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Geriatric
Urology
Many elderly patients suffer from urologic conditions particular
to their age group. Often times physicians are unfamiliar with
the treatment of such conditions. Furthermore, many urologists
are unfamiliar with the side effects in the elderly of commonly
used urologic medications. Dr.
Tomas Griebling focuses on urologic problems in the elderly,
their diagnosis and their treatment. Having completed a fellowship
to address urologic problems in the elderly, Dr. Griebling is
a nationally recognized leader in the field of Geriatric Urology.
In addition, he is the only urologist in the state of Kansas
with such specialized training.
Sexual Dysfunction
Sexual dysfunction is an extremely common problem affecting over
50% of men between the ages of 40 and 70. With newer treatments
available, public awareness of the problem has increased greatly.
Impotence, or erectile dysfunction (ED), as with many disease
processes, has a spectrum of severity. The most frequent symptom
that we see is the inability to achieve any penile erection at
all. Commonly, however, one may experience partial erection with
either incomplete rigidity or loss of rigidity before ejaculation.
In the past physicians often attributed ED to psychological causes.
However, we now know that psychogenic impotence is responsible
for less than 10% of cases of serious erectile dysfunction. Common
causes of ED include medications for other conditions, arterial
blockage due to atherosclerosis, peripheral nerve damage due
to diabetes, pelvic fracture, and spinal cord injury. Fortunately,
determining the specific cause of erectile dysfunction is usually
not necessary as treatment is fairly standard.
Often times, ED can be treated easily with prescription oral
medications. The physicians at the University of Kansas Hospital
will evaluate your erectile dysfunction and select the best medication
for you. If one of these medications is not effective, our physicians
are equipped with a wide range of options to treat erectile dysfunction
including intercavernosal injections, vacuum erection devices,
intraurethral therapy, and surgical placement of a penile prosthesis.
In the event that surgery is needed for your erectile dysfunction, Dr.
Ajay Nangia is currently the only physician in the Kansas
City area who is placing penile protheses for the treatment of
erectile dysfunction. This procedure which uses an artificial
device to provide erections has been reported to result in satisfaction
rates greater than 90%. With extensive experience in these techniques,
they offer the latest approaches for this surgical correction
of impotence.
Penile Curvature
Penile curvature also known as Peyronie’s disease is one
of the most challenging problems facing urologists today. Our
understanding of the disease is currently a topic of much research,
but remains largely unknown. However, the physicians in the Department
of Urology are providing state of the art care, using the latest
treatments available.
For those with a recent onset of Peyronie’s disease, treatments
provided in the office might be successful. However, patients
who have a long history of penile curvature often require surgical
intervention. Whatever your needs, the Department of Urology
at KU provides all of the options available.
Male Infertility
Infertility is a common problem affecting up to 15% of couples. In over 50% of cases a male factor is solely responsible or is contributing to the problem. Many causes of male infertility exist ranging from hormonal, blockages, genetic, environmental/lifestyle, medications or unexplained to name a few. Certain potentially life-threatening medical conditions may present for the first time as the inability to achieve a pregnancy and lower sperm counts, such as testicular tumors and some brain tumors. They are uncommon, and the reason why male patients should be evaluated in couples that have infertility.
The evaluation should involve a thorough history and physical and evaluate some of the risk factors that are known to cause male infertility e.g. some childhood disorders that do not become a concern until later in life e/g undescended testicle(s); infections; smoking, alcohol and drug use; certain issues with heat (not boxers or briefs – a myth); cancer treatments; spinal cord injury and other medical conditions. Blockages of the reproductive tract can sometimes be the cause and possible reconstruction using microsurgery can be performed to reverse this and avoid assisted reproduction techniques (ART) and have children naturally. Unfortunately these blockages sometimes cannot be corrected and sperm retrieval techniques and sperm freezing are required for in vitro fertilization (IVF) with intracytoplasmic injection (ICSI) – one sperm injected into an egg outside the body.
Correction of men with low counts and/or motility can also be corrected with a full evaluation, correcting any treatable causes e.g. manipulation of hormones, and correction of certain conditions such as varicoceles – dilated veins in the scrotum that are thought to increase scrotal temperature and affect sperm production. Up to 40% of men who present with infertility have a varicocele on exam. Treatment for this requires careful patient selection and can result in 40-70% improvement in sperm production and up to 40% improvement in pregnancy rates. Even some men with no sperm in their semen who have a varicocele may get return of sperm (approx 17%). It is important to know that the number of sperm is usually not enough for natural conception in these cases and would require ART with IVF. Correction of the varicocele is a same day surgery as an outpatient but is in the operating room and requires an operating microscope to tie off the veins accurately and completely without causing damage to the blood supply to the testicle. Embolization of the veins can also be performed.
- Vasectomy Reversal -
Vasectomy is a common procedure for permanent birth control in the US with over 520,000 performed a year. This is a form of secondary infertility. Six percent of men who have undergone a vasectomy desire a reversal with 12 times higher desire for reversal if the vasectomy was performed under the age of 30. Options for men who wish to have more children either with the same or new partner include vasectomy reversal, sperm aspiration (not undoing the vasectomy) with IVF-ICSI, donor sperm insemination, adoption or doing nothing. The decision to follow a particular option is determined on a case-by-case basis and depends on important factors such as length of time from vasectomy, experience and training of the surgeon and use of an operating microscope; age of the female partner; gynecological history of the female partner; and economic/financial issues since post vasectomy fertility management is most often not covered by insurance. A common myth is that men over 10 years should not have a vasectomy reversal – this is not correct, with the decision making based on the whole evaluation including examination and couples desires and time line as well as issues of views on family planning hopes of the couple. Vasectomy reversal is performed either as an end to end connection – removing the area of vasectomy and reconnecting, and this is called a vasovasostomy. The other type of reversal is a connection between the vas and the back of the testicle (the epididymis) called a vasoepididymostomy. The decision to perform one or the other of these operations depends on the fluid seen at the vasectomy site at the time of the vas reversal. The vasoepididymostomy is a very specialized microsurgery operation that requires significant training. Dr Nangia is trained in this operation. Vasectomy reversal is an outpatient surgery and then semen analysis checked 4 weeks after surgery and periodically there after until pregnancy occurs. Success rates are approximately 75% pregnancy if the vasectomy was performed under 3-5 years prior to approximately 30% if vasectomy was 15 or more years previously.
Sperm aspiration/retrieval techniques for use with IVF-ICSI can be performed in many ways (MESA, TESA, TESE, microTESE) depending on the situation for each patient/couple – ranging from men who have had a vasectomy to men who do not have sperm in the ejaculated semen, known as azoospermia. The reason men have no sperm in the semen and who do not have a blockage (known as non obstructive azoospermia) can be genetic, hormonal or unknown. In up to 10% of cases the genetic reason is felt to be due to missing a piece of the Y chromosome (the male chromosome), known as the AZF region. Some men may also have pieces of one chromosome on another (translocation) or too many X chromosomes. These can be checked by performing blood work. Azoospermia is not the end of the road for having biological children. Even though a man may not have sperm in the semen, there may still be pockets of sperm in the testicles that are not getting out and can be retrieved in up to 60% of cases. This does require a special type of sperm retrieval called micro TESE – which is an extensive biopsy using an operating microscope. This does have to be performed in the operating room. The number of sperm can only be used with IVF-ICSI. Genetic counseling of a couple is sometimes needed especially if a known genetic problem is found.
Another group of patients may develop infertility – those who receive chemotherapy or radiation for cancer. In these cases men should try to freeze sperm prior to treatment for later use if their counts are too low or zero. Hope is not lost in those who did not freeze and may require micro TESE or use of ART. Spinal cord injury in a young man is another reason for problems with fertility – mainly because of ejaculatory issues. In this situation special methods are required to retrieve sperm for couples to have children. Sometimes men have retrograde ejaculation – sperm going into the bladder e.g diabetics, spinal cord injuries, neurological issues, urological/prostate surgery and medications. Retrieval of the sperm from the bladder can be performed to use with assisted reproduction. Sometimes medications can be used to reverse retrograde ejaculation.
At the University of Kansas Medical Center, we have a comprehensive male infertility center that includes an andrology laboratory capable of semen analysis, cryopreservation, and other sophisticated sperm testing. Dr. Ajay Nangia works closely with the reproductive endocrinologists at KU and in the community when couples desire to pursue assisted reproduction – insemination or in vitro fertilization (IVF). Dr. Nangia is fellowship trained from the Cleveland Clinic in male infertility and microsurgery and specializes in vas and epididymis reconstruction, sophisticated sperm retrieval techniques, as well as problems of fertility following cancer and other illnesses including spinal cord injury. Dr. Nangia is a national leader in this field, as well as issues of male contraception.
Vasectomy
Vasectomy is a common urological procedure to result in permanent birth control. Over 520, 000 are performed a year in the USA. It is an outpatient procedure that is done in the clinic/office. It takes about half an hour. A piece of the vas is removed and either clips or ties are applied and some urologists turn the vas back or place the two ends in different levels. Ice pack, rest and pain medication are recommended after the surgery. Protected intercourse is needed until no sperm in the semen is confirmed. This is checked after a certain number of ejaculations (e.g. 15-20) or based on time frame (6 weeks or more after vasectomy). The patient is NOT CLEARED FOR UNPROTECTED INERCOURSE until the follow up semen analysis shows no sperm. Certain questions often asked are listed below:
Will a man have normal erections after vasectomy?
Answer: yes – any affect on erections may be psychological – there are no changes hormonally that cause a problem. Some residual discomfort may play a role possibly.Will a man still produce fluid?
Answer: yes – the main fluid a man produces is “down stream” from the vasectomy.Will a man still reach climax?
Answer: yes….no further explanation neededWill a man still have normal libido (sex drive)?
Answer: yes. Again the problem may be psychological or if he still has some pain may lead to less desire.Can a vasectomy increase the chance of testicular cancer?
Answer: no. There is no connection between the two. Also there is no connection with prostate cancer or any other cancers.Are there any diseases that a vasectomy can lead to?
Answer: no. There have been some associations made that a vasectomy can lead to an increased risk of heart disease, and Alzheimer’s disease. These have not been supported by adequate studies.Can a vasectomy reverse itself spontaneously?
Answer: This is called “recanalization” and unfortunately the answer is yes but rarely and the statistics range from 1 in a 1000 to 1 in 10,000 chance. The reason for this is that there is a sort of “honey combing effect” that the body manages to do in some cases. This however may be very much related to the technique of vasectomy performed and to the man being compliant with the instructions to get his semen checked to make sure there are no sperm. Under 50% of men get checked to make sure that they have no sperm. It is recommended that the analysis not be performed until at least 15-20 ejaculations have occurred. Some doctors recommend a time line e.g. analysis after 6 weeks. The exact time line is not completely clear.Can a vasectomy be reversed deliberately?
Answer; yes. Of the 520,000 or more men who have a vasectomy in the USA per year, approximately 6% feel that they have made a mistake or a change in their life situation has occurred to consider reversing this permanent means of contraception. It is important to also know that if a man is under 30 years of age, he has a 12 times higher chance of wanting a reversal. See male infertility section.What is the no scalpel vasectomy?
Answer: this isn’t quite what everyone thinks. No scalpel does not mean “no pain” or miraculously the surgery is performed like something out of Star Trek. No scalpel unfortunately doesn’t really mean it is any less anxiety provoking, nor any less of a procedure. The main issue is exactly what the name suggests. In place of a scalpel is an instrument that stretches the skin to open it up…..still requires local anesthetic. The main issue is that most times no stitch in the skin is required and the hole is small. Recovery may be better but I have not noticed any difference.
As a patient some time should be taken thinking about the options.
It is an important milestone so it is important to get it right
the first time. If a patient is unsure, vasectomy may not be
the right option.
Benign
Prostate Hypertrophy (BPH)
One of the most common problems in Urology is difficulty with
urination. Since Greek times, physicians have employed different
methods to relieve problems associated with urinary obstruction
due to an enlarging prostate gland. The Urology department at
Kansas University Medical Centers offers a comprehensive array
of diagnostic and treatment options for the enlarged prostate.
These include oral medications, minimally invasive techniques,
and transurethral resection of the prostate. We are the only
major medical facility in this area offering the transurethral
needle ablation (TUNA) of the prostate which involves the use
of radiofrequency to heat the prostate and shrink it over a 3-6
week period. In addition, we are now offering transurethral microwave
therapy (TUMT), which uses microwave therapy to help shrink the
prostate and can be done in the clinic without the need for anesthesia.
These procedures are offered as an out-patient therapy and have
very few complications with excellent results.
For those with more advanced enlargement of the prostate, our
physicians are very experienced in the surgical treatment of
the enlarged prostate gland. The standard transurethral resection
of the prostate formerly was associated with a large number of
complications, however newer technologic advances have decreased
these complications. The Department of Urology at the University
of Kansas Medical Center is always seeking options to improve
the outcomes of our patients who suffer from an enlarged prostate.
Urethral Stricture
Causes: In most cases, patients present with urethral strictures
and no obvious reason for the stricture. They can be congenital, inflammatory,
infectious, or traumatic. The inflammation, inflection, or injury to the urethra
results in scarring of the spongy tissue around the lining of the urethra,
and that scarring causes contracture and a smaller opening for the patient
to be able to urinate.
Symptoms: Most of patients present to the urology clinic with
slowing of their urinary stream. Other symptoms include burning with urination,
and at times, some bleeding with urination.
Treatment: The treatment of urethral stricture disease can
be done by cutting the stricture, dilating the strictured area, or trying to
definitively fix the stricture with an open operation. Dilating or cutting
the stricture with a knife or a laser results in a re-stricture the vast majority
of the time. Reconstruction of the urethra using a piece of the mouth called
buccal mucosa or using a flap of penile skin, results in a long-term success
rate of approximately 94%. At the University of Kansas Department of Urology,
we have one of the largest experiences in the country repairing all types of
urethral strictures. We perform buccal mucosal urethroplasty, vascularized
pedicle flap urethroplasty, two-stage mesh graft urethroplasties, and posterior
urethroplasty repair from trauma to the pelvis. Two surgeons in our department
perform the majority of these reconstructions, Dr. J. Brantley Thrasher and
Dr. Josh Broghammer. Both have fellowship training in reconstruction of the
urinary tract and an extensive experience in all repairs of the urinary tract.
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The University of Kansas Medical Center