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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.

Urinary System

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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

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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

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Procedures

• TURBT– Transurethral resection of bladder tumor

• TURP– Transurethral resection of prostate

• DVIU– Direct vision internal urethrostomy

• Cystolitholapaxy– To remove the bladder stone

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Indication

• Ureteroscopy– To examine ureter– To remove stone in the ureter– To remove tumor in the ureter

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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 robotic-assisted 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

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RLP – Dissection of Prostate

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RLP – Ligation of Dorsal Venous Complex

RLP – Anastomosis of Urethra to Bladder neck

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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)

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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

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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

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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

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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

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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

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Diagnosis of Priapism

• Past Medical History

• Past Surgical History

• Physical Exam

• ABG– Ischemic – hypoxic– Non-ischemic – arterial or mixed venous

• Duplex US

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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

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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.

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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

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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.

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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

Feldman et al. J Urol. 1994; 151:54-61, Decision Resources, Scott-Levin PDDA

92% Undiagnosed

8%Diagnosed

40%UNTREATED

60%Treated

NoNoEDED

48%SomeDegreeof ED

52%

Massachusetts Male Aging Study Age and Severity of ED

• 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

40 45 50 55 60 65 700

10

20

30

40

50

60

Pre

vale

nce

in p

opu

lati

on

(%)

MinimalModerateComplete

Degree of ED

Age (mid point)

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.

Male Sexual Response CycleMasters and Johnson

Pathophysiology

Organic

Psychogenic

Mixed

• Aging• Hypertension • Diabetes mellitus • Benign Prostatic Hypertrophy• Cardiovascular disease• Smoking• Depression• Alcoholism• Regional trauma or surgery• Chronic neurologic disease• Endocrinopathy• Drugs

Adapted from Morgentaler. Lancet. 1999;354:1713-1718.

Erectile Dysfunction:A Marker for Underlying Diseases

MASSACHUSETTS MALE AGING STUDY - FELDMAN HA, ET AL. J UROL. 1994;151:54-61

• 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

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 HypertensionAnti-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.

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Nitric Oxide-cGMP Mechanism ofNitric Oxide-cGMP Mechanism ofAction in Corpus Cavernosal Smooth Muscle Action in Corpus Cavernosal Smooth Muscle

Relaxation and Penile ErectionRelaxation and Penile Erection

Penile erectionPenile erection

NO = nitric oxide

NANC = nonadrenergic-noncholinergic neurons

PDE5 = phosphodiesterase type 5

NANCNANC

GMPGMP

GTPGTP

Endothelial cells

GuanylateGuanylatecyclasecyclase

NONO

PDE5PDE5

cGMPcGMP RELAXRELAX

• 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 over-dosing.

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 sensation, long term scarring and may cause priapism

Types of penile prosthesis1– piece non-inflatable2 – piece inflatable3 – 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 InflatablePenile 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 InflatablePenile 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