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Urologic Reconstruction and Indications For Referral
Krishnan Venkatesan, MD, discusses the specific conditions that may require urologic reconstruction, including erectile dysfunction (ED), Peyronie's disease, urinary fistulas, and urethral stricture. He outlines best practices in speaking to patients about these oftentimes sensitive subjects, as well as how to recognize when they might benefit from an appointment with a specialist.
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Learn more about Krishnan Venkatesan, MD
Krishnan Venkatesan, MD
Krishnan Venkatesan, MD, is the Director of Urologic Reconstruction at Medstar Washington Hospital Center.Learn more about Krishnan Venkatesan, MD
Transcription:
Urologic Reconstruction and Indications For Referral
Melanie Cole (Host): The surgical treatment of complicated urologic disorders in men requires extensive expertise and performing delicate surgeries. My guest today is Dr. Krishnan Venkatesan. He’s the director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome to the show, Dr. Venkatesan. Let’s just start with what has typically been done in the past for men with various urologic dysfunctions.
Dr. Krishnan Venkatesan (Guest): Hi, Melanie. Thank you for having me. Urologic dysfunction is a broad term, but for many men it can range from any issue, such as trouble with erection, or a curvature with erection, or trouble with urination. Generally, there has been a culture of machismo where men don’t see a doctor regularly and they don’t really seek out any kind of medical care until it’s too late or until the condition gets quite bad. Urologic conditions fall very much into that category of things that guys may be too shy to bring up with their wife, and even too shy to bring up in the locker room, so to speak. So, generally, what we like to encourage is that when primary care physicians are seeing gentlemen for any condition that they also try to broach the topics of how’s the urination, is their urinary quality of life good, or are there bothersome symptoms that they’re having that were so progressive that they didn’t really occur to them and they were just adjusting. And, similarly, for erectile dysfunction, if they’re having an issue in that department, so to speak, it’s something that we try to make very much a judgment-free zone and without any awkwardness so that men can feel comfortable bringing it up and speaking freely about it.
Melanie: What are some of the conditions that would indicate further referral or possibly reconstruction?
Dr. Venkatesan: As far as the indications or the conditions that would need reconstruction, generally they are divided into the anatomic differences in men. So, one condition would be urethral stricture, which is basically a scar tissue or obstruction in the urethra, which is the pipe that passes urine from the bladder to the outside world. So, this stricture can occur from any number of reasons. in fact, in almost half of men there’s no clear explanation, but in many men it could be a result of trauma, like landing hard on the bicycle bar, or on a handlebar, or on a stairwell, or even during horseplay, if there’s some trauma to the genitalia or the perineum, the area behind the scrotum, this could result in some damage to the urethra. It could also be a result of prior procedures, having had a catheter before, or even an infection. Some of the other conditions include urinary tract fistulas. A fistula is basically an abnormal connection between two adjacent structures. So, it could be a hole from the urethra to the skin or a connection from the rectum to the urethra, depending on what treatments the patient had previously or what other pathology the patient might have underlying. These fistulas generally are unlikely to heal with conservative management, so they may need surgery to repair them. There’s also a condition called hypospadias, which is actually congenital. This is when boys are born with the opening of the penis not right at the tip of the penis but rather on the underside somewhere along the shaft. Aside from being a cosmetic issue, in the long run that opening can get tight and cause urinary obstruction, and it can also cause issues with the ability to conceive children because men cannot deposit semen in the right location to be able to impregnate a female. There’s also other anatomy that basically could require reconstruction. Men can sometimes develop a curvature with erection. This is commonly known as Peyronie’s disease, and this may require surgery for correction. Not all men require surgery, but if the curvature is bad enough that they’re not able to penetrate, or if it’s painful to penetrate, or it’s painful for their partner, then it may be something that needs specific interventions. There’s also erectile dysfunction itself which may need either medical or surgical intervention. Then, there are also other traumatic injuries, like we mentioned previously, such as ureteral injury. The ureters are basically the tubes that connect the kidneys to the bladder and deliver urine that the kidneys make down into the bladder. These can be injured generally from other surgeries that are going on in the abdomen. They can be injured by stone surgeries or any manipulation of the ureters themselves and, of course, can be injured by outside trauma, such as blunt or penetrating trauma. That goes really for any other part of the urinary tract. Kidney trauma may require surgery, although that’s not that common that it does. Bladder injuries as well as injuries to the penis and urethra and testicles and anything else in the scrotum may all require some kind of intervention and sometimes, depending on the trauma, that may need to be done emergently.
Melanie: What are some of the current thinking in treatment approaches, doctor, because certainly, you mentioned at the beginning, getting men in to see the doctor is certainly a thing, so doctors have to be aware of that ability to get men to take action with some of these. So, what do you tell men and what it the current thinking in some of the treatment for urinary tract fistulas, for example?
Dr. Venkatesan: The general treatment for fistulas and for most conditions, the philosophy is to basically go from least invasive and end with the most invasive treatment option. So, if there’s something that is available that is the least invasive, the least likely to cause additional side effects or risks or compromise from the treatment itself, and has the quickest recovery, that’s obviously the most ideal option. The example I actually like to give is, for example, for erectile dysfunction, treatment starts with pills like Viagra and Cialis, and if those don’t work, moves on to a vacuum erectile device, and beyond that, then injections where the patient actually has to learn to inject themselves directly into the penis with the medication. And then, lastly, the most invasive option would be a penile prosthesis, which is actually a surgically implanted device that can restore erective function. Of course, the treatment options are not the same for different conditions, but the general philosophy is that surgery generally ought to be a last resort. Sometimes, there are not many other options aside from surgery, but if we can be conservative, then we’ll certainly try to be.
Melanie: What about indications for referral? If somebody has a urethral stricture or even BPH and their first line of defense is not working, give us some indications for other physicians for a referral?
Dr. Venkatesan: That’s a good point. Any time the patient has a known diagnosis or something like urethral stricture where they may have been treated many years ago and they finally realize that their symptoms have recurred; they’re having a slowing stream, trouble emptying, recurring infections, bladder stones, or a worst case scenario where they’re actually having some retrograde effect and it’s affecting their kidney function, then all of those are good indication or a good reason to refer somebody to a reconstructive urologist. Similarly, if you have a patient who has a known diagnosis of BPH or a presumed diagnosis of BPH, but they’re not responding to the first-line medications such as Tamsulosin, or their symptoms are progressively worsening despite being on medication, then that would be a good indication for the patient to see a urologist or perhaps even a reconstructive urologist to ensure that there’s no other underlying pathology that could be a confounding factor, like a stricture, for example, which will cause many of the same symptoms but won’t really respond to the BPH medication.
Melanie: And, what does the surgical game plan involve, who do you involve in all of this?
Dr. Venkatesan: The surgical game plan generally, of course, depends on the surgery that’s necessary. I work closely with my plastic surgery colleagues. So, for patients who have complex fistulas, we may need to recruit one of the muscles from the inner thigh to help sandwich that between the two areas that are having an abnormal connection. So, in that case, I will do part of the surgery to expose that anatomy, and then the plastic surgery team will come in and harvest that muscle that’s called the
“gracilis muscle”, and then they may interpose that between the bladder and rectum or the urethra and the rectum, and, in that case, of course, it’s a kind of a tag team approach. Otherwise, the surgical game plan, in general, for all patients starts with a good preoperative visit where we discuss all the treatment options. We discuss what is the best option for them and then we discuss the technical aspects of surgery, like how exactly I am going to do it; then, we talk about the risks, and we talk about the recovery; and, of course, we get all the patient’s questions answered. The important thing is that the patient is on the same page as us as far as expectations from surgery and that there are no surprises on the day of or afterwards.
Melanie: Wrap it for us, Dr. Venkatesan. As reconstructive surgery for men in urologic conditions, what do you tell your patients and what would you like other physicians to know about speaking to their patients about these delicate procedures?
Dr. Venkatesan: I think the best philosophy is that quality of life is very important, and patients often find it difficult to bring this up. So, sometimes the onus is 50/50. It is just as important for a primary care physician or that frontline of healthcare professionals to help bring this up and to help address those issues and triage them appropriately. The reason I say that is not only because quality of life is important for happy healthy people, but also because sometimes these are conditions that are the sentinel signs of some other underlying dysfunction. To go back to erectile dysfunction, for example, erectile dysfunction may be the first sign of some other cardiovascular disease or arteriosclerotic disease happening systemically. So, often in a patient who believes he’s otherwise healthy or has really never seen or followed up with a doctor, if he presents with complaints of erectile dysfunction, that’s a good conversation starter for a primary care doctor, or for a urologist, for that matter, to say, “Hey, there’s no clear explanation for this problem, we ought to probably have you get checked out and do a comprehensive health evaluation.” So, it’s helpful in both directions.
Melanie: Thank you so much for being with us today, doctor. You are you listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.MedStarWashington.Org. That’s www.MedStarWashington.org. This is Melanie Cole. Thanks so much for listening.
Urologic Reconstruction and Indications For Referral
Melanie Cole (Host): The surgical treatment of complicated urologic disorders in men requires extensive expertise and performing delicate surgeries. My guest today is Dr. Krishnan Venkatesan. He’s the director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome to the show, Dr. Venkatesan. Let’s just start with what has typically been done in the past for men with various urologic dysfunctions.
Dr. Krishnan Venkatesan (Guest): Hi, Melanie. Thank you for having me. Urologic dysfunction is a broad term, but for many men it can range from any issue, such as trouble with erection, or a curvature with erection, or trouble with urination. Generally, there has been a culture of machismo where men don’t see a doctor regularly and they don’t really seek out any kind of medical care until it’s too late or until the condition gets quite bad. Urologic conditions fall very much into that category of things that guys may be too shy to bring up with their wife, and even too shy to bring up in the locker room, so to speak. So, generally, what we like to encourage is that when primary care physicians are seeing gentlemen for any condition that they also try to broach the topics of how’s the urination, is their urinary quality of life good, or are there bothersome symptoms that they’re having that were so progressive that they didn’t really occur to them and they were just adjusting. And, similarly, for erectile dysfunction, if they’re having an issue in that department, so to speak, it’s something that we try to make very much a judgment-free zone and without any awkwardness so that men can feel comfortable bringing it up and speaking freely about it.
Melanie: What are some of the conditions that would indicate further referral or possibly reconstruction?
Dr. Venkatesan: As far as the indications or the conditions that would need reconstruction, generally they are divided into the anatomic differences in men. So, one condition would be urethral stricture, which is basically a scar tissue or obstruction in the urethra, which is the pipe that passes urine from the bladder to the outside world. So, this stricture can occur from any number of reasons. in fact, in almost half of men there’s no clear explanation, but in many men it could be a result of trauma, like landing hard on the bicycle bar, or on a handlebar, or on a stairwell, or even during horseplay, if there’s some trauma to the genitalia or the perineum, the area behind the scrotum, this could result in some damage to the urethra. It could also be a result of prior procedures, having had a catheter before, or even an infection. Some of the other conditions include urinary tract fistulas. A fistula is basically an abnormal connection between two adjacent structures. So, it could be a hole from the urethra to the skin or a connection from the rectum to the urethra, depending on what treatments the patient had previously or what other pathology the patient might have underlying. These fistulas generally are unlikely to heal with conservative management, so they may need surgery to repair them. There’s also a condition called hypospadias, which is actually congenital. This is when boys are born with the opening of the penis not right at the tip of the penis but rather on the underside somewhere along the shaft. Aside from being a cosmetic issue, in the long run that opening can get tight and cause urinary obstruction, and it can also cause issues with the ability to conceive children because men cannot deposit semen in the right location to be able to impregnate a female. There’s also other anatomy that basically could require reconstruction. Men can sometimes develop a curvature with erection. This is commonly known as Peyronie’s disease, and this may require surgery for correction. Not all men require surgery, but if the curvature is bad enough that they’re not able to penetrate, or if it’s painful to penetrate, or it’s painful for their partner, then it may be something that needs specific interventions. There’s also erectile dysfunction itself which may need either medical or surgical intervention. Then, there are also other traumatic injuries, like we mentioned previously, such as ureteral injury. The ureters are basically the tubes that connect the kidneys to the bladder and deliver urine that the kidneys make down into the bladder. These can be injured generally from other surgeries that are going on in the abdomen. They can be injured by stone surgeries or any manipulation of the ureters themselves and, of course, can be injured by outside trauma, such as blunt or penetrating trauma. That goes really for any other part of the urinary tract. Kidney trauma may require surgery, although that’s not that common that it does. Bladder injuries as well as injuries to the penis and urethra and testicles and anything else in the scrotum may all require some kind of intervention and sometimes, depending on the trauma, that may need to be done emergently.
Melanie: What are some of the current thinking in treatment approaches, doctor, because certainly, you mentioned at the beginning, getting men in to see the doctor is certainly a thing, so doctors have to be aware of that ability to get men to take action with some of these. So, what do you tell men and what it the current thinking in some of the treatment for urinary tract fistulas, for example?
Dr. Venkatesan: The general treatment for fistulas and for most conditions, the philosophy is to basically go from least invasive and end with the most invasive treatment option. So, if there’s something that is available that is the least invasive, the least likely to cause additional side effects or risks or compromise from the treatment itself, and has the quickest recovery, that’s obviously the most ideal option. The example I actually like to give is, for example, for erectile dysfunction, treatment starts with pills like Viagra and Cialis, and if those don’t work, moves on to a vacuum erectile device, and beyond that, then injections where the patient actually has to learn to inject themselves directly into the penis with the medication. And then, lastly, the most invasive option would be a penile prosthesis, which is actually a surgically implanted device that can restore erective function. Of course, the treatment options are not the same for different conditions, but the general philosophy is that surgery generally ought to be a last resort. Sometimes, there are not many other options aside from surgery, but if we can be conservative, then we’ll certainly try to be.
Melanie: What about indications for referral? If somebody has a urethral stricture or even BPH and their first line of defense is not working, give us some indications for other physicians for a referral?
Dr. Venkatesan: That’s a good point. Any time the patient has a known diagnosis or something like urethral stricture where they may have been treated many years ago and they finally realize that their symptoms have recurred; they’re having a slowing stream, trouble emptying, recurring infections, bladder stones, or a worst case scenario where they’re actually having some retrograde effect and it’s affecting their kidney function, then all of those are good indication or a good reason to refer somebody to a reconstructive urologist. Similarly, if you have a patient who has a known diagnosis of BPH or a presumed diagnosis of BPH, but they’re not responding to the first-line medications such as Tamsulosin, or their symptoms are progressively worsening despite being on medication, then that would be a good indication for the patient to see a urologist or perhaps even a reconstructive urologist to ensure that there’s no other underlying pathology that could be a confounding factor, like a stricture, for example, which will cause many of the same symptoms but won’t really respond to the BPH medication.
Melanie: And, what does the surgical game plan involve, who do you involve in all of this?
Dr. Venkatesan: The surgical game plan generally, of course, depends on the surgery that’s necessary. I work closely with my plastic surgery colleagues. So, for patients who have complex fistulas, we may need to recruit one of the muscles from the inner thigh to help sandwich that between the two areas that are having an abnormal connection. So, in that case, I will do part of the surgery to expose that anatomy, and then the plastic surgery team will come in and harvest that muscle that’s called the
“gracilis muscle”, and then they may interpose that between the bladder and rectum or the urethra and the rectum, and, in that case, of course, it’s a kind of a tag team approach. Otherwise, the surgical game plan, in general, for all patients starts with a good preoperative visit where we discuss all the treatment options. We discuss what is the best option for them and then we discuss the technical aspects of surgery, like how exactly I am going to do it; then, we talk about the risks, and we talk about the recovery; and, of course, we get all the patient’s questions answered. The important thing is that the patient is on the same page as us as far as expectations from surgery and that there are no surprises on the day of or afterwards.
Melanie: Wrap it for us, Dr. Venkatesan. As reconstructive surgery for men in urologic conditions, what do you tell your patients and what would you like other physicians to know about speaking to their patients about these delicate procedures?
Dr. Venkatesan: I think the best philosophy is that quality of life is very important, and patients often find it difficult to bring this up. So, sometimes the onus is 50/50. It is just as important for a primary care physician or that frontline of healthcare professionals to help bring this up and to help address those issues and triage them appropriately. The reason I say that is not only because quality of life is important for happy healthy people, but also because sometimes these are conditions that are the sentinel signs of some other underlying dysfunction. To go back to erectile dysfunction, for example, erectile dysfunction may be the first sign of some other cardiovascular disease or arteriosclerotic disease happening systemically. So, often in a patient who believes he’s otherwise healthy or has really never seen or followed up with a doctor, if he presents with complaints of erectile dysfunction, that’s a good conversation starter for a primary care doctor, or for a urologist, for that matter, to say, “Hey, there’s no clear explanation for this problem, we ought to probably have you get checked out and do a comprehensive health evaluation.” So, it’s helpful in both directions.
Melanie: Thank you so much for being with us today, doctor. You are you listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.MedStarWashington.Org. That’s www.MedStarWashington.org. This is Melanie Cole. Thanks so much for listening.