why urology podcast

This episode is an announcement that this podcast is set to close at the end of this month, August 2023. Thank you so much for listening to these episodes of Urological and to my previous episodes from the Why Urology podcast here on this feed.  You still have time to go back to relisten to or save the episodes you really enjoyed or found particularly helpful.  Thank you so much for listening. Be well and do good.

Thank you for listening to this episode of Urological.   

This podcast is an open ended conversation of ideas and topics that center around the practice of medicine and the field of urology.  Recently, one of my younger partners asked me the following question, “Todd, do you have a spot?” IHere is a quote from Stephen King.  “It starts with this: put your desk in the corner, and every time you sit down there to write, remind yourself why it isn't in the middle of the room. Life isn't a support system for art. It's the other way around.” I love my spot at a small desk in the corner of my screen porch. I cherish the time I get to spend here. As an introvert this quiet time fills me. Having a spot is critical to our lives if we are professionals, We need places to be quiet, to think, and to work to solve the world's problems and even some of our own. Life does not exist to support our art. Its the other way around.  As physicians our “art” is medicine.  Life does not exist to support our practice of medicine. It's the other way around. Our practice of medicine exists to support our lives.        

In this podcast we explore topics and ideas center around the practice of urology and the field of medicine. I am a urologist based in Woodbury and St Paul MN.   Patients ask me all of the time if anything is “new” since their last visit as they try to figure out what options they have as they consider treatment for whatever condition ails them. This is a challenging question because something is always “new.” There is always innovation, ideas, and new iterations. Change is constant. The reason this is top of mind for me is because within the last couple of weeks my partners and I have been exploring and discussing opportunities to innovate within our practice, as well as seeing some significant changes outside of our practice in our local medical community that have the potential to significantly change the way we practice. And I have lost a lot of sleep because of the expected changes. I am concerned that some of the ideas I have heard are a bit too much, impractical if not damaging to our practice if not executed or navigated properly.  There are only two responses to innovation, ideas, and iterations. The first response is to be skeptical, to find the fault in the ideas and to figure out all of the holes in the idea and to determine all of the ways in which the idea doesn't work. The second opposite response is to look at a half baked idea and to say, “Maybe there is something here” and then to build it despite its imperfections I wonder which of the two I am, a skeptic or a dreamer. The reason I have been thinking about this is that I have spent a fair amount of time this past couple of weeks shaking my head, skeptical of ideas, concerned about radical change, I see and essentially asking over and over again, “Why? why, why, why?” I am afraid that as an older physician, one who views myself as starting the last phase of my career, I am too resistant to change, and afraid of the new, the bold, and the crazy. But I think I should still be dreaming, to see the things that never were and ask, “why not?”  

In this episode, we will be  talking about kidney stone prevention and a very common problem for kidney stone formers, idiopathic hypercalciuria, or having too much calcium in the urine but otherwise normal body calcium metabolism.  This condition is often referred to as renal-leak hypercalciuria.  Calcium is one of the most important minerals in the body. The average adult body contains in total approximately 1 kg of calcium, 99% of which is stored in our bones and teeth.  In our bloodstream calcium also has many regulatory functions. Calcium enables our blood to clot, our muscles to contract, and our hearts to beat. Because calcium is a mineral that is so necessary for life our bodies regulate its metabolism very closely. The system monitoring calcium balance in the body is elaborate and our bodies sense when there is too little or too much calcium in the blood and will work hard to restore balance. Our bodies cannot produce its own calcium. We get our calcium from our food. When we don't get the calcium our bodies need in our diets, calcium is taken from our bones if our bodies need to maintain calcium balance. A lack of calcium in the diet, or disorders of calcium metabolism, can lead to osteopenia and osteoporosis. What is adequate calcium? Around 800mg-1200mg of calcium is adequate for most healthy, active men and women. Calcium supplementation is used for patients with bone loss or at risk for osteopenia or osteoporosis.   Because calcium is so important in our bodies our kidneys hold on to as much calcium.  That's a good thing that our kidneys work to resorb the filtered calcium because elevated levels of calcium in the urine can lead to kidney stones.  Calcium readily binds to other minerals in the urine, combining with oxalate and phosphate to produce the common calcium oxalate or calcium phosphate stones. Calcium oxalate stones form the most common form of kidney stones. 80-85% percent of kidney stones are calcium-based. People with normal kidney function lose very little calcium in the urine, less than 150 mg a day, as measured by 24 urine collection. But in kidney stone formers a common finding on 24-hour urine collections is hypercalciuria, higher than normal calcium excretion. A person's risk of forming kidney stones increases as the calcium levels in the urine rise.  There are a number of reasons there may be too much calcium in the urine but the most common one is idiopathic hypercalciuria. Idiopathic Hypercalciuria is not a disease per se, it is a condition and a risk factor for other diseases, kidney stones being one of them, but also long term, osteopenia and osteoporosis.  No red line determines when a patient has or needs treatment for Idiopathic Hypercalciuria. We know that values above 200mg of calcium excretion for 24 hour is a risk factor for kidney stones but historically we have used cutoffs slightly higher for patients to determine when to start or use medication, as high as 250 mg/day for women and 300 mg/day in men. Often simple dietary changes can be enough to lower kidney stone recurrence risk in patients with only a slightly increased level of calcium in the urine. Increasing fluid intake, moderating salt, animal protein and oxalate consumption, focusing on adding fresh fruits and vegetables and adding Lemonade (often in the form of Crystal Light to decrease sugar load), orange juice or even Lemon juice to increase citrate in the urine may be all a patient needs to help prevent stone formation.  If dietary changes are not effective, however, or if the calcium excretion is very high, then medication is advised. Medication to treat idiopathic hypercalciuria to prevent kidney stones is an ongoing medication, one that is needed indefinitely. The most common medication used for idiopathic hypercalciuria is a class of medications called thiazide diuretics, but another diuretic call indapamide can also be used.   Chlorthalidone is the most commonly used thiazide diuretic because of its long half life but hydrochlorothiazide is effective as well. Thiazide diuretics decrease the calcium levels in the urine. Dose adjustment, increasing or decreasing the dose, is done according to results on 24-hr urine testing. Repeat 24 hour urine test are needed initially to see if the medication is effective but also on an ongoing basis because some kidneys become tolerant to the medication. A short vacation from the diuretic often resets the body and resets the medication's effects. Thiazide diuretics can have side effects. Thiazide diuretics can be potassium wasting and cause low potassium levels in the blood. A plant based diet or increasing fruits and vegetables in the diet (I joke that I'm a fan a the banana) can increase the potassium in your diet but some patients taking the medication will need to take potassium supplements, either in the form of potassium pills or in some kidney stone formers,  Potassium Citrate. Potassium Citrate has the advantage of not only preventing hypokalemia (low potassium levels) but also increasing urinary citrate excretion.  So there you have it. Some of us have too much calcium in our urine leading to an increased risk of kidney stones as well as other conditions. For some kidney stone formers a simple diet change will be enough to offset the risk of a slightly increased amount of calcium, but for other people with very high levels of calcium in the urine medication may be needed. 

A picture, they say, paints 1000 words. Throughout my practice I have tried to draw as many pictures as I can for my patients. I find that the time I spend in the office often drawing complex anatomical relationships for patients pays off for me in the form of needing to talk less and pays off for the patient in an increased understanding. I find a simple picture drawn for a patient along with an explanation is the easiest way to convey complex surgical techniques and anatomy to help patients understand what we do during specific procedures. The problem is that I don't draw nearly enough. It takes time and, as I explain to my patients before I start drawing anything, I failed eighth grade art class. My drawings and diagrams would never win any awards, and outside of the context of a clinic visit, probably shouldn't be shown. But, I have shown my work to others. There is a YouTube video I have on my YouTube channel of my drawing a hydrocele, a collection of fluid around the testicle. It's an example of the types of drawing I do for patients. You can find that here: https://youtu.be/06euCzs7uAQ Our job as physician communicators is that same job that any scientist has in communication. Be brief, be clear, be simple. Don't talk too much. Carve every word so you say exactly what you mean.  Lastly, stealing from the great physicist Albert Einstein, make it as simple as possible, but no simpler. I understand how my patients must feel when I provide them with a simple drawing, even though I am not a trained artist. The picture remains even though nobody remembers exactly what I said.  In medicine we deal with seemingly complex things, difficult to understand, stuff that fills textbook after textbook with big, and unfamiliar words. We treat patients with sophisticated lab tests, fancy equipment, and a knowledge that takes years to get.  But we must remember that doctor means “teacher” and our job as doctors is to teach, instruct, and educate. To do this we must be brief and clear and as simple as possible.  And a picture often paints a thousand words. I should draw more of them. And so should you. Even if we failed eighth grade art we should hope that our patients leave our office saying, "how can something this beautiful not be right?"   

Kind, Quiet, and Competent. That's a good starting point for success.  Kindness, Quietness and Competence. Are these foundation elements for success at work? As I reflect on my own performance now over many years of practice I think my failures, times when I have not performed well, may all fall into one of three buckets, 1. A failure to be KIND 2. A failure to be QUIET, and 3. A failure to be COMPETENT. Let me explain...

This podcast is my personal exploration into podcasting and the field of urology, but in some episodes I am blessed with a guest and in this episode we have a great one.  Tom Bergman is a physician's assistant (PA-C) who works closely with the the urologists within my practice. He has gained special expertise working in kidney stone prevention strategies.  In this episode Tom and I review 1 what are kidney stones and why do they form, 2. What are some basic dietary recommendations to prevent kidney stones, 3. What are 24 hour urine tests and what abnormalities in the urine do we find and, finally, 4. We briefly review the most common abnormalities on the 24 hour urines and how we treat them. I think you are going to learn a ton listening to this episode with Tom Bergman. Thank you, Tom, for sitting down for this conversation.  Basic Dietary Strategies for Kidney Stone Prevention Hydrate Limit Sodium Get enough Calcium in your diet Limit or Moderate Animal Protein Limit High Oxalate Foods Eat Fruits and Veggies Link to Jill Harris webpage on high oxlalalte foods.  https://kidneystones.uchicago.edu/how-to-eat-a-low-oxalate-diet/

The best business strategy, plans, tactics and goals don't matter if your people aren't allowed to create or feel something beautiful or purposeful at work, to have a mission, and maybe make a little art that gives meaning to their job.  Here is the automaker Henry Ford on the subject: “Business must be run at a profit, else it will die. But when anyone tries to run a business solely for profit, then also the business must die, for it no longer has a reason for existence.” Hippocrates, often called the father of medicine brought high ethical and clinical standards to medicine in the years he practiced around 400 B.C, but  even Hippocrates, had to have business meetings with his partners, deal with human resources issues, figure out what his competitor practices and other schools of thought were doing at the time to stay current, hire new people and staff, and have enough money left over after a day's work to buy food and clothes for himself. Sure Hippocrates had a higher calling, but I would have loved to have a video recording of his practice's annual strategic planning meetings.  Governance, commerce, and mission. Politics, business, and art. Those are the three pillars on which our independent medical practices are built. We have to get our politics right and govern ourselves well, then we have to get our business right but we can't forget that we have a purpose, a higher mission that gives meaning to our life, our work lives, and to society as whole. We have to remember to put art back into medicine, even if we can't define it we will know it when we feel it. 

These episodes are my personal exploration into podcasting and the practice of medicine using my chosen specialty of urology as the pivot point.  Most of the episodes that I write and record begin with a single idea, thought, topic, or quote. This episode is no exception, and begins with a book I read recently about James J Hill, one of the most successful railroad magnates of the gilded age in the late 19th century. I recently read a book called James J. Hill: Empire Builder of the Northwest by Michael P. Malone and I read it as part of a book club assignment that, along with Wikipedia and other online resources, is the inspiration nad source material for this episode.  James J Hill was an extremely wealthy man at the time of his death. At the end of his life, Hill was asked by a newspaper reporter to reveal the secret of his success.  Hill responded : "Work, hard work, intelligent work, and then more work.” James J Hill worked. And worked. And worked. He once is to have said, “Give me Swedes, snuff and whiskey, and I'll build a railroad through hell.” Work, hard work, intelligent work, and more work. Such was the life of James J Hill. What fascinates me, what I would love to pick James J Hill's brain about, is this idea of intelligent work.  What did he mean when he said that? What for James J Hill would constitute intelligent work.  What I am thinking about today in this short episode is the addition of more intelligent work along with work, hard and more work as the key to success as I move forward in my career.  What is that? What does it look like? How do I get it? 

Bladder Cancers begin on the inner surface of the bladder, in the lining cells called the transitional cells. Bladder cancer is most often a transitional cell carcinoma.  Bladder cancers most often grow as a polyp on the surface of the bladder or as a flat tumor called a “sessile” tumor. Bladder cancers can invade the deeper layers of the bladder and they becomes much more likely to spread if they become invasive. Bladder cancers can also grow along the surface of the bladder into something called carcinoma in situ. Bladder cancers can be low grade (slower growing) or high grade (faster growing and more aggressive).  Cigarette smoking is the number one risk factor for forming bladder cancer and blood in the urine is the most common sign or symptom. Tumors that form along the surface of the bladder can be lopped off under anesthesia using a transurethral (through the urethra) resection technique. For many patients this is the only treatment they will need. Patients with invasive tumors or carcinoma in situ need more aggressive treatment.  Bladder cancer is a disease with a high recurrence rate. Even small low grade tumors resected completely have a high risk of recurrent tumors in a relatively short period of time either in the area of resection or in any part of the urinary system where we find transitional cells, most often the bladder but also the renal pelvis draining the kidney, the ureters that transport urine down to the bladder and the urethra. Even the slow growing bladder cancer grow quickly enough that if not caught early enough they will cause complications such as bleeding and pain, or, worse, they can convert to high grade tumors that become invasive. Bladder cancers take constant surveillance to make sure the cancer has not come back.

This is the last in this five part series about content creation. in this episode we will talk about keeping a scheduling. We need to be consistent.  Consistency creates loyalty from the audience, but it has intrinsic benefit to the creator as well. When we think about creation we need to think in terms of a defined length of time, usually daily, weekly, monthly, quarterly, biannually, yearly. And we can even extend those numbers  What should we do every Day, week, month, quarter, biannually or twice a year, yearly, bienially (every two years), quinquenially (every five years) decennially (every ten years) and quadracentenially (every 25 years)? When we create content for the medical practice I believe we should have a long view.  The practice of a physician and a medical practice doesn't allow for the time necessary for regular tweets and facebook and instagram posts of any meaningful content in my opinion.  Our daily responsibilities take up most of our time. Seeing and operating on patients. checking lab and X-ray results, calling concerned families and taking calls from the Emergency Rooms. Content creation is something important, but it's not urgent, and often gets pushed to the side and not done. Your schedule will be determined by the type of content you are creating. Some content will take more time. A piece of written content will take you far less time than audio or video content. But audio and video content is all the rage, so choose your efforts wisely and plan acordingly.

We are in the midst of a five part series talking about content creation for physicians and medical practices as a way to do content marketing for the practice.   This episode is dedicated to my fourth principle for content creation: do one thing well.   In the previous few episodes we have explored 1. share information and solve problems, 2. telling a story, 3. reimagine one form of content into a different form. This fourth principle, do one thing well and the next principle, keep a schedule, are the get down to business, get to work principles that require a bit of discipline. As a bit of review, content marketing is putting stuff online that provides immediate value to a potential patient even if they never pick up the phone to seek your services.  Content marketing shows expertise in a field. Content marketing builds trust. Content marketing helps people.  Doctors and professionals of all sorts put themselves online in the practice website, video platforms such as youtube or Vimeo, social media services, advertisements, and even encourage our patient to post reviews on online review sites. We are trying to tell the world who we are, what we do, and why people should choose us for their medical care. All physicians should consider themselves content creators. As physician content creators we want to share info or solve a problems using our expertise in our chosen field of medicine. We need to think of ourselves as storytellers when we create content to make us not boring. And because we serve many different people with many different needs we think to re-imagine our content for different audiences, a blog post for one or a youtube video for another. In the previous three episodes I have tried to expand the way that a physician sees him or herself as a content creator. You can do it; You should do it. Your phone in your pocket has everything you need to get started. But you can't be every thing to every body everywhere all of the time. The secret to any content creation, or any creative endeavor is that it is hard work and it takes a lot of time and effort to be any good.  Which really brings me to my fourth idea, to put a stake in the ground and try to do one thing well. For most of you and I think for most practices a simple organizational change, and my suggestion, will be to regularly review and update a practice website, the starting place for your content creation. There is always a bit of proverbial bed-making that needs to be done for the practice website. A phone number needs to be changed, a doctor moves out of state and leaves the practice, the current mask policy for the practice during covid needs updating. But maybe in addition to the regular updating of pictures and phone numbers your practice wants to have a place where you regularly update some information or help to solve problems for patients or people just looking to get some help, for lack of a better term we can call it a practice BLOG, and a few well written paragraphs with each post may be all that is needed to tell the story that can help a few patients.  The choice will be yours to make for your medical practice. The key is to get the one thing done well, or as well as you can, even if it seems like a small thing.  Your content creation may never expand beyond that; it may not need to.  But the one thing done well can serve as the foundation for anything else you want to do.  The call to action for this episode if you are thinking about content creation is to choose this year what is the one thing you are going to focus on to do well and to do the work to get it done.  In the next episode I am going to talk about the fifth principle for content creation, keeping a schedule.    

We are in the midst of a series of episodes that I am doing about content creation for the medical professional/doctors/medical practice. This five part series is based on five foundational principles or ideas for content marketing for the medical practice. Content marketing serves three purposes 1. it shows off your expertise, 2. it builds trust, 3. it helps people.  Our #1 job as physicians is to share information or solve problems for our patients. That is the first principle on my list. The trick in our content creation, and one I am far from mastering, is to avoid being boring, tedious, or dull. Which led me to my concept #2: tell a story. We are all storytellers and we all have stories to tell.  Stories educate,  entertain, inform or inspire. Stories aren't boring. They draw you in and pull you along. Stories are how we understand the world and how we understand ourselves. We tell our stories in many different ways. This brings me to my number three principle: reimagining our content, rethinking one form of educational or informational material into a different form. When we make content for patient education or information we should immediately turn and ask ourselves what else can this be. I have a handout for say kidney stone prevention. Can I make this an infographic or a short educational video for YouTube or TikTok? The answer I think is yes, of course. And I think we should always be considering HOW to do this.  Our printed educational handouts become videos becomes infographics become movies and maybe even an audio or podcast format. The reason we do this is both to expand our reach and the life of our content but also because the different forms will appeal to different people or patient populations. My call to action or encouragement to you is to think in various forms for content creation. For many or most practice our “content” will be simply our website. Other practices will venture beyond to audio and visual content.  But no matter what we do we have to think about what info we want to share, what problems can we solve, and what stories can we tell.  We have many tools for online content creation. All we have to do is use our imagination to be creative and resourceful and to figure it out. Principle #3: Re-imagine your content. 

I have 5 principles or concepts that I think are important for me to remember as I create “content.”  Those five things are  1 share information or solve a problem 2. tell a story 3. reimagine content 4. do one thing well 5. keep a schedule We are working through these 5 principles each as an individual podcast episode.  In the last episode I said the physician should focus on sharing information and solving problems. This is what we do in our everyday lives. We meet with patients one on one in the clinic or hospital setting and, well, share information and try to solve problems. Whenever we create a website, a podcast, a blog post, video, infographic or whatever we are doing the same thing, and we do it one on one because each view of our content is usually one person looking at that content. Your online content is just an extension of what you do every day as a physician. In this episode we try to tackle my #2, principle, tell a story. We are all story-tellers. And we are the stories we tell. Stories are how you and I, how we all, engage with and understand the world and engage with and understand ourselves and each other. The story we are ultimately telling in our content creation is the humble story of ourselves. Who are we? What do we do? How do we do it? Why? What is our mission, our vision, and our values when it comes to how we practice medicine and treat our patients? What do we offer in terms of services, and sometimes more importantly, what can't we offer our patients? Your content creation tells your story. Your content creation tells us something about you. Tell us your stories.

This is number two in a series of six podcast episodes I am making about content creation for content marketing for the medical practice or medical practitioner. share info or solve a problem tell a story re-imagine content do one thing well keep a schedule For each of the next five episodes I am going to work down the list and break down each principle or concept as I understand it.  These concepts are not original thoughts of mine, just a short list of five things I thought could help me frame what, why, and how to create online content for “content marketing. Marketing is finding our market, our niche, those people who need our services, and letting them know who we are, what we do, and where to find us. The idea in online content marketing is to put stuff—websites, blogs, videos, podcasts, etc.— out into the digital world that helps your market learn about your expertise and creates a bond and a trust that leads someone to become your patient or customer.  We should see content marketing as a positive. It allows those people who need us to find us. And it helps those who don't need us or who we can't service to look elsewhere.   If we are a doctor or a medical practice wanting to dive in to online content creation all we have to do to get started is to ask ourselves, what information do I have that I can share, and what problems can I help solve with whatever content I create? If you are a urologist or a urology practice the answer is actually pretty easy. We are experts in kidney stones, enlarged prostates, bladder/prostate/kidney cancers, recurrent urinary tract infections, incontinence and voiding dysfunction and the list goes on. Pick one of those and start typing or hit record on some electronic device and then pick a platform where you are going to put that out into the world.        

First, a huge thank you to those of you who have contacted me to encourage me as I reboot and rebrand the Why Urology Podcast into Urological. Thank you so much for listening and for your ongoing support. 1. share information or solve a problem, 2. tell a story, 3 re-imagine content, 4. do one thing well, 5. keep a schedule.  These 5 things are the 5 principle ideas or concepts that I wrote for myself as a guide when creating content, whether it's for education, information, marketing, or general engagement with my patients for my practice. Don't be boring. People get bored quickly. We all have limited time and attention spans shorter than a Goldfish, and we move on quickly when something is dull.  How to not be boring: 1. You do you, 2. be passionately curious, 3. pursue excellence, 4. share with others. Thank you for listening.

Welcome Back to the Why Urology podcast. I am Dr Todd Brandt.  This is a podcast is my personal experiment and adventure into podcasting and is centered around the field of urology and my very, very small place in it. I started podcasting on a lark in the Fall of 2016 with a simple premise. I was going to tell you why urology is such a great field of medicine and why I chose this as a specialty. I was able to write, record, edit and publish 120 episodes of the why urology podcast before deciding to take a break at the end of 2021 and I closed the show with no real plans to start podcasting again. I have spent little time this past year reflecting or asking myself if I was done as a podcaster, or as a content creator, but as I now look toward next year I begin to question if, and what, I may want to put out into the world. This podcast episode is the obvious answer. Apparently, I have more to say. The ancient Chinese philosopher, Lao Tzu is credited with the following quote, “Muddy water, let stand, will clear.” Here is what has become clear to me as I let the muddy water settle on podcasting during this past year away. I have missed the process of writing, recording, editing, and putting episodes out into the world and I would like to start recording them again. OK, but what comes next? First, I want to let you know that I am going to start recording under a different name. The Why Urology podcast will now become, simply… Urological. If you have been a listener in the past you know that many of the Why Urology episodes were only loosely based on something urologic. Much of the time the only association was that I was a urologist. I feel a name change reflects that I expect this podcast will continue to steer away at times from the middle lane of the urologic highway and on to some tangential side roads. Those roads may be bumpy at times, but I think the scenery may be better. Secondly, I want to apologize ahead of time that I am a bit rusty in podcasting and in all things related in any sort of content creation. It may take some time after I have turned on the microphone and opened the tap to let the old rusty water run out until the clear water begins to flow. This podcast will continue to be a work in progress. I both apologize and make no apologies for that all at the same time. I just feel the need to get going. There is a proverb I learned a long time ago that encourages a bias toward action. A word of caution: It was probably something I read from a fortune cookie or was written on the bathroom stall somewhere so take that for what it's worth. It's free advice and you get what you pay for. The proverb is this: The work will show you how to do it. The work will show you how to do it. I always took that to mean that if you just get started on the task at hand it will tell you what it needs. The clarity of what, where, how, and when comes in the doing, not from the idea, or the intention to do or the thinking about the thing. It comes from the action. Our task is to do a podcast. My idea is to just start, and to write, record, edit, publish and repeat, to keep going, until the rust is gone and the water runs clear. I appreciate your joining me on this journey, in listening to this episode and continuing to listen under its new name, “Urological” Urological. A podcast by a urologist, and whatever may be on his mind.  

  I will be ending this podcast in its current format at the end of this calendar year, 2021.  I have not run out of ideas for episodes of this podcast. I have not depleted my energy for doing something creative. I still want and would welcome any-and-all guests for interviews and conversations that center around some aspect of urology and the practice of medicine. I still want your comments and feedback. And I am still so grateful that you are listening to these episodes. My idea to start a podcast began around 6-7 years ago when I, myself, discovered the power of podcasting and podcasts in general were gaining a wider audience. For many years medical practices had been trying to figure out how to use all of the tools of “social media” as a form of marketing but also as a way to engage patients.  Video content was always the focus and still is today. Video is easily the most powerful and versatile tool for marketing and education, but video is expensive and difficult to do well. The audio only format of a podcast is far simpler.  It's cheaper, easier to edit, and nearly as powerful if used within the right context. So here was the thought. Why not try an audio format only rather than spend so many resources on video content?t. The great physicist Albert Einstein said, “I have no special talents, I am only passionately curious.” That is how I started podcasting, no special talents just a passionate curiosity. I have spent many hours of time and energy, and a little money, writing, recording, editing, and posting these episodes. Making this podcast happen has fed my passionate curiosity over the last five years. And although I am no Einstein, my mind has grown during this process and I hope you have learned a little something as well. The truth is that I find it difficult to pack it all up, put it all away and leave this podcast. I feel that I have more to give. I would like to continue to create in some way, to continue to tell stories. As I said in the previous episode of this podcast, we are all storytellers. And if we are a storytellers we first need to know and understand the story we are telling. Does our story inform, inspire, educate, or entertain?  And how is our story told best? On a page, a stage, or a screen? I have tried to tell a small part of the urology story in this podcast. It has been a silly affection, but it's been really, really fun and I am sad to leave it. Until the next story-time connect with me at whyurologypodcast.com. Be well.              

  Here is something that is true. You and I are all story tellers. My thesis is that a story does one of four things: inform or inspire, educate or entertain. A story teller is one who informs, inspires, educates, or entertains. I was listening to a podcast the other day where a screenwriter was talking about adapting a short story into a screenplay, how some stories lend themselves to the adaption, how the scope of the story changes with the format, and why some great novels, plays or short stories become really bad movies. As a story teller she would say, you have to know if your story should be told on a stage, a page, or a screen. Let's say you have a story to tell and you have a blank page. The question is does this story want to become a Broadway play, the great American Novel , or a Hollywood blockbuster? Or is it a short format story told best in a literary magazine, a community theater, or an independent short film festival? The story you have determines what you write. As physician story tellers we are asked to inform or inspire, educate or entertain. For most of us in medicine the stories that we tell will be intended for education and information rather than for entertainment or inspiration. As physician storytellers we need to know if our stories are meant for the stage, the page, or the screen.  A famous person once said that the most important part of every painting is the frame. A page lends itself to dense material, detailed pictures, and a reference for going back to later. A stage lends itself to a personal connection, a real time shared experience and developing a relationship between the story teller and the person hearing the story. A screen lends itself to a cinematic experience and story-telling on a large scale. But what, you may be asking, about the podcast format? Hmm. What about the podcast format? If you have been a listener you know that I do not have an answer to that question.  I have tried to tell you a story. I have tried to inform, inspire, educate, or entertain you. I have tried to make it as simple, to speak slowly and softly, to record often and always. I have tried to be complete, concise, clear, concrete, and correct. Finally I have tried to be compassionate. That's my story, and I'm stickin to it.          

The urethra is a crucial component of genitourinary system in the male, serving both as a way to get urine out of the body as well as to get semen from the prostate and ejaculatory ducts out of the body during ejaculation. We tend to think of the urethra as just a passive channel during urination, but the urethra is dynamic during ejaculation. We also tend to think of the male urethra is a single structure, again just a tube that connects the bladder to the outside world, beginning within the bladder wall and ends in the distal glans of the penis. But the urethra is composed of a heterogeneous series of segments along its average length of about 20 cm. Each segment has unique anatomy and physiology that help to serve a specific function. The four segments are the prostatic, membranous, bulbous and penile urethra. We tend to think of the urethra as just a straight tube, but it is not. If a man is standing with the penis in a flaccid state and we could see through him to look at the urethra we would see that the urethra forms an S shape as urine travels from the bladder and out to through the four segments of the urethra. Let's start at the top. The urethra begins as the bladder enters the prostate. For about one centimeter or so the bladder and the urethra come together as the urethra is embedded into bladder and is lined by transitional epithelium.   Next comes the true prostatic urethra is that portion of the urethra that is completely encompassed within the prostate gland itself. The urethra at this point is actually lining the prostate gland. This 3-4 cm length of urethra (depending on size of prostate) is generally the widest part of the male urethra, surrounded by the glandular and stromal tissue of the periurethral zone of the prostate. During cystoscopy we see the urethra widen here as we pass the scope, and often we simply refer to it as the prostate rather than the urethra. Because the prostate is responsible for semen production and the prostatic urethra is where semen is deposited prior to ejaculation the prostatic urethra contains the urethral crest, seminal colliculus, prostatic utricle (or verumontanum), and the orifices of the prostatic ducts. The kind of pathology we can see here the prostatic urethra is generally limited to what is happening within the prostate itself, benign hyperplasia or prostate cancer, and how that impacts the urethral channel. But the urethra here is lined by urothelial transitional cells and can also get the same kind of cancer as bladder cancer, which is difficult to treat if it invades the prostatic ducts, so we must be careful to identify any tumor development in patients with bladder or other urothelial cancers to make sure we are not missing any urothelial tumors within the prostatic channel. Travelling from the bladder outward, after the prostatic urethra comes the membranous urethra The membranous urethra is that part of the urethra which is surrounded by the urinary sphincter muscle of the pelvic floor and the facial layers of the perineum. This segment of the urethra is short, typically just 1.5 centimeters in length or so, a fairly short segment that we rely on to hold our urine and keep us dry.  The membranous urethra begins immediately outside of the prostate and ends just prior to entering the bulb of the penis and the bulbous urethra.  The lining of the urethra changes within the membranous urethra. The urothelium changes into pseudostratified columnar epithelium, with cells that are more elongated in shape, and look like they are in layers, but they are not. Pathologically the membranous urethra is susceptible to shearing forces from pelvic trauma. A disruption of the membranous urethra at the level of the sphincter is a difficult injury to manage and treat and can impact a man's ability to control the urine if the sphincter is permanently damaged. After we exit the perineum and the membranous urethra we get to the bulbous urethra.  Remember we talked about the urethra being an S shape? Here is the first curve of the S.  the urethra turns at this point to run along the perineum as the bulbous urethra. The bulbous urethra is that portion of the urethra surrounded by the bulbospongiosus muscle and the corpus spongiosum. The lining remains pseudostratified columnar epithelium. Congenital urethral strictures can occur in this portion of the urethra.  This portion of the urethra is also susceptible to straddle injury. Because the male urethra is a long structure that passes through several compartments in the body and therefore, receives blood supply and nerve innervation from several sources. The male urethra receives blood supply from the inferior vesical artery, bulbourethral artery, and the internal pudendal artery.  The venous drainage parallels the arterial supply. The sympathetic, parasympathetic and visceral innervation to the male urethra gets delivered through the prostatic plexus.  The lymphatic drainage is different for different parts of the urethra. The prostatic and membranous urethra drain to the obturator and internal iliac nodes. Lymphatic drainage from the spongy urethra drains to the deep and superficial inguinal nodes. The different lymphatic drainage has implications in cases where we find cancer in terms of which lymph nodes we need to look at to check for recurrence. The last portion of the urethra is the penile urethra. Here is the second curve of the S with the penis in the flaccid state. Typically around 15 cm in length the penile urethra is immediately surrounded by the corpus spongiosum and the pseudostratified columnar epithelium changes in the terminal portion just before the meatus to become stratified squamous epithelium. The penile urethra widens in the glans of the penis, forming the fossa navicularis. The penile urethra ends at the urethral meatus in the glans penis. The urethral meatus is typically a wide portion of the urethra but is susceptible to injury or inflammation which can lead to stenosis and a potential final spot for obstruction. Reach out to me with comments, questions, or concerns at whyurologypodcast.com.  

In this episode I reflect on some things that are important for building a healthy medical career: 1. Education, 2. Find meaningful work within medicine, 3. Move away from home/start a practice, 4. Find partnership in your practice or medical community, 5. Give back to your community, staff, and patients from a strong foundation from the first four steps. Connect with me at whyurologypodcast.com

Dr David Prall joins this episode of the podcast to discuss BPH and Urolift. Dr Prall is a partner in my practice with a center of excellence designation for the Urolift procedure. I ask Dr Prall the ten questions I think can be applied to any procedure about the Urolift procedure. Find more at www.urolift.com Connect with me at whyurologypodcast.com

September is prostate cancer awareness month. Prostate cancer is the most common non-skin cancer diagnosed in men. All men are at risk of developing prostate cancer as they get older. 1 in every 8 men will be diagnosed with prostate cancer during his lifetime. Not all men diagnosed with prostate cancer need treatment, Many prostate cancers grow slowly and stay in the prostate. but all men should know if they have prostate cancer. Getting prostate cancer screening with a digital rectal exam and an annual prostate specific antigen or PSA test is the way to detect prostate cancer earlier, while still contained in the prostate and still treatable. Here are the five things men need to do when first diagnosed with prostate cancer: 1. Men should take a moment to understand the basic anatomy of the prostate and pelvis, 2. Men should get clarity on what STAGE their cancer is, contained or has it spread, 3. Men should understand the PATHOLOGY REPORT on the biopsy…what GRADE is the cancer, 4. Men need to consider the current health status and expected longevity when deciding on treatment options, and 5. Men need to understand which treatment options are appropriate for THEIR cancer given their own priorities but also the facts of the cancer. Our goal is to try to pick the right treatment for each patient. That requires a process of educating each patient in a systematic way. I really hope that this episode helps you, especially if you are newly diagnosed and you are having or have had these discussions with your doctor. If it has please consider sharing this episode.  

Six things to ask yourself before you see your doctor In the previous episode of this podcast, I reviewed five things you need to do before seeing your doctor for your next appointment.  In that episode I said that the very first thing you need to do before even making an appointment is to sit down with a piece of paper or a notebook and to write down why you are going to be seeing the doctor in the first place. In this episode we are going to talk about  six questions to ask yourself about your elbow pain prior to seeing your doctor. These six questions are the same questions that your doctor is likely to ask you in one form or another, or at least are the things that your physician will use to frame the discussion about your elbow. And I would encourage you not only to ask yourself these questions but to write down the answers. Why should we write things down? If we don't write it down it is quite possible we will forget to tell the doctor during the visit about the details of the problem, or the doctor may not be on his or her game or make assumptions.  Small details matter. Don't trust yourself to remember all the details at the time of the appointment. Write them down ahead of time and go ahead and show the doctor what you have written down and let the doctor read those notes. It's faster and probably more accurately describes what you are going through. It's one of the reasons you get all of that paperwork to fill out prior to coming to your appointment or are encouraged to go online ahead of time and fill out the forms. Also, you will have more time thinking about the character of your elbow pain, where exactly in the elbow it hurts, how it came about, how long you have had it, how severe is it and what makes it better or worse. Writing it down will help you get the details right. And it will help you get the problem fixed.  Here are the six questions you need to ask yourself about any complaint that requires you to see a physician.  I have already given them to you. If you missed it, here they are again After naming the problem, in this case elbow pain we need to ask ourselves six questions. What is the location? How long have you had this problem? What is the character of the problem? What happened when it started? How severe is it? What makes it better or worse? Location. Duration. Character. Onset. Severity. Aggravating or relieving factors. One. Location. Where is the problem?How specific can you be? What part of your groin or stomach hurts. Where exactly in the elbow? Two. Duration.  How long has this been going on? 4 days or  2 Month or 9 Years? Or maybe the issue is better now. How long did the problem last after you got it before it went away?  Three. Character. What is the characteristicas of the problem? When describing your own problem try to describe the character of the problem in your own words. Is it like a pressure? A sharp pain? Does it come and go? Try to describe what you feel. Four. Onset. What was going on when the problem started? This is quite simply a questiona about what you were doing when it started. When did you first notice it? Was it a normal day or were there special circumstances surrounding the onset. Five. Severity. How severe is the problem? Usually, we try to use a scale on this, maybe a 1 to 10, with 1 being a not severe problem vs a 10 very severe. The problem may be more of a nuisance that is tolerable and not limiting other activities Six. Relieving or aggravating factors. This is self-explanatory by now. What make the problem worse and what makes the problem better? Location. Duration. Character. Onset. Severity. And relieving or aggravating factors. Let me take a moment to say that for those things that don't necessarily give you symptoms these questions can be a little tricky to answer. We see this in urology, in cases where blood is found microscopically in the urine during a routine general yearly physical. There are no symptoms.  In that case the character of the blood in the urine is microscopic and not visible blood, the location is urine, the duration is since the time of the urinalysis, the onset was routine physical exam. The severity will be defined by the amount of blood seen under the microscope and there will be no identifiable relieving or aggravating factors known since it is not symptomatic. If you work hard enough you can find an answer for each question, but I think to make it easier you should just try in that case to answer as many as you can. Here is what to do when you make a doctor's appointment. First, write down the list of problems you want to discuss with your physician. Then, for each problem, try to answer the questions about its location, duration, character, onset, severity, and relieving or aggravating factors. Doing those two things shouldn't take very long to do and will really help you get the most out of your clinic visit with your physician.

  Five Things You Need To Get Ready for your next Doctor's Appointment Here is the problem for this episode.  Many people are not prepared for their doctor appointments. Think about it for a second. Let's say your elbow hurts and you want to have it looked at. You call the doctor, maybe your primary care physician but probably your othopedic surgeon to take a look at it. You make an appt for Wednesday at 1015 in the morning. Now what? How do you prepare for that appt?  Today I want to give you the first few top priority things you need to do before, during, and maybe even after your appointment to make sure you get the most of any doctor's appointment. The idea for this episode comes from the National Institute on Aging and the National Institutes of Health website where you can find worksheets to help you prepare for your doctor's appointments.  https://www.nia.nih.gov/health/talking-with-doctor-worksheets This short list is what is known as a checklist. What is a checklist? A checklist is a list of actions to be performed in any given setting or activity with the goal being to ensure that no step or thing will be forgotten. Hospitals, emergency rooms and your doctors all use checklists. You should too. Here are Five things you can do to prepare for your doctor's appointment. Make a list of what you want to talk about and prioritize that list. Bring that list with you to the appointment and show the physician. Know what medications and supplements your take and what allergies you have. Keep an accurate list with you at all times. You may need help. That's OK. Prepare ahead of time to have the resources you need to help you navigate the appointment and remember what was done. Make sure you can see and hear during the appointment. Bring your reading glasses. Wear your hearing aids. Stay focused on why you are there. Clinic visits are impossibly short and there is so much to cover that's it's very difficult to get it all done. You don't really have that much time. Your doctor doesn't have that much time. Make the most of it. Use a checklist. Start doing these five things before your next doctors appointment.      

Here are my answers to the ten questions about the male urethral sling procedure. You can find more information at fixincontinence.com Connect with me at whyurologypodcast.com What is the diagnosis?             The diagnosis is urinary stress incontinence. A male urethral sling is placed for men with stress urinary incontinence, most often as a result of prostate removal for prostate cancer. Stress incontinence is leaking when a man coughs, sneezes, or lifts. Candidates for this type of surgery are generally men with mild to moderate leakage (1-4 pads daily). Ideally men considering a sling should also have good bladder function with a bladder capacity > 250 cc and no detrusor instability or overactive bladder. Cystoscopy is also performed prior to surgery to determine there is no bladder neck contracture or urethral strictures. Men must also be able to demonstrate urethral sphincter function either on urodynamics testing, starting and stopping midstream of micturition, or demonstration of urethral sphincter recruitment and closure on cystoscopy. Procedure description:  With a man in stirrups under spinal or general anesthesia, perineal incision is made below the scrotum and above the anus. The urethra is identified and mobilized to allow it to move when the sling is tensioned. Separate bilateral incisions in the inner thigh  are made and using a helical trocar the sling arms are brought from the perineal incision around the pelvic bones through the obturator fossa. The central portion of the mesh is fixed to the urethra and tensioning of the sling is done by pulling firmly on both arms of the sling. Cystoscopy is performed to confirm coaptation of the urethra. Once coaptation is confirmed, the wound is closed. Men spend one night in the hospital when I do the procedure with a catheter in place. The catheter is removed the next day and men are monitored to make sure they can urinat adequately after the procedure. Men must be able to pee the next day before discharge. Some men will need to go home with a catheter. What are the benefits of the procedure? The goal of the procedure is full continence or control of the urine. The male sling does not guarantee complete control. What are the drawbacks and risks of the procedure? As with any surgery there is a risk of infection, bleeding, anesthesia risk and of course the discomfort associated with surgery. These risks are relatively small for the urethral sling. I think the elephant in the room is that a man has a relatively high rate of leakage when compared with the artificial sphincter.  For men who do have continued leakage after a sling has been placed we can still place an artificial urinary sphincter at a later time. Obviously the goal is to get it right the first time, but it is important to know that it is not an either or proposition for men. Inability to urinate or urinary retention is also a risk if the sling ends up being too tight or causes too much restriction. Most often urine retention improves over time after the procedure but some men depend on intermittent catheterization after the procedure.             If the urethra is injured while placing the cuff, we need to stop the procedure and let that heal before attempting that again. That is rare but can occur. Also rare is a reaction to the mesh that would cause erosion or extrusion of the mesh.             Finally, over the long term, as our body tissues change some men will experience an increase in leaking years after the sling has been placed. Alternatives: Alternatives to the sling are continuing the use of the diapers or pads, using an external compression device on the penis such as a Cunningham clamp, biofeedback, and external catheterization such as a condom catheter. Several models from different manufacturers of the urethral sling exist. The artificial urinary sphincter is the alternative surgical approach. How common is this procedure? The male urethral sling is a common enough procedure. Most men who have had prostate removal do not need any surgery to help with urinary control or choose not to do any further treatment. But the number of surgeries done every year means there are enough men who have problems who need to have the sling placed. Why now or when should a man have the procedure? The timing of placing a male urethral sling is usually at least one year from the time of the prostatectomy. It takes time for some men to regain urinary control.  Most of you listening this far already know that you have continued problems with incontinence. You have tried Kegel exercises, biofeedback and possibly medication. You have also tried the external compression devices and the urinary pads, and you are looking for a definitive solution. As I have said before if you are a man considering this procedure take your time making this decision. Preparing for the procedure: Normal recommendations for prior to any surgery Do not eat or drink anything after midnight the night before the procedure.             You should take your usual medications as you normally would the morning of your procedure with a small sip of water or clear liquid only (avoid juice, milk, coffee). Starting 5 to 10 days prior to your procedure (ask your doctor for a specific time), it is important to stop taking medications that might increase your risk of bleeding. For a list of blood-thinning medications that should be avoided. Preparing your skin by washing with antibacterial soap or Hibiclens for a week prior to surgery will help decrease ethe bacterial count on your skin to help with infection.         Have a driver and know the route the hospital, how you will get home, and bow will take care of you when you do get home. After the procedure: You will stay the night in the hospital. Pain is controlled, you will eat a normal diet and begin to walk around after surgery right away. We leave a catheter in overnight and remove the next day. One of the critical steps when removing the catheter is making sure a man can void after the procedure. There is some risk of retention. If you need a catheter when you go home we will decide when to remove it at that time. You will go home on antibiotics. Take the complete course of antibiotics prescribed unless you have a reaction to the medicine. I usually will have an appt with you 2 weeks after the operation. Here is the critical, critical thing. Plan to do only light duty and limited activity for at least six weeks after surgery. The sling can move in position with too much lifting, bending, straining. It heals into place and the body fixes it in position but it takes a while to do. One of the big advantages of this surgery is the small incision we make, but this means that we aren't sewing the sling to bone or other structures to fix it in place. Your body must do that. That takes time. Insurance coverage: Yes, there is usually good insurance coverage for this procedure. There is a prior authorization process, and our business office will help guide you. Know that you have coverage for this procedure before you get to the hospital on the day of surgery. You don't want to have to sort through the billing issues after the procedure

Recently I have been working on putting some videos together using my ten questions model for the artificial urinary sphincter and the male sling procedures used to treat post prostatectomy incontinence. We last time talked about the artificial urinary sphincter was back in episode 15.   These are simple videos done vidscrip style, just me in front of a camera, and you find links to the videos at https://www.vidscrip.com/toddbrandt and more specifically at the link https://app.vidscrip.com/vidscrip/5726cbc9a254a5897c3cbdb9 You can find my episode on the ten questions at episode 97. Men who have leakage after prostate removal for prostate cancer most often have stress incontinence. Men will leak when coughing, sneezing, lifting or any activity that increase intraabdominal pressure. The urinary sphincter muscle and the urethral mucosa my not have sufficient coaptation after surgery to prevent leakage with those maneuvers. Men may have different amounts of leakage depending on the level of success from the surgery, anywhere from full control without any leakage (the most common result) to severe heavy leakage. Candidates for an artificial urinary sphincter are generally men with moderate to severe urinary leakage using multiple pads or diapers every day. There are 3 components to an artificial urinary sphincter. First, there is a balloon cuff that is placed around the urethra which does the work of pinching the urethra to prevent the leakage Second, there is a pump placed in the scrotum which can be manually squeezed to open the cuff to allow a man to urinate. The last component is a pressure regulating balloon that is placed in the abdomen underneath the stomach muscles usually right next to the bladder that pressurizes the cuff to squeeze on the urethra.   The cuff is always closed because there is pressure in the system. Upon squeezing the pump, fluid is shifted from the cuff to the pressure regulating balloon. This movement of fluid allows the cuff to open resulting in opening of the urethra allowing a man to urinate. The cuff spontaneously closes as fluid returns from the pressure regulating balloon to the cuff. You can find a video demonstrating the artificial urinary sphincter and how it works at fixincontinence.com and on my vidscrip site.  Here are the answers to the ten questions about artificial urinary sphincter.   What is the diagnosis needed to consider an artificial urinary sphincter? An artificial urinary sphincter is placed for patients with heavy stress incontinence from an incompetent urinary sphincter. In this episode's specific use case we are using it to correct leakage for the small percentage of men with severe leakage after prostate removal for treatment of prostate cancer. Can we briefly describe the procedure? The way that I place the device is to make two small incisions. The AUS is placed through an incision in the perineum (space between the anus and the scrotum) as well as a small incision in the lower abdomen. The three components are placed through the two incisions.  The cuff is placed through the perineal incision and the pressure regulating balloon and the pump are placed through the incision made in the lower abdomen. Alternatively, the device can be placed through a single incision in the scrotum. Some surgeons prefer that approach. I find it difficult to place the sphincter cuff in a position that I prefer from that single incision. The surgery can be performed with either a general or spinal anesthesia and patients typicallyspend one night in the hospital.  What is the goal of this procedure? The goal of the procedure is full continence and full control of the urine.  The artificial sphincter is not a guarantee of complete control. It is probably about 85% successful at getting men to a level of dryness that is minimal pad usage. The reason it is not more successful is due to the limit of how tightly we can squeeze on the urethra, how much pressure it will tolerate before the urethra begins to shows signs of damage. What are the drawback and risks? As with any surgery there are risks bleeding, anesthesia risk and of course the discomfort associated with surgery. But the risks the surgeon worries the most about are risks of infection and urethral injury during the procedure. Long term risks include urethral thinning and erosion,  mechanical breakdown of the device, a failure to relieve the amount of leakage.      What are alternatives to the artificial urinary sphincter? Alternatives to the sphincter are continuing the use of the diapers or pads, using an external compression device on the penis such as a Cunningham clamp, biofeedback, and external catheterization such as a condom catheter. Male urethral slings or periurethral balloons can be placed for patients with less incontinence, usually up to only a couple of pads a day, who also have some ability to start and stop the urine stream and some overall control. How common is this procedure? The artificial urinary sphincter is a relatively common procedure. Althoughh most men who have had a prostatectomy don't have leakage severe enough to require a sphincter, there are enough prostatectomies being done annually that a number of patients unfortunately need this procedure. When should I have an artificial urinary sphincter placed? The timing of placing a sphincter is usually at least one year from the time of the prostatectomy. It takes time after a prostate is removed for men to regain urinary control. Most men will have good urinary control within the first 3 months after surgery, but some men take much longer.  Men who are considering an artificial urinary sphincter have already tried Kegel exercises, biofeedback and possibly medication to control the leakage and are not finding any success. Many men choose to wear external compression devices and the urinary pads longer than they need to before making the step for surgery. Choosing when to do this surgery is such a personal decision and the risks are high enough that it's best to let men choose when the time is right for them.  Is there special preparation for this procedure?             There is little preparation needed for this procedure. The usual advice for stopping blood thinning medication, getting preoperative clearance for anesthesia, not eating or drinking prior to the surgery, getting to the hospital on time all exist as for any other procedure. Patients can help preparing their skin before surgery to help limit infections by washing with antibacterial soap or Hibiclens for a week prior to surgery Before the day of surgery make sure you have a driver and know the route the hospital, how you will get home the day after surgery (you stay overnight), and who will take care of you when you do get home. Can you tell me about recovery from this procedure? Although some doctors send patients home the same day of surgery if I do the surgery you will stay the night in the hospital. Pain is controlled, you will eat a normal diet and begin to walk around on the same day as your surgery. We leave a catheter in overnight and remove the catheter the next day. The sphincter is left deactivated for the first six weeks after surgery to allow the urethra to heal. That means that you will continue to leak after surgery until the sphincter is activated. I typically activate the sphincter for men six weeks after surgery.        You will go home on antibiotics. Take the complete course of antibiotics prescribed unless you have a reaction to the medicine. You will also have a prescription for pain medication if you feel you need something stronger than over the counter medications. Many men don't need the prescription for the pain medication and choose not to take it. Plan to do only light duty for a couple of weeks after surgery. I usually will have an appt with patients two weeks after the operation to check for adequate healing. That is typically when we negotiate when a man can go back to heavier physical activity. What about insurance coverage for the procedure? There is usually good insurance coverage for this procedure. There is a prior authorization process to make sure the procedure is covered handled in my practice by our business office. It's important obviously to know that you have coverage for this procedure before you get to the hospital on the day of surgery. I have had to cancel procedures for patients or move them from one hospital to the next at the last minute because of a breakdown in this process, and that is not at all fun.  If you are a man considering this procedure, I can tell you that you don't want to have to sort through the billing issues after the procedure. That finishes the ten questions about the artificial urinary sphincter. We have been discussing this in the context of men who have had their prostates removed for prostate cancer. For those men, as well as for patients with other forms of urethral sphincter injury or neurologic dysfunction this procedure can make a huge difference in a person's quality of life. Find out more about the artificial urinary sphincter at fixincontinence.com or at bostonscientific.com. Find me at whyurologypodcast.com and connect with me there Thanks for listening.

Patients are constantly asking me how they can make a change in their lives.  Here is what I tell people. And it is something almost nobody does. If you want to make a change in your life take your favorite writing instrument, a blank piece of paper, find a quiet place and write. Blaise Pascalm, a French philosopher and mathematician in the 1600s said, “All of humanity's problems stem from man's inability to sit quietly in a room alone.” In 1839 English author Edward Bulwer-Lytton wrote in a play, “The pen is mightier than the sword.” Here is something I know to be true. One of the most powerful forces that shapes our world is when one man or one woman sits quietly in a room alone with a pen in hand, writing. If you want to make a change in the world, in your world, or just make a change in yourself I would encourage to learn the power of the pen, to learn how to sit quietly in a room alone, and to take the time and energy to take ownership and put it into your own words. Thanks for listening

In this episode I welcome back Dr Spencer Hart Dr Hart and I go through my "Ten Questions" that I think can be applied to almost any procedure or surgery to cover the main questions a patient needs to know. We apply the ten questions to talk about an in-office treatment for BPH or the enlarged prostate called the ReZUM treatment. The ReZum procedure utilizes small blasts of steam into the enlarged prostate to destroy the tissue to create a better channel through the enlarged prostate for improved urinary flow. Here are the ten questions. 1. What is diagnosis? 2. Describe the procedure. 3. What are the benefits? 4. What are the risks? 5. Is this a common procedure? 6. What are the alternatives to the procedure? 7. What happens if I wait to do this procedure? 8 How do I prepare? 9. How do I recover? 10. Does insurance help cover this procedure? This is another great conversation with Dr. Spencer Hart. I hope you enjoy it. Thank you for listening. You can find Dr. Hart at https://mnurology.com/physicians/spencer-hart/ You can find the ReZum treatment information at https://www.rezum.com or text ReZum to 73771 Connect with me at whyurologypodcast.com

In this episode I have a conversation with Dr. Spencer Hart about the enlarged prostate, what is known as BPH.  In this conversation we try to answer the question, “I have an enlarged prostate, now what?” We start with a relatively brief introduction to the problem, move on to some of the first evaluation we do in the office, then we discuss the initial treatment of BPH with medical therapy. We finish with a brief discussion about how a man makes the decision to move on to a surgery or procedure if medication is not desired, or tolerated, or is not working.  You can find Dr. Spencer Hart at the Minnesota Urology website at https://mnurology.com/physicians/spencer-hart/ You can find information about the ReZum procedure at https://www.rezum.com You can find information about Urolift procedure at https://www.urolift.com You can connect with me at whyurologypodcast.com

We live in a social media-driven world. Facebook, twitter, Linked In, Instagram, YouTube, TikTok and many other platforms vie for our attention, and of course the advertising dollar.  Medical practices have been trying to figure out social media, medical review sites, and online marketing for years now.  Sadly, it is necessary for businesses to seek out the likes, and thumbs ups, shares, subscribes, stars or whatever other rating system is out there just to keep up. Enter content marketing as an antidote to chasing likes online. The idea of content marketing as I understand it is this. A business and professionals in business can earn credibility and trust through online content in the form of blog posts, videos, pictures, and websites that establishes authority and expertise within a certain field. Trust is then developed with a potential new client, customer, or a patient online well before any face-to-face meeting or phone call to that business or professional. If I am a plumber, for instance, I can make videos and post them online that show you how to troubleshoot a clogged drain. Not only am I being helpful to you when your drain is clogged, but you may end up calling me to help when it is beyond the simple do it yourself fix. We can apply the same idea to our medical practices, at least that was my thought when I got the idea for this podcast as well as other forms of online content creation. In this episode I share 5 principles that I think are important when we think about how to create online content marketing.  Here are the five principles: Share information and solve problems Tell a story Choose one form of content as the foundation Reimagine content Keep a schedule Connect with me at whyurologypodcast.com.

Medical education, we are told, that is aimed at our patients should be written at a sixth-grade level if we want to have a majority of our patients understand what we are trying to tell them. Many, many people do not read or understand material aimed higher than a sixth-grade level, nor do they want or have time to, so to capture our patient's attention and ability to understand we should aim no higher. I have heard this advice many times but, to be honest, I never knew what that meant, to write at a certain grade level, nor how to achieve it. What does it mean to read and write at the sixth-grade level? There are a number of ways to determine what grade level a certain piece of writing is. I am going to highlight two of them. Most of the ways to calculate the reading level is to calculate based on sentence length, word complexity, and paragraph length. THE ADRENAL GLAND The adrenal glands are hormone producing glands. You have two adrenal glands, one on each side of the body above each kidney. The adrenal glands are about two inches long, and inch wide and half an inch thick. The glands are a deep yellow color. The adrenal glands are surrounded fat which also surrounds the kidneys. A thin layer of fat separates the adrenal glands from the kidneys. Each adrenal gland is made up of two parts, an outer layer called the cortex, and an inner core called the medulla. The adrenal glands produce several different hormones. Adrenaline is made by the inner portion of the adrenal gland. Adrenaline is released during times of stress. During times of danger adrenaline increases blood pressure and heart rate, breathing and causes your blood vessels to narrow as a way to prepare your body to either run away from the danger or to stay and fight. The adrenal cortex has three layers. Each layer makes its own hormone. The first layer of the adrenal cortex produces a hormone called aldosterone that helps regulate of blood pressure and salt levels in the body. The second layer of the adrenal cortex makes a hormone called cortisol that helps regulate metabolism and the immune system. The innermost layer of the cortex makes a hormone that gets converted to sex hormones in other parts of the body. The adrenal gland can be seen on CT and MRI scans. A mass or tumor as an incidental finding can be seen in up to 3-5% of CT scans. Many of those unexpected small tumors are not functional and do not need to be treated. There are a number of diseases involve dysfunction of the adrenal gland. Insufficient production of adrenal hormones is called Addison's disease. Symptoms of Addison's disease include hyperpigmentation of the skin, sudden pain in the legs, lower back, or abdomen, vomiting and diarrhea, low blood pressure, low blood sugar, tiredness, confusion, low salt levels in the blood and fever. A famous patient who suffered from Addison's disease was the late President John F. Kennedy. Overproduction of cortisol within the body or taking prednisone for a long period of time leads to Cushing's syndrome. Cushing's syndrome produces a wide variety of signs and symptoms which include obesity, diabetes, increased blood pressure, excessive body hair, poor bone health, depression, and stretch marks in the skin. A variety of non-cancerous tumors are found in the adrenal gland and are commonly found on x-rays. The most common finding is a tumor that does not produce any hormones. A common functioning tumor that produces too much aldosterone is called a hyperaldosteronoma, which causes abnormalities of blood pressure and salt levels in the blood. A tumor that produces too much adrenaline is called a pheochromocytoma. Common signs of a pheochromocytoma include a sudden high blood pressure, sweating and a rapid heart rate. Cancer of the adrenal gland is uncommon.

In this episode I answer the ten question about Nesbit Plication, as surgery used to treat curvature of the erect penis caused by Peyronie's Disease. We first discussed Peyronie's Disease in episode 72 of this podcast. Question #1. Doctor, what is my diagnosis? Can you describe it? Peyronie's disease is a scarring process of the penis that creates a classic triad of symptoms: curvature, pain, and palpable deformity on the penis. It can also create erectile dysfunction.  Its incidence is estimated at around 1 in 10 men. Peyronie's disease can affect a man's penis with severe symptoms of pain or curvature with erection that affects his ability to be sexually active. Most men have mild to moderate symptoms that may hinder, but not prohibit, sexual activity. Why does the penis bend?  The curvature of the penis is due to the fact that scar tissue does not stretch as well as normal tissue, so with erection that area of the penis does not expand with the blood filling the corpora. The penis is then pulled towards the scar tissue. Most men will have a bend upward. Peyronie's disease usually presents as a rather sudden onset of pain and curvature during erection that, like any scar tissue, changes over time.  We usually think about Peyronie's having two phases, the active and the stable phase What we call the active phase of Peyronie's, the sudden onset of symptoms and the changing curve afterwards, may last up to 18 months or more as the scarring continues to change the shape, size, and curve of an erection. The stable phase of Peyronie's disease is when the scarring has stopped shaping the penis and a man is left with a stable, unchanging deformity that no longer is painful. Determining the phase of Peyronie's Disease is critical prior to a surgery. Surgery on the penis to correct its shape or curvature can be considered when a patient has reached the stable phase of erectile dysfunction, when there is a stable curvature--no pain, no progression. Question #2: What is the procedure you are recommending? Describe the procedure. The Nesbit plication “tucks” or plicates the tunica albuginea of the penis on the side opposite of the curvature. Think about putting a pleat in a pair of pants or alternatively altering a suit. The surgeon can simply place a suture in the tunica to pull it together, like a pleat or alternatively, the plication procedure can remove a piece of the tunica and sew the edges back together, like fitting a suit. The plication pulls the penis back to straight equal and opposite to the formed Peyronie's plaque. The procedure is done as an outpatient, in the hospital or surgery center, under general or spinal anesthesia. While a patient is asleep the surgeon exposes the tunica albuginea of the penis, creates an artificial erection to expose and measure the curvature, places the appropriate suture to correct the curvature, and then closes and bandages the incision. The man then wakes up and goes to the recovery area to prepare for going home the same day. Question #3: What are the goals and benefits and what can I expect to gain from this procedure? The goal is to create a straight and firm penis for sexual activity. The goal is not a cosmetic result. This is important. Many men are concerned about and how their erection looks, but it's the function that the surgeon cares about. A man with a small curve of the penis that does not inhibit sexual activity should not be considering this procedure. Question #4: What are the risks?   As with any surgical procedure bleeding, infection, and anesthetic risks exist but there are three unique risks to this procedure that should be discussed: failure to correct the curvature, penile shortening and subsequent erectile dysfunction. Failure to correct the curvature can happen when the artificial erection created intraoperatively doesn't simulate the actual erection a man gets during normal sexual activity.  Subsequently, there is potential for over-correction or under-correction of the curvature or failure to identify a secondary curve. Fortunately most all men have a very good result from this procedure. Erectile Dysfunction can also occur. The tunica albuginea of the penis is the part of the penis that gets firm during an erection. The tunica is responsible for the trapping of the blood. Peyronie's can affect the ability of the penis to trap blood but so can sutures placed into the tunica result in erectile dysfunction. Finally let's discuss penile shortening can occur as well.  The peyronie's disease limits the stretch to the penis on the one side of the penis. By tucking or plicating the side opposite we have effectively shortened the overall length of the penis. This is a major potential drawback to the procedure. Alternative procedures exist that can maintain length, but are more complicated and carry greater risk. Question #5: Are there alternative procedures?  Yes, there are alternatives to a Nesbit plication: Xiaflex injections, traction therapy, excision and grafting techniques, and penile prostheses. Question #6: Is this a common procedure? The Nesbit plication is a common  procedure. Question #7: Why now? Can I wait to have this procedure? Timing of a Nesbit plication is critical.  There are two phases of Peyronie's disease. There is an active phase, usually the first 6 months to 2 years of the problem where a man has ongoing curvature and discomfort. The plaque at this time is evolving and even has some ability for the curvature to correct itself. We do not want to operate in this phase. If we correct curvature in the active phase then the penis may develop more deformity after the surgery. In the second phase of Peyronie's the scarring is what we call “stable” and there is no further curve or deformity developing within the penis. A man should wait to have surgery until he knows the curve is stable. Question #8: How do I prepare for this procedure? There is no special preparation for this procedure. Get preoperative clearance by your primary care physician for the anesthesia. Stop blood thinning medication at an appropriate time before surgery. Follow your surgery center guidelines for NPO status. Get to the surgery center on time. Have plans for your care after and for going home on the same day of your procedure. Question #9: How do I recover from this procedure?  Recovery from this procedure takes a full six weeks before you are allowed to be sexually active. This is probably the most important part of this procedure. Resuming sexual activity too early can cause disruption of the suture line resulting in failure of the procedure. The initial phase of recovery takes a full two weeks. There will be some pain, especially with erection. Swelling and bruising are common and begin to resolve in 7-10 days. Ice packs can help reduce swelling. You will be able to shower. The incision line needs minimal dressing with antibiotic ointment. There are no dietary restrictions. You will most likely be able to stay on or resume all medication as prior to surgery, including any blood thinners. Most men can go back to light activity right away, taking care to protect the penis during physical activity, and resume heavier physical activity within a week or two. Your individual surgeon and postoperative needs will determine your postoperative care. Question #10: How do I pay for this procedure? Is it covered by insurance? Most insurance carriers will cover this procedure. Some do not. As with any procedure verify your coverage prior to your operation. Your insurance carrier will want to know the specifics of what the procedure is, who is performing it, where, and on what date.  Insurance companies like to authorize a specific event for surgery, not just a general procedure type.  

This is episode number 104 of this podcast that I started as a personal exploration into podcasting, the field of urology, and how we can combine the two to educate a general listening audience about different topics in urology.   Today's topic is bladder cancer, and I want to focus specifically on a procedure that is the first step for most patients in their bladder cancer journey after they are diagnosed with a suspicious bladder tumor, the transurethral resection of bladder tumor or TURBT.   The format of this episode is to walk through the ten questions to ask your surgeon about any surgery or procedure and to apply it to the transurethral resection of bladder tumor.   The ten questions is a set of questions that I have come up with that I think can apply to any surgical procedure. It is meant to be a general framework for discussing any surgery or procedure with your surgeon.  You can hear that episode of this podcast at  https://whyurologypodcast.com/ten-questions-to-ask-your-surgeon-before-an-operation-ep-97

In this episode I discuss the HOLEP (Holmium Laser Enucleation of the Prostate) with Dr. Andrew Bergersen.  The HOLEP procedures is used for men with very large, obstructive prostates causing urinary symptoms. You can find Dr. Bergersen at https://mnurology.com/physicians/andrew-bergersen/  Connect with me at  www.whyurologypodcast.com  

In this episode I interview medical student, Parker Adams. Parker is in his final year of medical school and applying for a urology residency training program. His match day for Urology this year is Feb 1st. Parker is also a podcaster. His podcast, Rod Squad, is aimed at medical students learning urology. Find his podcast at rodsquadpod.com Parker is passionate about using technology to improve medical and patient education. You can find me at whyurologypodcast.com

Welcome to the Why Urology Podcast. This is episode number 101, an interview with Dr. Alex Tatem about shock wave therapy (SWT) for treating men with erectile dysfunction. Shock wave therapy is a developing technology within the field of urology, a technology not universally endorsed, encouraged, or employed in urologic practices today. Dr Tatem is a urologist in Indianapolis Indiana specializing in men's health with a special knowledge about using shock wave treatment who uses it within his own practice.   Dr Tatem is also content creator, posting videos on YouTube and Vidscrip for patient education. Whenever I want to see what I should be doing on YouTube, I take a peek at Dr. Tatem's videos. I was doing this recently and I came across his video on using shock wave therapy for erectile dysfunction. I was immediately interested because this is a controversial technology within the field of urology and I was interested to see what Dr. Tatem had to say. I was impressed, not only with the quality of video, but with the depth and honesty of his presentation. https://www.youtube.com/watch?v=DS1XqgLHOvc If you are a man with erectile dysfunction considering shock wave treatment, I would encourage you to listen to this podcast or watch his video.  You will not only learn about shock wave treatments for erectile dysfunction but you will hear or see how a young, innovative physician employs a new, maybe unproven technology in his practice with the highest possible standards of care. This was a long conversation between Dr. Tatem and I and, even edited, it's a long interview. I chose to keep it long because there is such good content I did not want to cut out too much of it simply for the sake of time. Here are the takeaway points from this interview: Shock wave therapy is an easy to apply in office treatment being used to treat men with erectile dysfunction. Shock Wave Treatment will give the best results to men with mild to moderate ED. Long term benefits of Shock Wave Treatment are still being studied. There are different kinds of shock wave machines on the market, so buyer beware regarding what type of shock wave is being delivered to the penis. As of this date, the end of December 2020, there is only one shock wave machine on the market in the U.S. that delivers that kind of penetrating shock necessary to get the results equivalent to the medical research. The Storz Duolith SD1: https://www.storzmedical.com/en/disciplines/urology/product-overview/duolith-sd1-ultra-uro.html Thank you for listening to my interview with Dr Alex Tatem. I you have questions, thoughts or concerns please reach out to me. www.whyurologypodcast.com.  

Thank you for listening to this episode of the Why Urology Podcast. This is episode number 100, a milestone in my podcasting journey. This podcast started with a single question, “Why Urology?” In this podcast episode, at the very end, I give you the answer. Just a heads up this episode is the last episode for 2020. I am taking a break for the holiday season and to do some planning for next year. I will put an episode out if I feel so inspired before January, but don't count on it. If you want to take the time to listen to any of the old episodes of this podcast please go to whyurologypodcast.com. On this episode I have a special guest, my girlfriend Susan who has been a key player in this podcast for many of the 100 episodes. I couldn't have gotten to 100 without her help. A couple of months ago I had commented to her that I would be hitting 100 episodes sometime before the end of the year and I was starting to wonder if I should make it a thing. Her reply was a pleasant surprise. “I am going to be your 100th episode,” she said. On a cool Sunday morning here in Minnesota, with the kids still asleep and a freshly brewed pot of pumpkin spice coffee, we cleared a spot on a table in her basement where I set up a couple of microphones and hit the record button.   Her idea was that she would interview me, a transfer of host duties from me to her, about my podcast journey. You will hear that our interview starts that way, but I can't help myself and I begin to ask her about her job in surgical nursing before we swing around to podcasting again at the end. A surgical nurse is just one of the many people who play a critical role in keeping a patient safe as they go through their journey from diagnosis to treatment. There's a lot to unpack in that conversation and I hope you enjoy it. What struck me about this conversation was my dependence on so many others in my personal and professional life who help me actually be a urologist.  The list is very long, too long to get it all correct.  I can diagnose your prostate cancer and take your prostate out robotically. But that is the end of a long chain of people and events that help you and I get there safely and with the opportunity to create the best possible outcome. To steal a line from the Beatles, we get by with a little help from our friends. So, this is a special thanks my friends and to those of you who help me on a daily basis take care of my patients. I can't do it alone. You are needed. You are appreciated. Thank you.

Kidney cancer is most commonly a Renal cell carcinoma (RCC). Renal Cell Carcinoma, with its various subtypes, will be diagnosed in an estimated 73,750 adults (45,520 men and 28,230 women) in the United States this year. Kidney cancer is the sixth most common cancer for men, and it is the eighth most common cancer for women. A Renal Cell Carcinoma begins in what I call the meaty portion of the kidney, the renal parenchyma. It grows slowly most of the time, forming a mass somewhere in the kidney. If the mass is less than 7 cm and there is no spread to lymph nodes or distant organs it is a stage 1 tumor. If it is larger than 7 cm, but still no spread, it becomes a stage 2 tumor. Treatment for a Renal Cell Carcinoma, when it is large enough, approaching 2 cm or greater is to either remove or ablate the tumor. If possible, we can remove to tumor from the rest of the kidney leaving a large portion of the kidney intact and functional. A stage 3 tumor is one of several subtypes.  It can invade into the fat around the kidney, called Gerota's fascia, or into nearby lymph nodes, or, somewhat unique to kidney cancer, RCC has the ability to locally invade  the veins of the kidney with tumor thrombus that can propagate distally from the segmental renal veins to the main renal vein,  then into inferior vena cava (IVC) and all the way up to the heart into the right atrium. Around 5 % of cases of RCC are reported to have some level of venous invasion, most commonly into the segmental renal veins still within the kidney. Medicine, they say, is both an art and a science. The science part slowly removes the veil of mystery about disease. And once the mystery is gone, the art of medicine is at risk of fading in the background. It's a tug of war, and science is always winning. Because science is so powerful, there is a constant effort within medical education to make sure we are accepting and training young physicians who are caring, kind, and compassionate to balance the science with the art of medicine. It is a worthy goal. In this episode I tell you how poetry can help.

The idea of a keystone habit I think is attributed to Charles Duhigg in a book called, The Power of Habit. As I understand the concept, a keystone habit is a habit that leads to multiple other behaviors, and positive outcomes in your life. A keystone habit sparks a chain reaction. When you focus on, when you become intentional about, building keystone habits those few habits that will have a ripple effect. The Four Habits Model are four simple keystone habits a doctor can employ during a clinic visit to improve communication, outcomes and patient satisfaction. The Four Habits are invest in the beginning, elicit the patient's perspective, show empathy and invest in the end. Identifying and being intentional about developing these keystone habits can have a major impact in the lives of our patients. Here is the Wikipedia link to Aequanimitas https://en.wikipedia.org/wiki/Aequanimitas You can find more information about the Four Habits Model at http://www.thepermanentejournal.org/files/Fall1999/habits.pdf  

Consider this a top ten list of things to ask your doctor about your upcoming surgery or procedure. 1. What is my diagnosis? 2. What is the name of the procedure you are recommending? 3. What are the goals and benefits and what can I expect to gain from this procedure? 4. What are the risks? 5. Are there alternative procedures that I should be considering? 6. Is this a common procedure? It is a procedure you commonly perform? 7. Why now? What happens if I wait? 8. How do I prepare for the procedure? 9. How do I recover from the procedure? 10. How do I pay for this procedure? Is the procedure covered by insurance? Thank you for listening. You can connect with me at whyurologypodcast.com

The ureter is the long thin little muscular structure that transports urine from the kidneys to the bladder. The ureter is a relatively small player in the urinary system but a very important one. It doesn't get talked about enough because it is often thought of as just a transport tube from the kidneys, the star of the show where the urine is made, to the bladder, the supporting actor, where the urine is stored. What is most striking to me as a surgeon is how delicate the ureter is to have such a critical function to getting waste products out of the body, , how small it is and occasionally hard to identify within the body, how easily it can be injured during an operation, and how delicate we have to be when we operate. There's a lot relying on these little guys to do their job. The ureters are long, usually 20–30 cm (8-12 inches) long and around 3–4 mm (1/8 to ¼ inch American) in diameter. From the renal pelvis, they descend on top of the psoas major muscle to reach the brim of the pelvis. Then they cross in front of the common iliac arteries down along the sides of the pelvis, and finally curve forward and enter the bladder at the back of the bladder, tunneling through the bladder wall before opening into the bladder on its back surface at the level of the trigone of the bladder at small openings called the ureteral orifices. The inner lumen of the ureter is lined by transitional cells, the same type of cells that lines the urinary bladder. The transitional cell urothelium stretches in the ureters, appearing as a layer of column-shaped cells when relaxed, and of flatter cells when stretched and distended. Below the epithelium sits the lamina propria, a connective tissue layer with many elastic fibers, blood vessels, veins and lymphatic channels. The ureter's outer layers are two muscular layers, an inner longitudinal layer of muscle, and an outer circular or spiral layer of muscle. The lower third of the ureter has a third muscular layer. Because of it's length along the body the ureter's blood supply (arteries and veins), lymphatic drainage and nerve innervation come from many different sources at the levels along it's path. The ureters can be affected by a number of diseases.   Kidney stones are the most common problem. The ureters are so narrow it doesn't take a very big stone to get stuck in the middle. Stones even as small as 1-2 mm may get stuck in the ureter (although some ureters can pass stones as large as a centimeter). When the stone gets stuck the urine cannot pass. The urine backing up stretches the ureter and renal pelvis behind it causing hydronephrosis or hydroureteronephrosis. The muscular renal pelvis and ureter try to push the urine out with peristaltic waves of muscular contraction. The pressure buildup and stretch receptors in the renal pelvis and ureter cause pain. The pain often comes in waves and is referred to as renal colic. Because the nerve innervation comes from several levels along the course of the ureter the pain can be felt sometimes in the back, sometimes in the flank, or sometimes radiating around to the front lower abdomen and down into the testicle, scrotum or labia. To get a stone that is stuck in the ureter out of the body often requires a scope procedure called ureteroscopy to look into the ureter and pull out the stone and/or to break it up using a holmium laser. The ureter can also be blocked by obstruction. Obstruction of the ureter can occur intrinsically, as a result of narrowing within the ureter, or extrinsically, compression or fibrosis of structures around the ureter pushing on the ureter to narrow it. Intrinsic blockage can come from strictures, congenital or acquired, and ureteropelvic junction obstruction from abnormal development at that junction or from obstructive ureteroceles. Extrinsic compression can come from cancer, endometriosis, tuberculosis and schistosomiasis, and retroperitoneal fibrosis. A narrowed ureter leads to hydronephrosis and hydroureteronephrosis similar to a kidney stone but it does not always lead to pain because the conditions are usually more chronic. Other symptoms may be blood in the urine, infection, or a loss of kidney function. Often the condition is found incidentally, when an x-ray, ultrasound or CT scan is done for another condition. Treatment of any of these obstructions may involve treatment of the underlying conditions as well as ureteral stenting or nephrostomy tube, ureterolysis in the case of retroperitoneal fibrosis, or reinserting the ureters into a new place on the bladder called reimplantation.  Another class of ureteral problem is congenital abnormalities that affect the ureters, which can include the development of two ureters on the same side with subsequent obstruction and/or reflux, or abnormally placed ureters, called the ectopic ureter. Variants of ureteral anatomy such as duplication occur when the ureteric bud, an outpouching from the mesonephric duct, which forms the ureter, develops abnormally, sometimes duplicating completely or incompletely or budding from an abnormal position so the ureter drains not on the trigone of the bladder but higher or lower in the bladder, in the prostate, urethra or vagina. Congenital abnormalities can present with a number of symptoms and may need to be treated very early in life in some cases. Another condition commonly seen in children is vesicoureteral reflux. Reflux is when urine is pushed back into the ureter during urination. In the normal situation the ureter tunneling through the bladder creates an area of the ureter that prevents urine from going back into the ureter during urination. Many children with this vesicoureteral reflux have the reflux resolve as the bladder develops through childhood. The amount of reflux can be mild, going just to the end of the ureter, or severe, going to the renal pelvis and dilating the system from the backflow. Symptoms are most commonly recurrent infections. Occasionally surgery is needed to reimplant the ureter and correct the reflux. Lastly, I would like to mention ureteral cancer. Ureteral cancer is most often cancer of the cells lining the ureter, the transitional cells, and is called transitional cell carcinoma This is a similar cancer to most bladder cancers. Bladder cancers are more common that ureteral or renal pelvic tumors, but the risk factors are largely the same, including smoking and exposure to dyes such as aromatic amines and aldehydes. The most common symptom is blood in the urine. Diagnosis is made radiographically and through visual inspection called ureteroscopy. Treatment most often requires removal of the entire ureter, renal pelvis, and kidney on that side. For more information on that you can listen to the last episode of this podcast, an interview I had with Dr Mikhail Regelman about a procedure called nephroureterectomy. Find more episodes and connect with me at whyurologypodcast.com.  

Transitional Cell Cancer forms in the renal pelvis and ureter as well as in the bladder. In this episode Dr. Mikhail Regelman and I discuss how we diagnose and treat this disease 

This episode is about how, as we make choices in life, we often have to choose between two equally attractive paths with incomplete information and uncertain outcomes. Career choices are like that; life choices are like that. And often the choices feel limiting, like we are boxing ourselves in, closing off opportunities for our future selves. “Two roads diverged in a yellow wood/And sorry I could not travel both,” wrote the late poet Robert Frost in his poem, The Road Not Taken. But life's a marathon, not a sprint. We have long careers and long lives. There may be several segments to our careers, so we don't have to do everything all at once. We can, make small iterative changes. We can experiment, test, and correct course. We can focus on developing your abilities in the direction of your talents. We can stop worrying about winning awards or being high profile and instead focus on being so good we can't be ignored. Finally, we can remember to have fun. Life is short, after all. If it's not fun, why do it?        

What is success? What does a successful life look like? What does it mean to be a success? For too many urologists including myself the primary way we measure our lives as successful is through the building of a large and lucrative practice.  For the record, I believe these are important things to measure. A medical practice is after all a business and we must always pay attention to the bottom line. Ultimately, it's not about how many patients did you see, but about how many patients received excellent medical care. In 1889, William Osler called the “Father of Modern Medicine”, who would himself become a world-famous physician and educator by working long days and nights, had this to say to graduating medical students at the University of Pennsylvania in his most famous Speech “Aequanimitas.” Remember, this was in 1889… “…I would warn you against the trials of the day soon to come to some of you—the day of large and successful practice. Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.” There is a book I read by an author called Cal Newport. The title of the book is “so good they can't ignore you.” The book is about how to build a career that you love through skill development, not  by pursuing of a “passion.” The title comes from a Steve Martin quote. Here is his simple message. Focus on being good. Really good. Undeniably good. The rest will probably follow. The successful physicians, the ones I look up to, seem to be able to juggle the demands of being both “good” and “busy”. They possess that certain “Aequanimitas” that William Osler describes in his famous speech. They have developed skills through years of deliberate practice that allow them to be efficient and effective. They do not forget what makes life worth living. Here is a poem written in 1904 by Bessie Stanley of Lincoln Kansas as an entry into a magazine contest. The requirement of the contest was to define success in 100 words or less.   He achieved success who has lived well, laughed often, and loved much; Who has enjoyed the trust of pure women, the respect of intelligent men and the love of little children; Who has filled his niche and accomplished his task; Who has never lacked appreciation of Earth's beauty or failed to express it; Who has left the world better than he found it, Whether an improved poppy, a perfect poem, or a rescued soul; Who has always looked for the best in others and given them the best he had; Whose life was an inspiration; Whose memory a benediction    

I have spent half of my life as a physician, beginning as an intern just before my 26th birthday. It began in an inauspicious start on July 1st as an intern at the VA hospital. On our first day we spent most of the day in orientation, but at the end of the day I reported to my assigned general surgery team, currently on rotation at the VA hospital and doing afternoon rounds. When I arrived, I was informed I would be taking call that night, was shown to my call room at the end of rounds, and was given a few basic orientation tips. I will never forget being handed the “code” pager for the first time. The chief resident explained to me that carrying the code pager as a surgery resident wasn't a big deal. Be professional; be prompt; stay relaxed; work with the team; do your job. Basically, he said, you have to run to the code blue, announce that “surgery” was there. Surgery's responsibility was to make sure tube and lines, things like IV access were present and functioning well and, if needed, to perform whatever bedside procedures needed to be done.   I nodded my head and said goodbye for the night to my fellow residents and medical students. No sooner had I sat on the bed in the call room than the pager went off for a code blue. Code Blue. Intensive Care Unit. Room 9. Up I jumped, and made my way quickly to the intensive care room 9. There I found a number of doctors and nurses already gathered around a patient and performing CPR and delivering medication. This ICU patient had plenty of tubes and IVs but I was there and I thought I should let people know just in case. “Surgery is here!” I said as I entered the room. “What?!” said the nurse standing at the bedside, “Who are you kidding? Get out of here!” I took a look around the room, decided that surgery was not needed during this particular code blue, and slowly backed out of room 9 in the ICU and back to my call room. Such began my life as a physician. I learned two things that night You are not as important as you might think. Be professional; be prompt; stay relaxed; work with the team; do your job. And there are many days where I feel about as relevant as I did that night. But, like Sysiphus, I keep pushing my rock up the hill. And I have been doing so over the last 26 years. Enter 2020 and the abrupt halt to what I have come to know over the last half of my life. Clinics and surgeries cancelled, telehealth and video visits replacing in person interaction, time spent at home in isolation, wearing a mask not only the OR but many other places as well. Our practice faced the challenge head on, adopting telemedicine quickly, shutting down clinics and cancelling unnecessary surgery in preparation for the COVID-19 surge. Our changes felt and still feel like the right answer. We were ahead of the curve, if only slightly, still we were ahead. At first it was a break. An unwelcome break, but a break nonetheless. I vowed to take the time for personal development, hoped to make a few podcasts and videos, and, to be honest, did not expect our hiatus to last too terribly long. My positivity waned a bit after a few weeks as I personally began to feel more and more distanced from my family, my friends, and actually more concerning for me, my work. Without patient interaction, without the ability to touch people, either with a handshake or a scalpel, the practice of urology just isn't as fun…at least for me. But it's summer, which has always allowed me one of my life's simplest pleasures. I live on and grew up on body of water called the St. Croix River, on section of the river called the Lake St Croix because it widens into an area that is the size of a very large lake. The river is designated as a National Scenic Riverway, and it is fantastic in the summer.   A near nightly ritual for me in the summer is to put on a bathing suit at the end of the day and wash away the cares of the day with a dip in the water. This is not a workout.  I usually have a beer in hand. Think of this almost as a nightly baptism, and I emerge refreshed. I often think about a quote from an ancient philosopher as I go on my nightly swims. "A man cannot jump into the same river twice. It is not the same river, and he is not the same man." I am old enough now to know, and feel, that as I approach the river each night both the river and I have changed, if ever so slightly. The quote comes from Heraclitus who lived around 500 B.C. in the city of Ephesus, in modern-day Turkey and then part of the Persian Empire. His philosophy was characterized by Panta rhei or impermanence. He was most famous for his insistence on ever-present change, or flux or becoming. He wrote a single work, On Nature, which remains only in fragments. He was called “The Obscure” because he spoke, wrote, and taught in ways difficult to understand. He was also called "The Weeping Philosopher” because he was prone to depression. As we look on the tragedies of men we have a choice if we  want to turn away from anger. We can laugh, or we can cry. Heraclitus apparently chose to cry. Our current state of affairs has been a tragedy on so many levels. Over the last few months I have been angry; I have laughed; and I have cried. Fortunately, we have flattened the curve in Minnesota and we are beginning slowly, at least for the moment, to open back up. Even one of my favorite places, my local public library, is allowing a limited amount of traffic. I went there the other night to pick up some books.  The library was eerily quiet as I walked through the stacks of books. Where once would be families with kids, high school and college students studying, middle aged and elderly people reading magazines or looking for a novel now there was empty chairs and echoes. We are ever so slowly dipping our toe back into the water. But the river has changed; the world has changed; and, of course, we have changed. But what strikes me about it all is that life still feels familiar. As I begin to see patients in the office again, and operate again we know that medicine has changed and will continue to change, but it still feels much the same. People still need their medical care because, well, life is short, and it keeps moving on. Life is short; the art is long is attributed to Hippocrates, who lived 400 BC and is considered the father of Western medicine. Hippocratic medicine was notable for its strict professionalism, discipline, and rigorous practice. Hippocrates recommended that physicians always be clean, honest, calm, understanding, and serious. I suspect he would tell us this whether we were in an operating room, the clinic, or at home on our computers trying to tell patients how to unmute their microphones or maybe they could move the computer a little bit so the camera would show all of their face. Here is my point. I am a bit reflective as I face my 52nd birthday.  Half of my life has been spent as a physician. Which feels appropriate since I only half define who I am as a physician. The other half has been the guy in the swimsuit with the beer in his hand. This Great Reset has come at an interesting time in my life as I ponder the next 26 years, the third half of my life. What will I bring forward? How have I changed? How has the world changed? What is the best response to avoid anger, should I laugh or should I cry? I do not have the answers, by the way, but I continue to explore for the answers. Which brings me to a line I remember reading back in high school, it's from a poem by T.S. Eliot. “We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time.” Each day, whether I return to the clinic, or the river that I have been jumping into since I was a kid I arrive at the place and I know it for the first time.

This episode is another in the long line of podcast episodes I have done about kidney stones. In this episode we are going to talk about a less common form of kidney stone called a cystine stone, and a metabolic disorder called cystinuria. Cystine stones comprise about 1% of all stones in adults and about 6% to 10% of stones in children. Cystinuria is as you would expect by its name is disease that is characterized by high concentrations of cystine in the urine. Because cystine is highly insoluble in urine, frequent kidney stones are the result.  Patients with cystinuria are at risk of forming many, many stones over a lifetime. And the stones begin to form very young in life. Elevated cystine excretion can even be seen in infancy and symptoms of this disorder typically begin between 10 and 30 years of age. The average age at first presentation for cystinuria and kidney stones is around age 12 or 13. Cystinuria is an inherited disease, one is born with it. It's an autosomal recessive genetic mutation, which means that you have to get the gene from both your mother and father. The disorder is relatively uncommon, but far from rare. The disorder occurs in approximately 1 in 7,000 to 1 in 10,000 people in the United States. The prevalence of cystinuria varies in different countries and ethnicities. The Swedes, for instance have a low incidence of 1 in 100,000. Cystinuria affects males and females in equally. There are two gene locations that are involved in creating cystinuria, mutations form in the genes SLC3A1 and SLC7A9, which code for the 2 subunits of a transporter that mediate nearly complete reabsorption of cystine and other dibasic amino acids in the renal proximal tubule and the intestine.  The dibasic amino acids are cystine, ornithine, lysine and arginine (C O L A, cola). In cystinuria all those amino acids can all be found in elevated amounts in the urine. But cystine is the only one that matters to a great deal because it is the one that forms kidney stones. Ornithine, lysine, and arginine are soluble and do not form stones and are merely lost in the urine. Cystinuria was first correctly described in 1908 by Sir Archibald Garrod, describing it along with three other metabolic abnormalities that he classified as inborn errors of metabolism. The tetrad comprises four inherited metabolic diseases: albinism, alkaptonuria, cystinuria, and pentosuria. In any young person with a new diagnosis of kidney stones, cystine stones must be considered. Kidney stones are sent for analysis to determine their composition. Cystinurics tend to form stones that are 100% cystine. Cystine stones may be pink or yellow in color after removal, but later they turn to greenish due to exposure to air. People with cystinuria typically produce jagged stones that are small, though some form very large stones. Stones may be accompanied by urinary “gravel,” which consists of yellowish-brown hexagonal crystals. If a stone cannot be analyzed a suspicion for diagnosis can be made based on other clinical parameters. As I said any young patient presenting with stones should be suspect. The crystals of cystine are easy to distinguish from other crystals in the urine under the microscope. They are hexagonal, translucent, and white. The urine of a cystinuric may be identified by a positive nitroprusside cyanide test. When  urine cystine excretion is greater than 75 mg/L, this spot test will turn the urine purple in  color.  Quantitative testing is then recommended, such as 1) 24hour urine cystine measurement or 2) Random spot urinary cystine, ornithine, arginine, and lysine  excretion normalized by creatinine excretion. Cystine stone show up only faintly on standard xray of the abdomen due to the sulfide group. Calcium based stones show bright white, uric acid stones usually are radiolucent. Cystine stones can be seen with imaging techniques now more common, such as renal ultrasound and CT scans Treatment options for a cystine stone depends on the size of the stone as in any other stone. Small stones may pass spontaneously on their own with high fluid intake and, if needed, pain medications. If spontaneous stone passage is unsuccessful, stones may be removed using one of three options: ureteroscopy or extracorporeal shock wave lithotripsy, leaving  percutaneous nephrolithotomy for the largest of stones. Treatment of a single stone episode is not a cure and the patient with cystinuria must focus on prevention to try to decrease the risk of future stone formation. There are three core principles in the prevention of cystine stones. Hydration Alkalization Medications The first principle is adequate hydration. Crystals precipitate when the concentration of cystine in the urine is above 250 mg/L. The primary objective of treatment for cystinuria is to reduce the cystine concentration in the urine. Consumption of large amounts of fluid–both day and night­–maintains a high volume of urine and reduces cystine concentration in the urine. Reducing the concentration of cystine in the urine which prevents cystine from precipitating from the urine and forming stones. What high fluid intake means in this context is a recommendation of at least 4 liters (roughly 4 quarts) per day. That's essentially a gallon. More is better. The fluids must be spaced out as well, including through the night. It has been said that people with cystinuria must realize that "for them, water is a necessary drug." Secondly, cystine is more soluble in urine that has a higher pH. Cystine precipitates if the urine is neutral or acidic. Making the urine more alkaline (alkalization) with medication such as potassium citrate, sodium bicarbonate and acetazolamide helps cystine to dissolve more readily in the urine. Alkalization is not without risk because a urine with a high pH is at risk of form calcium phosphate stones. A brief mention here that efforts at urinary alkalization can be hampered by diets too high in salt or proteins so cystinurics should try to reduce salt and protein. If hydration and alkalization fail then patients are usually started on chelation therapy.  Chelating drugs containing a thiol group which exchange a disulfide with cystine. The result is the formation of a drug‐cystine complex which is soluble. The orphan drug alpha-mercaptopropionyl glycine, also known as tiopronin (Thiola) has been approved as a treatment for cystinuria. D-penicillamine and captopril have also been used.

Where does a cancer come from? One cell.  Cancer begins with one cell. A normal cell has cell membrane, a cytoplasm with lots of working parts within it, and a central nucleus. The nucleus contains the instructions, the DNA, that tells the cell exactly what it needs to do. A cell has a specific purpose, become a prostate cell for instance or skin or a brain. Our DNA is incredible. Using the nucleobases adenine, cytosine, guanine, and thymine base pair nucleosides of adenine-thymine and cytosine-guanine can be stacked, one on top of another, into chromosomes, long chains of coiled double helix code that is read by the cell as the ultimate instruction manual. The instructions contained within a single cell is more complex than any how-to book you have ever read. The full set of instructions is so long that it would take more than 3,000 books to print all of the instructions assuming that each book would have 1,000 pages. If you could take the DNA out of a single cell and stretch it into a line, it would be more than six feet long. To grow a prostate or skin or a brain, a cell must replicate itself over and over. Cell division and replication happens in a process called mitosis. During mitosis a cell's DNA needs to be replicated exactly to form a duplicate cell. One cell into two, two into four, four into eight and so on. The cells must then all work together to create a prostate or skin or a brain. Here is the origin of a potential cancerous cell. Any loss of integrity to the DNA causes the entire cell to be dysfunctional, either completely or partially. The new imperfect DNA contains an imperfect set of instructions. Most often the mutation will be fatal to the cell. That cell dies. No big deal. nfrequently, a mutation will form a non-lethal cell change and the abnormal cell will not follow the normal growth pattern. A cell that continues to grow and does not get the appropriate instructions for growth eventually becomes a problem. It continues to grow and divide, replicating its own DNA. One to two, two to four, four to eight and so on until there is a mass of cells, a tumor, that is not following normal instructions. An individual cancer cell, depending on the type of mutation within it, will have its own unique growth pattern. When we look at a cancer cell under the microscope we can predict how aggressively it will behave by how undifferentiated the cell is. Each cancer has its own grading system. Cancers start within one organ. Prostate cancer starts in the prostate cells, breast cancer from the breast, skin cancer in the skin, and colon cancer in the colon. Then it spreads to other parts of the body. Cancers metastasize. Cancers spread in one of two ways They grow 1. by local spread and 2. By distant spread, travelling hematogenously (through the blood) or lymphatically (through the lymph system). A metastatic cancer is one that has spread to other organs through either local invasion or through the blood or lymph. A cancers stage is often classified in a staging system we call TNM. T, tumor. What is the tumor doing? Is it confined to the organ or has it advanced locally? N, lymph nodes. Are there any swollen lymph nodes that would indicate that a cancer has spread to the lymph system. M, metastases. Is there evidence of cancer in other parts of the body? TNM each are given a number. An overall stage is often a number as well and is a consolidation of the TNM classification. How does a cancer do this, grow such that the body doesn't fight it off? Your body often does not recognize the cancerous cell as abnormal, or just downright turns its head away and ignores it until its too late.  Our immune system detects and kills bad stuff through a complex interplay of B cells, T cell, Natural killer cells, humoral immunity and cellular immunity working together to detect the abnormal and destroy it. The body has the ability to detect self from non-self. Our bodies tissues have normal markers on the cell surface that tell our immune system, “hey, we are one of the good guys.” Cancer cells evade the normal immune signals that would otherwise find and destroy it. They confuse it, or exhaust it, or disrupt it. And the cancer cells grow, spread and destroy. We must get rid of it to survive.  

80% of all kidney stones are calcium-based stones, mostly calcium combining with oxalate or phosphate to make calcium oxalate or calcium phosphate stones. This episode is about another kind of kidney stone mineral called uric acid. Uric acid stones makeup about 15 % of all kidney stones.  Calcium based stone and uric acid stones make up the vast majority of stones that we treat. What I want to do for the this episode is highlight 5 areas where uric acid stones differ from calcium based kidney stones in diagnosis, treatment and prevention. If you want to hear all of the episodes on kidney stones there is a link in the show notes to the category list of kidney stones on the website at whyurologypodcast.com. http://whyurologypodcast.com/category/Kidney+Stone  

May 31 is world no tobacco day sponsored yearly, since 1987 by the Member States of the World Health Organization. World No Tobacco Day every year informs the public on the dangers of using tobacco, the business practices of tobacco companies, what the world Health organization is doing to fight the tobacco epidemic, and what people around the world can do to claim their right to health and healthy living and to protect future generations. This year's theme is prevention of smoking by our youth and awareness of how tobacco companies market to younger generations. This year, the World Health Organization is encouraging efforts that empower young people to stand up to big tobacco companies by resisting their ads and marketing and refusing to use any tobacco or nicotine products including e-cigarettes and other vaping devices. Here are 5 reasons your urologist may tell you not to smoke according to the Urology Care Foundation:   Bladder Cancer: May is bladder cancer awareness month. This year over 80,000 will be told they have bladder cancer. Smoking causes harmful chemicals to collect in the urine. These chemicals affect the lining of the bladder and significantly raise your bladder cancer risk.  Erectile Dysfunction impacts 20-30 million American men. Erectile Dysfunction is most commonly a result of poor blood flow to the penis. Smoking harms blood vessels, mostly arterial health, which impacts the blood flow to the penis with the result in not being able to get or keep an erection firm enough for sexual intercourse. Kidney Cancer. Kidney Cancer is in the top ten most common cancers for men and women, combining for more than 70,000 cases of kidney cancer expected this year. When smoking, carcinogens are drawn into the lungs and then into the bloodstream where they are filtered by the kidneys. The harmful chemicals increase your risk of getting kidney cancer. Incontinence, urine leaking, and Overactive Bladder (OAB), impact more than 33 million men and women. The chemicals from smoking and vaping bother the bladder and can contribute frequent urination. Smoking can also cause coughing spasms that can lead to urine leakage. Smoking can harm the eggs in the female and sperm in the male. The infertility rate for smokers is twice the rates for those who do not smoke.  You don't have to do it alone. Your family, your friends, and your doctors will help you. Get ready.  Set a date to quit. Get support and seek help. The national tobacco quit line: 1-800-QUIT NOW (1-800-784-8669). Free smartphone and tablet apps are available. Try the National Cancer Institute's QuitPal. Websiters such as Smokefree.gov offers a ton of support and resources including a text messaging program called SmokefreeTXT.