Pelvi-Ureteric Junction Repair (PUJ) – Robotic Assisted

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A congenital or acquired narrowing in the ureteric pelvis junction. This narrowing is excised with a reconnection. There are several techniques described in repairing this: I prefer the Dismembered Pyeloplasty

Why is it done?

  • High grade obstruction.
  • Causing deterioration of renal function.
  • Thinning of renal cortex.
  • Chronic pain.
  • Chronic infection.
  • Recurrent renal calculi.

Causes

  • Congenital lack of muscle, or neuro transmission in this area, causing a non-functioning part leading to obstruction.
  • Vesico-ureteric reflux, longstanding can also cause this.
  • Usually diagnosed in kids.
  • Crossing vessel.

How is it done?

Robotic assisted pyeloplasty.

  • Types
      • Dismembered.
      • Foley’s Y-V Pyeloplasty.
      • Culp-Dewierd.
      • Pelvi-calyceal pyeloplasty.
      • Endopyelotomy with laser.
    • Patients will receive a general anaesthesia.
    • Prophylactic antibiotics is given.
    • The correct ureteric system is identified and marked while you are awake.
    • This will be mostly a robotic / laparoscopic procedure.
    • The endoscopic procedure is reserved as a second line in my practice.
    • Laparoscopic ports are placed
    • The affected ureter is exposed, the defect cut out with a re-anastomosis of a spatulated ureter to a trimmed renal pelvis over a ureteric stent.
    • An indwelling catheter is placed. A drain is placed.

What next?

  • You may be in hospital for 3 days
  • Your drain will be removed when there is no urine draining.
  • Your catheter will be removed the following day.
  • As soon as you are comfortable with no signs of pain and emptying your bladder sufficiently, you will be discharged
  • A ward prescription may be issued on your discharge, for your own collection at any pharmacy.
  • A follow-up appointment will be scheduled for 6 weeks to remove your ureteric stent under local anaesthesia with a Flexible Cystoscope.
  • A review with a CT IVP will be scheduled 6 weeks after this to check on the end result of the ureter.
  • Any pain or signs of fever require an urgent review.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Possible Complications

  • Re-stenosis with recurrent obstruction.
  • Second procedure.
  • With further deterioration of renal function, you may require a nephrectomy where affected kidney contributes < 15-20% of total renal function.
  • Urine leak, Urinoma, requiring drainage.
  • Infection possible sepsis requiring long-term antibiotics.

 

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Wes RA reair

Laser Endo-Pyelotomy

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Endoscopic opening of pelvi-ureteric junction stricture.

Endoscopic technique of incising a short stricture with a laser. A stent remains 6 weeks post operatively

Why is it done?

  • Stricturing or narrowing of the ureter causing significant hydronephrosis.
  • Leading to chronic infection.
  • End-result is loss of renal function.
  • An end-to-end anastomosis can be considered in the mid ureter.
  • A Reimplantation into the bladder with lower ureteric strictures.
  • A pelvi-ureteric junction repair in higher ureteric strictures.
  • A trans uretero-ureteric anastomosis joining one ureter to the other where long defects are present.
  • Renal Auto Transplantation where ureter is completely damaged or.
  • An ileal ureteric substitution where to whole ureter is damaged.

How is it done?

  • Endoscopic technique.
  • Patients will receive a general anesthesia.
  • Prophylactic antibiotics is given.
  • The correct ureteric system is identified and marked while you are awake.
  • This will be mostly an endoscopic procedure.
  • A cystoscopy will be done with placement of ureteric guidewires.
  • The affected ureter is entered with ureteroscopy. Laser is used to cut through the short stricture until peri-ureteric fat is observed.
  • This is not an advisable procedure where the stricture overlies vascular structures.
  • A ureteric stent is placed.
  • An indwelling catheter is placed.

What next?

  • You may be in hospital for 3 days.
  • Your drain will be removed when there is no urine draining.
  • Your catheter will be removed the following day.
  • As soon as you are comfortable with no signs of pain and emptying your bladder sufficiently, you will be discharged.
  • A follow-up appointment will be scheduled for 6 weeks to remove your ureteric stent under local anesthesia with a Flexible Cystoscope.
  • A review with a CT IVP will be scheduled 6 weeks after this to check on the end result of the ureter.
  • Any pain or signs of fever require an urgent review.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

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Wes Laser Endo-Pyelotomy

Greenlight Laser Trans Urethral Vaporization of Prostate

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This is an endoscopic technique of enucleation of the prostate using Greenlight laser therapy. Similar to a TURP – “Re-bore” only with minimal bleeding and shorted hospital stays. Some would argue this is ” The new Gold Standard”

Why is it done?

Endoscopic vaporization of a benign enlarged prostate, using laser.

Indications:

  • Patients on anticoagulation / anti-platelet therapy
    • Warfarin needs to be placed on Clexane 7 days prior.
    • Clopidogrel should be down scaled down to Aspirin.
    • This allows patients on anti-coagulation therapy to continue their medication with minimal risk of hemorrhage. It also allows a shorter stay in hospital.
  • Prostates up to 120cc.
  • Where conservative management has failed.
  • Patient choice.
  • This procedure is performed when the prostate gland is enlarged to such an extent that medication cannot relieve the urinary symptoms.
  • Symptoms include: LUTS
    • a weak stream,
    • nightly urination,
    • frequent urination,
    • inability to urinate,
    • kidney failure due to the weak urination (obstruction),
    • bladder stones,
    • recurrent bladder infections.
  • Medication such as Flomaxtra, Urorec or Minipress etc. should always be given as a first resort.
  • Step-up therapy could have been used for prostates larger than 35-50cc where indicated, with either Duodart, Avodart or Proscar.
  • Prostate cancer first needs to be ruled out by doing a PSA, and when indicated, with a 3T MRI scan of the prostate with an abnormal PSA with a possible prostate biopsy of any suspicious lesions.

How is it done?

    • Patients will receive a general anesthesia, unless contra-indicated.
    • A cystoscopy is performed by placing a camera in the urethra with the help of lignocaine gel.
    • Saline is used to irrigate the bladder, therefore NO DILUTIONAL HYPONATRAEMIA
    • The inside of the bladder is viewed for pathology. If any suspicious lesions are seen, a biopsy will be taken.
    • A vaporization of the prostate is then started and should take 60-120 minutes depending on the size of the prostate.
    • Prophylactic antibiotics will be given to prevent any infections.
    • Post– operative antibiotics will be continued for 10 days.
    • No specimen will be obtained due to vaporization, unless PSA was suspicious and an MRI with view to prostate biopsy has excluded a prostate cancer.

What can go wrong?

  • Any anesthesia has its risks, and the anesthetist will explain this to you.
  • No blood loss is expected.
  • In rare circumstances you may develop fluid overload requiring a High Care Facility admission, especially with the upper edge of prostate sizes.
  • You will wake up with a catheter in your urethra and bladder. This will remain in the bladder overnight.
  • Lower abdominal discomfort for a few days.
  • NB! Each person is unique and for this reason symptoms vary!

What next?

  • You will spend 1 night in hospital.
  • You will a trial without catheter the next day.
  • You will be discharged as soon as you can completely empty your bladder.
  • You may initially suffer from urge incontinence and dysuria (discomfort) and will improve within the next 6 weeks.
  • You will pass a grey, wet scab at the 2–3-week mark.
  • Some bleeding may be associated with this, especially if you are on anticoagulation therapy.
  • Allow for 6 weeks for stabilization of symptoms.
  • There may be some blood in your urine. You can remedy this by drinking plenty of fluids until it clears.
  • A follow-up appointment will be scheduled for 6 weeks. Remember there is no pathology due to vaporization.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Side–effects

  • Retrograde ejaculation in more than 90% of patients. Therefore, if you have not completed your family, this procedure is not for you unless absolutely necessary.
  • Infertility as a result of the retrograde ejaculation. Not a given, therefore continue your contraceptives
  • Stress incontinence especially in the elderly and the diabetic patients.
  • Patients with Multiple Sclerosis, Strokes and Parkinsons have a higher risk of incontinence and risks should be discussed and accepted prior to surgery.
  • Urethral stricturing in <2% of patients, requiring intermittent self-dilatation.
  • Regrowth of prostate lobes can occur within 3-5 years requiring a second procedure.
  • NB! Each person is unique and for this reason symptoms vary!

Remember

  • You still have a peripheral zone of your prostate and regular PSA reviews are required up to the age of 75. (This could be seen as controversial).

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Wes TUVP Greenlight

Low Dose Brachytherapy

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Perineal placement of Radioactive Iodine-125 seeds in the prostate as treatment for Intermediate-Risk Prostate Cancer

Why is it done?

This is a radiation therapy option for the management of a localized prostate cancer.

Criteria include:

  • PSA less than 10
  • Gleason 3,4 adenocarcinoma prostate,
  • Higher grades may have extra-prostatic extension requiring combined External Beam Radiation
  • Staging negative, (bone scan negative, CT negative)
  • Not younger than 65
  • It is the localized radiation of the prostate, by means of trans-perineal placement of Radio-active I-125 seeds.
  • This is a nerve sparing procedure and patients have a good opportunity to maintain this.
  • The procedure takes 2-3hours excluding the anesthetic time.
  • This is an alternative to a Radical Retropubic Prostatectomy for low-intermediate risk prostate cancer. Prostates are generally smaller than 50cc.
  • Could be ideal for those patients with excessive BMI and fitting the cancer specific criteria.

 

How is it done?

  • Under a General Anaesthetic
  • Presence of Radiation Oncologist and Physicist
  • Lithotomy position
  • Trans-rectal placement of an ultrasound probe
  • Real-time accumulation of digital images to allow real-time placement of Radioactive Iodine seeds according to an intra-operative plan

PSA failure:

  • PSA not dropping to a nadir value, preferably 0,2ng/ml.
  • 3 consecutive PSA rises following RRP.

Complications

  • Perineal hematoma
  • Wound infections
  • Urgency frequency and weak stream
  • Limited Erectile Dysfunction, which may only surface after 18 months after treatment.
  • Lower ejaculate volume.
  • Testicular pain similar to vasectomy for 2-3 days

 

Post operative care:

  • A post-procedure CT scan to account all the seeds and exclude migration of seeds.
  • Normal diet
  • A salt water or Betadine Douche is required after every stool for the first week
  • A 3-month course of Flomaxtra to ease Lower Urinary Tract Symptoms
  • Wounds generally heal in 7-10 days

Catheter care

  • Your catheter will remain until you are awake.
  • Post-operative review:
  • Radio-Oncology will review a few weeks later.
  • You will review with me at 6 weeks post-procedure to check if you are doing fine.
  • Review PSA roughly 3 months after the procedure to assess PSA track
  • You should reach your Nadir (lowest PSA) at 6– 9 months after the procedure. The lower the better.
  • 6 monthly PSAs thereafter.
  • Expect a PSA Bump at approximately 9-12 months after the procedure, The PSA should drop thereafter
  • If stable with good PSA outcomes, refer back to GP for 6 monthly PSA review

 

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Wes Low Dose Brachytherapy

Peri-Urethral Bulking Injections

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Periurethral bulking for a type 3 urinary incontinence: “lead-pipe urethra” (ISD): Bulkamid or Macroplastique

 

Why is it done?

  • Where Intrinsic Sphincter Deficiency has been proved after failed previous sling.

How is it done?

  • This procedure is done under a spinal / general anesthetic, as decided by the anesthetist.
  • The legs will be elevated into the lithotomy position.
  • This procedure is done cystoscopically.
  • 3 peri-urethral injections are made with injection of Macroplastique/ Bulkamid until the urethral lumen closes.
  • Your urine output will be measured each time you urinate, and the residual will be measured. (Patients will be required to do this up to 3 times.)
  • If the residual amount of urine is more than 1/3 of the total bladder capacity, the patient may have to self-catheterize, until the residual volume is acceptable.
  • Prophylactic antibiotics will be given to prevent infection.

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain all such risks.
  • Complications of hemorrhaging and urine retention.
  • Patients will have no catheter when they wake up.
  • If you cannot urinate after 2-3 attempts, an in-out catheter may be inserted to empty your bladder.
  • You may be required to self-catheterize for a week or two.
  • NB! Each person is unique and for this reason symptoms may vary!

What next?

  • Patients will have a trial of void without catheter after the procedure
  • Patients will be discharged as soon as they can completely empty the bladder.
  • Patients may be required to self-catheterize for a week or two (rarely necessary).
  • Patients may initially suffer from urge incontinence, but this will improve within the next 6 weeks.
  • Allow 6 weeks for symptoms to stabilize.
  • You may not experience a full return of continence, and the effects may worsen with time.
  • More than 1-2 treatments may provide the desired effects.
  • There may be some blood in the urine. This can be remedied by drinking plenty of fluids until it clears.
  • On discharge a prescription may be issued for patients to collect.
  • Patients are to schedule a follow-up appointment in 6 weeks.
  • Please direct all queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOPSITAL DIRECT WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Peri-Urethral Bulking

Male Advance Sling

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For those guys who suffer persistent low-intermediate grade of stress urinary incontinence after their radical prostatectomy for prostate cancer. Usually 2 level 2 pads per day.

Why is it done?

  • Male Stress incontinence
  • Usually after a TURP/TUVP, Radical Prostatectomy in 2% of cases.

 

How is it done?

  • This procedure is done under a spinal / general anesthetic, as decided by the anesthetist.
  • The legs will be elevated into the lithotomy position.
  • A 5-7cm incision is made on the perineum (space between scrotum and anus).
  • The sling is placed around the bulb of the penis.
  • The arms of the sling are brought to the skin at the inner thigh, with a small incision.
  • The sling is placed with descent tension, pulling the bulb inwards by at least 2 cm.
  • The bladder will be inspected with a cystoscopy to exclude any injuries to the bladder wall and urethra.
  • The wounds are closed with dissolvable sutures.
  • A local anesthetic is given for pain relief.
  • A urinary catheter is placed for 24hrs.
  • The catheter will be removed early the next morning.
  • The patient’s post void residual volume will be measured. (Patients will be required to do this up to 3 times.)
  • If the residual amount of urine is more 250-300 cc the patient may have to self-catheterize, until the residual volume is acceptable.
  • You may require an indwelling catheter for 7 days.
  • Prophylactic antibiotics will be given to prevent infection.

 

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain all such risks.
  • Complications: hemorrhaging, requiring blood transfusion <1%.
  • Patients will wake up with a catheter in the urethra and bladder. This will remain in the bladder for 24 hrs.
  • Inner thigh discomfort/pain will persist for a few days but this will subside / settle.
  • If you cannot urinate after 2-3 attempts, the catheter may be replaced for a further 7 days
  • You may be required to self catheterize for a week or two.
  • If there is no improvement the sling may be cut, to allow spontaneous urination
  • This may only be 50% effective in irradiated patients
  • NB! Each person is unique and for this reason symptoms may vary!

 

 

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Wes Male Advance Sling

Meatotomy

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Opening of a meatal stenosis (pinhole narrowing).

Why is it done?

  • To treat a narrowing in the tip of the urethra which has formed due to previous damage/injury to the urethra.
  • Where intermittent dilatation is not desired, as discussed with the patient.
  • Causes:
    • Circumcision in early childhood where the foreskin is still attached to the glans, usually neonatal circumcision
    • After bypass surgery where a drop in blood pressure has caused an area of low blood supply to the urethra.
    • trauma to the urethra (pelvic fractures/ urethral instrumentation).
    • and sexually transmitted diseases.
  • The procedure involves surgical refashioning of your meatus.

How is it done?

  • Usually done in male patients
  • Selected Female patients can be considered.
  • Patients will receive a general anesthetic.
  • Your meatus will be refashioned, in order to leave it patent without a narrowing.
  • An indwelling catheter is left till post-operative period.
  • Prophylactic antibiotics may be given to prevent infection.

What to expect after the procedure?

  • It may be slightly uncomfortable.
  • A catheter will be inserted in the urethra and bladder. This will remain in until you are awake.
  • Catheters can be very irritating and cause some discomfort.
  • Blood stained urine will be present.
  • Painful urination may persist for a few days.
  • NB! Each person is unique and for this reason symptoms may vary!

What next?

  • Patients will be sent home after a successful attempt at voiding.
  • You may experience some discomfort with every void, that will become less over the next few voids.
  • There may be some blood in the urine. This can be remedied by drinking plenty of fluids until it clears.
  • On discharge a prescription may be issued for patients to collect.
  • Patients should schedule a follow-up appointment with Dr Schoeman within 6-8 weeks.
  • Should patients have any problems with urination, please contact the rooms for an earlier appointment.
  • Please don’t hesitate to direct any further queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOSPITAL WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

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Trans Urethral Resection Prostate (TURP) – Monopolar

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This is the procedure used to resect the inside (enlarged, obstructive part) of the prostate. Known generally as the “Re-Bore”.  Glycine is used as an irrigate.                                                           

Why is it done?

  • This procedure is performed when the prostate gland is enlarged to such an extent that medication cannot relieve the urinary symptoms.
  • Symptoms include
    • a weak stream,
    • nightly urination,
    • frequent urination,
    • inability to urinate,
    • kidney failure due to the obstruction,
    • bladder stones,
    • recurrent bladder infections due to retaining urine.
  • Medication such as Flomaxtra, Urorec or Minipress etc. should always be given as a first resort.
  • Step-up therapy could have been used for prostates larger than 35-50cc with either Duodart, Avodart or Proscar, where indicated and appropriate.
  • Prostate cancer first needs to be ruled out by doing a PSA, and when indicated, with a 3T MRI scan of the prostate with an abnormal PSA with a possible prostate biopsy of any suspicious lesions.

How is it done?

  • Patients will receive a general anesthesia, unless contra-indicated.
  • A cystoscopy is performed by placing a camera in the urethra with the help of a lubricant jelly and an irrigant fluid.
  • The inside of the bladder is viewed for pathology. If any suspicious lesions are seen, a biopsy will be taken.
  • A resection of the prostate is then started and should take 60-90 minutes.
  • Prophylactic antibiotics will be given to prevent any infections.

 

Complications

Side–effects

  • Retrograde ejaculation in more than 90% of patients. Therefore, if you have not completed your family, this procedure is not for you unless absolutely necessary.
  • Infertility as a result of the retrograde ejaculation.
  • Stress incontinence especially in the elderly and diabetic patients
  • Patients with Multiple Sclerosis, Strokes and Parkinsons have a higher risk of incontinence and risks should be discussed and accepted prior to surgery.
  • Urethral structuring in 5% of patients, requiring intermittent self-dilatation.
  • Regrowth of prostate lobes within 3-5 years requiring a second procedure.

NB! Each person is unique and for this reason, symptoms vary.

 

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Wes TURP Monopolar

Copyright 2019 Dr Jo Schoeman

Focal Therapy for Prostate Cancer – NanoKnife

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Not covered by Medicare / Health Fund yet, possibly early 2026

What is IRE

  • Irreversible Electroporation Therapy—breaking up of cell membranes using electric current by means of creating holes in the cell walls (Nano-pores)
  • Non-thermal ablation

 

Why is it done?

  • Treatment for localized prostate cancer
  • Single focus disease
  • Prostate preserving
  • Ejaculate sparing
  • Continence preserving

 

How is it done?

  • Focal therapy of prostate cancer, usually a single lesion
  • Preferably Gleason 3,4 or more aggressive
  • Preserving prostate supporting tissue and erectile function and continence

You would have had a 3T MRI study possibly a PET PSMA as well prior to confirming your prostate cancer. Usually, whole gland biopsies are taken of the prostate via the perineum to prove unifocal cancer.

  • This procedure is done under general anesthesia as a day procedure and takes approximately 60-90min (incl anesthetic time)
  • It is performed with the patient lying in lithotomy (legs in stirrups) position
  • Prophylactic antibiotics are essential and a script with details is provided on the day of signing consent.
  • A trans-rectal ultrasound is placed
  • 4-5 NanoKnife electrodes are paced approximately 2cm apart surrounding the focal cancer.
  • An electrical current of 3A is run at 800-1331mcs pulse causing a non-thermal ablative technique
  • Total treatment as soon as electrodes are placed is < 5 minutes

 

Complications

Side–effects

  • Hematuria (blood in urine) 2-3days
  • Hematospermia (blood in ejaculate) will become less the more often you ejaculate.
  • Bacteremia (infection) with low-grade fever and feeling unwell
  • Perineal hematoma
  • Perineal pain and penis tip pain
  • Prostate swelling causing bladder outlet obstruction requiring a catheter for up to 5 days

ANY FEVER REQUIRES URGENT ATTENTION

What next?

  • You will be discharged with an indwelling catheter for 3-5 days depending on the size of your prostate and the lesion treated
  • You may have necrotic tissue developing requiring a resection (treatment involving the urethra).
  • Difficulty in urination up to 6 weeks after the procedure
  • It could feel like you are sitting on a golf ball for a week

 

Should there be any signs of fever or cold shivers, you are to return to the hospital or Emergency Department without hesitation

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Wes Nanoknife

Copyright 2019 Dr Jo Schoeman

One Stage Urethraplasty

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Primary excision and anastomosis of a short segment urethral stricture.

Why is it done?

  • To treat urethral strictures (narrowing) caused by trauma, infection, malignancy, etc. Shorter strictures less than 2 cm in length.

How is it done?

  • This procedure is done under general anesthetic.
  • Legs are placed in a lithotomy position.
  • A single incision is made on the midline raphe on the perineum (area between scrotum and anus).
  • The corpus spongiosum identified and exposed
  • Stricture located using urethral sounds
  • The stricture is excised with a spatulated anastomosis over an indwelling catheter
  • A long-term catheter will be inserted for 10 days.
  • A dressing is then applied, which should be removed after 72 hours.
  • A local anaesthetic is injected into the wound, thus giving post-operative pain relief for the next 4-6 hours.
  • A drain may also be left for 24-48 hours to prevent the collection of serous fluids.

What to expect after the procedure?

  • Any anaesthetic has its risks and the anaesthetist will explain all such risks.
  • You will be sent home with an Indwelling catheter for 7-10 days
  • Bleeding is a common complication.
  • A haematoma (blood collection under the skin) may form and needs to be reviewed by Dr Schoeman as soon as possible. Bruising is normal.
  • An infection of the wound may occur and requires immediate attention.
  • Erectile dysfunction (15%) may occur.
  • Re-stricturing (20-30%) may occur.
  • Owing to the area of the surgery the wound should be kept clean and dry.
  • DANGER SIGNS: A scrotum that swells immediately to the size of a football, fever, or puss. Please contact Dr Schoeman or the hospital immediately as this may occur in up to 15 % of all cases.

What next?

  • The dressing should be kept dry for the initial 72 hours after surgery and then soaked in a bath until it comes off easily.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • Arrangements will be made for the removal of the catheter after 7-10 days.
  • A urinating Urethragram will be arranged with radiology within 6 weeks to determine the final result of the surgery.
  • There will be signs of bruising for at least 10 days.
  • The suture-line will be hard and indurated for at least 8-10 weeks.
  • PLEASE CONTACT THE HOSPITAL DIRECT WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

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Wes Urethraplasty One-Stage