Bladder Cancer

Bladder Cancers are primarily Transitional Cell Cancers. Transitional cells are the type of cell that lines the inside of the bladder, the ureters and the inside of the collecting system of the kidney. Transitional cell cancers can develop in any of these areas, but are most often found in the bladder. These tumors usually present with gross (you can see the blood) painless hematuria. The blood may be minimal or very transient to very severe with clots. Diagnosis is usually made by cystoscopy, looking in the bladder with a small scope made for that purpose. Other tools for diagnosis and management are urine cytology, and various types of x-rays or ultrasounds.

Bladder Cancer is most common in men and tends to be more frequent with age. It is clearly associated with smoking and second hand smoke. There are other associations as well.

The majority of these tumors are low grade papillary tumors. Visually they look like white to pink broccoli. They often can be managed by removing the tumor through a scope. We increasingly use bladder treatments afterward to reduce the number and frequency of recurrences. Higher grade more aggressive tumors are serious and dangerous cancers. Determination of the tumor type, grade and stage are made by biopsy and removal of the tumor and by imaging studies. The proper approach to the tumor can then be determined. They usually require removal of the bladder and reconstruction of a new bladder. Surgical options for more advanced tumors can include ileal conduits, continent urinary reservoirs and neobladders. Chemo therapy is often used along with surgery in these cases. Radiation therapy is used much less often with this particular type of cancer.

Hematuria

Hematuria means blood in the urine. There are two categories, gross hematuria and microscopic hematuria. Gross hematuria implies that one can see the blood in the urine……. from just looking dark to obvious thick blood and clots. Microscopic hematuria is blood detected by the doctor or lab under the microscope or by urine dipstick test. Another categorization of hematuria is the absence or presence of pain. Painless hematuria especially when gross is concerning for tumors. Hematuria with pain is more concerning for infections or stones.

At Urology Group we try to identify the source of the blood as quickly as possible. Hematuria evaluations of course include a urine analysis, but also other tests including cultures to check for infection, x-rays, ultrasounds and CT scans to look for stones and tumors. Cystoscopy (looking in the bladder with specially designed telescopes) is often employed to look for tumors in the bladder. Other Urine tests sometimes utilized are cytology, Uro Vysion. We often find a reason for the blood and then will move on to treatment if that is warranted. Everyone has a few red blood cells in the urine. Urine dip sticks are developed to detect the “normal” amount and negative evaluations for hematuria are not infrequent.

We will endeavor to find the source of your hematuria as quickly as possible to put your mind to rest about this often concerning condition.

Holmium Laser

This precision device is used to break up bladder and kidney stones. A laser fiber is passed to the stone location. It is aimed at the stone just off the surface and the laser energy is then fired at the stone to fragment it into small pieces. These pieces are then passed naturally by the patient in most cases. This laser is used primarily for stones in the ureters, but is also used for bladder and kidney stones depending on the situation.

Incontinence

Urinary incontinence is a common problem in both men and women. It is seen frequently in children in both sexes. It is common in women during mid life and again in both sexes in later years. There are several types and causes. Our goal is to identify the type and cause of the leakage and then use whatever methods are required to resolve or manage the problem as expeditiously as possible.

Evaluation always begins with a good history of the problem. This includes not only issues related to the incontinence itself but also other medical conditions, dietary history, voiding habits and physical limitations. Physical examination including the abdomen, pelvis, rectum, vagina and prostate are often pertinent. Examination gives clues as to the physical abnormalities and tissue changes that may be contributing to the problem. In women, cystocele, pelvic prolapse or pelvic vault prolapse associated with bladder hypermobility are common especially after childbirth. Type I, Type II, and Type III stress incontinence are in part determined by physical examination and history.

Urinalysis is done to identify other conditions that may be causing or contributing to incontinence. Bacteria in the urine indicate an infection. Pyuria, the presence of pus or white blood cells in the urine can indicate infection or other inflammations. Glucosuria indicates too much sugar in the urine and probably in the blood stream. Occasionally, we diagnose cases of diabetes in this way. Hematuria, blood in the urine can indicate infections, stones, tumors and other problems in the urinary tract. Proteinuria, protein in the urine can indicate kidney disease and other conditions.

After the above evaluation, specialized testing can be used to further define issues that may impact the diagnosis and treatment of the incontinence condition. These tests are chosen individually given each patient’s complaints and situation.

Additional testing may include:

Cystoscopy – Special scopes are used to look inside the bladder to define anatomy and look for bladder wall changes (cystitis), inflammation, stones, and bladder cancer.

Post void Residual Volume (PVR) – We use a bladder scanner machine to look at the bladder with ultrasound, and in a noninvasive way determine the amount of urine remaining in the bladder after urination. This is a good way to determine incomplete voiding and urinary retention.

Urodynamic Testing – A newly acquired, state of the art, Mediscan urodynamic machine is often used in cases to determine how the bladder is functioning. Several tests may be involved from simple cystometry, to multichannel complex urodynamic testing. We use subtracted pressures to separate bladder (detrusor) pressures from abdominal pressures, leak point pressures and other parameters to assist in diagnosing and treating each patient’s condition.

Radiological Examinations - Sometimes ultrasound and x-ray examinations are useful in the evaluation of incontinence.

Treatment

Treatment is highly dependent on the cause and the results of the above examinations and testing.

Sometimes simply treating an unrecognized infection is all that is needed. Dietary modification, Kegel exercises, alteration of voiding habits can be helpful in some cases. Biofeedback and other pelvic floor exercises, sometimes using the assistance of physical therapy is available.

Treatment of prostate disorders, like enlarged prostate may resolve incontinence issues. This may be done with medications or surgery or other minimally invasive treatments like TUNA (PROSTIVA) done in the office.

Treatment of Neurogenic Bladders is often directed at managing incontinence and preserving the function of the kidneys.

Female incontinence is occasionally treated with injection therapy, either with Collagen or CoAptite.   

Surgical options are numerous and varied. Selection is based upon severity, anatomic changes and other factors. They include Marshall Marchetti Kranz (MMK), Birch Culposuspension, Stamey, Gittes or Raz needle suspensions.

Pubovaginal Slings are frequently used to lift the lower vaginal wall and stop stress incontinence. There are many types of sling procedures including the newer mesh slings (Gynecare TVT, Sparc, Monarc,). Transvaginal, suprapubic and transobturator approaches can be used in this category of cases. Major pelvic prolapse cases are handled by more involved and often combined procedures.

Kidney Cancer

Kidney Cancers comprise about 35% of all adult cancers. They primarily occur in the 50 to 70 year age group, but it is not uncommon to see them in the 40’s. Men develop this disease about twice as often as women. Smokers double their risk of this condition. By far, most kidney cancers are renal cell cancers. These are cancers that develop from the lining of the tubules in the kidney.

Kidney cancers used to be discovered when patients noted blood in their urine or a mass in the abdomen. In the last few decades, they are commonly found during ultrasound or x-ray examinations for other reasons. Sometimes passing a kidney stone leads to the discovery of these tumors.

Treatment for Kidney cancers is usually surgical. Removal of the entire kidney was often required in the past. As more cancers have been found incidentally, they are sometimes smaller in size and can be treated with only removing part of the kidney (a partial nephrectomy) or by freezing the tumor. The exact approach to each tumor depends on its location, size and the anatomy of the kidney. Dr. Snoy is adept at laparoscopic surgery to remove these tumors.

Kidney Stone Evaluation and Prevention Programs

Kidney Stones are terribly painful and expensive events. They can damage the kidney and even prove fatal in rare circumstances. Surgical procedures, hospitals, lithotripsy and time away from work are all part of the costs.

Stone prevention is therefore one of our main goals. We try to find the cause of the stone formation in almost anyone who has had multiple stones, large stones or a difficult time treating their stone.

The key to prevention is a large urine output to keep the urine clear and dilute. In most adults we recommend a 2 quart a day urine output. You may need to drink 3 to 4 quarts of liquid a day to produce 2 quarts of urine per day.

A good dietary history will be taken. We will send off to the lab any stones passed or retrieved for a composition analysis. Please bring us any stones that you pass…yes retrieve it from the toilet! Finally we often do a metabolic evaluation consisting of a blood tests and 24 hour urine collections to see why stones form in your urine. Urine collections are often done with collection kits called Litholink or UroRisk. We will order these for you when indicated. Once collected, all of the above information is evaluated and a specific set of recommendations will be given to each patient.

The tough part about managing your kidney s tones is sticking to the recommendations…for the rest of your life. Once you have made a stone you have a 30 to 70 % chance of having another one in your lifetime. Remembering your kidney stone pain is a useful motivator.

Did you know..stones were mostly a male problem until the last 15 years, now women predominate.

Did you know… obesity is a strong risk factor for making stones.

Did you know…there are 4 different kinds of calcium over excretion form the kidneys.

Lithotripsy
ESWL (Extracorporeal Shockwave Lithotripsy)

Most stones located in the kidney or upper ureters are broken up by lithotripsy. The patient is positioned on a special table, given anesthesia, and then shockwaves from the machine are focused on the stone inside the kidney or ureters. The shock waves break the stones into small fragments that are then passed out through the urinary tract. Original versions of these machines had the patient placed in a bath of water to transmit the shockwaves. We use the newer versions of the machines where the bath has been downsized to a small water balloon placed against the patients back. The treatments usually take about an hour and are done as an outpatient.

Urinary Tract Infection “UTI”

This is a broad term that covers infections of the entire urinary tract. Other names imply infections of particular areas.

• Pyelonephritis Infection of the Kidney
• Ureteritis Infection of the Ureter
• Cystitis Infection of the Bladder
• Epididymitis Infection of the Epididymis
• Prostatitis Infection of the Prostate
• Orchitis Infection of the Testicle
• Urethritis Infection of the Urethra

Sexually Transmitted Diseases “STD” are infections of any of the above organs by organisms or viruses that are passed by sexual contact.

“UTI” can be devastating, life threatening emergencies, a chronic disturbance or completely asymptomatic. We often try to cultures to grow and identify bacteria so to prescribe the correct antibiotic. Some infections and bacteria are treated without culture as we often know the correct antibiotic to use for certain bacteria.

Difficult to treat and resistant bacteria are increasingly common and include MRSA – Methicillin Resistant Staph Aureus, and Vancomycin resistant Enterococcus.

Urodynamics and Uroflow Evaluation

These examinations are used as an aid in the diagnosis and management of urination problems.

Uroflow studies involve voiding into a toilet equipped with a device that measures the rate, duration and volume of urination. This gives the physician a measurable quantfication of what happens during the voiding process. Using a bladder scanner afterward to determine the amount of urine remaining in the bladder provides more information.

Urodynamics are a more complex set of tests that provide additional understanding of exactly what is happening with the bladder muscle, prostate and sphincter muscles that are all part of the voiding process. These studies may include cystometrogram, multichannel, or subtracted cystometrogram, uroflowmetry and urethral pressure profile. We have recently acquired a state of the art Mediwatch machine that provides excellent studies!