General Practitioners

• Arthritis
• Cryotherapy
  Partial nephrectomy and percutaneous radiofrequency waves or cryotherapy ablation therapies can often be used for renal tumors. These techniques all intend to treat a lesion in the kidney without having to remove the entire kidney. These are termed nephron sparring techniques in that part of the goal of such treatment is to spare as many nephrons (the working units of the kidney) as possible while resecting or treating the threatening lesion. Partial nephrectomy involves resecting a part of the kidney containing the lesion while leaving the majority of the kidney in place. Open partial nephrectomy involves a large flank incision and increased blood loss over a radical nephrectomy and so there are increased perioperative risks such as blood transfusion or myocardial events (such as a heart attack). Certain lesions may qualify for a partial nephrectomy if they are not too large and do not enter into particularly vital areas of the kidney such as the center of the kidney where the major blood vessels travel and the collecting system (where the urine begins to collect inside the kidney) begins. Classically, partial nephrectomy is reserved for lesions that would be easy to identify in the operating room because they occur on the surface, lesions that are less that 4 cm in diameter, and lesions that are in patients who already have compromised kidney function (such as patients with a solitary kidney or significant kidney disease). Increasingly, partial nephrectomy is being applied to lesions greater than 4cm in diameter and in patients with normal renal function.
• Male Infertility
  According to the National Institutes of Health, male infertility is involved in approximately 40% of the 2.6 million infertile married couples in the United States. Some of these men experience irreversible infertility and cannot father children, and some of these cases are caused by a treatable medical condition.
• High Cholesterol
• Emergency Care
  For patients who fail oral phosphodiesterase inhibitors and/or the vacuum erection device, the next line of therapy is usually intracavernosal prostaglandin injections. Intracavernosal prostaglandin therapies (Caverject and Edex) can stimulate erections in more profound cases of erectile dysfunction and in the absence of other stimulation for erections. These agents are injected with a small needle directly into the penis. These agents can cause some dizziness or lightheadedness. These agents are best used initially in our office so that issues regarding safety and the correct administration can be reviewed. This is usually accomplished by a first-time demonstration injection in our office. These agents include a 1% to 2% risk of priapism. Priapism is an unwanted, painful erection that lasts over two hours. Priapism in the face of a prostaglandin injection is essentially an overdose of the medication. If your body has a very vigorous response to caverject and the erection is maintained beyond two hours the blood in the penis is not returning to the heart. Therefore, a lack of oxygen supply can lead to pain and even damage to the penis. Priapism needs to be treated rapidly to reverse the erectile process. This can be done in our office or in the emergency room. If you experience priapism you should immediately report to our office or the emergency room for prompt therapy. If priapism remains untreated for six hours it can cause permanent damage to the penis and further decrease your erectile performance.
• Constipation
• Erectile Dysfunction
• Electrocardiogram
  Urodynamics is an in-depth evaluation of the lower urinary tract (bladder and urethra). These studies are important in assessing problems of loss of urinary control or urinary retention (inability to pass urine) or frequency of urination. This evaluation involves placing small tubes through the urethra into the bladder to measure the pressure inside the bladder and a small tube inside the vagina or rectum to measure the pressure in the abdomen. There will also be EKG-type electrodes taped to the area near the rectum and thighs. These electrodes measure the electrical activity of your urinary sphincter muscles. The catheters and EKG leads are placed with the patient on a special exam chair.
• Urinary Incontinence
  Urinary incontinence is the uncontrolled leakage of urine. The problem is widespread and afflicts an estimated 13 million adults in the United States alone. Approximately 85 percent of those afflicted are women. Stress incontinence is a type of urinary incontinence in which the leakage occurs with physical activity such as coughing and laughing. The word “stress” in the term stress urinary incontinence does not mean emotional stress. The stress here is physical. It refers to increased pressure on the bladder from ordinary physical activities. These activities may range from lifting a bag of groceries to sneezing, coughing, laughing or rising from a sitting to a standing position. In stress incontinence, the time period during which leakage occurs may be quite short and the amount of leakage quite small. Stress incontinence can be treated both surgically and nonsurgically.
• Pneumonia

Ophthalmologists

• Glaucoma
  Treating frequency, urgency, and urge incontinence can involve behavioral therapy, medications, and reestablishing appropriate neuromodulation. Behavioral therapies would include moderating fluid intake, caffeine, and certain foods that might aggravate the problem. Medical therapy for these symptoms is usually directed at inhibiting the smooth muscles of the bladder to slowdown bladder contractions. Medications that inhibit smooth muscle are anticholinergic medications such as Ditropan, Ditropan XL, Detrol, Vesicare, Oxytrol, and Sanctura. All anticholinergic medications can inhibit all smooth muscle cells of the body including the salivary glands, and the ciliary muscle of the eye, and the GI tract or intestines. Therefore, anticholinergic medications can cause dry mouth, problems for patients with acute angle glaucoma, and constipation. Reestablishing neuromodulation of the bladder is accomplished by InterStim therapy.

Gynecologists

• Female Infertility
• Endometriosis
  UTI symptoms can sometime occur in the absence of infection; that is, the patient has typical UTI symptoms such as frequent, painful urinations with only small quantities voided each time but when the urinalysis and urine culture is performed the urinalysis may indicate infection but the urine culture is negative. The strict criterion for a documented UTI is a positive urine culture. Starting antibiotics before the culture is taken may cause a negative culture but otherwise a negative culture probably indicates that there is no significant infection even with a positive urinalysis and classic UTI symptoms. The symptoms of a UTI are caused by the body’s own immune system and not by the bacteria. When a patient has UTI symptoms but no UTI it may be that her own immune system is causing these symptoms in the absence of infection. This problem is not well understood but can occur with problems such as interstitial cystitis and endometriosis. Recent studies show that some patients will turn on genes responsible for this immune response and the genes may stay active after the UTI is clear. These patients can suffer lifelong UTI symptoms in the absence of infection. It is not yet clear how best to help these patients.
• Pelvic Pain
  Common presenting signs and symptoms of IC include recurrent urinary tract infections (UTI), pelvic pain, burning with urination, frequency of urination, night time frequency of urination, pain with intercourse, and a sense of incomplete bladder emptying. A very common clinical scenario for a patient who ultimately arrives at a diagnosis of IC is that they have been treated with mixed results for recurrent urinary tract infections and that sometimes the urinary cultures are positive and sometimes these cultures are negative. Commonly, in such a situation the patient may have some pelvic pain or pain with intercourse. Another common presenting scenario for IC is that a patient has unexplained, chronic pelvic pain and urinary frequency. Commonly, IC patients also experience significant bladder pressure.
• Pregnancy
• Labor and Delivery
  Stress incontinence is the unwanted loss of urine with coughing sneezing, getting up out of bed or a chair, or with other physical activities (sports). Stress incontinence reflects a weakness in the pelvic floor muscles responsible for lifting and closing the urethra (the urethral sphincter muscles). This problem is very common in females, especially after childbirth or pelvic surgery. This problem is less common in males and in males a common cause is prostatectomy (removal of the prostate) surgery for prostate cancer or prostate enlargement. The most effective treatment for stress incontinence is urethral sling surgery.

Internists

• Bladder Cancer
  Bladder cancer has a decreasing rate of new diagnosis in the United States over the past two decades. It is still a relatively common cancer with a high occurrence rate because even though the incidence of new diagnosis of bladder cancer is on the decline it tends to recur. Because bladder cancer tends to recur often it has a high rate of occurrence even with a decreasing rate of new diagnosis. Most bladder cancers are called transitional cell cancer.
• Urology
  Urethral diverticula present some of the more challenging diagnostic and reconstructive cases in urology. Patients may complain of the following symptoms: recurrent urinary tract infections, pelvic pain, incontinence, post-void dribbling, dyspareunia (painful sexual intercourse), dysuria (burning or pain with urination), urinary frequency and urgency, nocturia, or feeling of incomplete bladder emptying.
• Kidney Cancer
  The Da Vinci Robotic Partial Nephrectomy is revolutionizing kidney cancer treatment by minimizing bleeding, speeding recovery, and maximizing preservation of renal function.
• Kidney Stones
  A common surgical treatment of kidney stones is ureteroscopy. This involves going under anesthesia so that we can place a cystoscope in the bladder and then through the cystoscope we can place an even smaller scope, an ureteroscope, into the ureter. With the ureteroscope we can break up and remove stones in the ureter and kidney. After this procedure, you will need a plastic tube left in the ureter. This tube is called a ureteral stent and protects the ureter and kidney while the ureter is healing. Generally, this stent remains in place for seven or more days.
• Testicular Cancer
  If a testicular tumor is suspected the next step after ultrasonography, physical exam, and blood testing is often a radical orchiectomy (the removal of the testicle by way of an incision over the inguinal canal or lower abdomen). Because testicular tumors grow very rapidly radical orchiectomy is often suggested to be done as soon as possible upon diagnosis. This can be a shocking and surprising recommendation for the patient. Often, a patient recommended to undergo orchiectomy for a suspected testicular tumor will have some difficulty in proceeding with such a surgery. Frequently, these patients need time and the counseling of their family and friends to understand the wisdom of proceeding with the loss of the testicle to insure their future health. The diagnosis of testicular cancer cannot be safely made by doing a biopsy of the testicle as this can lead to spread of the cancer in a dangerous way. The pathologic diagnosis and effective treatment of testicular cancer begins with a radical orchiectomy. Once the testicle is removed a pathologist can examine the testicle to determine whether or not there is cancer in the specimen and what type of cancer is present. Watchful waiting or observation of a suspected testicular cancer is not recommended.
• Interstitial Cystitis
  The Interstim System was approved by the FDA in 1997 for urge incontinence and in 1999 for urinary retention and urgency-frequency. In 1994, it was FDA approved for fecal incontinence. It has been available in the United States for over a decade. While the Interstim device is not approved for the treatment of pelvic pain and interstitial cystitis, it is sometimes used for pelvic pain and interstitial cystitis with some success. InterStim therapy is a pacemaker for the bladder used to reestablish appropriate nueromodulation of the bladder and rectum. The device works by using a stimulator device in the buttocks to stimulate the S3 nerve root in the pelvis. This is the primary nerve root for bladder function. Stimulating the sacral nerve number 3 (S3) nerve root with the InterStim device can result in dramatic decrease in frequency, urgency and urge incontinence. InterStim therapy can also improve bladder emptying and result in decreasing post void residuals and therefore decreasing urinary tract infections and the other complications of incomplete bladder emptying.
• Urinary Tract Infection
  There are several different theories for causes of IC but it is not truly known what causes IC. For instance, some patients with recurrent UTI symptoms have had certain genes activated by a true UTI and the genes have remained activated despite resolution of the UTI. As a result the patient continues to experience UTI symptoms in the absence of active infection. Another theory for what causes IC is a deficiency of the protective bladder lining that protects the body from the caustic, noxious contents of urine. If the lining is deficient, then caustic agents in the urine can harm and inflame the underlying bladder tissue causing pain and urinary symptoms.
• Prostate Cancer
  Prostate cancer is a cancerous formation within the prostate gland. The prostate is a walnut sized and shaped organ wrapped around the urethra at the bottom of the bladder. Prostate cancer generally does not cause any symptoms until it is extremely late stage and no longer curable. It is because of this silent nature of prostate cancer that screening for prostate cancer is essential. Screening for prostate cancer involves identifying risk factors, performing screening blood tests such as PSA (prostate specific antigen), and performing digital rectal examination. If a patient has enough risk factors or an abnormal PSA or an abnormal digital rectal exam then generally the next level of screening is a prostate needle biopsy. Risk factors for prostate cancer include age, family history, and African American descent.

Neurologists

• Neurolysis
  Most men will experience some transient pain or discomfort in the testicle due to transmission of pressure from the abdomen down into the scrotum from time to time. For most men these brief episodes of scrotal pain are mild enough and infrequent enough that they do not bring them to the attention of a healthcare provider. There is no known treatment to prevent or the correct these brief, transient events. Some men, however have severe scrotal pain that is long-lasting and quite problematic for them and so they do bring it to the attention of a healthcare provider. In many cases these pain episodes will be evaluated with physical exam and ultrasonography and no abnormalities will be found. It is possible that these episodes are due simply to the increase pressure transmission from the abdomen down into the scrotum. This condition is called benign orchalgia which simply means pain in the scrotum for unknown causes. There are no known effective ways to cure this problem. There are some management options that might improve your ability to decrease the pain associated with benign orchalgia but there is no way to treat benign orchalgia to stop it altogether. In many cases benign orchalgia resolves spontaneously over time regardless of the treatment protocol. Some of the conservative management options include avoiding strenuous activity which may aggravate the scrotal pain, using ibuprofen or Motrin intermittently for the pain, using long hot baths for the pain, and using scrotal support to relieve some of the pressure on the scrotum. As a note of caution, one should not take daily doses of ibuprofen for long periods of time but it can be used sparingly and intermittently. There is no known surgical treatment connecting your benign orchalgia. Some urologists do practice neurolysis or nerve stripping of the spermatic cord for this problem. This procedure involves making an incision over the inguinal canal and stripping any possible nerve tissue around the spermatic cord to treat pain. Some urologists will offer removal of the testicle altogether for this problem. If a patient in our practice is interested in these treatment modalities we can refer the patient outside the practice to seek such treatments.
• Multiple Sclerosis
  Neurogenic bladder is any form of neurologic dysfunction of the bladder that results in incomplete bladder emptying. Such bladder dysfunction may occur in the presence of primary neurologic dysfunction (spinal cord injury, multiple sclerosis, etc) but often occurs with no identifiable neurologic disorder (often called non-neurogenic neurogenic bladder).

Psychiatrists

• Anxiety

Endocrinologist

• Diabetes Care

Radiologist

• Ultrasound
  The prostate needle biopsy is performed with a transrectal ultrasound probe to guide a needle into the prostate. We generally take two biopsy specimens each from six different areas of the prostate for a total of twelve samples. We sample the right and left side of the prostate at the base, mid gland, and apex. This is a very typical biopsy strategy among urologists. Under certain circumstances we may take more than twelve samples. The prostate biopsy specimen results are usually available in one week.
• MRI
  Other causes of frequency, urgency, and urge incontinence include bladder tumors, bladder infections, or foreign bodies in the bladder, other voiding dysfunction such as high-pressure bladder storage and neurogenic bladder, and spinal injuries. If a patient presents with other symptoms of a possible spinal injury or particularly young age presentation for urge incontinence an MRI of the spine may be indicated. To rule out the other possible causes of frequency, urgency, and urge incontinence office cystoscopy and urodynamics may be useful.
• X-Rays
• Computed Tomography
  A renal tumor is a mass within the kidney that may be benign or cancerous. Often the malignant potential of a renal mass (i.e. its likelihood of being cancerous) can be very accurately determined with x-rays such as a CT scan or MRI. Classically, 95% of the time when a renal mass has the appearance of a renal cell carcinoma or cancer of the kidney on CT or MRI imaging the pathology on nephrectomy (surgical removal of the kidney) confirms that this is an accurate diagnosis. In other words CT scan and MRI imaging can be very predictive of the malignant potential of renal tumors. Primarily for this reason when a CT or MRI demonstrates a high likelihood of cancer in a renal mass radical nephrectomy or surgical removal of the entire kidney is often recommended based solely on the x-ray imaging. Typically, biopsies are not done of renal tumors because of concerns that the biopsy will fail to access the tumor and thereby give you a potentially false negative (the biopsy missed the cancer) result or that if the needle does access the tumor it may seed cancer along the needle track and spread the cancer outside the kidney. So the typical pathway is that based on x-ray imaging alone a radical nephrectomy is recommended. Other x-ray imaging for possible kidney cancers would include chest x-rays and possibly a CAT scan of the head to rule out possible metastatic spread prior to surgical removal. The majority of renal tumors create no symptoms and no discomfort or pain. Therefore, the majority of renal masses and renal tumors and kidney cancers are identified serendipitously on x-rays obtained for other reasons. In most cases we can remove real tumors using robotic assisted laparoscopic technique to preserve kidney function, decrease blood loss, and speed recovery (please see our patient brochure on robotic partial nephrectomy).
• Chemotherapy
  Nonseminomatous germ cell tumors occur in many varieties and trying to understand which type of nonseminomatous germ cell tumor you have can be highly confusing but it is important information for the urologist and the pathologist to decide upon. Some varieties of nonseminomatous germ cell tumors are more dangerous and aggressive than others. In addition to deciding whether or not you have a more virulent form of nonseminomatous germ cell tumor, the orchiectomy specimen is also important for determining whether or not you have lymphatic or vascular invasion by the tumor within the testicle. Having a more virulent strain of nonseminomatous germ cell tumor or the presence of lymphovascular invasion are worrisome features and might indicate higher risk of metastatic spread. Metastatic nonseminomatous germ cell tumors may require chemotherapy or additional surgery (Retroperitoneal Lymph Node Dissection is a major surgery where the lymph nodes along the aorta/vena cava are removed) to treat the metastatic lymph nodes. The subject of whether or not to treat potential metastatic spread from nonseminomatous germ cell tumor can be highly confusing and very controversial.
• Radiation Therapy
  Urge incontinence is the unwanted loss of urine that is usually associated with an abrupt and very strong urge to urinate. Urge incontinence is often seen in people with nerve damage, spinal cord injury, multiple sclerosis, other neurologic disorders, a history of pelvic surgery, and sometimes urge incontinence occurs without obvious neurologic dysfunction. Urge incontinence can sometimes occur with aging. Another cause for urge incontinence is the presence of some irritating force within the urinary tract that causes the patient to lose urine involuntarily. This could be any type of infection or inflammation of the bladder or urethra. This would include various forms of cystitis or bladder inflammation or a bladder stone. This could also be seen in bladder wall-damaged patients such as those who have received radiation therapy. Urge incontinence can also occur from a long history of bladder outlet obstruction or voiding dysfunction. The treatment of urge incontinence depends on the causative factors. If the cause of the urge incontinence is any one of the irritating forces, then treatment may be directed at trying to relieve the bladder of the cause of the irritation (treating the infection, removing the stone). If the urge incontinence does not have a treatable cause (permanent nerve damage, advanced medical diseases, unknown causes) then the treatment could involve medications to limit the severity of the symptoms. In some cases, pelvic floor retraining and/or Interstimnerve modulation can be use to improve bladder function. Pelvic floor retraining is a directed form of physical therapy used to improve the function of the pelvic floor muscles. Interstim is a minimally invasive procedure similar to a pacemaker that helps improve neural function of the bladder.

Surgeons

• Wound Care
  Urethral sling placement in the male is accomplished with a small incision between the scrotum and rectum and four small puncture sites: two on either side of the scrotum and two above the pubic bone. The puncture sites will be covered with a small surgical dressing called steristrips. These steristrips will fall off on their own in 1-2 weeks. Covering the steri strips will be gauze and a clear tegaderm, you can remove these two days after surgery.
• Vasectomy
  Vasectomy is the process of dividing the vas (the tube that delivers the sperm from the testis to the prostate) in order to prevent conception. It is the most common method of male contraception in this country where about 500,000 vasectomies are done each year. Since vasectomy simply interrupts the delivery of the sperm, it does not change the hormonal function of the testis and so sexual drive and sexual function remain intact. Since most of the semen is composed of fluid from the prostate and seminal vesicles, the semen will look the same. Vasectomy is the safest and most reliable method of permanent male sterilization.
• Robotic Surgery
  Our website enables you to schedule appointments, review our patient medical education briefs ( Men's Health, Women's Health, Kidney Care, Robotic Surgery ) and learn more about us. Please feel free to contact us with any questions.
• Hysterectomy
  The uterus, ovaries, bowel, bladder, and rectum are suspended in the female pelvis on tendinous cords (ligaments) similar to bungee cords hanging from the pelvic bones. These ligaments and the pelvic floor muscles keep these pelvic organs in place and prevent these organs from descending down and out through the vagina. These ligaments and the pelvic muscles wear out over time and as a result the pelvic organs can descend down through the vagina (descensus). Along with time and age other risk factors for descensus include a history of pregnancy, deliveries, pelvic surgery (especially hysterectomy), and pelvic radiation.
• Laparoscopy
  With earlier detection many of these renal tumors can be removed without removing the whole kidney (partial nephrectomy). Partial nephrectomy allows for effective cancer treatment without losing significant renal function. Partial nephrectomy has historically been performed through the open flank incision rather than with laparoscopy because the surgeon needs to be able to have control of the major blood vessels to the kidney to prevent bleeding. The kidneys receive 12.5% of your entire blood flow every minute and cutting into the kidney to remove the tumor can result in significant blood loss.

Plastic Surgeons

• Botox
  Other treatments for overactive bladder include behavior modification, timed voiding, anticholinergics, pelvic floor retraining, and Botox bladder injections. Anticholinergic medications can be used to inhibit bladder smooth muscle to treat frequency, urgency, and urge incontinence. Anticholinergic medications will also inhibit smooth muscle in the ciliary muscle of the eye, the salivary gland, and the intestines. Therefore, these medications can cause problems for the patients with acute angle glaucoma and these medications can cause dry mouth and constipation. InterStim therapy does not cause changes to smooth muscle cells outside the bladder and so it does not cause problems for glaucoma patients and it does not cause dry mouth or constipation. InterStim therapy can improve the elastic properties of connective tissue in the bladder and therefore it can help many patients who do not respond to anticholinergic medications. Anticholinergic medications will have no effect on the connective tissue of the bladder wall. If a patient has significant frequency, urgency, and urge incontinence there may be changes in the bladder wall connective tissue. For these patients there may be minimal or no change with anticholinergic medications. Interstim therapy can be very effective in such cases.
• Laparoscopic Surgery
  Radical nephrectomy has been the gold standard for treatment of renal cell carcinoma or kidney cancers for decades. Radical nephrectomy in the past has been performed through a large incision on the side of the body called a flank incision. These incisions often involve the removal of part of a rib and were very long and painful incisions transecting many muscle groups. Most radical nephrectomies can now be achieved through a laparoscopic nephrectomy technique using robotic assisted laparoscopy or hand-assisted laparoscopy. Laparoscopic techniques allow for the safe and effective removal of the kidney without having to make a flank incision. Hand assisted techniques generally include an incision long enough to squeeze one hand through the incision and that incision can be performed in a location, such as the midline (middle of the abdomen), where no muscle needs to be transected. This greatly decreases postoperative pain and discomfort from radical nephrectomy. The midline is lying in the middle of the abdomen between the abdominal muscles. A 5 cm incision on or near the belly button or umbilicus allows for placement of one hand in the abdomen and several small ports can be placed through small holes the size of your pinky finger nail to allow instruments to be placed into the abdomen for radical nephrectomy. This allows removal of the entire kidney through the hand incision. Robotic assisted laparoscopy is the use of a surgical robot to facilitate laparoscopic surgery without placing a hand into the abdomen. The kidney is removed through a small midline incision at the conclusion of Robotic assisted laparoscopic radical nephrectomy.
• Gynecomastia
  The most common congenital cause of hypogonadism is Klinefelter syndrome. This condition, which is caused by an extra X chromosome, results in infertility, sparse facial and body hair, abnormal breast enlargement (gynecomastia), and smaller than normal testes.

Dermatologists

• Cyst
• Lesions
  Radiofrequency and cryoablation are techniques that are used to destroy renal lesions rather than resect renal lesions. These treatment modalities collect only a small amount of tissue for specimen for a pathologist to review to confirm the diagnosis. These techniques rely considerable on the accuracy of radiographic imaging both to establish initial diagnosis and to locate the lesion for treatment. These techniques can also be used on patients with compromised renal function or patients who cannot tolerate the risks of major surgery. Radiofrequency ablation and cryoablation can sometimes be accomplished without the use of general anesthesia and surgical exploration in the operating room. These treatment options do not have the same proven cure rate as surgical removal and so these treatments are usually reserved for patients who are at high risk for anesthesia.

Physical Therapists

• Physical Therapy
  Reestablishing neuromodulation of the bladder can be accomplished by Pelvic Floor Retraining or InterStim therapy. Pelvic Floor Retraining is a directed form of physical therapy used to improve the function of the pelvic floor muscles. Interstim is a minimally invasive procedure similar to a pacemaker that helps improve neural function of the bladder.