smaller or moderate-sized prostates with small-volume, and lower grade cancers.
During the procedure, between 40 and 100 rice-sized radioactive seeds are placed into the prostate through ultrasound-guided needles. The implant procedure typically lasts one to two hours and is done under general anesthesia. Most men can go home the day of the procedure. Sometimes, hormone therapy is used for a few months to shrink the size of the prostate before seeds are implanted. The seeds contain radioactive isotopes — either iodine or palladium. These seeds don't have to be removed after they stop emitting radiation. Iodine and palladium seeds generally emit radiation that extends only a few millimeters beyond their location. This type of radiation isn't likely to escape the body in significant doses. However, doctors recommend that for the first few months you stay at least six feet (1.83 meters) away from children and pregnant women, who are especially sensitive to radiation. All radiation inside the pellets is generally exhausted within a year.
Side effects of radioactive seed implants can include:
„X Urinary problems. Radiation causes inflammation and irritation of the bladder and urethra in the short term. In the long term, the bladder and urethra often lose elasticity and resilience. The most common signs and symptoms are urgency to urinate and frequent urination. Men can also experience slow and painful urination. Most men need medications and some men need to perform intermittent self-catheterization to help them urinate. Total urinary retention requiring long-term catheterization or surgery can occur. Urge-type urinary incontinence is the most common type of permanent of post-radiation incontinence.
„X Sexual problems. Most men eventually experience erectile dysfunction due to radioactive seed implants.
„X Rectal symptoms. Sometimes this treatment causes loose stools, discomfort during bowel movements or other rectal symptoms. However, rectal symptoms from radioactive seed implants are generally less severe than with external beam radiation.

Radical prostatectomy
Surgical removal of the prostate gland, called radical prostatectomy, is used to treat cancer that is confined to the prostate gland. During this procedure, the surgeon uses precise techniques to completely remove the prostate, gland, seminal vesicles and possibly lymph nodes. Three surgical approaches are available for prostatectomy — retropubic, perineal and robotic-assisted laparoscopic.
„X Retropubic surgery. The gland is taken out through an incision in the lower abdomen that typically runs from the navel to the pubic bone, just above the base of the penis. This surgical approach has largely been replaced by robotic-assisted laparoscopic prostatectomy.
„X Perineal surgery. An incision is made between the anus and scrotum. The perineal prostatectomy has been performed for 100 years, and is the most mature surgical approach. It provides the most direct access to the prostate gland. A perineal prostatectomy typically can be completed in less than two hours. Nerve-sparing can be readily accomplished by this approach. Preservation of urinary control (continence) is often best with the perineal approach due to less disruption of the supportive structures of the urethra and bladder. Bleeding and pain are usually modest. Hospitalization typically is two days. For men who have had previous pelvic surgeries or who are significantly overweight, the perineal approach is often the best. With this procedure, the surgeon isn't able to remove regional lymph nodes. The surgeons at Central Bucks Urology have collectively performed more that one thousand perineal prostatectomies.
„X Robot-assisted laparoscopic surgery. Robotic prostatectomy is the newest surgical approach. Since its introduction in 2001, robotic surgery has become the most popular technique. In robotic prostatectomy, five 1/3 to ½ inch laparoscopic ports are inserted into the abdomen. A high-definition, 3-D camera provides unparalleled, ten-fold magnified visualization. The Intuitive Surgical da Vinci Robotic Surgical System (www.davinciprostatectomy.com) is controlled by the operating surgeon. The advantages that the robotic system provides has led to its rapid adoption over the past few years, largely displacing standard, retropubic surgery as well a conventional laparoscopic prostate surgery; the majority of prostatectomies performed in the United States are now done utilizing the da Vinci robotic system. The surgeons at Central Bucks Urology have been operating with the da Vinci robotic system since 2008.
During any type of operation, a catheter is inserted into the bladder through the penis to drain urine from the bladder during recovery. The catheter remains in place for one to two weeks after the operation while the urinary tract heals.
Side effects of radical prostatectomy can include:
„X Bladder control problems (urinary incontinence). These symptoms can last for weeks or even months, but most men eventually regain bladder control. Many men experience stress incontinence, meaning they are unable to hold urine flow when their bladders are under increased pressure. This can happen during sneezing, coughing, laughing or lifting. In approximately 5% of men, urinary incontinence does not return completely.
„X Erectile dysfunction. This is a common side effect of radical prostatectomy, because nerves on both sides of the prostate that control erections may be disrupted or removed during surgery. Most men younger than age 50 who have nerve-sparing surgery are able to achieve erections afterward, and even some men in their 70s are able to maintain normal sexual functioning. Men who had trouble achieving or maintaining an erection before surgery have a higher risk of being impotent after the surgery.
Chemotherapy
This type of treatment uses chemicals that destroy rapidly growing cells. Chemotherapy can be effective in treating prostate cancer, but it is not yet capable of curing prostate cancer. Because it has more side effects than hormone therapy does, chemotherapy is reserved for men who have hormone-resistant prostate cancer that has spread to other parts of the body.
Cryotherapy
This treatment is used to destroy cells by freezing tissue. Cryotherapy involves inserting a probe into the prostate through the skin between the rectum and the scrotum (perineum). Using a specialized probe, the prostate is frozen in an attempt to destroy cancer cells. This method can damage the tissues of the urethra, bladder or rectum. Although progress continues, more time is needed to determine how successful cryotherapy may be as a treatment for prostate cancer.
Gene therapy and immune therapy
In the future, gene therapy or immune therapy may be successful in treating prostate cancer. Current technology limits the use of these experimental treatments to a small number of medical centers. 

• 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