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“Scopies” in Urology
and
Penile Dysfunction
David C. Wei, MD FACS
Clinical Assistant Professor of Surgery
John A. Burn School of Medicine,
University of Hawaii
Urology Consultant, Inc.
1
Urinary System
2
Scopies
• Cystoscopy
– To look into the bladder
• Ureteroscopy
– To look into the ureters
• Laparoscopy
– To look into the abdomen or retroperitoneum
within the space created by CO2 insufflation
3
Indications
• Cystoscopy
– To examine and/or perform surgery inside
the bladder/prostate/urethra
– Gross hematuria
• To rule out bladder tumor or bladder stone.
– Difficulty with urination
• To rule out bladder outlet obstruction such as
BPH or urethral stricture
– Frequent urination
• To rule out intravesical lesion
4
Procedures
• TURBT
– Transurethral resection of bladder tumor
• TURP
– Transurethral resection of prostate
• DVIU
– Direct vision internal urethrostomy
• Cystolitholapaxy
– To remove the bladder stone
5
6
Indication
• Ureteroscopy
– To examine ureter
– To remove stone in the ureter
– To remove tumor in the ureter
7
8
9
Laparoscopy
Da Vinci Robotic Surgical System
Minimally Invasive Surgery (MIS)
• LAPAROSCOPIC surgery
– Inflate the peritoneal cavity with CO2 to create a
space between intestines and abdominal wall
and then insert small camera inside to visualize
the diseased organ and insert small surgical
instrument to remove or repair diseased organ.
– Advantages
• Small incisions, better cosmesis, less pain, shorter
stay in hospital, faster recovery.
– Disadvantages
• Steep learning curve.
Improved MIS –Robotic Surgery
• da Vinci Surgical System
– A derivative of laparoscopic surgery.
However, instead of rigid, less maneuverable
instruments, Endowrists type of surgical
instruments were used. Now, surgery can be
performed as if your pair of hands are inside
patient’s abdomen.
– Advantages
• Everything a surgeon wishes for in surgery.
– Disadvantages
• Cost.
Genesis
• Late 1980’s – US Army contracted SRI
International to develop a system that would
perform battle field surgery remotely.
• 1995 – Intuitive Surgical was founded to
explore the commercial application of
remote surgery.
• 1999 – da Vinci Surgical System was
launched.
• 2000 – First robotic system to be cleared by
FDA for laparoscopic surgery.
Da Vinci Surgical System
da Vinci Surgical System Set Up
Surgeon Console
• Using the da Vinci
Surgical System, the
surgeon operates
while seated
comfortably at a
console viewing a 3-D
image of the surgical
field.
Surgeon Console
• The surgeon's fingers
grasp the master
controls below the
display, with hands and
wrists naturally
positioned relative to his
or her eyes.
• The system seamlessly
translates the surgeon's
hand, wrist and finger
movements into precise,
real-time movements of
surgical instruments
inside the patient.
Patient-side Cart
• Provides either three or
four robotic arms—two
or three instrument arms
and one endoscope
arm—that execute the
surgeon's commands.
• The laparoscopic arms
pivot at the 1-2 cm
operating ports,
eliminating the use of the
patient's body wall for
leverage and minimizing
tissue damage.
EndoWrist Instruments
• The instruments are
designed with seven
degrees of motion
that mimic the
dexterity of the
human hand and
wrist.
EndoWrist Instruments
• Each instrument has
a specific surgical
mission such as
clamping, suturing
and tissue
manipulation.
Vision System
• The Vision System,
with high-resolution
3-D endoscope and
image processing
equipment, provides
the true-to-life 3-D
images of the
operative field.
FDA approved procedures since 2000
• Urology
– Removal of cancerous prostate (Radical
prostatectomy)
– Repair Renal pelvis (Pyeloplasty)
– Removal of cancerous bladder (Cystectomy)
– Removal of kidney (Nephrectomy)
– Reconnect ureter to bladder (Ureteral reimplantation)
• Gynecology
– Removal of uterus (Hysterectomy)
– Removal of fibroid in uterus (Myomectomy)
– Repair of uterine prolpase (Sacrocolpopexy)
FDA approved procedures since 2000
• General Surgery
– Removal of Gallbladder (Cholecystectomy)
– Repair of stomach reflux (Nissen
fundoplication)
– Weight reduction surgery (Gastric bypass)
– Harvest kidney for transplant (Donor
nephrectomy)
– Removal of adrenal gland (Adrenalectomy)
– Removal of spleen (Splenectomy)
– Partial removal of intestine (Bowel resection)
FDA approved procedures since 2000
• Cardiothoraic surgery
– Internal mammary artery mobilization and
cardiac tissue ablation
– Mitral valve repair, endoscopic atrial septal
defect closure
– Mammary to left anterior descending coronary
artery anastomosis for cardiac revascularization
with adjunctive mediastinotomy
Popularity
• Over 1000 da Vinci Surgical Systems have
been installed worldwide.
• 5 years ago, less than 5% of prostate
cancer surgeries were done by roboticassisted laparoscopic prostatectomy
(RLP).
• More than 70% of all prostate cancer
surgery were done via RLP in the US.
• In Hawaii, greater than 95%.
Why is robotic surgery popular?
• Reduced trauma to the body
– Size of incision: One long incision vs. several
small “keyholes”.
– Tissue manipulation – Minimal injury to
tissues with small, manipulative surgical
instrument vs. hand and finger dissection.
• Less risk of infection
– Smaller incision and therefore less exposure
of wound to outside.
Benefits
• Reduced blood loss and need for
transfusions
• Less post-operative pain and discomfort
• Shorter hospital stay
• Faster recovery and return to normal daily
activities
• Less scarring and improved cosmesis
At the beginning, only OPEN surgery
• OPEN surgery
– To remove or repair diseased organ via an OPEN
incision.
– Advantages
• Direct inspection of the diseased organ with hands
and eyes. Better control of bleeding. Shorter surgical
time in the hands of experienced surgeon. Standard
for trauma surgery, transplant surgery, vascular
surgery, etc.
– Disadvantages
• More blood loss for certain procedures. Big incision.
Postoperative pain.
Prostate
Example of open surgery –
Open prostatectomy
Open Surgical Incision
Laparoscopic Surgical Incision
Laparoscopic Prostate Dissection
32
RLP – Dissection of Prostate
33
RLP – Ligation of Dorsal Venous
Complex
RLP – Anastomosis of Urethra to
Bladder neck
35
Compare the Benefits
 Open Procedure




Long Incisions
Hospital Stay of 3.5 days
Blood Loss 900ml
Catheter removal 14 to 21 days
 Robotic-Assisted Procedure




5 or 6 small keyhole incisions
Hospital stay of 1.2 days
Blood Loss 153 ml
Catheter 5 to 7 days
Penile Dysfunction
• Prolonged erection
– Priapism
• Prolonged waiting for erection
– Erectile dysfunction (ED)
37
Penile Erection
Anatomy and Mechanism
Lue T. New Eng. J. Med, 2000, 342:1802
Priapism
• Priapism is a persistent and painful penile
erection that continues hours beyond, or is
unrelated to, sexual stimulation. Typically,
only the corpora cavernosa are affected and
often defined as erection greater than four
hours duration. Priapism requires prompt
evaluation and may require emergency
management.
»
AUA Guideline 2003
40
Priapism
• Ischemic (veno-occlusive, low flow)
– characterized by little or no cavernous blood flow
and abnormal cavernous blood gases (hypoxic,
hypercarbic, and acidotic). The corpora
cavernosa are rigid and tender to palpation.
Patients typically report pain. A variety of
etiologic factors may contribute to the failure of
the detumescence mechanism in this condition.
Ischemic priapism is an emergency
»
AUA Guideline 2003
41
Priapism
• Non-ischemic or high flow (arterial)
– nonsexual, persistent erection caused by
unregulated cavernous arterial inflow. Cavernous
blood gases are not hypoxic or acidotic. Typically
the penis is neither fully rigid nor painful.
Antecedent trauma is the most commonly
described etiology. Nonischemic priapism does
not require emergent treatment
»
AUA Guideline 2003
42
Priapism
• Stuttering (intermittent)
– recurrent form of ischemic priapism in which
unwanted painful erections occur repeatedly with
intervening periods of detumescence. This
historical term identifies a patient whose pattern
of recurrent ischemic priapism encourages the
clinician to seek options for prevention of future
episodes
»
AUA Guideline 2003
43
Causes of Priapism
• Drugs that may cause priapism
– antihypertensives; anticoagulants; antidepressants;
psychoactive drugs; alcohol, marijuana, cocaine and
other illegal substances; and intracavernous
injection agents such as alprostadil, papaverine,
prostaglandin E1, phentolamine and others.
• History of pelvic, genital or perineal trauma,
especially a perineal straddle injury
• History of sickle cell disease or other hematologic
abnormality
44
Diagnosis of Priapism
•
•
•
•
Past Medical History
Past Surgical History
Physical Exam
ABG
– Ischemic – hypoxic
– Non-ischemic – arterial or mixed venous
• Duplex US
45
Treatment of Ischemic Priapism
• Ischemic
– Step-wise treatment to achieve resolution as
promptly as possible. Initial intervention may utilize
therapeutic aspiration (with or without irrigation) or
intracavernous injection of sympathomimetics.
– If ischemic priapism persists following
aspiration/irrigation, intracavernous injection of
sympathomimetic drugs should be performed.
Repeated sympathomimetic injections should be
performed prior to initiating surgical intervention.
»
AUA Guideline 2003
46
Treatment of Ischemic Priapism
– For intracavernous injections in adult patients,
phenylephrine should be diluted with normal saline
to a concentration of 100 to 500 mcg/mL, and 1 mL
injections made every 3 to 5 minutes for
approximately one hour, before deciding that the
treatment will not be successful. Lower
concentrations in smaller volumes should be used in
children and patients with severe cardiovascular
disease.
– The use of surgical shunts for the treatment of ischemic
priapism should be considered only after a trial of
intracavernous injection of sympathomimetics has failed.
47
Treatment of Nonischemic Priapism
• Nonischemic
– The initial management of nonischemic priapism should
be observation. Immediate invasive interventions
(embolization or surgery) can be performed at the
request of the patient, but should be preceded by a
thorough discussion of chances for spontaneous
resolution, risks of treatment-related erectile dysfunction
and lack of significant consequences expected from
delaying interventions.
– Surgical management of nonischemic priapism is the
option of last resort and should be performed with
intraoperative color duplex ultrasonography
48
Treatment of Stuttering Priapism
• Stuttering
– The goal of the management of a patient with recurrent
(priapism is prevention of future episodes while
management of each episode should follow the specific
treatment recommendations for ischemic priapism.
– Trial of gonadotropin-releasing hormone (GnRH)
agonists or antiandrogens may be used in the
management. Hormonal agents should not be used in
patients who have not achieved adult stature.
– Intracavernosal self-injection of phenylephrine should be
considered in patients who either fail or reject systemic
treatment of stuttering priapism.
49
Definition
“Inability of the male to attain and maintain erection of the
penis sufficient to permit satisfactory sexual intercourse.”
NIH Consensus Development Panel on Impotence, 1993
“The persistent or repeated inability, for at least 3 months’
duration, to attain and/or maintain an erection sufficient for
satisfactory sexual performance (in the absence of an
ejaculatory disorder, such as premature ejaculation).”
Process of Care Consensus Panel, 1998
“The consistent or recurrent inability to attain and/or
maintain a penile erection sufficient for sexual performance.”
WHO-ISIR. 1st International Consultation on ED, 1999
Int J Impot Res. 1999;11:59-74, JAMA. 1993; 270:83-90
Prevalence and Diagnosis
Some
Degree
of ED
No
ED
48%
52%
92%
Undiagnosed
8%
Diagnosed
40%
UNTREATED
60%
Treated
Feldman et al. J Urol. 1994; 151:54-61, Decision Resources, Scott-Levin PDDA
Massachusetts Male Aging Study
Prevalence in population
(%)
Age and Severity of ED
60
50
Degree of ED
Minimal
Moderate
Complete
40
30
20
10
0
40 45 50 55 60 65 70
Age (mid point)
• The combined
prevalence of minimal,
moderate, and complete
erectile impairment was
52%1
• The prevalence of
moderate or complete
impairment increased
from 8% to 40%
between the ages of 40
and 69 years 2
1 Feldman et al. J Urol. 1994; 151:54-61, 2 McKinlay. Int J Impot Res. 2000;12(suppl 4):S6-S11
Male Sexual Response Cycle
Masters and Johnson
1.Excitement. Penis erection, bulbourethal
gland secretions of lubricating, alkaline
fluid.
2.Plateau. Increased blood pressure, heart
rate, respiration. Testes
“enlarge”
and scrotum tightens.
3.Orgasm. Ejaculation of 3-4 ml of semen
with 300-500 million sperm, of which only
a few hundred reach the oviducts.
4.Resolution. Loss of erection; heart rate and
breathing normalize.
5.Refractory period. Unresponsive to sexual
stimulation.
Pathophysiology
Organic
Psychogenic
Mixed
Adapted from Morgentaler. Lancet. 1999;354:1713-1718.
•
•
•
•
•
•
•
•
•
•
•
•
Aging
Hypertension
Diabetes mellitus
Benign Prostatic Hypertrophy
Cardiovascular disease
Smoking
Depression
Alcoholism
Regional trauma or surgery
Chronic neurologic disease
Endocrinopathy
Drugs
Erectile Dysfunction:
A Marker for Underlying Diseases
• High prevalence of ED with certain treated
medical conditions
• In the MMAS, age-adjusted prevalence for
complete ED was:
– 39% in men with treated heart disease
– 28% in men with treated diabetes
– 15% in men with treated hypertension
– 9.6% for the entire study
MASSACHUSETTS MALE AGING STUDY - FELDMAN HA, ET AL. J UROL. 1994;151:54-61
Diagnosis
•
•
•
•
•
•
•
History of Present Illnes
Physical Examination
Serum Testosterone Levels (Prolactin/LH)
Glucose
Thyroid Panel
NPTT/Sleep Lab/Duplex Study
Psychotherapy/Sex Counseling
Treatment Options
• Change lifestyle (smoking cessation, dieting,
exercise, stress management,…)
• Medication changes
• Androgen replacement therapy (Androderm)
• Oral medications (Viagra, Levitra, Cialis)
• External vacuum device
• Intracavernosal PGE1 (Caverject, EDEX)
• Intraurethral suppository of PGE1 (MUSE)
• Penile prosthesis (American Medical
System)
ED and Hypertension
Anti-hypertensive agents associated with ED
Diuretics
• Chlorthalidone
• HCTZ
• Spironolactone
-Blockers
•
•
Tamsulosin
Terazosin
-Blockers
• Propranolol
• Atenolol
• Labetalol
Central -agonists
• Guanabenz
• Guanadrel
• Guanethidine
Sympatholytics
• Methyldopa
• Clonidine
• Reserpine
Vasodilators
• Hydralazine
Adapted from Finger, WW et al. J Fam Pract 1997;44:33-43.
Treatment (cont.) – Oral Agents
• PDE5 Inhibitors
–Sildenafil (Viagra/Pfizer)
–Vardenafil (Levitra/Bayer &
Staxyn/GlaxoSmithKline)
–Tadalafil (Cialis/Lilly ICOS)
–Avanfil (Stendra/Vivus)
Treatment (cont.) -Other Oral Agents
• Uprima: (apomorphine)
– Application in US on hold due to side effects of
nausea/vomiting and possibility of pass out.
• Topiglan: (alprostadil)
– Apply onto penis, instead of urethral suppistory
(MUSE) or injection (Trimix, Caverject, EDEX).(
• Melanocortin activators
– Work on central nervous system
– Still under investigation.
60
Nitric Oxide-cGMP Mechanism of
Action in Corpus Cavernosal Smooth Muscle
Relaxation and Penile Erection
Endothelial cells
NO
NANC
Guanylate
cyclase
cGMP
GTP
RELAX
GMP
PDE5
NO = nitric oxide
NANC = nonadrenergic-noncholinergic neurons
Penile erection
• Greater Specificity for PDE5 Receptors – results in
possibly fewer side-effects, better activity at
receptor
• Half Life
Sildenafil (Viagra) : 3.6 hours
Vardenafil (Levitra): 4.5 hours
Tadalafil (Cialas): 17 hours
• This longer half-life of these newer agents may
result in greater spontaneity.
• BUT it could also be translated into a higher cost
per tablet, prolongation of side-effects, greater
opportunity for drug-drug interactions or overdosing.
ED and Cardiovascular Disease
Conclusions
• ED and CAD/DM/HTN frequently co-exist
• Effective care of patients with ED requires an emphasis on
coronary risk assessment
• PDE-5 inhibitors, which enable sexual activity, do not
themselves increase cardiovascular risk
• Co-administration of nitrate preparations/alpha blockers
and PDE-5 inhibitors is contraindicated
Vacuum Pump Device:
Inexpensive and non-invasive.
But, cumbersome to use, unromantic, need
constrictive device at the base of penis which may
cause pain.
Transurethral Suppositories (MUSE):
Not as invasive as needle injection. Effective in some
patients.
But, expensive, may cause burning sensation and
significant hypotension.
Injection Therapy (Caverject, EDEX):
Effective in patients without vasculogenic cause of erectile
dysfunction.
But, need to use needles, expensive, may cause burning
Types of penile prosthesis
1– piece non-inflatable
2 – piece inflatable
3 – piece inflatable
Non-inflatable Penile Implant
ADVANTAGES
• Easy for you or your
partner to activate
• Good option for men with
limited dexterity
• Totally concealed in body
• The simplest surgical
procedure
• Least expensive
Non-inflatable Penile Implant
DISADVANTAGES
• Stays firm when not in
erect position
• May “show” through
clothes
3 – Piece Inflatable
Penile Implant
ADVANTAGES
• Acts and feels more like a
natural erection
• Expands the girth of the penis
• More firm and full than other
implants
• Feels softer and more flaccid
when deflated
3 – Piece Inflatable
Penile Implant
DISADVANTAGES
• Requires some manual
dexterity
• Possibility of leakage or
malfunction
• Possibility of
unintentional
erections
See Your Urologist!
• Discuss your options with your Urologist
• Your lifestyle and medical condition are
important factors