UROLOGY

  • UROLOGY
    UROLOGY

Hiperplasia Benign Prostate (BPH)
The prostate is a gland the size of a walnut in normal and part of the male reproductive system. It is located below the bladder and in front of the rectum and surrounds the urethra (tube through which urine comes out). Currently no one knows all the functions of this gland but if it is known that the liquid produced by it and turns during ejaculation helps nourish sperm and helps to reduce the acidity of the vagina.

Prostate growth
The prostate size increases with increasing age of the man and this enlargement is called benign prostatic hyperplasia (BPH).
The prostate has two periods of growth. The first occurs during early puberty, when the gland doubles in size. Later, around 25 years old, the prostate begins to grow again. Following this second growth, and several years later is that BPH occurs. Though the prostate continues to grow throughout most of man’s life, the enlargement does not cause problems until after 60-70 years. BPH rarely causes symptoms before age 40. However, over half of men age 60 and about 90% of men between 70 and 80 years presented problems urinating.

The growth of the prostate produces compression of the urethra that passes through it so the flow of urine becomes increasingly thin and powerless. With continued obstruction, the bladder begins to suffer and becomes sensitive to small amounts of urine so then the patient urinates often and very little quantity. If the blockage persists, the bladder becomes unable to completely empty so it begins to accumulate in the urine, so that the patient has the feeling of not having emptied the bladder completely. An enlarged prostate is a normal part of aging such as the gray in his hair. As life expectancy increases, so does BPH. This disease is more common in Western countries than in the eastern, which is attributed to a diet higher in fat in the West. It is also more common in married men than in bachelors.

Why does HBP occur?
It is not known what the mechanism is that increases the size of the prostate. What we do know, is that growth does not occur if the individual has removed the testes in childhood. As the testes produce the male hormone (testosterone) it is presumed that this hormone is of great importance for the growth of the prostate. During the growth of the prostate, we observe increases in both the glands (parenchyma) and the supporting tissue (stroma). Hence the growth is called fibromuscular hyperplasia and prostate gland.

Symptoms
Symptoms are determined by the obstruction of the urethra and gradual loss of bladder function, resulting in incomplete bladder emptying. The symptoms are varied but generally are associated with problems during urination, such as:

– Thin stream, weak and broken.
– Urgency to urinate and urine leakage.
– Frequent urination especially at night

The size of the prostate does not always determine how severe the obstruction is or the symptoms. Many men with a large prostate have few symptoms of obstruction, while others, with smaller prostates have more difficulty during urination, increased obstruction.

Since the onset of symptoms is gradual over the life of man, this gets used to the way you urinate but does so with difficulty, so sometimes you find that you suddenly can not urinate (acute urinary retention) this is when a catheter needs to be placed into the bladder in order to empty it. This is often triggered by long journeys without stopping to urinate, drinking, cold winter temperatures or by certain medications such as allergy. These medicines contain decongestant substances called sympathomimetics that as a side effect produce difficulty to open the neck of the baldder so then urine collects.

The previously reported urination problems are caused by the growth of the prostate in 8 of 10 patients, however, can also be caused by other illnesses more serious that your urologist will have to diagnose and treat such as prostate cancer which sometimes manifests with symptoms indistinguishable from benign prostatic hyperplasia.

Prostate Photovaporization with KTP laser
The prostate photovaporización (FVP) with KTP Laser is one of the latest developments for the treatment of benign prostatic hyperplasia (BPH). This minimally invasive technique offers significant advantages over conventional treatments such as transurethral resection and open surgery.

What is it and what symptoms produces BPH?
Hyperplasia is a benign prostate disease characterized by the growth of the gland that compresses the urethra that is the tube that carries urine from the bladder to the exterior and passes it into the prostate. Obstruction of the urethra in the male produces difficulty emptying the bladder, being the most frequent symptoms:
1 – get up to urinate several times during the night,
2 – difficulty and delay in starting urination,
3 – feeling of incomplete emptying of the bladder;
4 – a weak stream urination, thin,
5 – urgency to urinate and urine leakage.

BPH affects one in 4 men at age 50, one of every 2 at 60 years and almost all males over 80 years. Thirty percent of males at some point in their life will have to be operated by this disease and most not operated will need to be treated with medications for the prostate.

How is BPH treated?
Currently there are several effective medical treatments for BPH, however, an increasingly high percentage of patients (by increasing life expectancy) will need surgery to resolve their discomfort when urinating.

Until recently there were two surgical techniques for treatment of BPH. The first is open surgery (adenomectomy) which has over 100 years and involves making a cut in the abdomen below the navel, through which the benign tumor is removed from the prostate.
This technique requires being in the hospital overnight for 5-7 days, bleeding requiring transfusion occurs in 10-20% of patients, incontinence can result in whole or in part in 5-8% of patients, and sexual impotence in 10 -15% of patients. The second technique is transurethral resection which began performing around 1950 and involves passing a device through the urethra (resectoscope) and cutting the prostate in small pieces which then are aspirated with a large syringe.

This technique is less invasive than open surgery, although patients must remain hospitalized for 3 to 5 days, also causes bleeding during surgery requiring blood transfusion between 5 and 15% of cases, between 3 and 5% of patients with urinary incontinence are partial or total and about 5% will present impotence.

What is KTP?

In order to reduce this complication rate, in 1996 an investigation began at the Mayo Clinic in USA, a new type of laser, KTP/532 (potassium-titanyl-phosphate). The first studies were performed in dogs because these animals suffer from BPH very similar to human suffering. Since 1998, the initial results with patients were presented and since dozens of scientific papers were published that support the excellent results obtained with this technique until after 5 years of treatment. The KTP laser fiber operates with a beam of light with a wavelength of 532 nanometers and has a high affinity for hemoglobin pigment that makes it selectively absorbed into the blood by preventing significant bleeding during surgery .

The laser penetration into the prostate tissue is 2 mm which avoids the problems it had with other types of lasers that were used previously in which tissue penetration was 7 mm producing significant burns that led to stop the use.

How is KTP laser applied?

The KTP laser is applied through a 22F size cystoscope (smaller than that used for the RTU is 26F) that is passed through the urethra. The fluid used is sterile water, so complications have been observed caused by the absorption of glycine (irrigation fluid when performing TURP). The KTP laser evaporation produces 1-2 grams per minute of prostate tissue and therefore large glands can be treated with this minimally invasive technique (over 100 grams) previously it could only be treated with open surgery.

What happens with the prostate during KTP laser fotovaporización?
When applying the KTP laser to the prostate, the heat generated causes the tissue to become water vapor that is removed through a continuous irrigation system. At the same time it closes the blood vessels and thereby prevents the bleeding.

What patients can benefit from the KTP laser?
The KTP laser can be used in any patient who is capable of being anesthetized with general anesthesia or spinal (epidural). However, its the technique of choice for patients with serious diseases of other organs (heart, lung, etc.) or who are in treatment with anticoagulants (Sintrom, Heparin, etc.) or antiplatelet drugs (Aspirin ®, Adiro ®, Tromalyt ®, etc.) or in patients whose religious beliefs prevent the realization of blood transfusion (Jehovah’s Witnesses).

Results of the KTP laser treatment
Several scientific papers have been published that analyze the results after 5 years of KTP laser treatment. To date, 95% of patients are very satisfied with the procedure. The score on the symptom scale improved 87% compared with the results obtained before the fotovaporización. The urinary flow increased by 200% and was maintained over the years. In no patient was observed sexual impotence or incontinence, and none of them had to to be trieated again with KTP laser or another alternative technique.

Advantages of the KTP laser over the older BPH treatments:

  1. Admission to clinic for a few hours (24 or less)
  2. Need to probe for a few hours
  3. Few postoperative irritative symptoms (6%) and short-term
  4. No blood transfusion
  5. Return to normal activity within days
  6. Absence of urinary incontinence and sexual impotence
  7. No need for new operations for prostate

Information about Vasectomy
Vasectomy involves ligation of the tubes (vas deferens) that carry sperm from the testicles to the urinary duct (urethra). Through it they are carried out to the exterior at the time of ejaculation.

Sperm are only one component of semen. Therefore, after vasectomy, ejaculation is unchanged, although the semen can change a little in consistency.
Vasectomy does not affect the secretion of male hormones from the testis. Therefore, this surgery can never lead to impotence.

The vasectomy is indicated mainly in:
Stable couples with two or more children and over age 30 who want contraception.
In couples where the woman can not take birth control due to intolerance, side effects or diseases that contraindicate their intake (hypertension, heart disease, diabetes …..)

This operation is performed under local anesthesia through one or two cuts of 1 cm in the scrotum.

If you wish, before the vasectomy you can savesemen and keep frozen sperm. This allows, in the future to have children with your own semen.

Vasectomy is an irreversible intervention, since using microsurgical techniques can restore fertility. The success rate of this technique depends on the time after vasectomy, ranging from 90% at 2 years up to 35% at 10 years.

Recommendations before the operation

  1. To ensure maximum hygiene intervention, the night before surgery shave skin bag of testicles (scrotum) and next to groin.
  2. The day of surgery you must take a shower, washing the area with regular soap.
  3. Do not eat or drink 4 hours prior to surgery.
  4. Buy at your pharmacy a genital jockstrap. It is a garment similar to tight underpants. Your pharmacist will advise the most appropriate size. After surgery, the surgeon will position it. It is very useful as it prevents the movement of the area and therefore pain.
  5. Although anesthesia is local, it is desirable to come accompanied to the intervention. You should not drive after surgery, as you may feel some discomfort in the testicular area and that can take away the necessary concentration.
  6. Always refer to a urologist what medications you are taking. In some cases, you may indicate any treatment or suspend something you are taking.

Recommendations after surgery

  1. In most cases, you will only feel a slight discomfort in the area of intervention. However, it is normal to feel pain. The threshold of pain, is different in each patient and therefore you shouldnt be concerned. If it hurts, take the painkillers that your doctor has prescribed.
  2. Keep relative rest for 48 hours. This involves avoiding abrupt efforts, long walks, sports and similar situations.
  3. You can and should shower the next day, wash the wound thoroughly with soap. Dry the area with gauze and without rubbing.
  4. Perform a daily cure on the wound with iodine solution for 7 days.
  5. Keep the genital jockstrap for 10 days.
  6. You may get a small hematoma in the testis (blue area) and mild inflammation. If this occurs, apply ice to the area. Usually disappears within 20-25 days.
  7. It is not necessary to remove the points. They fall alone after approximately 7-15 days.
  8. Avoid sex for 10 days.
  9. Must maintain previous contraception until your doctor tells you to.
  10. Approximately 2 months after surgery a control analysis will be performed on you to confirm that there are no sperm in the semen.
  11. If you have any doubts, please consult your surgeon.

The Vasovasostomy (Recanalization of Deferens)
The micro-surgical vasovasostomy is the operative technique that is practiced in all patients previously operated on vasectomy and wishing to regain their fertility. In most cases the application is from new couples whose partner practiced vasectomy as a contraceptive and want to recover their fertility to have kids.

Surgical Procedure
The vasovasostomy is performed by using the operating microscope to ensure the optimum results of the intervention.

Its approximate length does not exceed two and a half hours of surgery being this varies according to the degree of difficulty that the surgical team can find.
Usuallylocal anesthesia is used in the area to intervene (scrotum and vas deferens). Only in special cases would epidural anesthesia or sedation be used.

It doesn´t require, in general conditions of admission to clinic so the patient can return to his home after surgery and discharge performed by the physician team ofPoliclinica Barcelona.

The postoperative special care is not needed, only rest for 48 hours at home and indications of the surgeon.

Impotence (general)
It is the inability to maintain an erection allowing sexual intercourse. Some doctors use the term “erectile dysfunction” to distinguish it from other problems that affect sexual intercourse such as lack of sexual desire or ejaculation problems.

In the name of impotence are grouped a wide range of disorders ranging from total inability to have an erection even those cases that have erection but that remains for a little time or is not strong enough for penetration

Impotence usually has a physical cause such as illness, traumatic injury (surgery) or the undesirable effect of a medication. Any injury that disrupts the blood supply to the penis can cause impotence. It occurs with a frequency of 5% in males at 40 years old to 15-25% in those 65 years or more.

Impotence can always be treated.

How is an erection produced?
The penis has two cylindrical chambers that run the whole length of it which are called corpora cavernosa and that are made of a spongy tissue containing muscle and wide spaces through which blood circulates. The chambers are surrounded by a rigid membrane called the tunica albuginea. Between the two corpora cavernosa is another cylinder which passes inside the urethra and is called the corpus spongiosum.
Erection begins with sensory or mental stimulation. The stimuli from nerves located in the penis or the brain produce the relaxation of muscles found in the corpus cavernosum. This relaxation allows blood into the corpora cavernosa and fill in the blanks. The blood produces pressure in the corpora cavernosa, causing them to dilate and get stiff. When muscles in the cavernous body contract, it stops the entry of blood and the penis becomes soft. The flaw in any of the steps mentioned above will produce impotence.

What causes impotence?
Approximately 70% of patients with impotence have some of these diseases: diabetes, kidney failure, chronic alcoholism, multiple sclerosis, atherosclerosis, or artery disease. Between 35 and 50 percent of diabetic men have impotence. The operations of bladder or prostate cancer can also cause impotence by damaging the erector nerves (nerves of erection) that lie immediately behind the prostate and bladder. Drugs that may cause impotence include antidepressants, tranquilizers, anti-ulcer (cimetidima, ranitidine, omeprazole), blood pressure medicines, allergy. Up to 20% of cases of impotence can be caused by psychological factors (stress, anxiety, guilt, depression, low self esteem, fear of sexual failure, etc). Other causes of impotence are tobacco or hormonal changes.

How is impotence diagnosed?
The questioning and physical examination help to define the extent and nature of impotence. The patient should be questioned about a history of surgery in the pelvis, ingestion of drugs, heavy drinking, etc..
Physical examination may show abnormal hair distribution which may indicate hormonal problems. The absence of pulses in the femoral arteries may indicate problems in the arteries. The curvature of the penis may indicate the presence of Peyronie’s disease.

Impotence caused by systemic diseases such as diabetes or kidney failure can be diagnosed with a complete blood and urine analysis. In cases with low sexual desire, one can observe a decrease in testosterone (male hormone). Confirmation that we are facing impotence of organic and non-psychogenic cause is done with a night test that measures the presence of spontaneous erections during sleep. The presence of a normal erection with this diagnostic test tilts toward a psychological cause.

Hematuria (Blood in urine)
Hematuria is the presence of red blood cells or erythrocytes in urine. In microscopic hematuria, the color of urine is normal when observed with the naked eye, however, when viewed under a microscope, there is a large number of erythrocytes. In gross hematuria the urine is red or the color of Coca Cola.

There are many diseases that can cause hematuria. For example, vigorous exercise may cause hematuria that goes away within hours. Many people may have hematuria without any other discomfort. However, because hematuria may be caused by a tumor or some other serious problem, you should see a urologist in all cases.

To find the cause of hematuria, the urologist will request a series of tests such as blood and urine, excretory urography and cystoscopy. In the analysis of urine, not only can red blood cells be seen but also leukocytes (white cells) that would indicate an infection in the urine. Another finding in the analysis of urine is the presence of cylinders, they are a group of cells that are arranged in ways that shape the small kidney tubes that indicate that there is damage to the function. The observed abundant proteins in urine is also indicative of damage to the kidney function. The blood tests may show elevated levels of urea and / or creatinine (waste which the body eliminates through the kidneys).
Intravenous urography is a series of photographs taken after injecting in a forearm vein a contrast substance that is excreted by the kidney, so that you can see the tubes (ureters) that connect the kidney to the bladder. Urography can show a kidney stone in the ureter or bladder, a tumor (kidney, ureter or bladder) or an enlarged prostate.

Cystoscopy involves passing through the urethra (tube that connects the bladder to the outside a thin device (metallic or flexible) with a cold light on the end that lets you explore the entire bladder and urethra. This test allows us to observe a tumor or a stone located in the bladder with much more detail.

Treatment for hematuria depends on the cause that had produced it.