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• Vasectomy
• Prostate Biopsy
• Cystoscopy

Vasectomy

Vasectomy refers to voluntary or "elective" surgical sterilization in men. In certain states, there is a mandatory waiting period from the time that you sign consent. In other states, you may have the procedure at any time after signing an informed consent. The waiting period is for your own protection to ensure that you and anyone else involved in the decision have thought about this carefully. In states that do not have a waiting period, you should take a little more time to ensure that this decision is right for you. A vasectomy may be reversible, but is considered a permanent form of sterilization. Reversal is technically difficult, has a moderate success rate, and is quite costly.

The vas deferens are small tubes that transport sperm from each testicle to the urethra where the sperm combines with the remainder of the contents (made in other glands) of ejaculation. After a vasectomy, the ejaculate fluid should appear unchanged in amount and consistency to the naked eye, but it will contain no sperm. Only under a microscope is the change perceptible. The sensation of orgasm and ejaculation are unaffected, and the operation does not affect sex-drive or erections.

Preparation

We ask that you purchase a scrotal support (jock strap) or a good pair of jockey shorts and wear them that day. You should have ice ready at home. Packs of frozen peas make a great substitute to ice packs. The procedure cannot be done if you are currently on, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners"). Please tell us if anything has changed since your previous visit. The most common are aspirin and all related pain reliever or anti-inflammatory compounds (whether prescription or over-the-counter). Your doctor will shave you at the time of your appointment.

Procedure

A vasectomy typically takes less than 30 minutes. Variations in time will depend on your particular anatomy. Your position will be supine (flat on your back) throughout the procedure. Local anesthesia (numbing medicine) is injected into the area of the scrotum where the procedure is performed. Although you might feel some pressure or mild pain during the procedure, you should not experience any significant pain. In most instances, very small incisions (one centimeter or less) are made on the left and right side of the scrotum. Some surgeons prefer one incision in the middle of the scrotum. Each vas deferens is located, separated from surrounding tissue, and divided. According to the surgeon's preference, a short segment of the tube can be removed as well. The ends are then either tied with suture or cauterized (electrically burned) the lumen (center hole through which the sperm flow) as well. The ends of the vas are placed back into the scrotal sac and the incisions are closed. The suture material used on the skin is self-dissolving and will just fall out on its own after 1-2 weeks. It is not necessary to place a dressing over the incision sites, but placing a clean gauze or pad against the scrotum will help to keep your underwear or scrotal support clean.

Post Procedure

After the vasectomy, you will have one to three small sutures on each side or just in the midline. They will dissolve over the following 1-2 weeks and need not be removed. Every patient has some degree of swelling, and it is not possible to predict who might have a minimal versus significant swelling. It is very important that you apply ice to the area as soon as you return home for several hours as instructed and wear a scrotal support (or jockey shorts) for several days. We strongly encourage you to take the following day off of work and perhaps more of if your occupation requires strenuous activity or heavy lifting. In the first 24 hours, it is to your advantage to minimize activity and spend a lot of time lying down. The more swelling you prevent in the first two days, the better off you are. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days to a week. Severe pain is unlikely but possible. We may provide you with a prescription for pain medication but you certainly may take an over the counter medication to which you are not allergic. Just like variation in swelling, the scrotum and surrounding areas can have a variation of bruising. This will typically resolve with time. You may shower the following day.

Expectations of Outcome

The effects of a vasectomy at resulting in sterilizations are not immediate. Despite a successful procedure, you are not considered sterile until 2 (some doctors require 3) semen analyses (under the microscope) demonstrate no evidence of sperm. Do not make the assumption that you are sterile just because time elapsed or because the first semen analysis demonstrated no sperm. You must wait for us to tell you, following the second semen analysis, that it is safe for you to have unprotected intercourse. Sometimes, it can take months for you to clear all of the sperm out of your tract. Please make sure to keep all follow up appointments as they are scheduled. While rare, a vasectomy can fail. We will have discussed the possible explanations for this.

Possible Complications of the procedure

All surgical procedure, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, the following list may generate questions if you are still concerned. It is important that every patient be made aware of all possible outcomes.

• Failure: As mentioned, a vasectomy may fail. This is rare and occurs less than 1% of the time by national average. In immediate failure, the patient never has semen analysis that demonstrates "no sperm". A delayed failure would mean that at one time, there were no, or few sperm but subsequently there were increased sperm again in the ejaculate. There are different reasons for each. Failure requires that the procedure be repeated.
• Inability to Complete: There are rare instances when a patient's anatomy makes it impossible to continue with an intended procedure (in the office) without causing too much discomfort or compromising the success or safety of the procedure. In this instance, we would stop and recommend that the procedure be rescheduled in the hospital with anesthesia.
• Hematoma: This is when a small blood vessel continues to ooze or bleed after the procedure is over. The result is greater swelling and bruising. Intervention (opening the incision to evacuate the blood) is very rarely necessary and it almost always resolves over time with compresses, much like any bad bruise or swelling. If this happens, it is usually in the first day after the procedure.
• Infection: Infection is possible in any procedure. Usually, local wound care and antibiotics are all that is necessary. Opening the wound to drain the infection may be necessary if more conservative measures fail.
• Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery. This is rare and would tend to disappear in time. If persistent, further evaluation may be necessary.

Transrectal Ultrasound-Guided Prostate Biopsy

A prostate biopsy is taking multiple small tissue samples from the prostate for evaluation by a pathologist (doctors who examine tissue under the microscope). We use ultrasound technology to accurately guide our biopsy needle. Prostate biopsies are not perfect in their ability to detect prostate cancer. At this time, however, there is no other method to differentiate benign tissue from malignant tissue in a patient with a suspicious PSA (prostate specific antigen) or digital rectal examination. It is possible that a very small (microscopic) area of cancer could be missed. We take samples that reflect each of the different zones of the prostate as well as the size of your prostate. In other words, we might take a few extra samples from a larger gland.

Preparation

The procedure cannot be done if you are currently on, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners"). Please tell us if anything has changed since your previous visit. The most common of these medications are aspirin and all related pain reliever or anti-inflammatory compounds (whether prescription or over-the-counter). You do not have to fast in order to have a prostate biopsy. It is recommended that you eat a very light breakfast (if your biopsy is in the morning) or a very light lunch (if your biopsy is in the afternoon). Try however, to eat at least 1 hour before the biopsy. If you are diabetic, make sure you do not miss your regular meal. You will be given antibiotic tablets as well. They should be taken as directed by your urologist. If possible, have a friend or family member come with you that day to keep you company and drive you home. While it is not absolutely necessary, we would prefer that you have someone accompany you. In some cases, a patient can unexpectedly feel light-headed or uncomfortable after any procedure. If you do not have anyone available, we may ask that you relax for a while in our waiting room after the procedure until we feel it is appropriate for you to leave.

Procedure

The actual procedure typically takes 5-15 minutes. Some urologists may give you an oral sedative medication before the procedure. This may be helpful in a patient who is very anxious. You will be placed lying down on your side on an examining table. An ultrasound probe will be gently placed in your rectum. Although it is slightly uncomfortable, very few patients believe it is painful. Nerve block will be injected through the needle guide (in the rectum) into the prostate to minimize discomfort when the biopsies are performed. We will then take the biopsies with a small needle. You will hear a click or snap sound for each biopsy and feel a little pinch. Again, while most admit it is uncomfortable, very few claim that it is painful. The amount of biopsy cores taken will depend on the decision of your urologist, your anatomy, and possibly on whether you have had a prostate biopsy done in the past.

Post Procedure

After the procedure, you might feel a bit sore in the rectal or anal area for a few hours. We rarely hear of problems beyond that, although patients with hemorrhoids might have discomfort a bit longer. It is very common to see some blood from the rectum, on the stool with the next bowel movement, or on the toilet paper especially that day and rarely the next day. Again, this is more common in patients with hemorrhoids. A small amount of blood in the urine or some discoloration of the urine is rarely seen but not impossible. You may commonly see blood in your semen (ejaculation) for 1-2 days and sometimes can be seen up to 8 months. It may be red or just discolor your semen brown. It will not harm you in any way. You have no restrictions after the biopsy other than to take it easy that day. If possible, have a friend drive you home.

Expectations of Outcome

After the biopsy, the specimens are sent to a pathology laboratory for evaluation by a trained pathologist. We cannot give you any accurate information from the ultrasound appearance of the prostate or from the look of the tiny specimens that we remove with the needle. We understand that you are anxious to have the results and can only ask for your patience. We will call you as soon as they are available to us. It usually takes 2 weeks to get the results.

Possible Complications of the Procedure

All procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, the following is a list so that you may ask questions if you are still concerned.

• Excessive Bleeding from the Anus: It is uncommon to require any treatment, and the majority of the time the bleeding stops on its own. This is far more common in patients with hemorrhoids.
• Blood Clots in the Urine: The needle can enter the middle of the prostate where the urethra or the neck of the bladder are located and cause blood in the urine. If the bleeding is significant, it can cause clots that can block urine flow. A catheter may need to be inserted to flush out the clots.
• Urinary retention: Even in the absence of bleeding, the prostate can become swollen from the biopsy or secondary to infection. In this instance, a catheter will be placed and your doctor will discuss the next step. Usually, the problem resolves with time after the swelling goes down. Sometimes medications are given that may help to open the prostate channel. Patients at greater risk are those who already have difficulty urinating before the procedure due to BPH (Benign Prostatic Hyperplasia).
• Urinary Tract Infection or Urosepsis: Although we give you antibiotics, it is possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection often presents with the urinary symptoms and any combination of the following: fever, shaking, chills, weakness or dizziness, nausea and vomiting. This occurs about 1% of the time. You may need a short hospitalization for intravenous antibiotics, fluids, and observation. This is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. Lastly, an abscess of the prostate, while quite rare, can develop. This is an infectious cavity that may respond to antibiotics alone or need surgical (needle) drainage. It can begin with urinary symptoms but also progress to the symptoms of bloodstream infection. Urinary retention is possible with an abscess. IF YOU HAVE SYMPTOMS OF ANY OF THE ABOVE, ESPECIALLY THOSE OF INFECTION, YOU MUST CONTACT US IMMEDIATELY OR GO TO THE NEAREST EMERGENCY ROOM.

Cystoscopy

Cystoscopy, except in special circumstances, is an office-based procedure. Simply put, it is the placement of a small telescope into the bladder by way of the urethra (the tube through which you urinate). The scope provides lighting and enhanced magnification so that we may carefully examine the inside. With this minor procedure we are able to see tumors, areas of inflammation, abnormal variations in anatomy, bladder stones, and sometimes the drainage of urine from the kidneys into the bladder. The procedure takes a few minutes and can be done using only numbing jelly to minimize discomfort. If you are anxious, please let us know during the consultation so that we may consider sedation if we feel it is appropriate. There is no particular preparation for a cystoscopy.

Procedure

The procedure typically takes a few minutes. In certain instances, we may decide to give you an antibiotic tablet just before or after the procedure. We will have you lie flat on your back on the exam table (with your legs in stirrups if you are a female patient). Your urethra will be cleaned with an antiseptic to create a sterile field. Numbing jelly is sometimes inserted into the urethra and allowed to remain for a short time. Next, the scope is guided through the urethra (under direct vision) and into the bladder. The doctor will look directly into the end of the scope.

Post Procedure

After the procedure you may have a little stinging or burning sensation in the urethra until the next time you urinate. In some patients, it may last a bit longer. While it is quite unusual to see any blood in a female patient, we occasionally see a little blood after cystoscopy in men. This is more common in men with large and obstructing prostate glands or in situations where the urethra contains a stricture (narrowing due to scar tissue). Unless otherwise instructed, you have no restrictions after a cystoscopy and may even return to work if you choose. Ideally, we would prefer that you take it easy at home for the remainder of the day or evening.

Expectations of Outcome

Because your urologist is looking directly inside in real time, he/she can discuss the results of your cystoscopy immediately after or even during the examination. In other words, there is no "waiting for results".

Possible Complications of the Procedure

All procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, the following is a list so that you may ask questions if you are still concerned.

• Urinary Tract Infection or Urosepsis (Bloodstream Infection): Even from a minor and sterile procedure, it is possible for you to get an infection with bacteria that typically cause urinary tract infections (UTIs). It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection often presents with the urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. This occurs in less than 1% of patients. You may need a short hospitalization for intravenous antibiotics, fluids, and observation. This scenario is more common in diabetics, patients on long-term steroid, or patients with any disorder of the immune system. IF YOU HAVE SYMPTOMS OF ANY OF THE ABOVE, YOU MUST CONTACT US IMMEDIATELY OR GO TO THE NEAREST EMERGENCY ROOM.
• Blood Clots in the Urine: Rarely, the scope can traumatize a small blood vessel on the surface of the prostate or less commonly, in the bladder. In this instance, you may develop hematuria (blood in the urine). In almost all instances, the urine clears on its own over the next few hours or so. Ongoing bleeding with the development of blood clots is uncommon. If the clots block the bladder, a catheter may need to be inserted to flush out the clots. If bleeding persists, we may have to look back in the bladder to control or cauterize the bleeding.
• Urinary retention: In men, pressure from the scope can occasionally cause swelling of the prostate. It may block the flow of urine and cause "retention". This is more common in men with a prior history of an enlarged prostate (BPH) or difficulty urinating. In most circumstances, it resolves with a catheter over the next few days.
• Inability to Pass the Scope: Occasionally, a severe stricture (scar in the urethra) or bladder neck contracture (full circumference scar at the neck of the bladder) may prevent safe passage of a scope in the bladder. In these instances, we would remove the scope and perhaps suggest a cystoscopy procedure in the hospital using anesthesia.