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Overview

The future of health care is moving toward specialization driven by the fact that medical science is advancing rapidly and becoming increasingly complex. As a result, new therapies are being developed and introduced into the medical marketplace at an accelerating rate. Effectively delivering these therapies require extensively trained professionals employing complex technology. UANT's approach to this trend has been to develop "Centers of Excellence" where our physicians narrow their focus and limit their practice to a particular urologic subspecialty and perform a large volume of only a few types of surgical procedures in facilities with the latest diagnostic and therapeutic technology. This "focused factory" approach leads to more experienced physicians performing more procedures with better equipment resulting in better outcomes for our patients.

John House, MD, Managing Partner, UANT

Urology Associates of North Texas (UANT), with 50 physicians in 20 locations throughout the Dallas/Ft Worth metroplex, is one of the nation's largest physician groups specializing in urology and urologic surgery. UANT has applied the concept of specialization by developing "Centers of Excellence" in every urologic subspecialty including

An example of how UANT has applied the concept of specialization to the field of urologic surgery is the development of the "North Texas Center for Robotic and Laparoscopic Surgery" headed by Dr Justin Lee. The program was started at USMD Hospital-Arlington in 2003 as the first Robotic-Assisted Laparoscopic Surgery program in North Texas.

With the referral and financial support of our group, this "Center of Excellence" has performed over 1500 procedures and has grown to become the 3rd largest robotics program in the world with 6 very experienced surgeons, 2 da Vinci Robots and its own fellowship training program.

John House, MD, Managing Partner, UANT

Another example of UANT's commitment to excellence through specialization is the "North Texas Center for Cryosurgery". Initiated by Dr David Ellis in 2000, this "Center of Excellence" has the distinction of now being the largest cryosurgery program in the world. Dr Ellis and his team of experienced cryosurgeons are recognized by their peers as "World Class" clinicians as evidenced by their widely published results and their commitment to training physicians world wide.

Our cryosurgery and robotics program have proven the concept that "practice makes perfect". These success stories only deepen UANT's commitment to further specialization in every field of urology and urologic surgery. Ultimately, our hope is to fulfill our mission and deliver "World Class" specialized urologic care to the patients of North Texas and beyond.

John House, MD, Managing Partner, UANT

A commitment to excellence through specialization is the "UANT Difference". This "difference" is that unlike the traditional urology practice where each physician attempts to provide a full range of subspecialty services, UANT makes it possible to have the full range of subspecialty services provided by a full range of better trained and more experienced sub specialists. We believe that this approach will ultimately lead to better outcomes, better patient satisfaction and better patient care.

We encourage you to review our Centers of Excellence to learn more about specific conditions and treatments. If you have questions, please call us at 817 784-UANT (8268).

General Urology

Urology is the medical specialty concerned with diseases of the urinary tract in men and women, and diseases of the genital tract in men. There are about 9,500 practicing urologists in the United States. The typical education track for a urologist is 4 years of medical school, 1 or 2 years of general surgery training, and 3 or 4 years of residency in urology. Some urologists continue their education after residency in a focused area of subspecialty- a fellowship. Fellowship training in urology can be accomplished in urologic oncology, pediatrics, voiding dysfunction, laparoscopy/endourology, sexual medicine, pelvic reconstructive surgery, clinical research and male infertility. The specialty combines medical and surgical training, and encompasses a wide variety of clinical problems in men and women of all ages. For more about the specialty and the requirements for certification see The American Board of Urology

The most common presenting complaints or conditions in a urology practice are:

  • Prostate Cancer
  • Kidney stones
  • Blood in the urine (hematuria)
  • Elevated PSA (screening test in men for prostate cancer)
  • Benign enlargement of the Prostate gland (BPH)
  • Urinary tract infections
  • Bladder cancer
  • Kidney cancer
  • Erectile dysfunction (ED)

The general urologists at UANT are highly qualified by their training and experience to manage the full evaluation and most treatment of all patients with these conditions and more. Occasionally a higher level of care may be needed for some conditions. What distinguishes UANT from other urology practices is the ability to concentrate (within the practice) the management of selected or complicated problems in the hands of subspecialists or Centers of Excellence. We believe by doing so we may achieve superior outcomes for our patients. If in the determination of the general urologist a patient may benefit from a referral to a physician with a very high volume of experience in a certain area, that patient can easily and quickly be referred within the practice to a COE. The UANT COE physician will have access to all of the medical records and tests performed to date. If and when appropriate, after evaluation and management of the condition the patient will be referred back to the UANT general urologist for follow-up.

Kidney Stones

The evaluation and management of most patients with kidney stones falls within the purview of the general urologist. Most stones form within the kidney and only cause pain when they block or obstruct a portion of the urinary tract. Stones are usually diagnosed with one or more types of imaging tests: IVP, ultrasound, CT scan, or KUB. UANT is able to offer these services to most patients within one or more of our locations.

The management options for kidney stones include observation, ureteroscopy, ESWL (shock wave lithotripsy), and percutaneous surgery. Many patients with small stones in the lower urinary tract will pass the stone without the need for further treatment. Careful observation and follow-up by your physician is necessary until it has been documented that the stone has passed; failure to do so can occasionally result in silent (painless) damage to the urinary tract.

Ureteroscopy is a minimally invasive procedure that requires anesthesia in an outpatient surgical facility. Ureteroscopy is most commonly employed for stones in the lower urinary tract. The surgeon places a slender rigid or flexible telescope through the ureter to the level of the stone, where it is then managed with extraction, fragmentation, or both. It may be necessary to leave a temporary soft stent in the ureter to prevent postoperative obstruction by fragments or swelling; in uncomplicated cases, the stent is removed 1-5 days later in a simple office procedure. Ureteroscopy has a very high success rate; injury to the ureter is a rare (1%) but recognized complication.

ESWL is a non invasive therapy that also requires sedation or anesthesia in an outpatient facility. ESWL is the treatment of choice for stones in the upper urinary tract and also suitable for stones in the lower urinary tract that can be visualized with xray. The involved area of the urinary tract is targeted by xrays to send a series of focused shock waves on the stone and break it into fine particles; the particles then pass out with the urine. ESWL does not require stenting in most cases. ESWL has a high success rate and an excellent safety record; there is no significant risk of serious injury to the ureter in most cases. Potential complications include inability to completely fragment a very hard stone and complications related to obstruction by incompletely fragmented pieces (<10% overall). UANT surgeons perform more than 1000 ESWL procedures per year.

Percutaneous surgery is a minimally invasive procedure that requires anesthesia and usually an overnight stay in the hospital. This procedure is indicated for very large stones in the kidney, certain types of very hard stones, and some otherwise complicated patients who are not candidates for other therapies. A small telescope is placed through the skin and the kidney to enter the inside of the urinary tract; once in position, the surgeon fragments the stone and removes the pieces. After the procedure a catheter is left in the kidney (exiting the skin) for 1-3 days. Repeat procedures are sometimes necessary to completely clear the stone from the urinary tract. Potential complications include bleeding and injury to adjacent organs from passage of the telescope. At UANT specialists in this technique perform over 50 procedures per year.

Pediatric Urology

The North Texas Center for Pediatric Urology

Pediatric Urology is dedicated to the treatment and care of problems related to the kidney, ureter, bladder, prostate, urethra, penis, vagina and testicles of children.

UANT has the largest medical staff in Tarrant County dedicated exclusively to pediatric urology. Our fellowship-trained physicians were first trained and board certified in general urology and have since received additional training in the care of the special urological problems presented by children.

The staff at the Center for Pediatric Urology wants you to fully understand your child's condition and the treatments available and to make caring for your child at this difficult time as easy as possible. Our pediatric urologists are well qualified to address the full range of urological problems, some of which are described below, and are available for questions and consultation.

Common Conditions

Nocturnal Enuresis (Bed wetting)

Nocturnal enuresis is defined as involuntary urination that occurs at night. There are two types of enuresis: primary and secondary. Primary nocturnal enuresis describes the condition in which an individual has wet the bed since early childhood. Secondary enuresis, describes the condition when it develops at least 6 months after an individual has already learned bladder control.

What Causes Enuresis?

Enuresis can be brought on by more than one cause. The most common causes are:

  • Hormonal Problems
    A hormone called antidiuretic hormone (ADH) causes an individual's body to produce less urine at night. In instances where not enough ADH is produced, the body can produce more urine than it should.
  • Bladder Problems
    In some people with enuresis, too many muscle spasms can prevent the bladder from holding a normal amount of urine. Some teens and adults also have relatively small bladders that can't hold a large volume of urine.
  • Genetics
    Enuresis in a child can often be linked to a parent who had the same problem at about the same age.
  • Sleep Problems
    Some children can sleep so deeply that they do not wake up when they need to urinate.
  • Medical Conditions
    Medical conditions that can trigger secondary enuresis include diabetes, constipation, and urinary tract infections. Spinal cord trauma, such as severe stretching of the spinal cord resulting from a fall, sports injury, auto accident, or other event may also play a role in enuresis, although this is rare. Abnormal development of the spinal cord can also lead to enuresis.
  • Psychological Problems.
    A disruption of sleep patterns may also cause enuresis. This disruption can be caused by events such as divorce, the death of a friend or family member, a move to a new town, adapting to a new school or social environment, or family tension.

Urinary Incontinence (Leakage of urine)

Urinary incontinence occurs when urine leaks from the bladder, or an individual cannot control the urge to urinate. It occurs more frequently in women than in men, often in older women and after pregnancy. Although incontinence is often caused by weakened, aging muscles, there are other causes that are treatable such as onset caused by an illness or infection, a blockage in the urinary passage, or because the bladder can't fully empty itself.

Once diagnosed, incontinence can be treated successfully through:
  • Exercise, which can help strengthen the pelvic muscles
  • Collagen injections, which narrow the area near the urinary sphincter muscle
  • Surgery, to reposition the muscles and connective tissues that support the bladder and the bladder neck.

At the North Texas Center for Urinary Control, our physicians can offer patients the solutions and options that will enable them to return to enjoying a more carefree lifestyle.

Undescended Testicle (Cryptorchidisn)

About 5 out of every 100 baby boys are born with an undescended testicle, which occurs when a testicle does not move into the scrotum as it should. It is most common in babies who were born before their due date or who were very small at birth. In more than half of cases, the testicle descends on its own by the time a baby is 3 months old. If the testicles have not descended by the time a child is 6 months of age, your doctor may suggest treatment.

Hypospadias (Abnormal urethral opening)

Hypospadias is a male birth defect in which the opening of the tube that carries urine from the body (urethra) develops abnormally, usually on the underside of the penis. There are four types of hypospadias, based on where the urethral opening occurs. They are: glandular hypospadias, coronal hypospadias, penile shaft hypospadias and perineal hypospadias.

Hernia

A hernia occurs when the inside layers of the abdominal wall weaken then bulge or tear. The inner lining of the abdomen pushes through the weakened area to form a balloon-like sac. This, in turn, can cause a loop of intestine or abdominal tissue to slip into the sac, causing pain and other potentially serious health problems.

Men and women of all ages can have hernias. Hernias usually occur either because of a natural weakness in the abdominal wall or from excessive strain on the abdominal wall, such as the strain from heavy lifting, substantial weight gain, persistent coughing, or difficulty with bowel movements or urination. Eighty percent of all hernias are located near the groin. Hernias may also occur below the groin (femoral), through the navel (umbilical), and along a previous incision (incisional or ventral).

What are the symptoms of hernias?

  • A noticeable protrusion in the groin area or in the abdomen
  • Feeling pain while lifting
  • A dull aching sensation
  • A vague feeling of fullness

How can a hernia be repaired?

Hernias usually need to be surgically repaired to prevent intestinal damage and further complications. The surgery takes about an hour and is usually performed on an outpatient basis. This surgery may be performed by an open repair (small incision over the herniated area) or by laparoscopic surgery (minimally invasive). Your surgeon will determine the best method of repair for your individual situation.

Hydrocele

A hydrocele is a collection of fluid in the scrotal sac of male infants that drains downward from the abdominal cavity. The baby's scrotum will appear swollen or large, but he will not have other symptoms.

There are two types of hydroceles:
  • Communicating hydrocele -- This is a hydrocele that has contact (or communication) with the fluids of the abdominal cavity. A communicating hydrocele is caused by the failure of the processus vaginalis (the thin membrane that extends through the inguinal canal and descends into the scrotum) to close completely during prenatal development. If this membrane remains open, there is a potential for both a hernia and a hydrocele to develop.
  • Non-communicating hydrocele -- This condition might be present at birth or might develop years later for no obvious reason. A non-communicating hydrocele usually remains the same size or has a very slow growth.

Unlike an inguinal hernia, a hydrocele generally is not painful and does not have noticeable symptoms. (An inguinal hernia is tender and causes intestinal symptoms.)

How can a hydrocele be repaired?

A non-communicating hydrocele usually does not need to be surgically repaired, since it usually goes away spontaneously within six to 12 months. A communicating hydrocele needs to be surgically repaired to prevent further complications. The surgery takes about an hour and is usually performed on an outpatient basis.

Urinary Tract Infections (Bladder/Kidney infections)

Your urinary tract is the system that makes urine and carries it out of the body. It includes the bladder, the kidneys and the tubes that connect them. When germs get into this system, they can cause an infection. Most urinary tract infections are bladder infections. A bladder infection usually is not serious if it is treated right away. If you do not take care of a bladder infection, it can spread to your kidneys. A kidney infection is serious and can cause permanent damage.

Vesicoreteral Reflux

Urine normally flows in one direction-down from the kidneys, through tubes called ureters, to the bladder. Vesicoureteral reflux (VUR) is the abnormal flow of urine from the bladder back into the ureters. VUR is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). About one-third of children with a UTI are found to have VUR. VUR can lead to infection because urine that remains in the child's urinary tract provides a place for bacteria to grow. Sometimes, however, the infection itself is the cause of VUR.

There are two types of VUR. Primary VUR occurs when a child is born with an impaired valve where the ureter joins the bladder. This happens if the ureter did not grow long enough during the child's development in the womb. The valve does not close properly, so urine backs up (refluxes) from the bladder to the ureters, and eventually to the kidneys. This type of VUR can get better or disappear as the child gets older. The ureter gets longer as the child grows, and the function of the valve improves.

Secondary VUR occurs when there is a blockage anywhere in the urinary system. The blockage may be caused by an infection in the bladder that leads to swelling of the ureter. This also causes a reflux of urine to the kidneys.

Infection is the most common symptom of VUR. As the child gets older, other symptoms, such as bedwetting, high blood pressure, protein in the urine, and kidney failure, may appear.

The goal for treatment of VUR is to prevent any kidney damage from occurring. Infections should be treated at once with antibiotics to prevent the infection from moving into the kidneys. Antibiotic therapy usually corrects reflux caused by infection. Sometimes surgery is needed to correct primary VUR.

Circumcision

Males are born with a hood of skin, called the foreskin, covering the glans (head) of the penis. In circumcision, the foreskin is surgically removed, exposing the end of the penis. A circumcision is best performed within the first 2 to 3 weeks after birth, as it can become more complicated as a child gets older, but the procedure is usually performed during the first 10 days, often within 48 hours of birth.

Benefits of Circumcision

Studies indicate that circumcised infants are less likely to contract a urinary tract infection (UTI) in their first year of life. About one out of every 1,000 circumcised boys has a UTI in the first year, whereas the rate is one in 100 (at most) for uncircumcised infants.

Some studies also suggest that circumcision may offer an additional line of defense against sexually transmitted diseases, HIV in particular, but the results of these studies are inconclusive.

While circumcision appears to offer some medical benefits, it also carries the same potential risks as any surgical procedure. Complications resulting from newborn circumcision are uncommon, occurring in between 0.2% to 3% of cases. Of these, the most frequent are minor bleeding and local infection, both of which can be easily treated by your child's doctor.

Hematuria (blood in urine)

When red blood cells are detected in the urine - but the urine doesn't appear red from blood - this is called "microscopic hematuria." Blood in urine can be caused by many conditions, including:

  • Urinary tract infection (cystitis)
  • Bladder or kidney stone
  • Noncancerous or cancerous enlargement of the prostate in men
  • Bladder or kidney cancer
  • Kidney disease, such as nephritis
  • Medications such as warfarin, aspirin, ibuprofen and naproxen

To try to determine the cause of blood in urine, your doctor may recommend additional tests, such as:

  • Urine tests (urinalysis)
  • Blood tests
  • Kidney- and bladder-imaging studies
  • Cystoscopy, a procedure in which a narrow tube is inserted through your urethra and into your bladder, which allows your doctor to visually inspect your urethra and bladder. Sometimes the cause can't be determined. In such cases, your doctor may simply monitor the condition to see if it persists. If blood is visible in your urine (gross hematuria), consult your doctor.

Obstructed kidneys (UPJ Obstruction)

Ureteropelvic junction (UPJ) obstruction is defined as a blockage in the area that connects the renal pelvis (part of the kidney) to one of the tubes (ureters) that move urine to the bladder. Generally, the condition occurs in the womb and most of the time, the blockage is caused when the connection between the ureter and the renal pelvis narrows, causing urine to build up, damaging the kidney.

The condition can also be caused when a blood vessel is located in the wrong position over the ureter. In older children and adults, UPJ obstruction can be due to scar tissue, infection, previous treatments for a blockage, or kidney stones.

Hydronephrosis

UPJ can lead to hydronephrosis, a swelling of the urine-collecting structures of one or both kidneys due to obstruction of urine flow from the kidney. This can impair kidney function. Hydronephrosis isn't a specific disease, but a sign of an underlying problem. Other causes include:

  • A kidney or ureteral stone (nephrolithiasis)
  • A blood clot
  • Scarring of the ureter, usually from injury, radiation therapy or previous surgery
  • A tumor in or around the ureter
  • Prostate gland enlargement (benign prostatic hyperplasia)

Kidney Stone

A kidney or bladder stone is formed from minerals in urine that crystallize and harden. Kidney stones are usually painless while they remain in the kidney, but they can cause severe pain if and when they break loose and travel through narrow tubes to exit the body.

Our pediatric urologists are available for questions and consultation. If you have questions, please call us at 817 461-UANT (8268).

Dr. McQuiston
Leslie McQuiston, M.D.
Dr. Pinto
Kirk Pinto, M.D.
Dr. Pugach
Jeff L. Pugach, M.D.

Robotic & Laparoscopic Surgery

The North Texas Center for Robotic Surgery

At USMD hospital, UANT Urologists performed the first robotic prostatectomy using the da Vinci robot in North Texas back in 2003. Since that time UANT has performed over 1500 robotic surgeries. UANT was also the first to perform a robotic partial nephrectomy (removal of a tumor from the kidney) in North Texas in 2004. Last year UANT's robotic surgical experience was in the top five in the United States. At USMD hospital there are typically 12-20 robotic surgeries performed each week.

Robotic surgery at UANT is performed using the da Vinci Surgical System, a technologically advanced system that utilizes robotic instruments introduced via tiny incisions or laparoscopic ports. These instruments are under the direct control of the surgeon and are incredibly precise, offering more control and range of motion than standard instruments. Additionally, the specialized telescope of the robot allows the surgeon to see the operative field under 12X magnification and in three dimensions - as opposed to the standard two dimensional view (like television) that standard laparoscopy offers - providing greater visual detail than ever before possible.

Robotic prostatectomy

Robotic prostatectomy or robotic-assisted laparoscopic prostatectomy is the complete surgical removal of the prostate gland and seminal vesicles. The procedure is performed laparoscopically using the da Vinci Surgical System. The da Vinci Surgical System provides the surgeon with better vision and better 'hands' through the use of advanced optics and computer and robotic technology.

Since 2003, the team at UANT's North Texas Center for Robotic & Laproscopic Surgery - dedicated to treating cancers of the urologic organs such as the bladder, prostate and kidney - has completed more robotic prostatectomies and cryosurgical procedures than any other practice worldwide. This Center of Excellence team, consists of David L. Shepherd, M.D., Scott A. Thurman, M.D., Harrison A. Mitchell, M.D., Justin T. Lee, M.D., David Ellis, M.D., Cliff Vestal, M.D., Pat Collini, M.D., and Keith A. Waguespack, M.D.

How Is a Robotic Prostatectomy Performed?

The procedure is begun by inflating the abdomen with carbon dioxide gas in order to provide the surgeon with "working room". Next, six small incisions, 1/4 to 1/2 inch in length, are made in the abdomen and plastic or metal ports are installed to keep the incisions open. Seated at the da Vinci System console nearby and using both the laparoscopic surgical instruments and a pencil-sized video camera, the surgeon directs the da Vinci's robotic arms to dissect the prostate gland and adjacent tissue. The video camera's 12X magnification and 3D view enable the surgeon to identify the many delicate nerves, tiny blood vessels, and other structures surrounding the prostate gland. Once the procedure is completed and the prostate is removed, the patient awakens, is ambulating later that day and typically is discharged within 24 hours.

What Advantages Does Robotic Prostatectomy Offer?

Robotic prostatectomy, which has been shown to be as effective as conventional procedures in treating localized prostate cancer, offers these advantages:

Patient Benefits

For qualified candidates, the robotic prostatectomy offers numerous potential benefits over the traditional open prostatectomy, including:

  • Shorter hospital stay
  • Less post-operative pain and pain medication
  • Less anesthesia
  • Less blood loss and transfusions
  • No blood donation necessary from patient
  • Less scarring
  • Fewer postoperative complications than open surgery including fewer post operative infections
  • Faster and more complete recovery
  • Of our patients, 97% go home the morning after surgery. By comparison, time in the hospital for patients treated with open radical prostatectomy is two to four days
  • Quicker return to normal daily activites
  • Most patients return to work two to three weeks after the procedure and resume exercising or golf in 3-4 weeks, recovery time for patients treated with radical open prostatectomy is six to eight weeks.
  • The catheter that drains the bladder is removed after seven days in robotic surgeries. In open radical prostatectomies, the catheter is removed after two to three weeks
  • Covered by almost all insurance
  • Costs the same as traditional open surgery

Surgeon Benefits

The da Vinci© Surgical System used at USMD Hospital for robotic prostatectomy extends the surgeon's capabilities to provide these significant benefits:

  • 3-D Visualization: Provides the surgeon with a true 3-dimensional view of the operating field. This direct and natural hand-eye instrument alignment is similar to open surgery with "all-around" vision and the ability to zoom-in and zoom-out.
  • Dexterity: Provides the surgeon with instinctive operative controls that make complex minimally invasive surgery procedures feel more like open surgery than laparoscopic surgery.
  • Surgical Precision: Permits the surgeon to move instruments with such accuracy that the current definition of surgical precision is exceeded.
  • Access: Surgeon perform complex surgical maneuvers through 9-mm ports, eliminating the need for large traumatic incisions.
  • Range of Motion: EndoWrist© Instruments restore full range of motion and ability to rotate instruments more than 360 degrees through tiny incisions.
  • Reproducibility: Enchances the surgeon's ability to repetitively perform technically precise maneuvers such as endoscopic suturing and dissetion.

What Are the Side Effects of Robotic Prostatectomy?

The side effects associated with robotic prostatectomy, which are similar to those associated with open radical prostatectomy, include:

  • Urinary incontinence
    Stress incontinence is the term given to the leakage of urine that can occurs when a patient coughs, sneezes, or lifts a heavy object after the procedure. All patients wear urinary pads after the procedure; 70% of patients are able to discontinue the pads by three months; 85% by six months; and 95% by one year.
  • Erectile dysfunction
    Recovery of erectile function is dependant upon the pre-operative state of each patient. However, a nerve-sparing procedure can be performed better with "the robot" than with the open radical prostatectomy. Because of the precision and gentleness of the robotic prostatectomy procedure, these side effects are less common than they are with open radical prostatectomy. Patients also recover from the robotic procedure in a shorter time than from the open radical procedure.
Dr. Shepherd
David L. Shepherd, M.D.
Dr. Scott Thurman
Scott A. Thurman, M.D.
Dr. Abrahams
Harrison Mitchell Abrahams, M.D.
Dr. Lee
Justin T. Lee, M.D.
Dr. Waguespack
Keith A. Waguespack, M.D.

Male Infertility

The North Texas Center for Male Infertility

Infertility has traditionally been defined as 'failure to conceive after one year of unprotected intercourse'. Statistics show that a male infertility factor is involved in nearly half of all infertility cases, sometimes exclusively, sometimes as a contributing factor. There are, however, a variety of treatment options and advanced reproductive technologies available to couples who wish to have a child but for some medical reason, cannot.

Here at UANT, the subspecialty of male infertility is dedicated to the medical and surgical treatment of abnormalities of male fertility and spermatogenesis, with the goal of helping a couple conceive a child in as natural a way as possible. Our program is led by one of the elite fellowship trained male infertility specialists in North Texas, Weber W. Chuang, M.D.

"Our goal," says Dr. Chuang, "is to help a couple experiencing infertility to achieve a pregnancy as naturally as possible. The first step is an evaluation of the male partner to identify the possible male factors involved." This evaluation begins with a thorough medical history and physical examination, to reveal possible causes of infertility, such as a hernia repair, trauma, or a urinary tract infection. In addition, extensive laboratory tests are conducted, including a reproductive hormone profile and at least two semen analyses, with advanced sperm tests such as an antisperm antibody assay, a white blood cell count and strict morphology.

Conditions contributing to infertility

Varicocele

A varicocele is defined as a dilation of the veins that drain the testicle. It is present in about 15% of the general population but is diagnosed in 40% of the men who are evaluated for infertility.

A varicocele develops when valves in the internal spermatic veins fail, allowing blood to flow back towards the testicle from the abdomen. A varicocele, it is believed, can impede the development of normal sperm by elevating testicular temperature, causing abnormal concentrations of adrenal and renal substances, increasing metabolic waste products, or reducing the availability of oxygen and nutrients.

Fortunately, the varicocele is one of the most treatable causes of male infertility. A microsurgical repair, involving meticulous ligation of the dilated vessels under microscopic visualization and doppler guidance, can improve semen parameters and pregnancy rates.

Hypogonadism

Low levels of testosterone (the male hormone) can lead to symptoms of low energy, low libido, and poor erections.. Testosterone replacement can relieve those symptoms and is available in many forms, including intramuscular injections as well as more convenient daily gels or patches. While under treatment, the patient should be monitored closely with regular blood work and physical exams. While treatment may increase libido and, subsequently, the frequency of intercourse, men with low testosterone who are trying to have children should not receive testosterone replacement as doing so may actually reduce their sperm counts significantly. Other forms of treatment to help these men maintain their testosterone levels, while improving their sperm counts, are available and should be used instead.

Azoospermia

Azoospermia is defined as the absence of sperm in the ejaculate (azoospermia). In some instances, the reproductive ducts may be absent or blocked; this condition is referred to as obstructive azoospermia or OA. In other individuals with normal anatomy, where there is no sperm production, the condition is called non-obstructive azoospermia or NOA.

The diagnosis of no sperm in the ejaculate should be thoroughly investigated with a complete physical exam and a battery of tests including hormone and possibly genetic evaluation, as well as radiological studies, such as scrotal, renal, and transrectal ultrasound. Ultimately, a testicular biopsy may be performed, with the goal of determining the cause of azospermia, and if necessary and/or possible, of retrieving sperm for use in assisted reproductive techniques.

Vasectomy Reversal

Vasectomy reversal is a procedure in which reconstructive sperm duct microsurgery is employed with the goal of returning sperm to the ejaculate. Two procedures may be performed in a vasectomy reversal: a straight-forward reversal called a vasovasostomy (VV) or procedure that involves connecting the vas deferens to the ducts closer to the testicle (epididymis) called an epididymovasostomy (EV). The choice of procedure is dependent upon the nature and length of time of the obstruction, the quality of the testis, and the quality of the intravasal fluid. The process begins with a patient history and physical examination, which will provide some indication of the required procedure; however, the determining information is provided by an examination of the vasal fluid. Success of the vasectomy reversal depends on several factors including the required procedure (vasovasostomy vs. epididymovasostomy), the length of time of the obstruction, as well as the post-operative healing.

Operating time for a vasovasostomy or epididymovasostomy is approximately 4 to 5 hours under a general anesthetic. Postoperative care includes an evaluation of wound healing at 2 weeks and a first semen analysis at 6 weeks. Semen analyses are then obtained at 2 month intervals until the semen analysis stabilizes or pregnancy is achieved. Routine follow up semen testing and visits will provide the best success rates.

In addition, sperm can be retrieved during the procedure and through cryopreservation, frozen for future use should the procedure not lead to pregnancy.

Advanced Reproductive Techniques

Although there are numerous factors that can contribute to the problem of infertility, reproductive medicine continues to meet each obstacle to conception with a solution that improves the odds of conception. As Dr. Chuang notes, "We begin with the most natural, least complex approach; but if that fails, we can turn to advanced techniques to help couples achieve a pregnancy.

"Nature provides multiple barriers to conception that advanced reproductive techniques can help overcome," Dr. Chuang explains. The various techniques are available to help sperm overcome these barriers by placing the sperm closer to the egg, including intrauterine insemination (IUI), in vitro fertilization (IVF), and IVF with intracytoplasmic sperm injection (ICSI). These advances in reproductive technology have offered many couples the possibility of conception who would not otherwise have been able to conceive."

For a great start to creating that family you have always dreamed of schedule your consult with Dr. Chuang today!

Cryotherapy

The North Texas Center for Cryotherapy

Prostate cancer is the second most common cancer and the second leading cause of death in American men. The American Cancer Society estimates that 230,000 cases of prostate cancer are diagnosed each year and more than 28,000 men die from the disease.

Our Director of Cryosurgery, David S. Ellis, M.D., has individually performed more cryosurgical procedures than any other physician. Joining him are two of the nation's leaders in performing minimally invasive prostate cancer procedures: James C. Vestal, M.D., Director of The North Texas Center for Urologic Oncology, and M. Patrick Collini, M.D., both of whom also perform prostate and kidney cryosurgeries.

What is Cryotherapy?

Cryotherapy is a treatment for prostate cancer and is an effective yet minimally invasive alternative to surgery and radiation therapy. The treatment utilizes slender probes called 'cryoprobes' that deliver cycles of extremely cold temperatures and warm temperatures to freeze, thaw, and ultimately destroy cancerous cells in and around the prostate gland. Under ultrasound guidance, the probes are inserted through the skin and are strategically placed in and around the prostate to target the entire gland and minimize damage to surrounding healthy structures. After two or more freeze/thaw cycles, the cancer cells die and the dead tissue is re-absorbed or remains in the body as scar tissue posing no further health threat.

The procedure is performed with the patient under either general or epidural anesthesia. Since it is minimally invasive and of a relatively short duration (1 -1.5 hours), it offers a quicker recovery and reduced severity of potential side effects, such as incontinence or impotence.

Targeted Cryoablation of the Prostate (TCAP)

Recent technological advancements have introduced a safer and more effective cryosurgical procedure called Targeted Cryoablation of the Prostate (TCAP). TCAP uses between six and eight ultrasound-guided cryoprobes to deliver a lethally cold temperature to specific areas in the prostate. The resulting ice ball that forms ensures that all cancer cells are immediately destroyed. It also uses thermosensors that enable surgeons to monitor the process and determine when the exact target temperatures have been reached. The treatment is highly effective for low, moderate and high risk localized prostate cancers; freezing kills cancer cells on contact regardless of how aggressive they are.

The most frequent complication associated with cryosurgery is sexual dysfunction, which occurs when the "erection" nerve bundles are damaged during the freeze/thaw cycle discussed earlier. "Fortunately, those nerve bundles can regenerate and sexual function can return in 18% of men in one year and in 40% of men in two years," explains Dr. Ellis. With nerve warming, the rates of successful erectile function are even higher - between 46% and 74%. During the nerve warming procedure, the nerve bundles are identified with a Doppler device; then a probe placed between the bundles is warmed during the freeze cycle to prevent or limit nerve damage.

What to expect with the Prostate Cryosurgery Procedure

  • 1.5-2 hours under spinal or general anesthesia
  • Discharged later that day or the next day

After procedure:

  • Icepacks to scrotum and perineum for 3-5 days
  • Suprapubic or Foley catheter for 1 week
  • Anti-inflammatory medications for several days
  • Can start golfing at 10-14 days

Early Side effects of Prostate Cryosurgery

  • Swelling around scrotum and perineum for up to two weeks
  • Urinary retention
  • Uncomfortable to sit down (< 2 wks)
  • Late side effects of cryosurgery
  • Impotence 82-100 % initially, 47% have recovery after 3 years
  • Urethro-rectal fistula (0-0.25%)
  • Incontinence (1-4%)
  • TURP needed (1-5.5%)

Prostate Cryosurgery Advantages

  • Minimally invasive, minimal pain
  • Hospitalization less than 24 hrs, brief recovery
  • Favorable success & complication rate
  • Very effective in patients at risk for positive margins
  • Can be repeated
  • Radiation or surgery is still an option for failures
  • Excellent option for patients after failing radiation or brachytherapy

Prostate Cryosurgery Disadvantages

  • Early Impotency (potentially permanent)
  • Prostate should be < 45 gms
  • Most larger glands can be downsized with several months of hormone therapy
  • Catheter or suprapubic tube for 1 week

Unlike radical prostatectomy or radiation therapy, cryotherapy can be repeated if necessary. Clinical data indicates that for locally confined high-grade prostate cancer, cryotherapy offers the highest average long-term success rates across all stages of localized prostate cancer. "Cryotherapy is the preferred method of treatment for all moderate and high-risk patients. The procedure is minimally invasive, enabling patients to sustain the highest quality of life possible," says Dr. Ellis.

When performed by Drs. Ellis, Vestal and Collini, cryotherapy takes minimally invasive treatment for localized prostate cancer to a new level - a level that offers patients a more enhanced quality of life than ever possible with conventional procedures.

Dr. Ellis
David S. Ellis, M.D.
Dr. Vestal
James Clifton Vestal, M.D.
Dr. Collini
M. Patrick Collini, MD

Human Sexuality

The North Texas Center for Human Sexuality

True or false? Everyone around us enjoys a completely carefree sex life. If you guessed "false," you're correct. In fact, experts estimate that one in three adults suffer some form of sexual dysfunction that can cause either temporary problems or develop into a chronic problem with serious emotional and physical results.

Urology Associates of North Texas has brought together, under the leadership of V. Gary Price, M.D., Director of the Center for Human Sexuality, specialists from several different areas with experience in human sexuality. These physicians in this Center of Excellence are specially trained in both the latest technology and procedures in order to effectively address conditions such as:

Male Erectile Dysfunction

Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. The number of men in the United States who suffer from ED to some extent is estimated at one in ten, nearly 50% of men over 40 years of age.

Says V. Gary Price, M.D., Director of the Center for Human Sexuality at UANT, "Because of the complexity and subtlety of diagnosing and treating ED, a referral to a urologist trained in this specialty is often indicated. Current widespread consumer advertising for pharmacological ED 'cures' notwithstanding, a specialist can pinpoint the cause and optimum treatment for each patient's ED."

Since an erection requires a complex sequence of events, ED can occur when any of the events in this sequence - such as nerve impulses in the brain, spinal column and area around the penis, along with responses from muscles, arteries and tissues - is disrupted. Factors that can lead to a disruption include:

  • damage to nerves or tissues
  • diseases such as diabetes, Parkinson and alcoholism
  • surgery involving the prostate or bladder
  • psychological factors such as stress and anxiety
  • some medications commonly prescribed for high blood pressure, antidepressants and tranquilizers
  • lifestyle choices such as smoking

The most prevalent of causes is disease. In fact, diseases such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease account for about 70% of ED.

Only a thorough diagnostic procedure can pinpoint the exact cause of the problem. This begins with a detailed medical and sexual history, followed by a physical exam. Due to the tremendous technological advances made in this area, there are now several treatment options available, from medication to improve blood flow to surgical implants. Counseling for psychological problems relating to ED is also available. Treatments include:

  • Oral medications such as Viagra, Levitra and Cialis. All increase blood flow into the penis. Studies have shown that up to 70% of impotent men experienced some improvement in erections when taking these drugs.
  • Intaurethral pellets can be inserted into the urethra at the tip of the penis, causing blood vessels to relax and increasing the blood flow.
  • Penile implants, an irreversible procedure. The primary surgical treatment for ED, inflatable devices or semi-rigid rods of silicone or polyurethane are inserted into the penis.
  • Vacuum device. A hand pump is used to create a vacuum inside a cylinder placed over the penis. The vacuum draws blood into organ, making it erect.
  • Hormone therapy is a less common treatment as less than 5% of men with ED have a testosterone deficiency. With this treatment, testosterone is administered by patch, topical gel or injection.
  • Counseling, provided by specialists who treat diseases of the genitals and urinary tract, can help patients overcome the psychological factors associated with ED such as low self esteem and depression.

Premature (rapid) ejaculation

Premature or rapid ejaculation occurs when a man reaches climax before he and his partner are ready, which can have an adverse effect on their relationship. This condition can present itself at any time in a man's life and can be either learned behavior or a response to an unhealthy lifestyle. The good news is that the condition can be successfully treated by the human sexuality specialists at UANT with medications, counseling or a combination of the two.

Female Sexual Dysfunction

Sexual dysfunction effects approximately 4 out of every 10 women. This dysfunction can take several forms; the inability to achieve orgasm, a lack of desire or pain during intercourse. The causes can physical/medical, psychological, a symptom of stress or a combination of all of these.

The Human Sexuality Center of Excellence at UANT is currently expanding its offering of services in order to better diagnose and treat women's sexual problems. Following a complete physical assessment, your physician may recommend treatment ranging from pelvic muscle relaxation techniques to a surgical procedure that could correct a physical problem that is interfering your ability to have/enjoyment of sexual intercourse.

Penile and Vaginal Reconstruction

This type of surgery is one of the more difficult types of surgery for men and women to handle emotionally and physically. While extremely rare, cancer of the penis or vagina can lead to partial (glansectomy, partial vaginectomy) or complete (penectomy, radical vaginectomy) removal of these parts of the body. Reconstructive surgery is performed to restore these parts - most often using tissue from other parts of the body - and return their functionality as best as possible.

Counseling (Individuals and Couples)

Consider this: No one's sexual problem is their own. Whenever an individual suffers with some physical or emotional sexual dysfunction, it has a profound effect on their partner as well. Sex therapy is a focused form of counseling that helps people overcome emotional, physical and medical concerns that may be prohibiting them from having satisfying sex. This therapy, which we encourage you to participate in as a couple, can enhance self-esteem, add warmth and intimacy to your relationship and finally, enrich your life.

The first step is recognizing the problem.

Says V. Gary Price, M.D., Director of the Center for Human Sexuality at UANT, "Problems with sexual dysfunction are more common than you think. The first step in any treatment is recognizing the problem. Once you've taken that first step, the specialists here at the Center for Human Sexuality are well trained to provide you with the treatment you need in order to have a more fulfilling sexual relationship."

Dr. Price
Gary Price, M.D.

Urinary Control (Incontinence)

The North Texas Center for Urinary Control

Nearly 10 million Americans suffer from urinary incontinence and/or overactive bladder . Contrary to popular belief, urinary incontinence is not simply "something that effects older people." The truth is, it can affect anyone. This includes children, elderly individuals, women who have had children, anyone who exercises and men who have had prostate surgery. Incontinence can leave you exhausted, sleep deprived and make long-distance travel uncomfortable or even impossible. In short, it keeps many from enjoying a full life. Yet, despite these frustrations, only about one in 12 people seek relief... often because they're embarrassed to seek treatment and also because many don't know just how many treatment options are available to them, non-surgical options in particular.

Says James Daniel Johnson, M.D. of UANT's Center for Urinary Control: "There is an undiagnosed epidemic among American households, one that leaves millions depressed, isolated and sometimes even housebound. Yet it is almost entirely curable. It is a problem that primary care physicians, with just a few moments of their time, could turn from a crippling, secret affliction to a routine part of maintaining wellness."

Urinary incontinence is defined as a loss of bladder control. Symptoms can range from mild leaking to uncontrollable wetting. Most bladder control problems happen when muscles are either too weak or too active. If the muscles that keep your bladder closed are weak, you may have accidents when you sneeze, laugh or lift a heavy object. This is called stress incontinence. If bladder muscles become too active, you may feel a strong urge to go to the bathroom when you have little urine in your bladder. This is called urge incontinence or overactive bladder.

What causes urinary incontinence?

The most common causes are:

  • For women, thinning and drying of the skin in the vagina or urethra, especially after menopause
  • For men, enlarged prostate gland or prostate surgery
  • Weakened pelvic muscles
  • Certain medicines
  • Build-up of stool in the bowels
  • Immobility
  • Urinary tract infection
  • Problems such as diabetes or high calcium levels

Types of incontinence

There are three types of incontinence. Treatment depends on the type of problem you have and what best fits your lifestyle. It may include simple exercises, medicines, special devices or procedures prescribed by your doctor, or surgery.

Stress incontinence

Caused when the pelvic muscles slip down and the bladder neck is not in the correct position. As a result, activities that increase pressure on the abdominal cavity and bladder, such as coughing, laughing, sneezing and exercising, can cause urine leakage.

Urge incontinence

Caused by an overly sensitive bladder, which feels full even when it contains even a small amount of urine. The bladder contracts unexpectedly and, if the external sphincter is weak, urine in the bladder is expelled. Symptoms of urge incontinence include going to the bathroom at least every two hours, and getting up frequently during the night.

Overflow incontinence

Caused when scar tissue or dropped organs make the urethra (urine channel) very narrow, or might arise temporarily after pelvic surgery or childbirth. Overflow can also occur when the bladder stops contracting due to medications, injured nerves, prostate enlargement or a habitually overstretched bladder. Some symptoms of overflow incontinence include getting up frequently during the night to urinate and dribbling urine throughout the day.

Incontinence Treatments

What are some treatment options for each type of incontinence?

In most cases of incontinence, minimally invasive management (fluid management, bladder training, pelvic floor exercises and medication) is prescribed. However, if that fails, surgical treatment can be necessary.

Stress incontinence - Men

For men, urethral injections of bulking agents to improve the function of the sphincter can be employed, but the cure rate with this treatment is only 10-30%. The most effective treatment for male incontinence is implantation of an artificial sphincter. The device is inserted under the skin and consists of a cuff around the urethra, a pressure-regulating balloon in the abdomen and a pump in the scrotum. The fluid in the abdominal balloon is transferred to the urethra cuff, closing the urethra and preventing leakage of urine.

Stress incontinence - Women

In women stress incontinence is treated initially with behavior modification and pelvic exercise. Sometime techniques like biofeedback or electrical stimulation of the pelvic muscles can help. But when the symptoms are more severe and conservative measures are ineffective, the treatment is surgery. In selected cases bulking agents can be used to increase continence. The operation is done under local anesthesia and is minimally invasive but the cure rates are lower compared to open surgical procedures. Another option is abdominal surgery, in which the vaginal tissues are affixed to the pubic bone. The long-term results are good but the surgery requires longer recuperation time and is generally only used when other abdominal surgeries are also required. The most common and most popular surgery for stress incontinence is the sling procedure. In this operation a strip of tissue is applied under the urethra to provide compression and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. The tissue used to create the sling can be a segment of the patient's abdominal wall, specially treated fascia, skin from a cadaver or a synthetic material such as polypropylene.

Urge incontinence

There is a wide range of treatment options available for this type of incontinence. The first step should be behavior modification - drinking less fluids; avoiding caffeine, alcohol or spices; not drinking at bedtime and urinating around the clock and not at the last moment. Pelvic muscle exercises also help. The most common treatment for overactive bladder is medication, such as bladder relaxants, that prevent the bladder from contracting without the patient's permission. Other alternatives can be considered in patients who fail to respond to behavior modification and/or medication, one of which is the bladder pacemaker. This treatment consists of a small electrode that is inserted in the patient's back and is connected to a pulse generator. The generator's electrical impulses control bladder function. This treatment has proven highly effective, with a 60-75% cure or improvement rate.

Overflow incontinence

For overflow incontinence, the treatment is to completely empty the bladder and prevent urine leakage. Patients with diabetic bladder or patients with prostatic obstruction often develop this type of incontinence. Overflow incontinence due to obstruction should be treated with medication or surgery to remove the blockage. If no blockage is found, the best treatment is to instruct the patient to perform self-catheterization a few times a day. By emptying the bladder regularly the incontinence disappears and the kidneys are protected.

Says Dr. Johnson: "There is more money spent on controlling and dealing with incontinence - on purchases such as pads and protective underwear - than on all women's cancer care. With help from the medical community, the public could become much more aware of how common - and how treatable - this condition is." See any of our urologists at UANT, they can discuss this and several other issues with you and guide you to the Center for Urinary Control, if necessary and start living life to the fullest once again.

Dr. Rudy
Delbert C. Rudy, M.D.
Dr. Cannon-Smith
Tracy W. Cannon-Smith, M.D.
Dr. Tchetgen
Marie-Blanche Tchetgen, M.D.
Dr. Johnson
James Daniel Johnson, M.D.

Urologic Oncology

Cancers of the prostate, kidney, bladder, testis and other genitourinary organs are conditions evaluated and treated by urologists. Occasionally a higher level of care may be needed for some conditions. What distinguishes UANT from other urology practices is the ability to concentrate (within the practice) the management of selected or complicated problems in the hands of subspecialists or Centers of Excellence. One such Center of Excellence is Urologic Oncology. The physicians staffing this center have specialized training and/or experience in the management of complex urologic malignancies.

Fellowships in urologic oncology consist of 1, 2 or 3 years of post residency training in cancer care specific to urology; these programs are often based in large cancer institutions or academic centers. Our aim at UANT is to bring this same level of expertise and specialization into our local medical community by recruiting fellowship trained urologic oncologists. Should a UANT physician determine a need for specialized cancer care, a patient can be quickly and seamlessly referred to the COE physician best able to care for that particular oncology related problem.

Dr. Vestal
James Clifton Vestal, M.D.
Dr. Shepherd
David L. Shepherd, M.D.