The diagnosis of bladder cancer or other serious bladder disease may sometimes necessitate the surgical removal of the bladder.
In this situation, it is necessary to create a new way for the patient’s body to pass urine.
This type of surgery is known as urinary diversion surgery. There are several options available for patients requiring urinary diversion.
When the bladder is removed, the ureters need to be surgically connected to some type of urinary diversion to drain urine.
All forms of urinary diversion use a part of the body's intestinal tract.
This surgery can be performed to have the urine drain into an opening in the abdomen in either a continent or incontinent fashion, or can drain through the urethra (the tube in the penis/vagina) in a continent fashion.
Jonathan “Nick” Warner, M.D. is here to discuss reconstructive urology and who requires reconstruction, what does this treatment involve and what recovery is like?
Selected Podcast
What is Reconstructive Urology?
Featured Speaker:
In his international work experience, Dr. Warner travelled to Guadalajara, Mexico, to serve as a rotating resident, and attended an International Workshop in Reconstruction in Pune, India. He is a reviewer for multiple publications including the American Journal of Managed Care, the International Journal of Urology, and The Journal of Nephrology and Urology Research. Dr. Warner is an active member of his community. He volunteered for Americorps and received the Bishop Flannigan Award for commitment to community service. To date, he has authored several publications and has been invited to present his work internationally.
Jonathan “Nick” Warner, MD
Dr. Warner earned his undergraduate degree from Carroll College in Helena, MT, graduating magna cum laude, then went on to receive his medical doctorate from the University of Utah School of Medicine in Salt Lake City. While there, he was elected student body president and selected as a member of Alpha Omega Alpha (AOA) Honor Society. He continued his education at the Mayo Clinic in Phoenix, AZ, where he enrolled in a preliminary surgical program followed by a urology residency. During his residency, Dr. Warner was awarded a Resident Scholarship from the Western Section of American Urologic Association. Recently, he completed a fellowship in trauma and reconstructive urology at the Michigan State School of Medicine, where he was also an associate instructor.In his international work experience, Dr. Warner travelled to Guadalajara, Mexico, to serve as a rotating resident, and attended an International Workshop in Reconstruction in Pune, India. He is a reviewer for multiple publications including the American Journal of Managed Care, the International Journal of Urology, and The Journal of Nephrology and Urology Research. Dr. Warner is an active member of his community. He volunteered for Americorps and received the Bishop Flannigan Award for commitment to community service. To date, he has authored several publications and has been invited to present his work internationally.
Transcription:
What is Reconstructive Urology?
Melanie Cole (Host): At City of Hope, the physicians are leading experts in treating patients with all types of urologic cancers. Just as no two patients are alike, cancer requires a unique treatment plan that's tailored to each individual to attain the best possible outcomes. My guest today is Dr. Nick Warner. He’s a reconstructive urologist at City of Hope. Welcome to the show, Dr. Warner. Tell us, what is reconstructive urology and who would require treatment from you?
Dr. Nick Warner (Guest): Okay. The first thing is what is reconstructive urology? The best way to think about it is bringing normal function back to the urologic system. So, in relation to cancer, any patient that's undergone prostate cancer treatment or bladder cancer treatment might suffer from urinary incontinence after the procedure or erectile dysfunction after the procedure. My specialty is bringing those functions back to the patients after the treatment. In addition, a lot of my practice revolves around what's called the urethral stricture disease and this can be from benign things or it can be cancer related. My specialty is repairing the strictures no matter where they occur in the urinary system, whether it's a tube that drains the kidney or the tube that drains the bladder, and repairing those problems.
Melanie: So, if somebody needs reconstructive urology or reconstructive surgery, this would be if they've had their prostate removed or part of their bladder cut out or removed. Is that what we are talking about?
Dr. Warner: Yes, as far as the cancer side of the thing goes. Absolutely. Or, if they've had radiation in that area. Radiation can affect the nerves that supply erection and it can also cause strictures or narrowing of the tubes that people pee through. So, we work with those patients as well.
Melanie: What does that treatment involve? What's it like when we hear about those strictures and you want to help someone regain sexual function or help for their incontinence?
Dr. Warner: So, there are a lot of options for their regaining the erectile function. So, we usually start with oral medications that help enhance the blood flow to the penis. Oftentimes, those aren’t successful because the nerves are damaged and the oral medication depends on those nerves. So, we have to directly work on the penis and we can do that through different therapies. One is the injection therapy that we can put right into the penis, which sounds terrible but actually is very well tolerated. There's vacuum erection devices which basically create suction over the penis that pulls blood in the penis and also works very well. Then, the last step is really a surgery that replaces the natural erection with an inflatable device, which also doesn't sound good but patients are very happy with these options. And then, as far as the strictures go, it depends on the location of the strictures. Oftentimes, what we do is we take a graft from somewhere else in the body, usually the inside of the mouth, and patch it into the urethra where there is a narrowing. And again, that sounds terrible but patients actually do quite well and are very happy with this procedure once it's done. Especially if they can urinate normally and regain their normal functions.
Melanie: Wow! Absolutely fascinating. How amazing are you? What is recovery like because these sound like bigger procedures than I imagine that they are? And are these done laparoscopically? Are they done more minimally invasive? What are they like?
Dr. Warner: Well, the majority of the external genital procedures we do—so, erectile dysfunction surgery or urethroplasties--are actually done outside the body, so we can't really do them laparoscopically, but the recovery time is very short. Most patients go home the same day as the operation or, it’s a short, overnight, 24-hour admission into the hospital and then they go home, most of the times with the Foley catheter if it's a stricture and recovery is about two weeks after the operation before people feel like their normal selves again. If it's an abdominal stricture—so, someone who's had, say, radiation to the abdomen for some kind of cancer that caused a narrowing of the tube that drains the kidney--most of the time, we can repair those through robotic approaches which is a small little incision in the abdomen. Again, a one night hospital stay and they are doing pretty good within two weeks as well.
Melanie: So then, are these strictures things that come back, Dr. Warner? Or, once you've fixed them are they gone then?
Dr. Warner: Unfortunately, with any surgery there's always chance for recurrence but for the most part with urethral strictures, the success rate is around 90%. So, anything I do works about 90% of the time. And then, in the abdomen, in any of the ureteral stricture repairs, the success rate is slightly higher. About 95% of the time, we fix those problems.
Melanie: So then, what can patients expect for their outcome? Who would be a patient that couldn't have this reconstructive procedure done?
Dr. Warner: If somebody has had a lot of abdominal surgeries and it's just not a safe environment to operate on, or somebody who's not healthy enough to undergo the operation. I'd say those are the two instances where we probably would find another means to treat the stricture. There are things that we can do to bypass the stricture. Stents allow us--it's not a permanent fix but it can be something that we change on a routine basis to help keep the ureter open or keep the urethra open. That isn't fixing the problem but definitely temporarily solving the problem.
Melanie: When we are talking about some of the side effects of bladder cancer, prostate cancer and you've talked about the strictures and the reconstructive surgery, then those side effects and you've mentioned erectile dysfunction, and that's what you're intending to do. Does this go along, Dr. Warner, with medication, then, for the future of this man?
Dr. Warner: Absolutely. Some of the therapies we use to treat erectile dysfunction, will make it so they no longer have to take the oral medications and so it all depends on what we're working with. Some of them you can use together; others you can't.
Melanie: And where is fertility in all of this?
Dr. Warner: Unfortunately, after a prostate is removed, the fertility option is pretty minimal in a natural way. There are still options if somebody is young enough and they are interested in having children, then they can harvest sperm through another means. But for the most part, fortunately, the majority of men who do get cancer are beyond the desired age or the interested age of having more children.
Melanie: And where bladder cancer is concerned, of course incontinence is something that people worry about because it really affects that quality of life. What do you tell men and/or women about the change that you can help them make in the quality of their life?
Dr. Warner: I'd say they are quite dramatic, actually. What we first start with is the severity of the incontinence. So, some people are real bothered if they leak at small amount whereas other men could be filling a diaper and they don't really care. So, we first start on that plane: where are they in their bother scale? And then, we look at the actual volume that they are leaking and then we really determine what the best approach is. If somebody leaks only a small amount, then we have options of putting a sling in, which essentially is support for the urethra making it more effective at its job. And if somebody leaks a significant amount, we actually have artificial devices that act as a natural sphincter, so it's a loop around the urethra or cuff around the urethra that closes the urethra off. When they're ready to urinate, they squeeze a button; that cuff opens and allows the urine to pass. So, we really have good options that can keep people quite happy.
Melanie: Is there anything people can do to prepare for these surgeries? Is there a learning curve? Does doing Kegels or strengthening those pelvic floor muscles help at all?
Dr. Warner: In my opinion, I think those things are good in anybody. Whether you've had cancer or not I think those things are just healthy; healthy pelvic floor exercises that everybody should be doing, especially in these patients because outcomes will be better no matter what we do if those things are up to par.
Melanie: Is there physical therapy required afterwards at all?
Dr. Warner: Not really, no. No
Melanie: Wow that is just absolutely amazing. And in just the last few minutes, what's on the horizon, Dr. Warner, for the urologic cancers? What do you see happening that could be very new, advanced and exciting that you're doing there at City of Hope?
Dr. Warner: I think the most important thing that City of Hope is working on is new cancer therapies through chemotherapies and immunotherapies that are targeting cancer cells specifically in a way that doesn't have the same side effect profile as traditional chemotherapy agents and, especially with kidney cancer, the chemotherapy options are not outstanding and so I think if we can develop a better option for people, we can really make a difference in the survival of these patients.
Melanie: And why should patients come to City of Hope for their care? And also, give your best advice for patients that are considering these types of reconstructive surgery and might be afraid to ask you certain questions.
Dr. Warner: First thing I'd say is, never be afraid to ask a question and never be afraid to get a second opinion. And I fully believe that if somebody--one of my patients--needs a second opinion, then I'm going to be in full support of that and I would actually have good recommendations for them of people I trust that they should see. The other thing I'd recommend is know all the information you can. So, do your research beforehand and understand that City of Hope is probably on the forefront of the majority of the cancers that you are facing, both in research and surgical technique. Look at the place that you are being treated or considering being treated and make sure that they are doing everything they can to advance the fields in all these ways, both surgical and research.
Melanie: Thank you so much, Dr. Warner. It's great information. Absolutely fascinating. You are listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
What is Reconstructive Urology?
Melanie Cole (Host): At City of Hope, the physicians are leading experts in treating patients with all types of urologic cancers. Just as no two patients are alike, cancer requires a unique treatment plan that's tailored to each individual to attain the best possible outcomes. My guest today is Dr. Nick Warner. He’s a reconstructive urologist at City of Hope. Welcome to the show, Dr. Warner. Tell us, what is reconstructive urology and who would require treatment from you?
Dr. Nick Warner (Guest): Okay. The first thing is what is reconstructive urology? The best way to think about it is bringing normal function back to the urologic system. So, in relation to cancer, any patient that's undergone prostate cancer treatment or bladder cancer treatment might suffer from urinary incontinence after the procedure or erectile dysfunction after the procedure. My specialty is bringing those functions back to the patients after the treatment. In addition, a lot of my practice revolves around what's called the urethral stricture disease and this can be from benign things or it can be cancer related. My specialty is repairing the strictures no matter where they occur in the urinary system, whether it's a tube that drains the kidney or the tube that drains the bladder, and repairing those problems.
Melanie: So, if somebody needs reconstructive urology or reconstructive surgery, this would be if they've had their prostate removed or part of their bladder cut out or removed. Is that what we are talking about?
Dr. Warner: Yes, as far as the cancer side of the thing goes. Absolutely. Or, if they've had radiation in that area. Radiation can affect the nerves that supply erection and it can also cause strictures or narrowing of the tubes that people pee through. So, we work with those patients as well.
Melanie: What does that treatment involve? What's it like when we hear about those strictures and you want to help someone regain sexual function or help for their incontinence?
Dr. Warner: So, there are a lot of options for their regaining the erectile function. So, we usually start with oral medications that help enhance the blood flow to the penis. Oftentimes, those aren’t successful because the nerves are damaged and the oral medication depends on those nerves. So, we have to directly work on the penis and we can do that through different therapies. One is the injection therapy that we can put right into the penis, which sounds terrible but actually is very well tolerated. There's vacuum erection devices which basically create suction over the penis that pulls blood in the penis and also works very well. Then, the last step is really a surgery that replaces the natural erection with an inflatable device, which also doesn't sound good but patients are very happy with these options. And then, as far as the strictures go, it depends on the location of the strictures. Oftentimes, what we do is we take a graft from somewhere else in the body, usually the inside of the mouth, and patch it into the urethra where there is a narrowing. And again, that sounds terrible but patients actually do quite well and are very happy with this procedure once it's done. Especially if they can urinate normally and regain their normal functions.
Melanie: Wow! Absolutely fascinating. How amazing are you? What is recovery like because these sound like bigger procedures than I imagine that they are? And are these done laparoscopically? Are they done more minimally invasive? What are they like?
Dr. Warner: Well, the majority of the external genital procedures we do—so, erectile dysfunction surgery or urethroplasties--are actually done outside the body, so we can't really do them laparoscopically, but the recovery time is very short. Most patients go home the same day as the operation or, it’s a short, overnight, 24-hour admission into the hospital and then they go home, most of the times with the Foley catheter if it's a stricture and recovery is about two weeks after the operation before people feel like their normal selves again. If it's an abdominal stricture—so, someone who's had, say, radiation to the abdomen for some kind of cancer that caused a narrowing of the tube that drains the kidney--most of the time, we can repair those through robotic approaches which is a small little incision in the abdomen. Again, a one night hospital stay and they are doing pretty good within two weeks as well.
Melanie: So then, are these strictures things that come back, Dr. Warner? Or, once you've fixed them are they gone then?
Dr. Warner: Unfortunately, with any surgery there's always chance for recurrence but for the most part with urethral strictures, the success rate is around 90%. So, anything I do works about 90% of the time. And then, in the abdomen, in any of the ureteral stricture repairs, the success rate is slightly higher. About 95% of the time, we fix those problems.
Melanie: So then, what can patients expect for their outcome? Who would be a patient that couldn't have this reconstructive procedure done?
Dr. Warner: If somebody has had a lot of abdominal surgeries and it's just not a safe environment to operate on, or somebody who's not healthy enough to undergo the operation. I'd say those are the two instances where we probably would find another means to treat the stricture. There are things that we can do to bypass the stricture. Stents allow us--it's not a permanent fix but it can be something that we change on a routine basis to help keep the ureter open or keep the urethra open. That isn't fixing the problem but definitely temporarily solving the problem.
Melanie: When we are talking about some of the side effects of bladder cancer, prostate cancer and you've talked about the strictures and the reconstructive surgery, then those side effects and you've mentioned erectile dysfunction, and that's what you're intending to do. Does this go along, Dr. Warner, with medication, then, for the future of this man?
Dr. Warner: Absolutely. Some of the therapies we use to treat erectile dysfunction, will make it so they no longer have to take the oral medications and so it all depends on what we're working with. Some of them you can use together; others you can't.
Melanie: And where is fertility in all of this?
Dr. Warner: Unfortunately, after a prostate is removed, the fertility option is pretty minimal in a natural way. There are still options if somebody is young enough and they are interested in having children, then they can harvest sperm through another means. But for the most part, fortunately, the majority of men who do get cancer are beyond the desired age or the interested age of having more children.
Melanie: And where bladder cancer is concerned, of course incontinence is something that people worry about because it really affects that quality of life. What do you tell men and/or women about the change that you can help them make in the quality of their life?
Dr. Warner: I'd say they are quite dramatic, actually. What we first start with is the severity of the incontinence. So, some people are real bothered if they leak at small amount whereas other men could be filling a diaper and they don't really care. So, we first start on that plane: where are they in their bother scale? And then, we look at the actual volume that they are leaking and then we really determine what the best approach is. If somebody leaks only a small amount, then we have options of putting a sling in, which essentially is support for the urethra making it more effective at its job. And if somebody leaks a significant amount, we actually have artificial devices that act as a natural sphincter, so it's a loop around the urethra or cuff around the urethra that closes the urethra off. When they're ready to urinate, they squeeze a button; that cuff opens and allows the urine to pass. So, we really have good options that can keep people quite happy.
Melanie: Is there anything people can do to prepare for these surgeries? Is there a learning curve? Does doing Kegels or strengthening those pelvic floor muscles help at all?
Dr. Warner: In my opinion, I think those things are good in anybody. Whether you've had cancer or not I think those things are just healthy; healthy pelvic floor exercises that everybody should be doing, especially in these patients because outcomes will be better no matter what we do if those things are up to par.
Melanie: Is there physical therapy required afterwards at all?
Dr. Warner: Not really, no. No
Melanie: Wow that is just absolutely amazing. And in just the last few minutes, what's on the horizon, Dr. Warner, for the urologic cancers? What do you see happening that could be very new, advanced and exciting that you're doing there at City of Hope?
Dr. Warner: I think the most important thing that City of Hope is working on is new cancer therapies through chemotherapies and immunotherapies that are targeting cancer cells specifically in a way that doesn't have the same side effect profile as traditional chemotherapy agents and, especially with kidney cancer, the chemotherapy options are not outstanding and so I think if we can develop a better option for people, we can really make a difference in the survival of these patients.
Melanie: And why should patients come to City of Hope for their care? And also, give your best advice for patients that are considering these types of reconstructive surgery and might be afraid to ask you certain questions.
Dr. Warner: First thing I'd say is, never be afraid to ask a question and never be afraid to get a second opinion. And I fully believe that if somebody--one of my patients--needs a second opinion, then I'm going to be in full support of that and I would actually have good recommendations for them of people I trust that they should see. The other thing I'd recommend is know all the information you can. So, do your research beforehand and understand that City of Hope is probably on the forefront of the majority of the cancers that you are facing, both in research and surgical technique. Look at the place that you are being treated or considering being treated and make sure that they are doing everything they can to advance the fields in all these ways, both surgical and research.
Melanie: Thank you so much, Dr. Warner. It's great information. Absolutely fascinating. You are listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.