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The physicians of Tri-County Urologists regularly author newsletters and articles on new treatments and procedures of general interest in the field of urology. We hope that you will find the following selection helpful and informative.
Tri-County Urologists is comprised of eleven BC/BE urologic physicians plus clinical nurses, physician assistants and a highly trained support team. We have been responsible for a substantial portion of urologic care in the greater metropolitan Detroit area since 1973. Our dedication is, and always has been, to our patients’ well being and health. Staff appointments are maintained at several state-of-the art hospitals in order to achieve the best individualized treatment for our patients. |
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da Vinci ® Robotic Assisted Laparoscopic Prostatectomy
Clinically evident prostate cancer affects one in six men and is the second most common cause of cancer death. Because the incidence of prostate cancer increases with age and the life expectancy of American men is increasing, the number of men with prostate cancer is expected to rise. The surgeons of Tri-County Urologists offer all modalities of treatment for prostate cancer, including the da Vinci ® Robotic Assisted Laparoscopic Prostatectomy. The implementation of this new and exciting surgical technology at Tri-County Urologists is being led by Jon Suleskey, D.O. and Darryl Reaume, D.O.
Why surgery as a treatment for prostate cancer? Surgery provides the highest durable chance for cure. Quality of life studies show patients are happier and healthier at one year and three years post treatment over all other modalities. The goal of surgery is many fold:
- To cure the patient of cancer (80% at 5 years, 77% at 15 years)
- To preserve continence (92% dry at 1 year)
- To preserve sexual function (76% potent – age less than 60 years)
The da Vinci ® robotic minimally invasive prostatectomy provides a number of benefits to the patient a number of benefits:
- Safer surgery with less blood loss (typically less than 500 cc)
- Less scarring Shorter length of hospital stay (usually one day)
- Reduced pain and pain medications Faster recovery and return to work
Tri-County Urologists surgeons have performed successfully hundreds of radical prostatectomies utilizing may methods. The proven minimally invasive da Vinci ® robotic assisted technology now used by our experienced surgeons is making a significant difference in the health of our community.
Further information provided below is excerpted by permission from an article that appeared in a recent issue of Focus, a Mount Clemens General Hospital publication. You may also learn more about Mount Clemens General Hospital by clicking on the following link: www.mcgh.org
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First Robotic-Assisted Surgery at Mt. Clemens Regional Medical Center
A surgical team at Mt. Clemens Regional Medical Center successfully completed the hospital’s first robotic-assisted laparoscopic surgery. The team, led by urologists Jon Suleskey, D.O. and Darryl Reaume, D.O., utilized MCG’s new da Vinci ® Surgical System to perform a radical prostatectomy.
The da Vinci ® Surgical System from Intuitive Surgical, Inc., is a state-of-the-art robotic platform designed to advance the hospital’s minimally invasive surgery initiative. The robotic system complements the important benefits of minimally invasive surgery for patients undergoing cardiothoracic, urologic, gynecologic, oncologic and general surgical procedures.
The robotic system introduces a new degree of freedom and control for the surgeon by advancing the laparoscopic surgical technique. “Before robotic assistance, surgeons performed laparoscopic procedures with rigid instruments that were ergonomically difficult on the surgeon,” said Dr. Suleskey. “The robotic system allows the use of surgical instruments that are designed to mimic the movement of the human hands, wrists and fingers.”
Procedures using the da Vinci® Surgical System are performed with no direct mechanical connection between the surgeon and the patient. The surgeon works a few feet from the operating table while seated comfortably at a computer console with a magnified, three-dimensional view of the operating field. The surgeon operates two controls that work the mechanical arms and precise instruments on the robot. The system enhances surgical capabilities by enabling complex surgery to be performed through small ports rather than large incisions.
Robotic-assisted surgery is different from traditional “open” surgery in that the surgeon does not experience the same sense of touch, but Dr. Suleskey states that the system’s high-tech optics make up for the loss of sensation. “Surgeons work within a three-dimensional field that offers an enlarged, highly detailed view of blood vessels, nerves and arteries,” he said.
Dr. Suleskey pointed out that the goal of cancer surgery is to extricate all cancerous tissue (tumors) and check the surrounding area of “margins” for any evidence of remaining cancer. Early studies have shown that margins containing cancer are reduced with the precision offered by the da Vinci® Surgical System.
“The robotic option is advancing laparoscopic surgery by improving patient safety,” said Dr. Suleskey. “Surgery is made safer with less blood loss and a lower transfusion rate, much smaller incisions plus less trauma to nerves. In a robotic-assisted radical prostatectomy, the patient experiences less pain and there appears to be reduced rates of impotence and incontinence.”
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New Minimally Invasive Office Procedure (“T.U.N.A.”) for the Treatment of BPH
Benign prostatic hyperplasia, or BPH, affects more than eight million American men in the United States and usually begins in the fourth decade of life with significant symptoms present in one-fourth of me by age 70. History, physical examination, bladder scanning for post-void residual urine and occasionally urodynamic evaluation all contribute to the effective diagnosis of BPH.
Symptoms of BPH are divided into two categories – obstructive and irritative. Obstructive symptoms include: weakness of urinary stream, hesitancy, terminal dribbling, intermittency, sensation of incomplete bladder emptying and straining to urinate. Irritative voiding complaints include: urinary urgency, frequency, nocturia and occasionally incontinence. In addition to significant symptoms, BPH can result in the development of urinary tract infections, bladder stones, urinary retention, chronic renal insufficiency and/or renal failure. Many of these symptoms respond to treatment if diagnosed early, although renal failure may be irreversible.
Primarily, the severity of symptoms direct the need for treatment. Patients with moderate to severe symptoms require intervention, medical or surgical. Medical treatment includes alpha receptor blocking agents to relax the bladder neck and prostatic smooth muscle, such as tamsulosin (FlomaxTM), terazosin (HytrinTM) or doxazosin (CarduraTM). Finasteride (ProscarTM) typically can shrink the prostate gland by approximately 25 percent over a 3 to 6 month period. Additionally, may herbal products such as saw palmetto and others are available, but lack FDA approval for increased efficacy.
When medication fails to decrease symptoms and post-void residual urine, other forms of therapy are entertained. Transurethral resection of the prostate (TURP) remains the standard in the treatment of symptomatic BPH. Although a relatively safe surgical procedure, TURP usually requires an overnight hospital stay and has potential intra-operative and post-operative risks.
Transurethral Needle Ablation of the prostate, also known as “T.U.N.A.” is an innovative approach for the treatment of BPH. This minimally invasive, office based procedure involves the use of low-level radio frequency energy to shrink the prostate, thereby relieving the intra-urethral obstruction. “The procedure usually can be performed in less than on hour in the office with minimal local anesthetic required,” says Dr. Steven Roth of Tri-County Urologists. Most patients return to normal activity within 24 hours and notice consistent improvement over the following 6 to 12 weeks. Tri-County Urologists in its dedication to total urologic care is pleased to offer the new FDA approved treatment.
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“Cutting Edge” Lithotriptor First Employed Successfully
in Michigan by Tri-County Urologists
The physicians at Tri-County Urologists have successfully utilized the new Swiss “Lithoclast UltraTM” while performing percutaneous nephrolithotripsy for staghorn calculi. This latest technology made available by Boston Scientific/Microwave Corporation combines the beneficial effects of pneumatic ad ultrasonic lithotripsy in the fragmentation of both large volume renal and bladder calculi. What makes the Lithoclast Ultra unique is the speed and efficiency at which complete stone fragmentation and clearance out of the collecting system can be safely performed.
The Lithoclast Ultra offers simultaneous Ultrasonic Lithotripsy and Pneumatic Lithotripsy functionally operated through a single combined hand-piece and foot pedal. Ultrasonic fragmentation, used in conjunction with a suction device, relies on rapid vibration of the probe tip thereby grinding the stone into fragments. The complementary technology, Pneumatic Lithotripsy, was originally developed in Lausanne, Switzerland, and is based on a jackhammer principle. A piston inside the hand-piece is propelled by compressed air through the Lithocast Ultra probe, resulting in the effective fragmentation of “harder stones” once their tensile strength is exceeded. Based on extensively researched histological examination and in-vitro applications, both modalities possess an impressive safety threshold to human urothelium.
Tri-County Urologists continues to pioneer this safe, new combined technology in Michigan because of the significantly enhanced speed at which patients can be cleared of their urinary stone burden. Dr. Jeffrey Schock and Dr. Jon Suleskey, both physicians at Tri-County Urologists indicate that “… we have been able to effectively treat and clear staghorn calculi in approximately one-third of the time previously necessary using the more tedious separate, stand alone modalities such as: holmium laser, electrohydraulic lithotripsy and earlier ultrasonic and pneumatic methods. Most importantly, the Lithocast Ultra brings the benefit of getting the patient safely off the operating table faster than ever before …”
Tri-County Urologists is pleased to offer its patients this new FDA approved treatment for urinary stones of the bladder and kidney. The physicians at Tri-County Urologists have successfully used this technology at a number of their affiliated hospitals including Mount Clemens General, St. John Oakland and Bi-County Community.
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Bladder Treatment Update: InterStim Neuromodulation and Male Slings
There are five types of urinary incontinence: urge, stress, mixed, functional and overflow. The specific type of bladder dysfunction can usually be diagnosed by history, physical examination, voiding diary and urinalysis. However, certain factors such as: recurrent urinary symptoms, recurrent infections, hematuria, prior surgery, vaginal prolapse, neurologic disease or incomplete bladder emptying warrant a more extensive urologic work up.
The “overactive bladder” is a common disorder consisting of symptoms of urinary urgency, frequency, nocturia and urge incontinence. First line treatment of the overactive bladder consists of behavioral therapy with or without pharmacological therapy, and, occasionally, newly available procedural intervention. The current mainstay of pharmacological therapy is long or short acting anticholinergic medication such as: oxybutnin (DitropanXLTM), tolterodine (Detrol LATM), flavoxate (UrispasTM) and hysocyamine (LevsinTM).
When conservative therapy fails, treatment with InterStimTM Neuromodulation is considered. This highly effective and safe procedure utilizes a pacemaker-like device which hyperstimulates the peripheral nerves innervating the bladder, often producing dramatic, subjective improvement in patients with severe urgency, frequency and incontinence.
Stress urinary incontinence occurs when the pressure inside the bladder overcomes urethral closing pressure, resulting in loss of urine during sneezing, coughing, physical exertion or any activity that increases intra-abdominal pressure. Previous child bearing, post-surgical damage and/or neuromuscular disorders can all contribute to stress incontinence. By quantifying abdominal leakpoint pressures with urodynamic testing, stress incontinence caused by either intrinsic sphincter deficiency (ISD) or uretheral hypermobility can be differentiated. Because there are yet no approved pharmacological agents available for the treatment of stress incontinence, surgical intervention is usually required.
It is well documented that pubovaginal slings and open bladder culposuspensions provide the best results to date in the treatment of female stress incontinence. Alternatively, effective treatment for male stress urinary incontinence can involve surgical placement of either a prosthetic genitourinary sphincter device or a “Male Sling.” The male sling, utilizing cadaveric allografts, is a safe, new approach for treating stress incontinence. Tri-County Urologists is proud to offer both of these new and exciting FDA approved treatments – InterStim Neuromodulation and the Male Sling – to our patients.
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The Urologist, Urodynamics and Bladder Dysfunction UroTrends Volume 12, No. 1
The urinary system is responsible for three major functions in the human
body: maintaining normal body water volume, controlling acid/base balance, and
removing waste products in the form of urine. Urination is a coordinated
mechanical process that when malfunctioning causes patient distress and
substantial medical costs worldwide. Urinary Incontinence (UI) is the
uncontrollable loss of urine. For the Urologist, this is a prevalent and
underdiagnosed entity due mainly to patient misconceptions and fears of
embarrassment.
The workup of UI begins with a detailed history as well as a complete
physical examination. Urodynamics (UDS) is an adjunctive tool designed to
dynamically evaluate bladder and/or urethral function. Using objective
parameters, the test attempts to reproduce the patient’s bothersome voiding or
incontinence symptoms. UDS is most commonly indicated for evaluation of various
types of lower urinary tract symptoms (frequency, urgency, incontinence, etc.)
collectively known as voiding dysfunction. 3 The test
should document: first sensation, first urgency, strong desire to void, bladder
capacity, uninhibited detrusor contractions, bladder compliance, detrusor
pressure, and valsalva leak point pressure measurements (vLPP). UDS ought to be
performed on patients who do not respond to initial therapy and potential future
candidates for a surgical incontinence procedure. Other indications are patients
with neurological disease, prior failed incontinence surgery, prior radical
pelvic surgery or radiation, and refractory urge incontinence.
Although found on rare occasions in female patients, overflow incontinence is
more common in older men with benign prostate hyperplasia (BPH). Also, more than
90% of UI cases are accounted for by stress, urge, and mixed incontinence. For
maximum patient benefit, each entity ought to be treated individually. Urge
incontinence can be treated with:
- Behavioral modification (timed voiding
to prevent urinary leakage with progressive lengthening of intervals between
voiding)
- Dietary modification (avoidance of caffeine, spicy foods, highly
acidic fruit juices, vegetables, carbonated beverages, and alcohol)
- Biofeedback
- Medication (antimuscarinics)
- Neuromodulation
(Interstim
® Uroplasty®)
When considering treatment for Stress Incontinence (SUI), valsalva leak
point pressure measurement is used to confirm both the presence and sometimes
the severity of intrinsic sphincteric deficiency (ISD). In our practice, we use
the Gyrus ACMI SmartFlow UDS system to differentiate severe ISD (very low vLPP
<60cm/H2O), vs. borderline ISD (vLPP 60–90cm/H2O). Stress incontinence
treatment options include: - Non-surgical treatments (kegels, biofeedback,
pelvic floor rehabilitation)
- Injectable medications (i.e. collagen,
Durasphere,
® Coaptite®) Oral medications (Imipramine) Minimally
Invasive procedures (i.e. bladder neck slings, TVT,®
Transobturator tape procedures, TVT Secure,® or other midurethral slings) Colposuspensions
/Urethropexy
 the three symptoms of Overactive bladder
(OAB) usually, but not always results in UI. It is estimated that between 17–33
million Americans suffer from this condition (Figure 1). associated with OAB
include: frequency (more than 8 times/24 hrs.), urgency (uncontrollable need to
urinate), and urge incontinence (strong need to urinate followed by leaking or
involuntary and complete voiding). Both men and women with OAB often experience
urgency at inconvenient and unpredictable times. It interferes with daily
routines, intimacy, and sexual function. Also it may cause embarrassment and
diminish self-esteem.
In a 2004 survey by the Simon Foundation For Continence, 60% percent of women
stated that OAB affects their quality of life. Additionally, 30% of women waited
two years to speak with a physician about their bladder problem and 42 stated
medication didn’t help their symptoms. 1 Therein lies the dilemma with a reported 80%medication drop-out rate
after 12 months. To improve patient compliance, the goal of therapy ought to
include efficacy, tolerability, low adverse event profile, and ease of therapy.
Most commonly the cause of OAB is detrusor overactivity; identified on UDS as
uninhibited detrusor contractions (UDC) and sometimes a small capacity bladder.
UDCs are graphically represented by a spike in the PVES
lead, but not in the PABD lead. A basic
understanding of micturition is necessary prior to instituting treatment,
especially when dealing with rare, and/or more serious conditions (Figure 2).
These may include: nerve damage caused by abdominal/pelvic trauma, prior
surgery, bladder calculi, drug side effects, and neurological disease (e.g.,
Multiple Sclerosis, Parkinson’s disease, stroke, spinal cord lesions). When a
centrally acting etiology of OAB is suspected, the condition is termed
"Neurogenic Detruso Overactivity." In an otherwise healthy individual without
neurological disease, the terminology is "Idiopathic Detrusor Overactivity."
 Conservative measures can significantly improve the
symptoms of an overactive bladder. Behavioral therapies in conjunction with
dietary modification are used as first line treatment. Second line therapy
involves blocking Acetylcholine (Ach), the primary neurotransmitter of bladder
contraction (Figure 3).
Via the
oral or transdermal route, the antimuscarinic medication class is the mainstay
of pharmacological therapy for OAB in the United States. Commonly prescribed
oral therapies are: darafenacin (Enablex
®), oxybutynin chloride (Ditropan XL®), tolterodine (Detrol LA®),
trospium chloride (Sanctura®), and
solifenacin (Vesicare®). They relax the smooth muscle of the bladder via
M2/M3 receptor inhibition; thereby reducing bladder contractility (Figure 4).
 Other modalities that can be used in the treatment of OAB are: biofeedback,
pelvic floor rehabilitation, tibial nerve stimulation (Uroplasty
®), and neuromodulation (Inter-Stim® therapy). The latter is a minimally invasive
procedure delivering minute electrical stimulation to the S3 pelvic nerve. After
a successful two-week test phase, a small generator (43mm x 51mm x 7.5mm) is
placed subdermally in the supra-luteal region. Many patients with OAB, UI, and
interstitial cystitis/bladder pain syndrome have been successfully relieved of
their symptoms with neuromodulation. Other considerations for UDS testing is
treatment of complex neurologic cases. One such example is Multiple Sclerosis
(MS). Up to 90% of people with MS during their lifetime will be affected somehow
by bladder dysfunction.2 There is
disruption of normal processes, and interference with the transmission of
signals between the brain and urinary system.4 Urination becomes less controlled and the urge to urinate becomes a
reflex response to the frequent, repeated spinal cord signals. Alternatively,
emptying dysfunction results as the bladder fills with urine and the spinal cord
is unable to send the appropriate message to the brain (to signal the need to
void) or to the external sphincter (to signal the need to relax).4
 Not uncommonly, MS patients suffer from a severe form of OAB: Neurogenic
Detrusor Overactivity. Conversely, Detrusor Hyperreflexia, sphincter dyssynergia
(DSD) is a potentially serious situation where the bladder contracts against a
closed sphincter; occurring in approximately 25% of patients. If formal video
urodynamics are not available to visualize DSD, than multichannel office
urodynamics may demonstrate persistent high amplitude EMG signal during the
voiding phase. As represented by the EMG lead, the pelvic floor doesn’t "relax"
and patients complain of symptoms of urgency with voiding difficulties and
sometimes require "straining" to void. High detrusor pressures are transmitted
retrograde to the collecting system risking upper tract damage. During an
autopsy review in 1964, 55%of MS deaths were due to complications of
hydronephrosis or pyelonephritis.
5 However, in a study approximately 30 years later, only of 5% deaths were
associated with urinary tract pathology.6 Some of the reasons for this change in urinary tract morbidity may be
fromimproved diagnosticmethodology, clean intermittent catheterization (CIC),
and the use of anti-cholinergic medication to reduce upper tract deleterious
pressures.7 Upper urinary tract
complications such as hydronephrosis, renal insufficiency, or renal failure have
been reported in 15 to 20 percent of MS patients with bladder
dysfunction.8 (Table 1)
 Bladder dysfunction can affect anyone. Most cases can be treated empirically
based on history and physical examination. Also cultural factors in modern
society can promote the symptoms of OAB on the basis of diet alone. The presence
of upper motor neuron disease can substantially contribute to the symptoms and
make treatment plans more complex. The adjunctive benefit of urodynamics in
complex cases can positively impact both diagnosis and treatment of OAB. The
good news for sufferers is that new therapies such as minimally invasive
neuromodulation provide viable, effective, and acceptable treatment. This is an
alternative to patients who have either failed medical therapy, or refuse the
lifetime commitment to pharmacologic consumption. Of paramount importance is the
holistic, comprehensive counseling, and appropriate use of technological
modalities that is integral to successful diagnosis and treatment of bladder
dysfunction.
REFERENCES
1. Simon Foundation for Continence, Urology Times May 2004, Surveys show
significant impact of incontinence, confusion over condition, Urology Times
Daily Meeting Report
2. McGuire EJ, Savastano JA, Urodynamic Findings and Long-term Outcome
Management of Patients with Multiple Sclerosis-induced Lower Urinary Tract
Dysfunction, J Urol 132:102,1984
3. AUA UPDATE SERIES, Lesson 19, Volume XXI pg 146–147, Practical
Urodynamics, Rovner, MD, Alan J. Wein, MD © 2002 American Urological
Association, Inc. Office of Education, Houston, Texas
4. The National Multiple Sclerosis Society, November 1– 4, 2006, 2006
National Conference in Orlando, Florida
5. Samellas W, Rubin B, Management of Upper Urinary Tract Complications in
Multiple Sclerosis by Means of Urinary Diversion to an Ileal Conduit, J Urol
93:548,1965.
6. Betts CD, D’Mellow MT, Fowler CJ, Urinary Symptoms and the Neurological
Features of Bladder Dysfunction in Multiple Sclerosis, J Neurol Neurosurg
Psychiatry 1993; 56:254–250
7. Chancellor MB, Blaivas JG, Multiple Sclerosis in Problems in Urology, Vol
7 No 1, March 1993, JB Lippincott Co
8. Staskin DR, Hydroureteronephrosis after spinal cord
injury. Urol Clin North Am 1991: 18(2):309–325.
Jeffrey Schock,
DO, FACOS, is Vice Chairman, Dept. of Urology, Botsford General Hospital and
Clinical Assistant Professor, Dept. of Surgical Specialties, Mich. State
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