Common Procedure

Urodynamic testing is often used to try and find out what is causing bladder problems. It is the study of the bladder’s ability to hold and empty urine. It measures the way the bladder relaxes to fill and then contracts to empty. The evaluation is assisted with a computerised study.

Allow a total appointment time of one and a half hours for test and review by the doctor.

Before the Procedure

• No special preparation is required for the procedure. You may eat and drink as normal.
• Keep taking your usual medications. You will not be required to stop taking Aspirin, Warfarin or anti-inflammatory medications unless specifically instructed by your doctor.
• Please do not pass urine prior to the test.
• Please do not feel embarrassed or upset if you have difficulty controlling your bladder during the test, as the test is designed to find the cause of your problem.

During the Procedure

• You will be escorted to theatre and asked to change.
• You may be asked to empty your bladder into a special flow meter, similar to a toilet.
• You will be asked to lie on the examination table, the nurse will explain the procedure and be in attendance throughout the procedure.
• The area will be cleaned with an antiseptic solution.
• Two small catheters are placed into your bladder. The first catheter is used to fill your bladder with fluid and the second catheter measures the pressure inside your bladder.
• A small catheter is also placed into your rectum. This allows the computer to calculate the true bladder pressure. Your bladder will be filled with sterile water.
• The doctor/nurse will ask you to describe the differing sensations you feel during the procedure and the computer will record these.
• Once your bladder is full you will be asked to pass the water into the flow meter, which can measure the bladder pressure and flow of urine. The computer can then calculate whether your bladder has a normal emptying capacity.
• A bladder ultrasound scan is performed at the completion of the urodynamics study.

After The Procedure

• The tubes will be removed and you will be able to get dressed.
• The results are printed and discussed with you by your doctor.
• A sick certificate and a follow-up appointment will be arranged if necessary
• You should be able to resume normal activities the next day.
• A courtesy call may be made as part of our quality control programme.

A prostate biopsy is a safe and effective sampling technique during which tissue is obtained from the prostate gland for the purpose of detecting cancer.

Trans rectal ultrasound guided biopsy is the preferred approach in most cases. It involves the examination of the prostate by an ultrasound probe inserted into the rectum. After local anaesthetic has been injected, a fine needle is inserted into the prostate and a number of small samples (biopsies) are taken.

Allow a total appointment time of 30 minutes, although the procedure itself normally takes 5-10 minutes.

Before the procedure

• Do not take aspirin or anti-inflammatory medications for 7 days before the procedure. This will reduce the risk of bleeding.
• Please advise your doctor if you are taking Warfarin or any blood thinners as he will need to discuss this with you.
• A dedicated antibiotic protocol is used before and after the procedure to significantly diminish the risk of infection.
• A microlax enema may be used prior to the procedure if ordered by your doctor.
• In line with infection control guidelines, we recommend antibiotic treatment to minimise the risk of infection.
• You will be provided detailed pre-procedure preparation instructions including hours of fasting prior to procedure.

During the procedure

• You will be escorted to theatre and asked to change.
• The procedure is carried out with you lying on your left side in a similar position to a rectal examination.
• The ultrasound probe is inserted into your rectum.
• Local anaesthetic is injected around the prostate to make the biopsies more comfortable.
• The biopsy samples are obtained by a biopsy needle.
• It is important to lie as still as possible and let the doctor know if the procedure is painful.

After the procedure

• The biopsy specimens are sent to the Pathologist for examination.
• A sick certificate and follow-up appointment will be arranged as requested by your doctor.
• Limit your activities and rest for 24 hours.
• You should be able to resume normal activities the following day.

Risks and complications

Infection

If you feel unwell with a headache, sweating, fevers, chills, painful testicles or problems passing urine, you need to contact your Urologist immediately as you may require admission to hospital for further treatment.

Bleeding

You may experience blood in your urine, bowel motion and semen and this will gradually subside over the next 2 weeks and rarely causes a problem. If bleeding persists or is very heavy, contact your doctor.

Inability to urinate

This can occur due to swelling around the prostate and may rarely lead to a complete blockage of urine flow. If this occurs, contact your doctor.

Pain and discomfort

You may experience discomfort in the rectum or base of the penis. This is very common and should settle within 24-48 hours.

What is Laparoscopic surgery?

Laparoscopic surgery (‘keyhole’ or ‘minimally invasive’ surgery) is the technique of performing surgery through multiple small incisions, rather than one large incision Through these small incisions, ‘ports’ are placed to pass a telescope, light source, and instruments, and carbon dioxide is used to inflate an operating ‘workspace’.

Advantages

• Reduces pain and shortens the recovery associated with traditional open surgery
• Close up magnified view of internal organs
• Reduced blood loss
• Less post-operative pain
• No large scar – better cosmetic result

Disadvantages

• May take longer to perform
• Requires specialist training

What is a laparoscopic nephrectomy?

This procedure involves removing the kidney through ‘key hole’ surgery. The procedure is most commonly performed to remove cancer but may be indicated to remove a kidney severely damaged by obstruction, stones, or infection. The procedure is performed through 3 or 4 incisions in the front of the abdomen, or the back, depending on specific technique used. If the kidney is removed for cancer, one incision is enlarged to 6 – 8 cm to allow removal of the kidney intact for further analysis. If it is too difficult to complete the surgery laparoscopically, a larger cut is made to remove the kidney through more traditional open surgery. This is necessary in around 5% of cases.

How long does it take?

What are the risks?

• Infection – uncommon
• Bleeding/blood transfusion – uncommon
• Damage to bowel/spleen/liver – very rare
• Wound pain hernias – rare

What can I expect after surgery?

• Hospital stay is 2 – 4 days
• Pain after surgery should be controlled with oral pain killers
• Most people will be eating, drinking and out of bed the next day
• Recovery at home and avoid strenuous physical activity for at least 3 weeks
• Initial follow-up at 6-8 weeks, with further follow-up as instructed at that visit, depending on the precise reason for your surgery

Living with one kidney
One kidney can easily support a normal and active life. There is no need to limit activities or lifestyle.

What is a laparoscopic pyeloplasty?

This is an operation to remove the blockage between the outlet of the kidney (renal pelvis) and the kidney tube (ureter). This condition is called pelvi-ureteric junction (PUJ) obstruction. This blockage is mostly due to a blockage that occurs from birth, due to abnormal development of the kidney. Rarely it can be due to the previous scarring that narrows the tube, caused by stones, trauma or previous surgery.

Key-hole surgery is performed through 3 – 4 incisions through the side of the abdomen to remove the blockage. A small tube (stent) is left in the ureter for 4-6 weeks to allow the tube to heal. This is then removed under local anaesthetic by passing a small telescope (cystoscope) into the bladder.

Conversion to a conventional open operation can occur if the procedure can not be performed through key-hole surgery. This occurs in approximately 5% of cases.

Why do I need this?

The operation is needed if the blockage causes kidney pain, kidney infections or the kidney function becomes damaged. It can also be associated with kidney stones and high blood pressure.

How long does it take?

4-5 hours under a general anaesthetic

What are the risks?

• Infection – uncommon
• Bleeding – uncommon
• Wound pain/hernias – uncommon

What can I expect after surgery?

• Expect some discomfort but this should be easily controlled with pain killers
• Most people will be eating, drinking and out of bed the next day
• Hospital stay is 2 – 4 days
• Recovery at home and avoid strenuous physical activity for at least 3 weeks
• While the stent remains inside you, there may be the urge to pass urine more frequently, and it is not uncommon to have some visible blood in the urine from time to time. This should not cause concern, and it is advisable to drink more than usual when blood is visible
• Overall success rates to relieve the blockage are approximately 95%

What is Ureteroscopy?

• Examination of the upper urinary tract with a small calibre telescope
• The telescope is passed through the urethra and bladder, into the ureter to locate the stone
• An optical fiber is passed through the telescope to transmit LASER energy to the stone which fragments it into dust
• A small “basket” may be used to retrieve stone fragments for chemical analysis

Why do I need this?

You have a stone in your ureter, less than 2 cm in size, which may be causing pain, obstruction, bleeding or infection

How long does it take?

30 – 60 minutes under a general anesthetic, depending on the stone size, location, and hardness

What are the risks?

• Infection in your urine or blood (sepsis) – antibiotics are given
• Need for a second procedure – if the ureter is too narrow to pass the telescope, vision is poor due to bleeding or the stone is very large and hard. A stent tube is inserted and the procedure is repeated 2 weeks later
• Ureteral injury – a stent tube is inserted to allow healing, or rarely an open operation in needed

What can I expect after surgery?

• When you wake up you may have a catheter in your bladder and an internal stent tube
• The stent is a temporary tube which passes between your kidney and bladder and allows drainage while there is swelling present
• Stents may cause the following symptoms;
• flank pain while urinating
• urinary frequency
• a feeling of incomplete bladder emptying

• The stent is removed 1 – 2 weeks later and these symptoms resolve immediately

The following day, any catheter if placed, is removed and you can go home once you have passed urine

What is TURBT?

• TURBT stands for transurethral removal of bladder tumor
• This is removal of a bladder tumor via a telescope inserted through the urethra
• No cuts are made on the outside of the body

Why do I need this?

To remove a bladder tumor and determine if it is a cancer and its extent

How long does it take?

20 – 40 minutes under a general anaesthetic

What are the risks?

• Bleeding and blood clots in urine
• Need for blood transfusion
• Infection in urine or blood (sepsis) – antibiotics are given
• Perforation of the bladder

What can I expect after surgery?

• A catheter may remain overnight to drain urine and wash out any blood clots
• Hospital stay is 2 – 3 days
• You may have some urinary frequency, urgency or blood in your urine during recovery, which can take up to 6 weeks to settle

Bladder Cancer Patient Guidebook
Canadian Patient Guidebooks – Downloads – Bladder Cancerhttps://bladdercancercanada.org › canadian-patient-guide

What is a ‘TURP’?

• TURP stands for trans urethral resection of the prostate, otherwise called a ‘re-bore’
• Obstructing prostate tissue is removed with a telescope to improve urine flow
• Only the inner part of the prostate is removed, to increase the internal diameter
• This may identify cancer being present, but is not a cure for prostate cancer

How long does it take?

• 40 – 60 minutes under a general or spinal anesthetic
• Please discuss details of the anesthetic with your anesthetist

What do I need to do before surgery?

• Stop taking blood thinning medication when advised by your surgeon
• You must not eat or drink for 6 hours before your operation

What are the risks?

• Bleeding and blood clots in urine
• Infection in urine or blood (sepsis) – antibiotics are given
• Dry ejaculation
• Narrowing of the urethra or bladder neck
• Erection difficulties – rare
• Need for blood transfusion – rare
• Incontinence – very rare

What can I expect after surgery?

• A catheter remains for 2-3 days to drain urine and wash out any blood clots
• Hospital stay is 2 – 3 days
• You may have some urinary frequency, urgency or blood in your urine during recovery, which can take up to 6 weeks to settle
• You will be given a post-op review appointment about 6 weeks following surgery

Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and a general anaesthetic. A catheter (a tube which drains the bladder) is required for 1-2 days until the urine is clear. Patients are advised to take life quietly and to avoid straining or heavy lifting for four weeks after the surgery.

Who is it suitable for?

• HoLEP can be performed on men of any age with urinary outflow obstruction caused by an enlarged prostate. It is particularly indicated in men with large prostates (over 60 mls) and men on medications to thin the blood such as warfarin, aspirin or clopidogrel.

What does the procedure involve?

A laser is used to help remove tissue from the prostate gland which is causing a restriction to the flow of urine out of the bladder.

What are the advantages of HoLEP?

• There is often less bleeding than after a TURP
• Discharge is often quicker than after TURP at 1-2 days
• The chance of recurrence requiring further surgery is very low
• Unlike greenlight laser operations, large quantities of prostate tissue are sent for pathological analysis
• The PSA generally drops to very low levels after HoLEP operations

What problems can occur after surgery?

Common (greater than 1 in 10)
• Temporary burning, bleeding and frequency of urination
• No semen produced with orgasm (75 out of 100 men) – permanent
• Not all urinary symptoms may resolve
• Infection of bladder, testes or kidneys
• Failure to pass urine requiring temporary catheter placement

Occasional side-effects (1 in 10 to 1 in 50)

• Loss of urinary control
• Damage to erections
• Injury to urethra (water-pipe) causing scarring, further operation may be required
• Finding of unsuspected cancer in the tissue removed from the prostate

Rare side-effects (less than 1 in 50)
• Repeated treatment for re-growth of prostate gland (1% at seven years)
• Self-catheterisation or indwelling catheter if bladder is weak
• Ongoing loss of urinary control (incontinence), further operation may be required (less than 1%)
• Retained tissue fragments in bladder, may require telescopic procedure
• Injury to ureter (drainage tube from kidney)
• Perforation of bladder needing further surgery
• Bleeding requiring return to operating theatre
Your Urologist will be happy to discuss HoLEP with you.

What is an insertion of penile implant?

• This procedure involves a surgical incision to allow two inflatable cylinders to be inserted into the shaft of the penis
• The cylinders are usually connected to a pump and a reservoir and filled with saline
• The hydraulic pumping action allows an erection to form and it can be released with a deflate button

Why do I need this?
This procedure is reserved for severe erectile dysfunction where sexual intercourse is not possible and other treatments have failed or are unsuitable

How long does it take?

What are the risks?

• Infection is a major concern and antibiotics are given. In 1 – 2% of cases this occurs and requires removal of the device
• Bruising and swelling may occur and improves over 2 – 3 weeks
• Penile shortening is sometimes noticed and is contributed to by the underlying cause of erectile dysfunction
• Penile pain and awareness of the connecting tubes
• Loss of sensitivity is uncommon
• Thrombosis (blood clots and emboli) are uncommon.

What can I expect after surgery?

• Hospital stay is 2-4 days
• The devices give a good erection with good rigidity and some girth expansion
• Orgasm should still feel normal
• Patient satisfaction rates are over 80%

ZSR Stapler Circumcision

Circumcision surgery is the surgical removal of the penile foreskin for various medical reasons (infection, balanitis, BXO, penile cancer, STD prevention). It is also performed for religious or cosmetic reasons to have a cleaner appearance of the male genital.

Circumcision reduces the risk of contracting UTIs, STIs, HIV, etc. It can even lead to lower risk of developing penile cancer in men and cervical cancer in their sexual partners.

What is Stapler Circumcision?

Stapler circumcision is a minimally invasive technique to perform circumcision that is used for safe, quick and efficient removal of the penile foreskin. The procedure is performed using a circumcision stapler (also called anastomat), an instrument specially designed for circumcision.

Stapler Circumcision Procedure

During the procedure, a local anaesthetic is administered at the base and shaft of the penis. This ensures safe and effective pain relief during the surgery and minimises post-operative pain for several hours.

Thereafter, the stapler is fitted over the penis, and once fired, it removes the foreskin in one quick motion and closes the incision using a silicone ring/non-bioabsorbable staples. Since the amount of foreskin to be removed is predetermined in the procedure, it is extremely safe and provides the desired results for both the patient and the surgeon.

Recovery and Healing Tips

• 1. After the surgery, you will be discharged within an hour and you can rest and recover at home.
• 2. You will need to visit for a follow-up consultation and wound inspection 2-3 days after the surgery- appointment will be booked by our clinic.
• 3. During the first follow-up visit, the compression bandage is removed, wound examined for any signs of bleeding or infection. After this, the wound will be either covered or left open depending on the wound status and the next follow-up is planned.
• 4. It is advisable not to keep the staples wet to ensure healing and avoid infection. During this time, local antiseptic lotion and cream may be applied as instructed by the surgeon.
• 5. The silicone (white) ring left on the penis usually fall off on its own within 10-14 days with spontaneous extrusion of the staples. Some patients can experience a delay in the separation of staples and till all staples are removed periodic visits will be arranged. On some occasions, the staples may be removed in the clinic if they haven’t extruded spontaneously.
• 6.It is important to avoid swimming and heavy weight lifting for 2-3 weeks following the procedure. Full recovery usually takes 4-6 weeks. Some individuals may experience oversensitivity of the glans, which can resolve over a few months.
• 7. Sexual activity can be resumedabout 4-6 weeks after the procedure and minimum 2 weeks after the last staple extrusion. The wound should be fully healed before sexual activity is resumed.
• 8.To minimise the impact of night erections on the staplers during the initial days after circumcision, emptying your bladder before bedtime and a few times during the night is recommended. Sleeping on your side or back and drawing your knees into a fetal position can also help.
• 9.Wearing tight underwear after the circumcision can prevent unnecessary movement. Following the aftercare advice and keeping the wound dry for three days is also crucial.
• 10.Regular ten-day vitamin C intake can promote healing, while vitamin E cream, Mederma gel, or bio-oil can be applied to the scar after 15 days once the staplers have been removed. For further advice and support, don’t hesitate to contact us.

Stapler Circumcision – Benefits & Side Effects

Stapler circumcision is an advanced circumcision procedure that allows for faster recovery and better results as compared to open circumcision.

• The surgery can be performed under both general and local anesthesia, but commonly performed under local anesthesia, thereby avoiding the side effects of general anesthesia and delay in recovery.
• No special preparation is required- patients can walk-in for the procedure and leave within an hour of the procedure avoiding prolonged hospital stay and inconvenience.
• Shorter surgical times (the actual procedure can be completed in 5-10 min).
• Higher satisfaction with the aesthetic appearance of the penis (cosmetic neat look).
• Reduced operative pain.
• Minimal blood loss during surgery.
• Decreased post-operative wound bleeding.

The downside of stapler circumcision is the delay in extrusion of staples that may happen in some cases but in routine surgical circumcision the sutures take time to fall off as well.

Some cases depending on the penile anatomy may not be suitable for stapler circumcision and surgical circumcision is advised in these cases.