Percutaneous nephrolithotomy (PCNL)

Percutaneous removal of kidney stones (PCNL) is keyhole surgery. Under general anaesthetic the stone is removed by passing a small telescope through your side directly into the kidney. The stone is broken up and the fragments are removed.

 

Before your operation

You have a kidney stone visible on x-ray that is suitable for PCNL. The operation and outcomes will be explained to you by your surgeon. When you feel comfortable that you understand what is to be done and have had all your questions answered you will be asked to sign a consent form. This consent form should be signed by both yourself and your surgeon, and forwarded to the hospital prior to your admission.

A blood test will need to be performed, and a urine sample may need to be taken 4-5 days prior to surgery. Your surgeon will give you a form to take to the laboratory to have these tests done.

An x-ray may be performed just before your surgery to check the position of your stone.

If you are over 60, or have other medical problems, you may also have an electrocardiogram (ECG) to check the health of your heart prior to surgery.

Operation day

You will be advised when to stop eating and drinking before surgery. You should bring all your own medications with you to hospital.

On arrival to the ward the staff will show you to your bed and guide you through what is required prior to your operation.

This operation is performed under general anaesthesia. The anaesthetist will see you before the operation. Just prior to surgery you may be given a tablet to help you relax.

You will have protective stockings fitted.

 

The operation

First, a small tube is inserted up the ureter (tube from kidney to bladder) by means of a telescope passed into the bladder. 

You are then turned face down (on your stomach) and a small (keyhole) incision is made into the kidney, using x-ray guidance. Sometimes you will be on your back.

Finally, a telescope is passed into the kidney. The surgeon locates and removes the stone by breaking it into pieces using laser or ultrasound.

When you wake up you will have a small tube coming from your kidney draining the urine into a bag. This is usually removed the next day. You will also have a catheter in your bladder draining urine. This will also be removed the next day. You will usually go home the day following your surgery.

 

After discharge

You will receive a follow up appointment for 6 weeks after your operation. 

It may take at least 2 weeks to recover fully from the operation. You should not expect to return to work within 10 days, especially if your job is physically strenuous.

You can usually resume driving when you feel that you could perform an emergency stop without being concerned about pain (usually about two weeks).

When you get home you should drink twice as much as you would normally to flush your system through and minimise any bleeding. You should aim to keep your urine permanently colourless to minimise the risk of further stone formation.

 

Complications

All procedures have a potential for side effects. You should be reassured that although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

• It is common to have blood in the urine
• Occasionally more than one puncture site (keyhole) is required into the kidney
• Sometimes, not all stones are able to be removed from the kidney
• It may not be possible to gain access to the kidney, resulting in the need for a different type of surgery such as ureteroscopy or lithotripsy

Lithotripsy (ESWL)

Mobile Medical Technology lithotripsy bus

Extracorporeal shock wave lithotripsy (ESWL) or lithotripsy for short, is a commonly used non-invasive alternative to surgery for the treatment of kidney stones.

The procedure is done under sedation or anaesthetic on the lithotripsy bus. It works by focusing high energy acoustic pulses that pass through the skin and disintegrate the stones. The sand-like fragments can then pass out of the body in urine.

While the vast majority of stones in the urinary tract can be treated successfully with lithotripsy, some are resistant to this method and may require a repeat or alternative treatment. 

Lithotripsy has the advantage of typically a much faster recovery than conventional stone surgery.

 

Before your operation

The operation and outcomes will be explained to you by your urologist. When you feel comfortable that you understand what is to be done and have had all your questions answered, you will be asked to sign a consent form. This consent form should be signed by both yourself and your surgeon and forwarded to the hospital at least five days prior to your admission.

If you are over 60, or have other medical conditions, you may also need an electrocardiogram (ECG) to check the health of your heart prior to surgery.

Operation day

You will be required to come to the hospital approximately two hours prior to your treatment. This will be confirmed by the hospital the day before your admission.

On arrival you will be taken through pre-admission requirements and shown to your room.

An x-ray of your abdomen may be performed to check the location of the stone.

When it is time for treatment a nurse will escort you from the ward to the Lithotripsy bus which is set up outside the hospital, where you will meet the urologist.

After lying down on the lithotripsy table, a drip is inserted into a vein in your arm. Through this drip the anaesthetist can give you sedation medicine and pain relief during the treatment depending on your individual requirements.

You will be positioned so that you are in the ideal place for treatment. A rubber pad covered with a special gel is placed against the skin. Using ultrasound or x-ray guidance, the shock waves are focused on the stone and treatment will begin.

 

The procedure

The lithotripsy machine makes a sound like a hammer tapping.

The treatment normally lasts between 1 to 1.5 hours. At the end of the treatment you will be transferred to a wheelchair and taken to the ward for recovery.

 

Recovery

You will go to day surgery area after the procedure. Once able, you will be encouraged to drink plenty of fluid to assist flushing out the stone fragments.

It is common to have a little nausea immediately following the treatment but this is usually resolved by the time of discharge.

After a period of observation you will be discharged home. Some cases may require an overnight stay. Usually work and other normal activities may be resumed the following day if you feel able. You can discuss this with your urologist.

 

After discharge

You may eat and drink normally following this treatment and it is important to keep up a good fluid intake. 

Stone fragments will pass out of the body into the urine.  Occasionally this can cause discomfort and pain as they travel out. You will be given a prescription for pain relief in case this happens.

You will receive a follow-up appointment to see your specialist at six weeks to discuss the results of your treatment. Prior to this you will have an x-ray to check the stone has passed.

 

Complications

Seek immediate advice from Urology Associates or the on call urologist if you develop high fevers and pain. You may have developed an infection following lithotripsy treatment.

Some blood in the urine can occur after this treatment.

Seek prompt advice from Urology Associates or your GP if you experience difficulty urinating or the blood in your urine does not resolve.

There is often bruising or a mild graze on the skin where the shock waves have passed through the body. There may be some bruising to the kidney which can be painful.

 

Unsuccessful treatment

There is a chance that lithotripsy may not be successful in breaking up a stone on the first attempt. If the stone is not fully treated, a second lithotripsy may be recommended. Alternatively a surgical option may be explored if it is decided that further lithotripsy is unlikely to help. Your urologist will discuss these options with you.

Active surveillance

Active surveillance is a way of monitoring prostate cancer which aims to avoid unnecessary treatment in men with less aggressive cancer. 

Active surveillance is suitable for men with low risk, early stage prostate cancer. To decide if you are suitable for active surveillance, your urologist will consider:

• your PSA level
• your biopsy findings
• what your prostate feels like during digital rectal examination (DRE)

 

Active surveillance vs Watchful waiting

Active surveillance and watchful waiting are two ways of monitoring prostate cancer and avoiding immediate treatment.

Watchful waiting involves yearly PSA blood tests with the aim to control the cancer, rather than getting rid of it completely. It is suitable for older men and men who have other health problems where prostate cancer is unlikely to affect their life expectancy.

Active surveillance involves regular tests with the aim to treat to cure the cancer promptly if it shows signs of changing.

 

Active surveillance tests

• Prostate specific antigen (PSA) blood test to measure the amount of PSA in your blood.  PSA is a protein produced by your prostate.
• Digital rectal examination (DRE) where the urologist will feel your prostate gland for changes through the wall of your back passage (rectum).
• Prostate biopsies involves taking small pieces of prostate tissue.  This is sent to the laboratory to look for signs of prostate cancer.  It will be like the biopsy you had when your cancer was first found.  This may be called a transrectal ultrasound prostate (TRUS) biopsy. 
• Saturation grid biopsies are sometimes required if the urologist decides a larger sample of prostate tissue is needed to assist the diagnosis.  This procedure is done under a general anaesthetic.
• Magnetic resonance imaging (MRI) scans may be undertaken to look for any abnormal areas in the prostate.  This will assist the urologist with their diagnosis. This is only required for a small number of men, particularly if the cancer has been hard to find.

If tests show signs that the cancer is changing, your urologist will discuss with you whether you should have treatment and what your options are.

 

Active surveillance protocol

Your urologist will follow a strict protocol which is internationally recognised for the safe follow-up of prostate cancer.

PSA: this will be tested 3 monthly for the first year, then 6 monthly for the next 18 months, then yearly thereafter. Your PSA usually fluctuates each time it is tested, but the general trend is more important than each individual value. This is why it is tested regularly to begin with.

TRUS biopsy: repeat biopsies will be recommended after 6 months, again after a further 2 years, again after a further 3 years, then every 5 years thereafter. The reason to repeat the biopsy is to make sure the cancer is not changing.

DRE: your urologist will feel your prostate gland each time you need a repeat biopsy. This is to ensure that there is no obvious sign of growth of the cancer.

Pubovaginal sling (rectus fascial sling)

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Rectus fascia sling procedure

Rectus fascia sling (also known as pubovaginal sling or autologous sling) is an operation to treat stress urinary incontinence. Stress incontinence is leakage of urine that occurs with activities which cause an increase in abdominal pressure such as coughing, sneezing, jumping, lifting, exercising and in some cases walking.

This leakage occurs because the muscles at the bladder neck have lost their supports and strength. As a valve mechanism, the urethra (waterpipe) no longer stays closed when extra pressure is put on the bladder.

In this operation a strip of tissue is taken from the lower abdomen (tummy) and used as a sling or hammock around the bladder neck and urethra. This differs to other types of sling such as the TVT sling, which uses a synthetic material/mesh to create the sling. The rectus fascia sling therefore provides a mesh-free alternative.

The rectus fascia is the thin but very tough layer that covers the abdominal muscles. A small incision is made just below the bikini line and a strip of the rectus fascia is removed. It is then placed in position under the urethra through an incision in the vagina as a supportive sling.

On average most women are in hospital 2 nights following this type of surgery.

 

Before your operation

In the weeks just prior to surgery it is common to come to Urology Associates to see the continence nurse specialist for a pre-op appointment.

You may have a routine blood test and a urine sample taken prior to your operation. Depending on your age and other medical problems you may also have an electrocardiogram (ECG) to record the electrical activity of your heart.

The operation and possible complications will be explained to you by the doctor. When you feel comfortable that you understand what is to be done and have had all your questions answered you will be asked to sign a consent form.

It is important to avoid constipation. Try to establish and maintain a regular, soft bowel habit leading up to your operation. Identify the foods that can help you in this area for your post-op period.

 

Operation day

You will be advised when to come to hospital (usually by phone the day before your operation).

It is usual to stop eating and drinking at least 6 hours prior to surgery. You should bring your own medications with you and the staff will advise you if you need to take them on the day of your operation.

Before the operation you will be given supportive stockings to wear until you leave hospital to minimise the risk of blood clots forming.

Whether you have a spinal or general anaesthetic will be decided after discussion with the anaesthetist. This usually occurs during in the ward pre-operatively. Just prior to surgery you may be given a pre-medication tablet to relax you.

You will be encouraged to commence deep breathing and coughing exercises to prevent any breathing complications or chest infection occurring following the surgery and anaesthetic.

 

Recovery

When you first wake you will be in the recovery ward. You may feel sleepy and perhaps a little disorientated, but this feeling will pass.

You may eat and drink as desired but initially it is better to start slowly with fluids as the anaesthetic often makes people feel nauseated. There is medication available to control nausea if necessary.

An intravenous line (drip) will be attached to your arm for one or two days to give you some extra fluids. There will be a light dressing on your lower abdomen over the incision.

You will have a catheter (tube) in your bladder via your urethra, draining your urine into a bag. 

While in hospital you will be prescribed paracetamol and you should take this regularly to keep any discomfort to a minimum. Ask the nurses for stronger pain relief if needed.

The day after surgery you will be assisted to shower and encouraged to sit in a chair at least twice during the day. Early mobilisation will minimise the risk of complications.

If a gauze pack was placed in the vagina during surgery, it will usually be removed the next morning before your shower.

One you are drinking normally and your pain is controlled, your drip will be removed.

 

Catheter

• This will usually be removed after two days.

• After a normal intake of fluid it is usual to pass urine every 3-4 hours.

• Initially you should not wait longer than this time before trying to empty your bladder.

• You may find emptying your bladder feels different as it recovers from the surgery and the associated swelling of the surrounding tissues.

• Try to relax your abdominal muscles and the muscles underneath your bladder. Take your time and just let the urine flow out. Do not push or strain as this forces the urethra against the sling, closing it off and stopping the flow of urine.

It is common not to be able to pass urine afterwards. If you cannot pass urine, can pass only a small amount or have bladder discomfort please let your nurse know. The nurse may check your residual urine and arrange a self-catheterisation program if needed. This is called Clean Intermittent Catheterisation (CIC) and can be performed in the privacy of your own bathroom or any toilet. Initially you may have to catheterise each time you need to pass urine but as things return to normal the frequency of your CIC will be reduced. It is not expected that you will need to do this in the long-term unless your urologist advises you of this before the operation.

 

After discharge

Our nurses will contact you by phone to check on your progress. If you have any concerns you may ring any time or arrange an appointment. You will also have a follow-up consultation with your surgeon at approximately six weeks post surgery.

 

Bowels

Keeping a regular, soft bowel motion is important. Kiwi fruit or "Kiwi Crush" are also recommended.

 

Pain control

Take regular pain control. Paracetamol or anti-inflammatory medication such as diclofenac (Voltaren) or ibuprofen (Nurofen) are usually effective.

The more you do, the worse your abdominal pain will get. Use this as a guide for the amount of activity that you do over the next few weeks. If you are sore, rest.

Wound pain sometimes may be worse on one side than the other.

 

Wound care

Your abdominal incision and vaginal wound should heal within 7-10 days however the muscle layer beneath your skin will take up to 3 months to heal. The dressing tape can be removed after 7-10 days.

If you notice the incision becomes inflamed, there is an increase in pain, or it is red, hot or swollen, contact Urology Associates for advice.

 

Vaginal discharge

It is normal to have some vaginal bleeding on and off for a few weeks and then a brown discharge for a few weeks following that. If the bleeding becomes heavy, you pass clots or have a smelly vaginal discharge, contact Urology Associates.

You may also notice the remains of some stitches in your underwear or in the toilet after emptying your bladder. Do not be concerned as these are vaginal stitches which have started to dissolve and that is expected.

 

Pelvic floor exercises

It is important to continue pelvic floor exercises once you have recovered from surgery. If you have any concerns about your technique, please contact our continence nurse specialist.

 

Activity

Initially when you go home you will not feel like doing very much, so listen to your body and rest. Sitting with your feet up will be the most comfortable position.

Things you can do include:

• Showering

• Preparing light meals

• Walking up and down stairs slowly

• Gentle walking is to be encouraged – it is better to do two short walks in the day rather than one long walk

Things you should not do for 6 weeks include:

• Picking up heavy objects off the floor

• Housework except light work at bench height

• Vacuuming

• Carrying supermarket bags / rubbish bags

• Carrying children / pets

Things that you should not do for 12 weeks include:

• Heavy lifting

• Shifting the furniture

• Lawn mowing or digging the garden

• Weights at the gym

• Carrying rubbish bags or washing baskets

• Carrying children / pets

Driving

You should not drive until you feel that you could perform an emergency stop without being concerned about abdominal pain (approximately 3-4 weeks).

Returning to work

Ask your specialist about returning to work. This will vary according to the type of operation performed and whether you have a manual or sedentary occupation.

Usually people are off work for about 4-6 weeks.

Sexual intercourse

You can resume sexual intercourse at 6 weeks but some women may need to adopt alternative positions if they experience any discomfort. You can discuss this with your specialist.

Complications

Seek help from your GP or Urology Associates if you develop:

• Flu like symtoms

• A temperature over 38°C

• Pain or discomfort not controlled by pain medication

• Bleeding or difficulty passing urine

• Pain or tenderness in the calf or thigh

• Symptoms of a urinary tract infection such as pain on passing urine, going more often or smelly urine. 

Click here to download our Pubovaginal sling booklet for more information 

TVT sling (tension-free vaginal tape)

Side view: TVT in position, supporting bladder neck

TVT Sling is an operation to treat stress urinary incontinence. Stress incontinence is leakage of urine that occurs with activities which cause an increase in abdominal pressure such as coughing, sneezing, jumping, lifting, exercising and in some cases walking.

This leakage occurs because the muscles at the bladder neck have lost their supports and strength. As a valve mechanism, the urethra (waterpipe) no longer stays closed when extra pressure is put on the bladder.

TVT sling is a minimally-invasive operation requiring three small incisions to insert and position the tape. A 1 cm cut is made on either side of the lower abdomen (tummy) with a 3 cm incision in the vagina to allow the tape to be put in place.

Women are usually in hospital for one night following this type of surgery.

Mesh Complications

Mesh slings have been around for more than 20 years and most women have had very successful results. The success rate is about 80%.

Erosion of the mesh into the bladder or urethra may occur in a small number of woman (<1%) sometimes many years after initial surgery. They will require surgery to remove this. This surgery may require going through the abdomen or the vagina.

Erosion of the mesh through the vaginal wall occurs in 2-8% of woman. If this occurs a further day surgery operation to cover or remove the mesh will be necessary.

Pain after the surgery is normal for 2-3 weeks. Uncommonly this pain in the lower abdomen may persist.

Mesh used to treat stress incontinence has a much lower risk of complication than that used to treat prolapse as a smaller piece of mesh is used. If you have concerns, discuss this with your urologist. Alternatives are available such as making the sling out of a piece of tendon from your abdomen.

Before your operation

In the weeks just prior to surgery it is common to come to Urology Associates to see the continence nurse specialist for a pre-op appointment.

You may have a routine blood test and a urine sample taken one week prior to your operation. Depending on your age and other medical problems you may also have an electrocardiogram (ECG) to record the electrical activity of your heart.

The operation and possible complications will be explained to you by the doctor. When you feel comfortable that you understand what is to be done and have had all your questions answered you will be asked to sign a consent form.

It is important to avoid constipation. Try to establish and maintain a regular, soft bowel habit leading up to your operation. Identify the foods that can help you in this area for your post-op period.

Operation day

You will be advised when to come to hospital (usually by phone the day before your operation).

It is usual to stop eating and drinking at least 6 hours prior to surgery. You should bring your own medications with you and the staff will advise you if you need to take them on the day of your operation.

Before the operation you will be given supportive stockings to wear until you leave hospital to minimise the risk of blood clots forming.

Whether you have a spinal or general anaesthetic will be decided after discussion with the anaesthetist. This usually occurs in the ward pre-operatively. Just prior to surgery you may be given a pre-medication tablet to relax you.

You will be encouraged to commence deep breathing and coughing exercises to prevent any breathing complications or chest infection occurring following the surgery and anaesthetic.

Recovery

When you first wake you will be in the recovery ward. You may feel sleepy and perhaps a little disorientated, but this feeling will pass.

You may eat and drink as desired but initially it is better to start slowly with fluids as the anaesthetic often makes people feel nauseated. There is medication available to control nausea if necessary.

An intravenous line (drip) may be attached to your arm overnight to give you some extra fluids. There will be a light dressing on your lower abdomen over the two small cuts.

 

Catheter

You will have a catheter (tube) in your bladder via your urethra, draining the urine into a bag. Your catheter will usually be removed the day after surgery.

• After a normal intake of fluid it is usual to pass urine every 3-4 hours.

• Initially you should not wait longer than this time before trying to empty your bladder. You may find emptying your bladder feels different as it recovers from the surgery and the associated swelling of the surrounding tissues.

• Try to relax your abdominal muscles and the muscles underneath your bladder. Take your time and just let the urine flow out. Do not push or strain as this forces the urethra against the TVT sling, closing it off and stopping the flow of urine.

It is not uncommon to be unable to pass urine afterwards. If you cannot pass urine, can pass only a small amount or have bladder discomfort please let your nurse know. The nurse may check your residual urine and arrange a self-catheterisation program if needed. This is called Clean Intermittent Catheterisation (CIC) and can be performed in the privacy of your own bathroom or any toilet. Initially, you may have to catheterise each time you need to pass urine but as things return to normal the frequency of your CIC will be reduced. You would not be expected to do CIC in the long-term but sometimes just in the days and weeks following your surgery, as the swelling settles down.

 

Pain control

While in hospital you will be prescribed paracetamol and you should take this regularly to keep any discomfort to a minimum. Stronger medication is available if required.

The day following surgery your drip will be removed and you may eat and drink as usual. You will be encouraged to shower and mobilise around the ward in preparation for going home later that day.

 

Lifting

Following surgery it is important to avoid any abdominal straining while your surgical repair heals. In particular patients should avoid doing any heavy lifting or exercise for four to six weeks after their surgery.

 

Bowels

Keeping a regular, soft bowel motion is important. Kiwi fruit or "Kiwi Crush" are also recommended.

After discharge

Our nurses will contact you by phone to check on your progress. If you have any concerns you may ring any time or arrange an appointment. You will also have a follow-up consultation with your surgeon at approximately six weeks post surgery.

 

Pain control

Take regular pain control. Paracetamol is usually effective medication.

The more you do, the worse your abdominal pain will get. Use this as a guide for the amount of activity that you do over the next few weeks. If you are sore, rest. Wound pain sometimes may be worse on one side than the other.

 

Wound care

Your abdominal cuts and vaginal wound should heal within 7-10 days however the muscle layer beneath your skin will take up to 3 months to heal. The dressing tape can be removed after 7-10 days.

If you notice the cuts become inflamed, there is an increase in pain, or it is red, hot or swollen, contact Urology Associates for advice.

 

Vaginal discharge

It is normal to have some vaginal bleeding on and off for a few weeks and then a brown discharge for a few weeks following that. If the bleeding becomes heavy, you pass clots or have a smelly vaginal discharge, contact Urology Associates.

You may also notice the remains of some stitches in your underwear or in the toilet after emptying your bladder. Do not be concerned as these are vaginal stitches which have started to dissolve and that is expected.

 

Bowels

• Try to keep your bowel motions soft by using high fibre foods such as kiwi fruit, fruit, vegetables, wholemeal bread, nuts and seeds.

• Do not become constipated or strain to have a bowel motion.

• If you are constipated and conservative measures have not helped, take an oral laxative.

• Use a footstool to help bowel emptying. Discuss this with our continence nurse specialist if you need further information.

 

Pelvic floor exercises

It is important to continue pelvic floor exercises once you have recovered from surgery. If you have any concerns about your technique, please contact our continence nurse specialist.

Activity

Initially when you go home you will not feel like doing very much, so listen to your body and rest. Sitting with your feet up will be the most comfortable position.

Things you can do include:

• Showering

• Preparing light meals

• Walking up and down stairs slowly

• Gentle walking is to be encouraged – it is better to do two short walks in the day rather than one long walk

Things you should not do for 1-2 weeks include:

• Housework except light work at bench height

• Vacuuming

• Carrying supermarket bags / rubbish bags

• Carrying children / pets

Things that you should not do for 6 weeks include:

• Heavy lifting

• Shifting the furniture

• Lawn mowing or digging the garden

• Weights at the gym

• Carrying rubbish bags or washing baskets

• Carrying children / pets

Driving

You should not drive until you feel that you could perform an emergency stop without being concerned about abdominal pain (approximately two weeks).

Returning to work

Ask your specialist about returning to work. This will vary according to the type of operation performed and whether you have a manual or sedentary occupation.

Usually people are off work for about 1-2 weeks.

Sexual intercourse

You can resume sexual intercourse at 6 weeks but some women may need to adopt alternative positions if they experience any discomfort. You can discuss this with your specialist.

Complications

Seek help from your GP or Urology Associates if you develop:

• Flu like symtoms

• A temperature over 38°C

• Pain or discomfort not controlled by pain medication

• Bleeding or difficulty passing urine

• Pain or tenderness in the calf or thigh

• Symptoms of a urinary tract infection such as pain on passing urine, going more often than usual or smelly urine.

Click here to download our TVT (tension-free vaginal tape) information booklet

Brachytherapy

X-ray showing the placement of radioactive seeds within the prostate

Brachytherapy (properly known as low-dose rate brachytherapy or LDR brachytherapy) is a day surgery procedure where the surgeon implants small radioactive seeds (smaller than a grain of rice) into the prostate under a general anaesthetic. These deliver radiation to the cancer from inside the prostate. The implanted seeds are small enough that they will not be felt by the patient. Brachytherapy is also referred to as 'interstitial radiation therapy' or 'seed implant therapy'.

Before the seeds are implanted, the patient will have a special ultrasound test of the prostate to plan the appropriate treatment. This is usually a few weeks before the day when the seeds are implanted and is called a "planning study." Needles containing the seeds are then inserted through the skin of the perineum (the area between the scrotum and anus) using transrectal ultrasound guidance. The seeds remain in the prostate and the radioactive material gives off localised radiation for a number of months to destroy the prostate cancer. This procedure allows high doses of radiation in the prostate with minimal contamination of the surrounding organs (bladder/rectum). Most men can resume work and normal activities a few days after the treatment.

Brachytherapy is a very effective and safe way to treat selected prostate cancers. Your urologist will recommend if this is right for you. Long-term results are similar to open surgery when brachytherapy is chosen to treat the correct sort of cancers, typically the slower growing, less aggressive forms of prostate cancer.

Click on the image above to download our Brachytherapy information sheet for more detailed information about the treatment.

Radical prostatectomy

A radical prostatectomy is an operation for men with prostate cancer. It involves removing the entire prostate gland through a cut in the lower abdomen. Removing the prostate can be curative if the cancer is in an early stage (confined to the prostate and not spread).

Occasionally, this surgery may involve the removal of the pelvic lymph nodes. The lymph nodes are part of the lymphatic system, which is the cleansing system of the body. 

The pelvic lymph nodes drain the prostate gland and if the cancer is of a higher grade and spreads from the prostate it may be identified within the lymph nodes. 

Radical prostatectomy can be performed by an open approach (shown in the picture on the left) or using a minimally-invasive approach called robotic-assisted laparoscopic radical prostatectomy (RALP), shown in the picture on the right. See here for further details on RALP. RALP is now the most frequently performed method of prostate removal in the USA and here in Christchurch we have the largest expertise in this procedure in New Zealand. Both methods may be right for your - ask your urologist for more information.

Click the image above to download our Radical Prostatectomy patient booklet

Ureteroscopy and laser of stones

Ureteroscopy and laser of stones is an incision-free operation to remove or break up a stone from the ureter by passing a small telescope up the ureter (tube from the kidney to the bladder). Usually a laser is used to shatter a stone but on occasion a stone can be removed in one piece with a basket.

 

Before your operation

You have a stone visible on x-ray or CT scan that is suitable for removal by ureteroscopy.  Your surgeon will discuss this treatment with you and also go over other stone treatment options that are appropriate.

The operation and outcomes will be explained to you by your surgeon. When you feel comfortable that you understand what is to be done and have had all your questions answered you will be asked to sign a consent form. This consent form should be signed by both yourself and your surgeon and forwarded to the hospital at least five days before your admission.

A blood test will need to be performed and a urine sample may need to be taken 4-5 days prior to surgery. Your surgeon will give you a form to take to the laboratory to have these tests done.

An x-ray or CT scan may be performed just before your surgery to check the position of your stone.

If you are over 60, or have other medical conditions, you may also have an electrocardiogram (ECG) to check the health of your heart prior to surgery.

Operation day

On arrival to the hospital, the staff will show you to your bed and guide you through what is required prior to your operation. You should bring all your own medications with you to hospital.

This operation is usually performed under general anaesthesia. The anaesthetist will discuss this with you before the operation. This usually occurs in your hospital room pre-operatively. Just prior to surgery you may be given a premedication tablet to relax you.

The operation

The surgeon passes a small instrument called a ureteroscope through the urethra (water pipe) and bladder into the ureter (tube from the kidney).  This is done with the assistance of x-ray screening.

The surgeon then locates the stone and either removes it with a wire basket or shatters it with a laser.  A stent (tube) may be left in the ureter for a few days to help the urine and any stone chips to flow out.  You may also have a catheter (tube) in your bladder after the procedure.

Expect to go home the same day as your operation.  If you have a catheter in your bladder this will be removed before you leave.  

 

After discharge

You will receive a follow-up appointment for 6 weeks after your operation.  A letter will also be sent to your own doctor about your operation. 

When you get home you should drink twice as much as you would normally to flush your system through and minimise any bleeding.  You should aim to keep your urine permanently colourless to minimise the risk of further stone formation.

You may experience pain in the kidney over the first 24-72 hours due to the swelling caused by insertion of the instrument or by the presence of a stent. Anti-inflammatory painkillers will help this pain which normally settles after 72 hours.

If a stent (tube between kidney and bladder) is inserted you will be informed before your discharge when the stent needs to be removed.  Stents can be removed by you if a string is attached or by flexible cystoscopy at Urology Associates. Click here for more information on stent removal.

 

Complications

All procedures have a potential for side effects.  You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

• It is common to have blood in the urine.
• If you develop a fever, severe pain on passing urine, inability to pass urine or worsening bleeding you should contact Urology Associates or your GP immediately. 
• Small blood clots or stone fragments may travel from your kidney resulting in renal colic. Renal colic may present as intense pain in the side of your abdomen (tummy) which may spread down into the lower abdomen or groin. In this event you should contact Urology Associates any time of the day or night or your GP immediately. 

Caverject

Caverject is an injection used for erectile dysfunction including weak erections or impotence. It is usually used if oral medications for erectile dysfunction have not worked or have caused side affects which means you are unable to comfortably or safely continue them.

Caverject contains alprostadil which is similar to the natural substance in your body called prostaglandin E1. It widens blood vessels so that blood can flow into your penis more easily. This makes it easier for you to have an erection.

If you urologist recommends this treatment and you would like to proceed, we will arrange for you to see our nurse specialist who will instruct you on the technique and make sure that you are comfortable with it before trying it for yourself at home.

Click on the image above to download our Caverject patient information booklet

Artificial urinary sphincter

A sphincter is a circular muscle structure which controls the flow of bodily fluids such as urine. A normal sphincter prevents urine from leaking, however sometimes the sphincter fails and urine leaks out making you incontinent.

This can sometimes occur after surgical removal of the prostate for prostate cancer (such as a radical prostatectomy or robotic-assisted laparoscopic prostatectomy), or very rarely after surgery to improve the flow of urine (TURP).

It is quite common to become temporarily incontinent after undergoing prostate surgery. Occasionally this does not improve and treatment is required. Your urologist will advise you on the best type of treatment if you are having ongoing problems with leakage of urine after your prostate surgery.

An artificial urinary sphincter (AUS) is a device for men who have urinary incontinence. It takes the place of the damaged sphincter to restore control of the flow of urine. It is a fluid-filled device that opens and closes the urethra to give you control of your bladder. The device is an implant (also known as a prosthesis), and is called an AMS800. It is designed and manufactured in the USA but has been implanted in men all over the world for over 30 years.

Click here for more information.

Click here to download our Artificial urinary sphincter booklet

Abdominal sacrocolpopexy

Sometimes the body’s natural supporting structures are weakened and the vagina slips down from its normal position. Weakness of these supporting structures may be due to vaginal childbirth, aging, hysterectomy and changes in your hormone levels.

An abdominal sacrocolpopexy is an operation performed through a cut in the abdomen (tummy). It lifts the vagina or uterus back into its normal position by attaching a piece of synthetic mesh between the top of the vagina and a bone in the lower part of the spine. This is the gold standard treatment for all types of prolapse and is usually recommended as first-line treatment for more severe prolapse problems. As the mesh is placed via the abdomen and not via the vagina, it is considered very safe and is not associated with the complications seen with vaginal mesh placement. Your urologist will discuss if this is right for you.

Click the image above to download our Abdominal sacrocolpopexy information booklet

Bladder removal surgery

A radical cystectomy is the removal of the bladder and surrounding organs. In men, the bladder, prostate gland and seminal vesicles (small glands near the prostate) are removed. In women, the bladder, urethra, uterus and ovaries are removed and the vagina is shortened. The bladder is usually removed by open surgery but the da Vinci robotic method is available for suitable patients.

If you are having a radical cystectomy, another way must be found to collect urine and remove it from the body. There are different ways this can be achieved surgically. These are called an ileal conduit or a neobladder. Information on these options are shown below.

 

Why do I need a cystectomy?

A cystectomy may be required for one of the following reasons: 

• Cancer of the bladder 

• Cancer of the uterus, vagina or bowel that involves the bladder 

• Severe radiotherapy damage with ongoing bleeding from the bladder

• Interstitial cystitis/painful bladder syndrome that hasn't responded to simpler treatments

 

Cystectomy and formation of ileal conduit

An ileal conduit is a tube made out of a short segment of bowel. The ureters (tubes from your kidneys) are attached to one end of the conduit, while the other end is brought through to the surface of the skin.  The open end is called a stoma and is similar in colour to the inside of the cheek.  An external bag (urostomy bag) covers the stoma and collects the urine. 

 

Cystectomy and formation of neobladder

This operation uses a small segment of bowel to create a new bladder (neobladder) that will collect the urine. The ureters (tubes from your kidneys) are attached to the neobladder. The neobladder is then attached to your urethra (out flow pipe). This will allow you to pass urine naturally through your urethra.

Botox for overactive bladder

Botox (or botulinum toxin) is a purified toxin made from the botulinum bacteria. It is widely used to treat urological conditions which have not responded to standard therapies.
 
Botox acts by binding to the nerve endings of muscles, blocking the release of the chemical that causes the muscle to contract. When injected into specific muscles, the muscle becomes paralysed or weakened but leaves surrounding muscles unaffected allowing for normal muscle function.

This is typically used as a treatment option for overactive bladder, where people experience problems such as:

• Going to the toilet frequently day and night

• A sudden, urgent desire to go to the toilet which if ignored may lead to urine leaking

• Leakage which occurs for no apparent reason

• Leakage of urine associated with a variety of conditions including multiple sclerosis, spinal cord injury and stroke

Usually oral medications will have been trialled first and either not worked sufficiently or side effects have not been tolerable. Your urologist will recommend if Botox is right for you.

This procedure is done in the rooms and takes approximately 10 minutes. No anaesthetic or sedation is required and you can drive home directly after your appointment.

Click here to download our Instillation of Botox booklet for more information

Vasectomy

A vasectomy is performed for contraceptive reasons and will render the patient sterile and incapable of having further children. The procedure takes 30 minutes and can be performed under local anaesthesia in the clinic rooms at Urology Associates or under general anaesthesia in a private hospital. It involves a small puncture in the scrotum and removal of a small segment of the vas tube (the tube that carries the sperm from the testicles) on each side. The procedure that we use in called a "no-scalpel" vasectomy or NSV. There will be some dissolving stitches (sutures) and you will be able to drive home after the procedure.

The procedure does not cause immediate sterility. Other forms of contraception must be used until you provide two consecutive sperm samples which are proven to be clear of sperm. After your procedure, you will be given two specimen containers and instructions on what to do with the samples and how to get the results.

Vasectomy is a simple procedure that should be considered to be irreversible. Whilst surgery for revision can be performed, its success is not guaranteed and is a more major procedure than vasectomy itself. If you are unsure if you have completed your family, continue to use alternative contraceptive measures until you are sure that you do not wish to have any further children.

Phone us today to book your vasectomy on 03 355 5129 - no referral is required!

Please note that we do require a non-refundable deposit of $300 prior to the day of the procedure to cover costs in the event that you do not attend. Vasectomies performed under local anaesthetic cost $1,684 including your initial consultation with a Urologist. Vasectomies performed under general anaesthetic cost $6,490 plus $241 for your initial consultation.

Patient Information

Vasectomy patient information and consent form

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Robotic prostatectomy (robotic-assisted laparoscopic prostatectomy)

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da Vinci Robot (centre) with the surgeon's console on the right

Robotic-assisted laparoscopic prostatectomy (RALP) is the surgical removal of the prostate to treat prostate cancer.  The robot is a state-of-the-art surgical interface system. It includes fine instruments that a urologist uses to remove the prostate gland through several small incisions (keyhole surgery).

Due to magnified 3D-visualisation of the anatomy, very precise surgery is possible. This results in less blood loss and faster recovery after surgery compared to conventional open surgery. Some studies show that there is a better outcome with regards to post-operative continence and sexual function.

The robot is completely controlled by the surgeon at all times and cannot operate independently. 

 

Before your operation

The operation and outcomes will be explained to you by your surgeon. When you feel comfortable that you understand what is to be done and have had all your questions answered you will be asked to sign a consent form.

• This consent form should be signed by both yourself and your surgeon and forwarded to the hospital a few days prior to your admission.

• A blood test will need to be performed and a urine sample may need to be taken 4-5 days prior to surgery. Your surgeon will give you a form to take to the laboratory to have these tests done.

• If you are over 60 or have other medical conditions you may have an electrocardiogram (ECG) to check the health of your heart prior to surgery.

• It is important to avoid constipation. Try to establish and maintain a regular, soft bowel habit leading up to your operation. Identify the foods that can help you maintain a regular bowel habit for your post-op period.

 

Operation day

RALP is an operation performed by making several small cuts in the abdomen between your navel and pubic bone.

Laparoscopic ports are placed into these cuts and the robotic camera and instruments are introduced into the abdomen via these ports. The prostate will be removed. The cut at the navel will be enlarged slightly to remove the prostate. The bladder is joined back into the urethra (outflow pipe) and a catheter is placed to drain the urine.

The procedure takes about 2 hours.

 

Recovery

You will probably be in hospital 1 or 2 nights following this type of surgery.

When the operation is completed, you will go to the recovery room for a short while where you will be cared for until you are ready to be transferred to your room. When you wake up it is common to feel an urgent desire to pass urine. This is due to the catheter in your bladder.

 

Pain control

Pain control is managed in conjunction with your anaesthetist. For pain relief it is likely you will have a PCA (Patient Controlled Analgesic) pump attached to your intravenous line. You will be able to control the amount of pain relief by pressing a button connected to the pump. 

Our aim is to keep you as comfortable as possible: it is important to let your nurse know when the pain or discomfort starts. At all times your nurse is there to help you. Please ring your bell if you need assistance and your nurse is not nearby.

 

Catheter

Your nurse will monitor your catheter drainage which is likely to be blood stained for the first 24 hours. Your catheter usually is left in place for 1-2 weeks after surgery. You will therefore go home with a catheter in.

Our continence advisor will contact you to organise a date to have your catheter removed at Urology Associates. The catheter is removed by deflating the balloon holding it in place. Once the balloon is deflated, the catheter slides out easily causing little discomfort.

Once the catheter comes out you may at first have a burning sensation when passing urine. If the burning sensation lasts for longer than 3 days, or there is sign of infection or obstruction, it is important to contact your surgeon or GP.

 

Bladder control

Initially, you will probably have to wear pads to control varying amounts of urinary leakage. At the appointment for catheter removal, pelvic floor exercises will be taught to help you regain control of your bladder. You will probably not require pads after 3-6 months.

Wound and drain tube

You will have six small wounds on your abdomen. The sutures are dissolvable and do not need to be removed. 

You may have a drain tube coming from your abdomen. This will be removed after 1-2 days.

 

Expected symptoms

After surgery, you may or may not experience some of the following symptoms:

• A stinging or burning sensation at the tip of the penis where the catheter enters. This is generally due to irritation and may be relieved by increasing fluid intake or ensuring the catheter is well supported.

• A feeling of having a full bladder and low to nil drainage of urine through the catheter. This can be caused by blockage of the catheter tube either by a blood clot or by accidental kinking of the tube. Catheter blockages are easily cleared by the nurse.

• Bladder spasms (short, sharp, grabbing pains) due to the bladder trying to expel the catheter because of irritation. These are easily treated with medication.

After discharge

You will receive two follow up appointments after your surgery. The first is for the removal of your catheter with the continence nurse and the second with your surgeon six weeks after the operation.

You can do most activities after your operation except heavy lifting, straining, intercourse or strenuous activity which should be avoided for 2-3 weeks after surgery. You will be able to continue with your normal daily routines as you feel able.

Generally when you feel that you could perform an emergency stop without being concerned about abdominal pain (at about 3 weeks), then you can resume driving. 

You will be asked to drink extra fluids after your surgery and for the next few weeks after your discharge. This helps to keep the catheter draining. 

It is normal to have some leakage or discharge at the end of your penis/catheter. The discharge may be urine, blood or brown coloured. You should wash the area with soap and water to remove this discharge and reduce any irritation. It is also normal to see blood occasionally in the catheter bag. 

Some patients experience bladder spasm. Symptoms may include:

• leakage of urine around the catheter

• a feeling of wanting to pass urine

• lower abdominal pain

Medication can be prescribed to relieve the spasm.

 

Complications

Bleeding

Bleeding severe enough to bring you back to the hospital is rare. This risk disappears when healing is complete, 6-8 weeks after surgery. If you notice an increase in bleeding or are unable to pass urine, contact your GP.

Incontinence

Urgency is common. Incontinence, or leakage of urine without control, may occur temporarily. Only very few patients have incontinence which lasts beyond the first few months. 

If you have any incontinence after your operation, you will be given information and instructions about exercises that you can do to strengthen the pelvic floor muscles. Your surgeon or nurse can also provide you with information about the management of leakages.

Urethral stricture

In a small number of cases tightness may develop in the urethra. This may occur either near the tip of the penis or further up the urethra, several months after the operation.

You may notice your urinary stream, which was better after the operation, slows down again. Please mention this problem to your doctor. If detected early and treated with gentle stretching under local anaesthetic most strictures resolve. An operation to cut open the tight area may be appropriate.

Sexual function

A RALP can cause impotence – the inability to have an erection. The likelihood of this occurring depends on a number of factors.  

At best only 35% of men retain normal erections which may take a year to return after surgery. This does not mean that you cannot continue to have a satisfactory sexual life. With some creativity, men can have orgasms without having an erection. There are also a number of treatments available to help bring back erections. Talk to your urologist about this if you are experiencing difficulties in this area.

Prostate Surgery

Booklet with more information about the Robotic Assisted Laparoscopic Prostatectomy (RALP)

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Kidney removal surgery

A nephrectomy or partial nephrectomy is the surgical removal of all or part of your kidney.  Many people will live a normal, healthy life with only one kidney. Your urologist will perform tests to ensure that your other kidney is functioning normally before proceeding with surgery.

Common reasons for a nephrectomy include: 

• cancer of the kidney

• very large kidney stones that have caused significant damage to the kidney

• non-functioning kidney causing problems like pain or infections

• kidney donation for transplant

The reason for your surgery will determine which type of nephrectomy will be performed:

• partial nephrectomy removes only part of the kidney

• radical nephrectomy (or total nephrectomy) is the removal of the whole kidney, the surrounding fat and possibly the adrenal gland

• nephroureterectomy is removal of the kidney as well as the ureter (the tube that drains into the bladder)

The surgery can be performed through an open method, laparoscopically (keyhole surgery) or using the da Vinci robotic-assisted method. Your surgeon will discuss which options are right for you. Not all kidneys are suitable for removal buy all methods.

Click on the image above to download our Nephrectomy patient information booklet

External beam radiation therapy

Urology Associates work with Dr Chris Wynne and Associate Professor Chris Atkinson at St George's Cancer Care Centre to provide men the option of external beam radiation therapy (EBRT) for the treatment of prostate cancer.

Dr Wynne and Associate Professor Atkinson are both radiation oncologists - doctors with specialist expertise in the use of radiation therapy to treat cancers.

The radiation oncologists run visiting clinics in our rooms at Urology Associates. Your urologist will offer you an appointment to see one of them if this is appropriate for your type of prostate cancer. If you choose to have EBRT treatment, the treatments will be given at St George's Cancer Care Centre.