Erectile Dysfunction surgery and injectables often produce results when oral meds can't.

Does your doctor have experience with all of them?

Author: Dr. Lieberman

Long before there were commercials advertising oral medications for resolving erectile dysfunction … long before there were jokes about the side effect of a four-hour erection … and long before anyone was familiar with the phrase “the little blue pill” … I began practicing as a trained, board-certified urologist in the area of male sexual dysfunction. It was 27 years ago to be exact.

Now, some nearly three decades later, I can proudly state that I am still helping men come to grips with their erectile dysfunction issues — and, more importantly, — solve their E.D. In this time, the field of medicine has made great strides in identifying the causes of E.D. and its treatments. In fact, it probably surprises you that treatment options for E.D. are not merely limited to the heavily-advertised oral medications like Cialis and Viagra. Injectable treatments and penile implants are other available treatment options — and they have much higher success rates than their more well-known oral-medicine counterparts. Injectables typically have an 85% success rate with patients. A penile implant — a device that is surgically implanted in the patient that allows him to have a reliable erection whenever  he so desires — has an even more impressive success rate of greater than 95%.

Surprisingly some men are put off by the idea of having an operation to cure their E.D., despite its nearly 100% success rate with producing erections and despite the fact that in their current state, they cannot have the sex they want. To these patients I typically ask, “Which sounds better to you – a 95% chance that you can have an erection whenever you want one if you have the surgery … or a 0% of having an erection if you don’t have a penile implant?” (It’s actually more of a rhetorical question isn’t it?)

I speak from experience. I’m the only urologist in the Lehigh valley who performs penile surgery on a regular basis. In fact, I have the broadest experience in this area of any doctor in the Lehigh Valley. And many of my patients are specifically referred to me for the surgery by other urologists in the valley after oral and injectable options failed. The surgery takes less than an hour. And is performed on an outpatient or short-stay basis. Patients can return to sexual activity about eight weeks after the procedure. If you have E.D. and wish to talk about ways to address it such as a penile implant, talk to a trained urologist who specializes in the area of male sexual dysfunction such as myself, or at the very least, ask your primary care physician for his or her advice. 

Provenge is the first FDA-approved immunotherapy for prostate cancer. But … is it right for you?

Author: Dr. John Maggioncalda

The goal of every Urologist is to diagnose and treat prostate cancer early. The earlier the detection, the greater the chance a treatment will lead to long-term survival. Sadly, some patients progress even after their treatment and still others are diagnosed with advanced disease from the very beginning of our interaction with them. The next step for these patients is to ensure their testosterone level is very low. This is usually accomplished by using an agent, or a combination of agents, such as Lupron, Zometa, Eligard, or Casodex. These medicines will block the body’s production of testosterone and its attachment to receptors in cells preventing the growth of prostate cancer. Unfortunately, they work for a variable amount of time, in some cases only 2-4 years. What next?  Recently, a new immunotherapy called Provenge has been approved for patients with metastatic prostate cancer with rising PSA levels despite low, castrate levels of testosterone. 

Provenge is the first FDA approved form of immunotherapy for the treatment of metastatic prostate cancer.  Patients must have a rising PSA, despite castrate levels of testosterone, and some demonstrable form of metastatic disease by CT/MRI, ultrasound or bone scan.  Potential patients must also be healthy enough to receive Provenge with at least a 6-month life expectancy and no or limited pain from their metastases. 

Provenge is not a form of chemotherapy; it is considered immunotherapy.  The treatment uses the body’s own cancer fighting cells and energizes them to attack prostate cancer cells.  Once approved for treatment a patient will have blood drawn and the immune cells separated from the red cells.  These immune cells are then stimulated so that they will begin attacking the prostate cancer cells.  The immune cells are reintroduced into the body after stimulation and the process is repeated two more times.  These three treatments are all that is required and the total treatment takes 4-5 weeks.  The side effects of Provenge can include bruising from the needle sticks, fatigue, backache, and low-grade fevers. 

Once a patient receives Provenge the progress of their disease will continue to be monitored by their Urologist or Oncologist.  There is often no direct reduction in a patient’s PSA level after treatment but, studies have shown an improvement in overall survival compared to subjects that did not receive the treatment.  Patients are still able to receive other forms of chemotherapy once Provenge is administered. 

If you are a patient with metastatic, castrate-resistant prostate cancer, I encourage you to talk with your Oncologist or Urologist about Provenge to see if it is an option for you.  Remember, not every patient may be a good candidate for Provenge.

Spending too much time in the men's room?

Author: Dr. Murphy

You're probably heard the ads on TV —  Trouble going?  Always in the bathroom?  Take this medication and stop being bothered by your aging prostate!

Prostate enlargement, called "Benign Prostatic Hyperplasia," or BPH for short, affects a lot of us — up to a third of all men will be bothered by it at some point. As the prostate enlarges, it pinches off the flow of urine from the bladder. Slowing of the stream, difficulty starting, and poor bladder emptying are the most common signs. A strong urge to go right away, even leaking before making it to the bathroom can happen, as well as getting up more often at night. We're not really sure why some men get it and others don't. It isn't caused by the things we eat or drink, or anything we do — you could say it's just part of aging, like arthritis or getting cataracts.

Fortunately there are ways to treat it. Some men feel that herbal remedies such as saw palmetto help them (although medical studies that compared saw palmetto to a sugar pill do not seem to show much benefit).  There are a couple of different types of prescription meds that work well:  

• Flomax, now available as the generic drug Tamsulosin, is the most commonly used medication for BPH. It relaxes the muscle fibers where the bladder empties through the prostate to open up the urinary flow. This medication starts working in just a week or two.
• Avodart, and a similar generic called Finasteride, shrink the prostate to improve the urinary stream, although it can take a few months to notice any improvement.  

Side effects of both of these meds are usually temporary and aren't too bothersome.

For some men, medications don't help enough. They might need a procedure to open up the urinary channel. These treatments are done under a sedative or fully asleep so there isn't any pain:

• Microwave Hyperthermia heats the prostate tissue up, and over the next few weeks it shrinks to open the channel.
• Another type of treatment removes the enlarged prostate tissue through a scope in the urethral channel. Some people call this a "Roto-Rooter."  In one technique, a laser uses a beam of energy to vaporize the tissue. The other, called Transurethral Resection, or TURP, trims out the tissue. Most men are back to full activities within a week or two. 

So all those ads on TV do make a good point. Prostate enlargement can be really annoying, and there are lots of ways to treat it. Like they say, talk to your doctor and see what you can do to urinate normally again.

Why we do what we do

Author: Dr. Dan Silverberg

I want to tell you about Jack and Maryanne (names are changed to protect privacy). Jack died a few months ago at the age of 86 of cardiac disease.  

Twenty-three years ago I removed Jack’s urinary bladder for extensive bladder cancer. Without surgery, he would have died of bladder cancer within just a year or two. This surgery is one of the most complex operations we perform as urologists. The patient's body is changed forever. For the rest of his life, Jack wore a bag on his abdomen to collect his urine. A patient's decision to undergo this surgery is never an easy one, even when staring cancer in the face. Following the surgery, Jack made a successful recovery and lived for many years in good health.

I received a note from his widow recently. It reads, in part, as follows:

Dear Dr. Silverberg and Staff,

Thank you so much for your expression of sympathy.

I also want to thank you for the wonderful care you and your staff gave Jack.

Dr. Silverberg thanks to you, Jack and I had 23 additional years together. In 1989 you told us that without the surgery Jack would have a year or two at the most. If Jack would allow you to remove his bladder, he would live for many years and die from something else.  

You were so right. 

Fondly Maryanne

This note reminds us beautifully that we do not just take care of patients. We take care of real people. They have families who love them. They have hopes and dreams for the future. When we give them an additional 23 years of life, they have the time to see their children grow to adulthood. They have that time to enjoy their grandchildren. They have the time to pursue and realize their hopes and dreams.

After all of the time we spend in the office, after all the time spent in the hospital, after all the time that we spend being doctors and nurses and medical assistants and office staff, the success of our work is measured by the extra years of life that we give to our patients.

Kidney Stone Treatment

Author: John Maggioncalda MD

Once you have been diagnosed with a kidney stone the treatment options vary.  Your urologist must take into account your health, the size of the stone, its location in the kidney or ureter, and even your prior history of passing stones.

One of the easiest ways to treat a kidney stone is to let it pass.  In many cases a small stone (<4mm) will pass spontaneously with increased fluids and pain medication.  If you have a history of passing stones in the same kidney previously, you are more likely to pass another one.  This approach reduces the need for surgical intervention and any post-op pain associated with it.  The time to pass the stone can vary however, from a few days to a few weeks.  If the pain is too intense or the time to pass the stone becomes great (>4 weeks), or you have a solitary kidney or some form of obstruction to the ureter, then spontaneous passage may not be preferred.

If your stone is clearly visible on an x-ray and in the top part of the ureter, shockwave lithotripsy or ureteroscopy is a good option for treatment.  Shockwave lithotripsy involves sending focused sound waves on to the stone to break it to small pieces.  It is done under anesthesia in the operating room, and takes about 30 minutes.  It is generally greater than 80% successful in breaking up a stone.  There can be post-op discomfort but it is usually mild to moderate.  Keep in mind that the stone must be visible on x-ray for this technique to work.  Ureteroscopy involves passing a flexible fiber optic scope up the ureter to see the stone.  A laser fiber is then passed through the scope and breaks up the stone on contact.  This procedure is more invasive, takes about 30 minutes, and usually requires a stent for 5-7 days afterwards.  Post-op pain can be significant but, it is more often moderate at worst.  The benefit of ureteroscopy is that it can work on all stones, even those not visible on x-ray.  It is also >93% successful in eradicating the stone.

Large stones in the kidney (>2cm) are very challenging and often require more invasive techniques to treat.  Percutaneous nephrolithotomy involves the passage of larger instruments into the kidney through a patient’s back.  It is also done in the operating room under anesthesia with the patient face down or prone.  Larger instruments allow the urologist to fragment and remove larger stone pieces using this technique.  Unlike the other procedures mentioned, this technique requires a hospital stay of 1-2 days and can be quite painful.  The risk of bleeding as well as other complications is also higher with this procedure.  The benefit of percutaneous nephrolithotomy is that a larger stone can often be treated efficiently with one trip to the operating room.

It is important to make sure you discuss all your treatment options with your urologist prior to planning surgery for a stone.  Remember each stone episode may be different and the treatment will vary by stone and by patient.

Greenlight Laser — An excellent treatment option for BPH

Author: Jeffrey Gevirtz, MD

Are you spending too much time in the men’s room? If you’re bothered by weak flow, frequency and urgency of urination, an inability to empty the bladder fully and sleep interrupted by the need to urinate frequently, you should be evaluated by a board- certified urologist, who can accurately diagnose the cause of your symptoms and discuss the different treatment options available.

The prostate is a walnut-sized gland that lies below the bladder and around the urethra in men. With age, the prostate grows in size and compresses the urethra, blocking the bladder outlet. Many men develop bothersome symptoms from this enlargement of the prostate.

There are many treatment options available to help improve the symptoms of prostate enlargement. Medications called alpha blockers can relax the prostate. Other medications can shrink the prostate. The gold-standard surgical treatment is transurethral resection of the prostate (TURP). During a TURP the obstructing prostate tissue is removed and the bladder outlet opened.
  
Many patients are unhappy with the cost, side effects and level of symptom relief that medications offer. On the other hand TURP offers excellent symptom relief but possible complications, recovery time and a few days in the hospital are a drawback.

The Greenlight Laser is a safe, effective treatment for the symptoms of prostatic obstruction. During this outpatient procedure the laser is used to vaporize the blocking prostate tissue. Symptom relief is the same as for a TURP with less risk of bleeding, no hospitalization and earlier return to normal activities. The procedure can even be done on men taking anticoagulants. The Greenlight Laser represents an excellent new option for treatment.

Experience Matters

Author: Dr. Joseph Trapasso

Is your urologist board certified? If you don’t know, you should ask.

The American Board of Urology awards certification … and recertification … to those individuals who meet specific qualifications to assure every patient that their physician has not only received appropriate training, but that he or she also has the level of urologic knowledge to practice safe and effective urology.

Board certification is a rigorous credentialing process that a urologist seeks, usually after completing a residency and training or fellowship … and then maintains. It confirms that the urologist satisfies the standards for high-quality practice. It includes a written and live exam. For patients, it adds an extra assurance of quality.

Board certification is not mandatory, but at USLV all of our physicians are board certified, and we take it very seriously. We want our patients to be confident that the doctor they are seeing has passed the urology boards and maintains certification as the years go by. They trust us with their health … so we do everything we possibly can to earn that trust.