• Prostate and Bladder TUR Surgery
Prostate Enlargement Treatment
Patients whose complaints do not affect their quality of life much can be followed up at intervals not exceeding 1 year without the need for any treatment.
Prostate Drug Treatment
Today, the first choice in the treatment of prostate enlargement is medical treatments. These drugs, which are non-surgical prostate treatment methods, increase the quality of life of patients and reduce the need for surgery. Prostate drugs are effective on the day they are used, and their effects disappear when they are discontinued. Our first choice is always to use the non-surgical treatment methods. However, we strongly recommend our patients to apply for a routine examination without delay.
Prostate Surgery
Surgical treatments are applied in cases where drug therapy is insufficient or there are additional pathologies such as bladder stones. About 90-95% of patients are now treated with closed (endoscopic) surgeries. After this procedure, which requires a hospital stay of approximately 2 days, patients go home without a probe. He also performs open surgery in patients with very large prostates or additional pathologies such as bladder diverticulum.
In closed or open prostate surgeries, the tissues inside the prostate gland are removed, but the crust is not removed. Therefore, the risk of prostate cancer in patients who have undergone these surgical operations continues at the same rate as their peers who have not undergone surgery. People who have had prostate surgery should also have annual checkups.
Loss of sexual function (impotence) is very rarely observed after surgeries due to prostate enlargement. However, since the prostate gland cannot fully perform its functions after these operations and during the use of prostate drugs, sperm may leak back into the bladder (urinary bag) during ejaculation (retrograde ejaculation). For this reason, sperm may not come out during intercourse after prostate surgery.
• Kidney and Urinary Tract Stone Surgery with Flexible URS and Laser
Kidney Stone Treatment with Flexible Ureteroscopy
Many surgical and non-surgical methods are used in the treatment of kidney stones. The advancement of technology has led to the emergence of many useful methods in kidney stone surgery. Although the surgical methods to be applied in kidney stones have been determined according to the size of the stone, size is no longer as important as it used to be thanks to the recent flexible ureteroscopy. Even very large stones can be removed with the Filexible ureteroscopy method. While doing this, no incisions are made and there is no scar. It is entered through the urinary tract with a flexible ureteroscope, and the kidney stones inside are broken by laser and removed through the same route. One of the most important advantages of the flexible ureterorenoscopy method is that the postoperative recovery period is very short and comfortable. The patient can go home the same day and return to work the next day if he wishes.
Flexible URS is the process of reaching the stone by entering the urinary tract with a fiberoptic aid. It is done under general anaesthesia. The kidney is reached by passing through the urinary tract and urinary bladder. Stones can be removed in one piece with a special tool called a basket, depending on both the location and size of the stone. If the size of the stone is large, it is removed by breaking it inside.
Advantages of Flexible Ureteroscopy
• Ability to remove larger stones.
• No incision is made.
• No scarring as no incision is made.
• Safer surgical procedure.
• Faster healing process.
• Discharge from the hospital on the same day.
• Immediate return to normal life.
• Multiparametric Prostate MRI and MR Fusion Prostate Biopsy
MR Fusion Biopsy
Just 10 years ago, there was no imaging method that could show prostate cancer, but today, prostate cancer can be diagnosed with multiparametric prostate MRI thanks to the advancement of MR technology and our better understanding of prostate cancer. Although it is still not possible to make a definite distinction between the presence and absence of cancer today, at least suspicious areas can be monitored with MRI. Perhaps in the coming years, with the development of MR technology and our better understanding of the appearance and behavior of this disease, there will be a transition to only local treatments.
Today, we can use multiparametric MR images in biopsies. While in standard ultrasound-guided biopsies, pieces are taken from the outer surface of the prostate with a certain systematic, in MR FUSION BIOPSY, MR images and ultrasound images can be superimposed, so that pieces can be taken from the suspicious areas mentioned in MR. So these areas can also be examined without being overlooked. In addition to standard biopsies in MR FUSION BIOPIES, direct biopsy from the lesion greatly reduces the possibility of missing a possible cancer. This procedure, like standard biopsies, can be performed with a mild sedatives or local anesthesia.
• Male Sexual Dysfunctions
What is Varicocele?
Varicocele is the enlargement of the veins leading to the testicles. The testicles, which are in the abdomen in the mother's womb, descend into bags over time. The temperature of 36-37 degrees in the abdomen is not suitable for sperm production in the testicles. At this temperature, the testicles cannot produce quality sperm. For this reason, they descend into the bags (scrotum) to be 2-3 degrees cooler. The reason why the testicles hang down in hot weather and stay closer to the body in cold weather is to protect this temperature difference. In the case of varicocele, that is, the enlargement of the veins leading to the testicles, these large veins cause the testicles to heat up, just like a heater core, and this may lead to deterioration in sperm quality.
Varicocele is usually cumulative. It leads to some deterioration in sperm quality with each passing day. This deterioration may cause infertility, or it may not go below the sterility level. Therefore, it is not possible to say that every male with varicocele will remain infertile. But the younger the varicocele develops, the greater the risk of infertility.
DIAGNOSIS OF VARICOCELE
The complaint of the patients is usually that they do not have children. Since it has a cumulative effect and gradually decreases the quality of sperm over time, they may also apply to us with the complaint that their partner was pregnant before, but they do not have children at the moment.
From time to time, palpable swelling in the testicles or enlarged veins that are visible from the outside are also noticed by the patients and may appear during the examination.
The diagnosis of varicocele is made by physical examination. The diagnosis is also supported by scrotal color Doppler. According to the results of the sperm count, it was decided whether to apply the treatment or not.
Varicocele disease can also cause pain that hits the testicles. Scrotal pain may also be the reason why patients apply from time to time. However, studies that have been going on for years have shown that half of the patients who underwent varicocele surgery for pain only continued after the surgery.
TREATMENT OF VARICOCELE
The only treatment of varicocele is surgery. Not every patient with varicocele needs surgery. Varicocele surgery should be performed in patients with deterioration in sperm quality or reduction in testicular size due to varicocele.
If Azoospermic patients with no sperm output or no viable sperm have varicocele, treatment is recommended. In this patient group, even if they do not have children by normal means, the chance of finding viable sperm and success in assisted reproductive methods such as in vitro fertilization increases after varicocele surgery.
Surgery should be recommended without waiting for the deterioration of sperm quality or shrinkage of testicles due to the presence of ADOLESCENT VARICOCELE (varicocele seen in childhood). Since varicocele will impair sperm quality over the years, infertility will be inevitable if it is expected in this patient group.
Today, varicocele surgery is performed by microsurgery. When the microsurgery method is mentioned, some patients think that there will be no scars. However, varicocele surgery is performed with an incision of approximately 4-5 cm from the inguinal region. The enlarged veins surround the testicles like the roots of a tree. From here, they converge towards the inguinal region and proceed. Thus, they become 2-3 veins in the groin area. Here, the separation of the veins can be made more easily. This is where the microsurgery method comes into play. Under the microscope, the veins are separated and the enlarged veins are ligated and canceled. Thus, the return of warm blood to the testicles is prevented.
The production of a sperm takes about 3 months and considering that it is necessary to wait for a while for the testicles to come to itself after the surgery, it is necessary to wait 4-6 months to see the success or benefit of the Varicocele surgery. Studies have shown that 75% of patients have improved sperm quality after surgery. 25% can maintain at least the same levels.
• Prostate Cancer Surgery
Prostate cancer
Prostate cancer is the most common type of cancer in men over 50, together with lung cancer. Although prostate cancer is the most common cancer, it is a type of cancer that usually progresses slowly and can be treated.
Prostate cancer has no cancer-specific symptoms. It has no effect on the urinary tract as it develops from the shell that surrounds the outer surface of the prostate. Generally, the disease is detected during routine examinations or going to the doctor with complaints related to benign prostatic enlargement. The aim of the recommended annual prostate examination is to detect prostate cancer early. Prostate cancer is suspected with an increase in blood PSA values or an abnormal finding that is palpable during finger examination (rectal tap). Any elevation in PSA value or abnormalities on examination does not mean prostate cancer. There is no imaging method to diagnose prostate cancer. Diagnosis is made by prostate biopsy.
People with a family history of prostate cancer have a higher risk of developing cancer than the general population. Normally, annual controls are recommended for patients after the age of 50, while follow-up and controls are recommended for those with a family history from the age of 40.
Prostate cancer is a male hormone (testosterone) dependent cancer. People who are castrated at a young age do not develop prostate cancer. For this reason, although there is a belief that the risk of cancer increases in people with high libido and having a lot of sexual intercourse, there is no medical facts supporting it. Food habits also play an important role in the formation of cancer. Populations with a high consumption of animal food have higher rates of prostate cancer than those with a high consumption of vegetables and soybeans.
Prostate cancer treatment differs from person to person. Closed methods have no place in surgery since it also contains the shell surrounding the prostate. The surgery is completed with the complete removal of the prostate tissue and all surrounding tissues. Active monitoring, radiotherapy and hormone treatments or combinations of these can be used according to the patients' conditions and accompanying diseases.
There is no single treatment for prostate cancer. Different treatment options can be offered to each patient. Surgery, radiotherapy and removal of male hormone from the body (with drugs or surgical removal of the testicles) are the main topics of treatment.
Prostate Cancer Surgery (Radical Prostatectomy)
It is the main treatment recommended for patients where disease is limited to organ and has not spread elsewhere. It is a completely different form of surgery than the surgical techniques applied for the treatment of benign prostate enlargement. During this surgery, the entire prostate gland is removed along with some of the sperm ducts and surrounding lymph nodes.
It is the most effective treatment for cancer. The biggest side effects of this surgery are incontinence and loss of masculinity. Today, the incidence of these undesirable side effects decreased considerably thanks to the advancement of surgical technique and increased experience,
• Testicular Cancer Surgeries
Radical Orchiectomy and testicular sparing surgery operations are successfully performed for our patients diagnosed with testicular cancer in our hospital. • Kidney Cancer Surgery
In our hospital, Laparoscopic (closed) and open Nephrectomy operations are performed for our patients diagnosed with kidney cancer. Depending on the size and localization of the tumor, kidney-sparing operations can be performed. • Bladder Cancer Surgery
In our hospital, endoscopic TUR-T operation and cystectomy operations according to the pathology results are successfully applied to patients diagnosed with bladder. • Percutaneous Kidney Stone Surgery (PCNL)
PCNL (Closed Kidney Stone Surgery)
The type of treatment that should be applied in patients with kidney stones larger than 2 cm is PCNL. PCNL is a surgical technique performed by reaching the kidney through an incision of approximately 2 cm from the back under general anesthesia. A working channel is placed between the skin and the kidney, and the stone is crushed out of this channel. It is a suitable technique for stones of all sizes and localizations. In case of choosing the right angle and entrance to the kidney, all stones can be removed by entering through a single hole, even in stones that cover the entire kidney (deer antler). After the surgery, a tube is placed where the working canal is in order to guarantee the urine output from the kidney and to prevent bleeding. This tube is removed within 1 or 2 days and the patient is discharged.
After Kidney Stone Surgery
Since PCNL (percutaneous) and ureterorenoscopy surgeries are closed (endoscopic), patients can return to their normal lives the next day. Although they can go back to work the next day, they may be advised to rest for a few days. In the first days, problems such as burning in the urinary tract, frequent urination, bleeding at the beginning and end of urine can be seen. In order to minimize these problems, patients are asked to consume plenty of fluids in the first 15-20 days. Antibiotic treatment is also recommended for patients, as urinary tract infections may also occur due to stones. After ureterorenoscopy, if a double J catheter is placed, a constant sense of urine and a stinging sensation in the area of the urinary tract may be seen due to the irritation of this catheter to the urinary tract.
Since there is a high risk of stone formation in a person who has formed a stone once, plenty of fluid consumption and regular doctor check-ups should be kept in mind for a lifetime.
• Incontinence
Incontinence is a common problem in both men and women, especially over a certain age. Although incontinence is more common with age, it is not a normal process of aging.
As a result, although all of them result in the uncontrolled discharge of urine, the causes, consequences and treatments of incontinence differ. Some of these are beneficial with surgery, while others can be improved with medication.
We can roughly list the causes of incontinence as follows:
Neurological diseases (such as MS, Alzheimer's)
Diabetes
Past surgeries (especially prostate surgery)
Organ prolapse- prolapse (cystocele)
Past births
Incomplete emptying of the bladder due to prostate enlargement.
How is the diagnosis made in patients with incontinence?
a. Anamnesis (Patient's story).
The most important evaluation method to establish the diagnosis in patients with incontinence is to examine the patient's history in detail. Diagnosis can usually be made by asking questions to the patient, timing of incontinence, and examining the conditions under which incontinence occurs.
b. Physical examination
In patients with incontinence, a physical examination must be performed. With a good physical examination, it can be understood whether this incontinence is a problem due to prostate disease or whether it occurs due to prolapse of organs (cystocele, total prolapse) in women.
c. Voiding diary
It is important to fill in a voiding diary (frequency volume chart, F-V chart) in order to see how much it affects the severity of incontinence and quality of life in patients with incontinence. Incontinence and frequent urination are subjective concepts, and their impact on quality of life and patients' perception of the situation vary greatly from person to person. For this reason, with the voiding diary to be filled before and after the treatment, we can reach an objective data about the condition of the patients.
d. Urodynamics
In cases where the diagnosis cannot be made, the treatment is not successful or surgical intervention is required, it is important to request urodynamic tests from the patients, so that if there is an underlying unexpected condition, it is important to determine it.
Types of Incontinence can be listed as follows:
URGE INCONTINENCE
Patients usually describe this situation as sudden urination and incontinence before they reach the toilet. Incontinence is not seen due to reasons such as coughing and sneezing. This is somewhat similar to childhood incontinence. The bladder is not under control in childhood. For this reason, children leak urine and nappy as they contract uncontrollably. Over time, the body takes control and we start urinating whenever we want. With the deterioration of this control mechanism over time, the bladder begins to contract uncontrollably. As a result of this, as soon as we feel the urine coming, the bladder suddenly contracts and incontinence occurs until we reach the toilet. Over time, the bladder capacity also shrinks due to these contractions, and patients apply to the doctor with the complaints of constant urination and frequent incontinence.
There is no surgical treatment for this type of incontinence. Non-surgical incontinence treatment can be applied to this patient group.
STRESS INCONTINENCE
Stress incontinence is defined as incontinence caused by coughing, sneezing, and sudden movements. The reason for this type of incontinence is the weakness of the pelvic floor muscles. Normally, if the muscle tissue under the bladder is strong, it responds to sudden pressure increases such as coughing and sneezing, by closing the mouth of the urinary bladder. Muscle tissue loses its strength with births or with age, and the muscle tissue loses its strength and cannot enable closure of mouth of the urinary bladder under such pressure, which results in incontinence.
There are 3 different treatment options for stress incontinence. Treatment is selected according to the patient's condition and complaints.
*Kegel exercises are beneficial in the early stages and in young patients by strengthening the weakened muscles. In order to benefit from these exercises, it is necessary to repeat the exercises regularly and for a long time.
*Drug therapy can be considered as an alternative in patients whose efficacy is low and surgery cannot be performed
*Surgical interventions. This is the most successful treatment for incontinence types.
Incontinence after prostate cancer surgery in men is almost the same. In this form of incontinence, the muscles that allow urine retention (external sphincter) are damaged during cancer surgery, and it is not possible to hold urine in pressure increases. Treatment options in these patients are Kegel exercises, drug therapy, or insertion of an artificial sphincter (AUS, artificial urinary sphincter).
MIXED INCONTINENCE
In this type of incontinence, patients have both urge and stress incontinence. The treatment is applied for whichever complaint is more dominant.
OVERFLOW INCONTINENCE
It is a type of incontinence seen especially in men when prostate disease progresses. Since the patient cannot empty his urine, his bladder is fully filled. Just like when a bucket is full, further urine overflows. Overflow incontinence should be kept in mind especially in patients over a certain age who have urination problems or have neurological diseases.
NON-SURGICAL AND SURGICAL TREATMENTS OF INCONTINENCE:
a.Drug Theraphy.
The first-line treatment in patients with urge incontinence is drug therapy. The majority of patients benefit from drugs in the treatment of non-surgical incontinence. In patients who do not benefit from treatment or who cannot continue treatment due to side effects, second-line treatments are started. These treatments are temporary paralysis with injections into the bladder or neuromodulation therapy.
In those with stress incontinence, some complaints of the patients may regress with drug therapy.
b.Temporary bladder paralysis procedure
The main problem in patients with urge incontinence is the uncontrolled contraction of the bladder. The aim of drug therapy is to slow down these contractions. In cases where the drugs are insufficient, effective results can be obtained by paralyzing the bladder muscles.
Certain drugs cause temporary paralysis by blocking the transmission of nerve cells. Today, it is frequently applied around the eyes for aesthetic purposes, etc. By applying it into the bladder muscles, uncontrolled contractions of the bladder (overactive bladder) are prevented and incontinence is prevented. The average duration of action is 6-9 months, and the duration of action increases with repeated applications. It does not have side effects such as dry mouth, constipation, palpitations seen in drug treatment. In my personal opinion, it is the most effective treatment option for patients with this type of complaint.
c.Neuromodulation - Peripheral Nerve Stimulation (PNS)
Excessive stimulation of the nerves going to the bladder causes these nerves to become numb and thus to prevent their functioning. The nerves to the bladder and the tibial nerves to the sole of the feet originate from the same nerve root. Stimulating the tibial nerve approximately once a week for half an hour with a small needle such as acupuncture causes regression of incontinence complaints.
d.Kegel exercise
The main cause of stress incontinence is weakness of the pelvic muscles. By strengthening these muscles, incontinence can be prevented by coughing and sneezing. It is more effective especially in young patients and in the initial period when incontinence is less. For these exercises to work, they must be done regularly and for long periods of time.
e.Incontinence Surgery (TOT, TVT)
The definitive treatment of stress incontinence is TOT or TVT surgeries called middle urethral sling surgeries. In these surgeries, it is aimed to place materials to close the mouth of the bladder instead of the loosened muscle tissues under the bladder in sudden pressure increases such as coughing and sneezing so that the mouth of the bladder is closed. These materials placed under the bladder lift the bladder like a hammock and prevent incontinence. After these operations, which are performed with an incision of approximately 4-5 cm from the vagina, patients can go home on the same day. It is recommended that they protect themselves for about 1 month and not lift heavy loads for 3 months so that the placed materials do not move and the success of the surgery does not decline.
f. Insertion of the artificial sphincter (AUS)
Involuntary incontinence may occur in men when the urinary retention mechanisms are damaged. This muscle group, called the external sphincter, which provides urine retention, can often be damaged during surgery. In this case, the only treatment option is artificial sphincter placement. A ring-shaped balloon placed in your urinary tract puts pressure on your urinary tract, keeping it constantly blocked. When the pump placed between the testicles is activated, the balloon opens and allows your urine to pass. Then the balloon starts inflating on its own in about 90 seconds and your urinary tract is closed. There is a significant increase in the quality of life of patients who underwent artificial sphincter, and the success rate is over 90%.
