Urological Procedures

Below you will find preliminary, procedural and post-opt information regarding some of the more common urological procedures performed here at Bellevue Urology. If you have questions about a procedure not listed here, please contact our office for further information.

Cystoscopy (“cysto”)

Preliminary Information:
  1. Your physician has indicated that a direct visual inspection of the bladder and urethra is indicated. This can be done as part of evaluation for unexplained blood in the urine, follow up of a known history of bladder cancer, recurrent infections, or examination of the prostate in men for BPH, amongst other reasons to do this exam.
  2. You may need to have IV sedation (per physician discretion) for this and with this in mind you may be asked to not only have someone available to drive you home, but also to not have anything to eat or drink for 8 hours prior to procedure.
  3. The possibility of substituting a less invasive procedure like ultrasound, x-ray, or CT scan ("cat scan") has been considered, but there is some information that can only be ascertained via direct visual inspection.
  4. You will be getting a pre-procedure phone call (per Medicare requirements) to go over such things as what medicines you currently take and any drug allergies you have – including latex as we use latex gloves in the exam. You will be reminded to have an escort home, unless it was clearly stated by your physician that you will only be getting local anesthesia and not IV sedation. You will be reminded to have nothing to eat or drink for 8 hours prior to procedure (unless clearly stated that no IV sedation will be used). You will be asked if you have a living will or durable power of attorney.
Procedure:
  1. Please arrive 15 minutes prior to examination to facilitate any outstanding paperwork that may need to be completed.
  2. After sterile preparation of the region (please inform us if your skin is sensitive to betadine iodine) a gel lubricated thin telescope is advanced through the urethra into the bladder.
  3. The duration of the procedure is generally quite short, as little as 4-5 minutes depending on findings.
  4. The amount of discomfort during this is generally not very great and the measures taken to address this are individualized to each patient as the procedure progresses.
  5. An explanation of findings will be forthcoming immediately after exam, although admittedly this discussion can be a little difficult for sedated patients to remember.
Post-Procedure:
  1. Expect that there can be a small amount of blood passage with urination following procedure along with some burning discomfort. This will last usually ½ or 1 day.
  2. If a prescription is given for antibiotics or other medicines following the procedure, take these according to directions.
  3. Call the office phone number (454-8016) if you experience fever greater than 101 degrees, heavy blood or significant clots in the urine, or significant pain. You may get the on-call doctor if these problems occur after 5 PM.
  4. You will receive a post-procedure phone call to determine level of patient comfort, presence of fever, amount of blood in the urine, ability to eat and drink normally, or any changes in other unrelated medical problems.
  5. Please take the time to return the follow up questionnaire.

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Female Sling Procedure

Preliminary Information:
  1. Slings are used to treat Stress Urinary Incontinence (SUI) They are not effective in treating urge incontinence.
  2. There are a wide variety of slings, including the pubovaginal sling, the midurethral retropubic slings and the transobturator slings.
  3. Most women with SUI have movement of their urethra away from the pubic bone when they increase abdominal pressure, such as during coughing. The sling remains stationary, and comes in contact with the urethra during its downward movement, essentially compressing it. It can be likened to stepping on a hose with running water and shutting the stream off.
  4. You will be getting a pre-procedure phone call (per Medicare requirements) to go over items such as what medicines you currently take and any drug allergies you have – including latex as we use latex gloves in the exam. The sling procedure is carried out under general anesthetic so you will be reminded to have nothing to eat or drink for 8 hours prior to procedure. You will be asked if you have a living will or durable power of attorney.
Procedure:
  1. Please arrive 1 hour prior to examination to facilitate any outstanding paperwork that may need to be completed, and consult with anesthesia.
  2. Your total procedure time will be approximately 20-30 minutes, however, total time in center is 2 hours.
  3. You will not be allowed to drive yourself home following this surgery.
Post-Procedure:
  1. No heavy lifting >10 lbs, exercise, sex, or anything in the vagina for six weeks.
  2. You may have spotting for up to one week, this is normal. If brisk bleeding occurs (saturating one pad per hour) call the office.
  3. You may feel that your urine stream has changed.
  4. You may experience a pulling sensation on one side of your pelvs, this is normal.
  5. You may experience worsening of your urge incontinence after surgery for a time, if this is bothersome, discuss with your doctor who may offer you medications.

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Lithotripsy (ESWL)

Preliminary Information:
  1. Extracorporeal Shock Wave Lithotripsy (ESWL) is a non-invasive means of breaking up kidney or ureteral stones to facilitate passage of smaller fragments later on.
  2. There are a variety of indications for doing this procedure depending on stone size and location and your physician will go over reasons for choosing this approach versus any other.
  3. There are some instances when a small stent (tube) is placed in the ureter between the kidney and bladder to prevent the pain of renal outflow obstruction as stone fragments are passing.
  4. The procedure is done on an outpatient basis and generally takes an hour to complete.
  5. You will need to hold aspirin, coumadin, or any other blood thinning medicines for one week prior to procedure (4 days for coumadin). Advil, Tylenol, and other narcotic pain relievers like vicodin are ok.
Procedure:
  1. ESWL is carried out under a general anesthetic, so you will not be allowed anything to eat or drink for 8 hours prior to procedure.
  2. There are generally 1,000 to 2,400 individual shocks delivered and this is done under x-ray guidance to localize the stone.
  3. You will be in the recovery room for 1 hour post procedure and to a step down unit thereafter. Depending on how well this goes you may be home within an hour or 2 thereafter.
  4. You will not be allowed to drive yourself home following this surgery.
Post-Procedure:
  1. Expect that there will be some blood in the urine and some discomfort in the region of the shock wave delivery. This should be controlled by oral analgesics.
  2. You will be asked to strain the urine for a period of time afterward to collect any stone fragments that pass. These can be stored dry in a baggy or in the stone collection device to be brought into the office later to be sent off to the lab for analysis.
  3. You can return to work the following day if you are feeling well enough.
  4. If there is a stent left in the ureter during the procedure, there may be a drawstring left protruding through the urethra (urinary outflow channel) to facilitate this stent's easy retrieval later in the office.
  5. Follow up in the office will generally be in 1 to 2 weeks. An hour or so prior to appointment we'll generally request that the patient go to a radiology office for a follow up abdominal x-ray to determine the adequacy of the stone fragmentation.
  6. Lithotripsy for stone eradication is a good means of treating the problem, but nonetheless there are times when the procedure needs to be repeated, or other adjunctive procedures employed, as residual stones may remain in 10-15% of patients.

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Prostate Biopsy

Preliminary Information:
  1. Prostate biopsy is a procedure to make the determination as to whether there is prostate cancer present. This is indicated in instances where the PSA blood test is considered out of acceptable range or where the physical exam of the prostate is considered suggestive of the presence of prostate cancer.
  2. Patients are to hold blood thinning medicines such as aspirin, ticlid, and aggrenox for 1 week prior to procedure and coumadin should be held for 4 days prior to procedure.
  3. A prescription and instructions will be provided for taking an antibiotic prior to procedure and again after procedure.
  4. Prior to procedure patients are to self administer a fleets enema at home 2-3 hours prior to procedure.
  5. Patients should come with a driver to get home in that there are times when patients may require some IV sedative medicines to complete the procedure.
  6. If IV sedation is to be employed, you’ll need to hold off anything to eat or drink for 8 hours beforehand.
Procedure:
  1. An ultrasound probe will be introduced into the rectum to obtain images of the prostate.
  2. A series of needle punctures is carried out, generally 6 or 8, to get a fairly representative sampling of the prostate tissue. These are admittedly uncomfortable for some and again IV sedation may be employed.
  3. The duration of the procedure is generally less than 10 minutes.
  4. You will remain in the recovery area for a brief period of time following procedure if IV sedation is employed.
Post-Procedure:
  1. Rest and avoid vigorous activity the day and evening of procedure.
  2. Drink plenty of fluids for the ensuing several days.
  3. If you’ve had IV sedative medicines, no driving or engaging in any task requiring quick reactions or higher level cognitive function for 12 hrs.
  4. Expect that there will be some blood with urination and even some blood with bowel movement for the following day or 2. If there is a large amount of blood with urination, passage of clots, or inability to urinate, please call the office. (If after hours, you’ll get the on-call physician.)
  5. Expect that there can be evidence of blood in the ejaculate for upwards of several weeks after biopsy. This is commonly described as a rusty discoloration, isn’t generally associated with discomfort, and unless profuse shouldn’t be cause for alarm.
  6. Don’t take aspirin or other blood thinners until 2 days after procedure. If there is still a moderate amount of blood in the urine at that point in time, it’s best to continue holding blood thinners even beyond that point until the urine has cleared.
  7. You will get a phone call in 2-5 days with a result on the biopsy report. If there is prostate cancer present, the usual recommendation is to plan to come back sometime in the next 1-2 weeks for further consultation regarding treatment options. If there is no cancer present, then further surveillance beyond that will be as per physician discretion.

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Ureteroscopy

Preliminary Information:
  1. Ureteroscopy is a minimally invasive means of assessing the ureter (the tube transporting urine from the kidney down to the bladder) and is a procedure most commonly done for kidney stones that have come part of the way down this tube, but not quite to the bladder. There are other reasons to do the procedure such as small tumors in the upper urinary system or narrowings of this tube.
  2. The procedure is done under either general or spinal anesthesia and as such the usual pre-anesthesia instructions apply, such as nothing to eat or drink for 8 hrs. prior to procedure and holding blood thinning medicines like aspirin (for 7 days prior to procedure if possible) and coumadin (for 4 days prior to procedure if possible).
  3. Most patients can go home the same day, but this has to be with someone that can drive you. Occasionally patients will have to stay overnight.
Procedure:
  1. Depending on the reason for doing the procedure, the operating time can be 30 to 90 minutes in length. A "routine" kidney stone case would be expected to be 30 to 45 minutes in length.
  2. Oftentimes a stent (small pliable tube) is left in the ureter to act as a conduit through which the urine can pass to bypass any post procedure obstruction. This tube is left indwelling for 3 days to 2 weeks afterward per physician discretion. This is entirely contained inside the body and patients can urinate on their own. (This is different from an externally draining urinary catheter that’s connected to a bag drainage system.)
  3. Patients will be in the post-op recovery room for about an hour following the case and then either to the step down area where family can be with them or up to an inpatient bed as deemed necessary per physician.
  4. The amount of discomfort is usually not remarkable. In fact, as most of these patients are stone patients the discomfort is considerably less. Admittedly the presence of an indwelling stent can be an irritation, but overwhelmingly preferred to the pain of a kidney stone.
Post-Procedure:
  1. You may have a small nylon thread protruding from the urethra, which is connected to a tube (stent) in the ureter. This is placed to prevent the ureter from spasming and obstructing the passage of urine from that kidney to the bladder leading to "stone-like pain" after the procedure. This thread is used to pull the stent later in the office. You should be able to void and stay dry despite the presence of this. Just take appropriate precautions to avoid accidentally pulling this string.
  2. The stent will likely need to stay for 1-2 weeks, sometimes more and sometimes less, to help keep the ureter open and avoid the obstruction that can cause the back pressure (pain) on the kidney.
  3. Expect that there will be some blood in the urine and this may even persist throughout the entirety of the time that the stent is in place.
  4. Expect that the stent itself will cause some symptoms like an increased sense of urinary frequency. Many patients will confuse this for a urinary infection, which also causes urinary frequency, but this is not commonly the case. Some patients may even require bladder antispasm medicines when the sense of urinary frequency is too much of a bother for them.
  5. Some patients will also have some discomfort up in the region of the kidney at time of urination due to back pressure to the kidney from the bladder pressure being generated. This pressure is transmitted up the stent itself to the kidney causing this phenomenon.
  6. Many patients will be able to return to their regular activities within a day or 2, although check with any specific instructions on the discharge sheet.
  7. If there is a stent in place, its removal in the office is a simple procedure not requiring any anesthesia and most patients will report that it was easier than they had expected.

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Vasectomy

Preliminary Information:
  1. Patients are to come by for consultation with procedure scheduled for a later date. In rare instances both consultation and vasectomy can be done on the same day.
  2. The amount of fluid (ejaculate) that comes out at time of orgasm after vasectomy is a little lower, but not usually by a lot as most of the fluid comes from the seminal vesicles and prostate which aren’t influenced by vasectomy.
  3. The testicles still produce sperm, but with the system being obstructed the sperm will just get broken down and reabsorbed into the body. This isn’t harmful or painful.
  4. There should be no alteration in erectile function.
  5. The risks with the procedure are skin infection and bleeding initially, but the bigger concern is failure to achieve sterility. Reports have shown re-establishment of ductal patency in upwards of .5% of men (1 in 200). As such, follow up semen tests will be necessary to assure that sterility has been achieved.
  6. There was a report many years ago that suggested that men that have had a vasectomy will be at an increased risk for prostate cancer later in life, but subsequent reports have disproved this theory.
  7. A vasectomy reversal is later sought in 6% of men that have the procedure. While this is possible to do, don’t think of this as an "out" as the expense of a reversal is considerable and the success rate in terms of later pregnancies is about 50%.
Procedure:
  1. No aspirin or blood thinners for 1 wk. prior to procedure (tylenol or ibuprofen ok).
  2. Shave the front of the scrotal skin up to the base of the penile shaft the day prior to procedure, have snug briefs style underwear or an athletic supporter to wear afterward, and come with someone to drive you home afterward.
  3. You may or may not get IV valium prior to the procedure per physician discretion. The main thing that makes the procedure possible is the injection of lidocaine local anesthesia to numb the skin and underlying structures.
  4. There will be either 1 or 2 incisions in the scrotal skin to divide the vas defrens (sperm duct) on each side.
  5. Any sutures in the skin will dissolve with time, so no office visit will be necessary for suture removal.
Post-Procedure:
  1. Ice the scrotum intermittently for 24-48hrs. in 15-30 min. intervals.
  2. A prescription for a mild narcotic painkiller will be written and you can take this every 4-6 hrs. as needed. Ibuprofen 400-600 mg. every 4-6 hrs. can be substituted.
  3. You may shower the next day, no ejaculation for 1 week following procedure.
  4. Call office for temperature >100.5, bleeding, or significant testicular swelling.
  5. Expect some swelling and possibly bruising of the skin.
  6. You can return to light duty in 2-3 days like sitting @ a desk. No strenuous activity for @ least a week.
  7. There will be no impact on urinary function, no painful urination.
  8. The source of sperm is blocked, the rest of the system is still "primed," and there’s a "washout" interval of weeks.
  9. Plan to return @ 6 and 8 weeks after the procedure with a semen sample to be checked here to make sure there are no sperm. This should be collected not more than 1 hr. prior to delivery to office. Once 2 specimens without sperm you are considered sterile, but precautions should be taken until then as you are still potentially fertile.

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