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Sunday, December 14, 2014

Testosterone take away message from NYU Update 14

Low T is associated with cardiovascular disease.
Low T is associated with bone loss.
Low is associated with impaired glucose metabolism.

Restoring T to normal is safe.  


Tuesday, December 02, 2014

Kidney stones can be challenging.

Upper ureter stone targeted for destruction.  Treatment of kidney stones can be challenging.  I never approach them in a cavalier fashion as complications can happen even in what seems to be a simple setting.  This patient has 10mm upper ureteral stone with obstruction of the kidney and a tortuous ureter from prior spine surgery that complicated treatment of her stone.  I had to place a nephrostomy tube smd then proceed to definitive stone treatment.  

Monday, November 24, 2014

Saturday, November 22, 2014

A better way to biopsy a prostate

Prostate biopsy is undergoing a period of rapid change.   The days of the blind biopsy are gone and the era of the random 12 core biopsy is coming to a close.  New technology that is now availaible right here Suffolk County Long Island will revolutionize the evaluation and even the management of prostate cancer.  
The Artemis System for prostate biopsy and fusion biopsy is an amazing tool in our fight against prostate cancer.  I can see a future of improved detection, less often used radical treatments and focal therapy as a result of this techniques' accuracy.  
At present, the technology is available in Suffolk County only though Dr Schoor and Zwanger-Pessiri Radiology.  Makes me proud.  

Wednesday, November 12, 2014

Ejaculatory Duct Obstruction: A Challenge to Diagnose

EDO, or blockage of the ejaculatory duct, is a rare but treatable cause of severe male factor infertility. Men have severe oligopermia with low volume ejaculate, low to no seminal fructose, and no sperm on post ejaculate UA.   TRUST may show dilated seminal vesicles, a dilated ejaculatory duct, and on occasion a midline prostate cyst.   Often all findings are not present and a certainly of diagnosis remains elusive. In these cases MRI may help verses the more traditional approach of vasography followed by TUR-ED--resection of the ejaculatory ducts.  When the diagnosis is correct, outcome of treatment is dramatic and full fertility can be restored immediately following the procedure.   

Tuesday, November 11, 2014

AUA Vasectomy Guidelines: Part 1

  • The minimum and necessary concepts that should be discussed in a preoperative vasectomy consultation include the following:
    • Vasectomy is intended to be a permanent form of contraception.
    • Vasectomy does not produce immediate sterility.
    • Following vasectomy, another form of contraception is required until vas occlusion is confirmed by post- vasectomy semen analysis (PVSA).
    • Even after vas occlusion is confirmed, vasectomy is not 100% reliable in preventing pregnancy.
    • The risk of pregnancy after vasectomy is approximately 1 in 2,000 for men who have post-vasectomy azoospermia or PVSA showing rare non-motile sperm (RNMS).
    • Repeat vasectomy is necessary in ≤1% of vasectomies, provided that a technique for vas occlusion known to have a low occlusive failure rate has been used.
    • Patients should refrain from ejaculation for approximately one week after vasectomy.
    • Options for fertility after vasectomy include vasectomy reversal and sperm retrieval withfertilization.  These options are not always successful, and they may be expensive.
    • The rates of surgical complications such as symptomatic hematoma and infection are 1-2%.  These rates vary with the surgeon’s experience and the criteria used to diagnose these conditions.
    • Chronic scrotal pain associated with negative impact on quality of life occurs after vasectomy in about 1-2% of men. Few of these men require additional surgery.
    • Other permanent and non-permanent alternatives to vasectomy are available.

Sperm Freezing

Sperm freezing, or cryobanking, is a great technology that can enhance and preserve a couple's fertility.  Indications for banking include:
Fertility preservation prior to cancer therapy
Fertility preservation for men with severe oligopermia--low sperm counts. 
Prior to elective vasectomy
During and after vasectomy reversal
After sperm extraction procedures: TESE, PESA, MESA

Sperm can remain viable once frozen for an indefinite period.   

Sunday, November 09, 2014

Not all stones are easy to localize

Some stones can be seen plain as day on a standard x-ray.  Follow-up and treatment of these stones is typically easy and straight forward.  Yet how does the urologist follow the 15% of stones that can be seen at all on plain X-ray  films?   

The options are repeat CT scan, which is expensive and the most radiation intensive (albeit very low dose for adults). 
Renal sonogram is pretty good for kidney stones, especially larger ones and is totally safe.   This modality can also be used to follow ureter stones that are obstructive.  Bladder ultrasound can be used to folllow stones at the junction of bladder and ureter, the UVJ.  Intravenous urography is the final option.  Old school for sure,  the IVP as it is known, is still quite good.  Disadvantages are that the test is time consuming, requires IV dye that may be allergenic and nephrotoxic to some, and utilizes low dose ionizing radiation.