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why urology podcast
14 minutes | 2 days ago
I'm Nobody, Who Are You?: Content Marketing, Podcasting and the Medical Practice ep 107
We live in a social media-driven world. Facebook, twitter, Linked In, Instagram, YouTube, TikTok and many other platforms vie for our attention, and of course the advertising dollar. Medical practices have been trying to figure out social media, medical review sites, and online marketing for years now. Sadly, it is necessary for businesses to seek out the likes, and thumbs ups, shares, subscribes, stars or whatever other rating system is out there just to keep up. Enter content marketing as an antidote to chasing likes online. The idea of content marketing as I understand it is this. A business and professionals in business can earn credibility and trust through online content in the form of blog posts, videos, pictures, and websites that establishes authority and expertise within a certain field. Trust is then developed with a potential new client, customer, or a patient online well before any face-to-face meeting or phone call to that business or professional. If I am a plumber, for instance, I can make videos and post them online that show you how to troubleshoot a clogged drain. Not only am I being helpful to you when your drain is clogged, but you may end up calling me to help when it is beyond the simple do it yourself fix. We can apply the same idea to our medical practices, at least that was my thought when I got the idea for this podcast as well as other forms of online content creation. In this episode I share 5 principles that I think are important when we think about how to create online content marketing. Here are the five principles: Share information and solve problems Tell a story Choose one form of content as the foundation Reimagine content Keep a schedule Connect with me at whyurologypodcast.com.
14 minutes | 16 days ago
Adrenal Gland: The Adrenal Gland for Sixth Graders ep 106
Medical education, we are told, that is aimed at our patients should be written at a sixth-grade level if we want to have a majority of our patients understand what we are trying to tell them. Many, many people do not read or understand material aimed higher than a sixth-grade level, nor do they want or have time to, so to capture our patient’s attention and ability to understand we should aim no higher. I have heard this advice many times but, to be honest, I never knew what that meant, to write at a certain grade level, nor how to achieve it. What does it mean to read and write at the sixth-grade level? There are a number of ways to determine what grade level a certain piece of writing is. I am going to highlight two of them. Most of the ways to calculate the reading level is to calculate based on sentence length, word complexity, and paragraph length. THE ADRENAL GLAND The adrenal glands are hormone producing glands. You have two adrenal glands, one on each side of the body above each kidney. The adrenal glands are about two inches long, and inch wide and half an inch thick. The glands are a deep yellow color. The adrenal glands are surrounded fat which also surrounds the kidneys. A thin layer of fat separates the adrenal glands from the kidneys. Each adrenal gland is made up of two parts, an outer layer called the cortex, and an inner core called the medulla. The adrenal glands produce several different hormones. Adrenaline is made by the inner portion of the adrenal gland. Adrenaline is released during times of stress. During times of danger adrenaline increases blood pressure and heart rate, breathing and causes your blood vessels to narrow as a way to prepare your body to either run away from the danger or to stay and fight. The adrenal cortex has three layers. Each layer makes its own hormone. The first layer of the adrenal cortex produces a hormone called aldosterone that helps regulate of blood pressure and salt levels in the body. The second layer of the adrenal cortex makes a hormone called cortisol that helps regulate metabolism and the immune system. The innermost layer of the cortex makes a hormone that gets converted to sex hormones in other parts of the body. The adrenal gland can be seen on CT and MRI scans. A mass or tumor as an incidental finding can be seen in up to 3-5% of CT scans. Many of those unexpected small tumors are not functional and do not need to be treated. There are a number of diseases involve dysfunction of the adrenal gland. Insufficient production of adrenal hormones is called Addison's disease. Symptoms of Addison’s disease include hyperpigmentation of the skin, sudden pain in the legs, lower back, or abdomen, vomiting and diarrhea, low blood pressure, low blood sugar, tiredness, confusion, low salt levels in the blood and fever. A famous patient who suffered from Addison’s disease was the late President John F. Kennedy. Overproduction of cortisol within the body or taking prednisone for a long period of time leads to Cushing's syndrome. Cushing’s syndrome produces a wide variety of signs and symptoms which include obesity, diabetes, increased blood pressure, excessive body hair, poor bone health, depression, and stretch marks in the skin. A variety of non-cancerous tumors are found in the adrenal gland and are commonly found on x-rays. The most common finding is a tumor that does not produce any hormones. A common functioning tumor that produces too much aldosterone is called a hyperaldosteronoma, which causes abnormalities of blood pressure and salt levels in the blood. A tumor that produces too much adrenaline is called a pheochromocytoma. Common signs of a pheochromocytoma include a sudden high blood pressure, sweating and a rapid heart rate. Cancer of the adrenal gland is uncommon.
15 minutes | a month ago
Peyronie's Disease: Nesbit Plication Ten Questions ep 105
In this episode I answer the ten question about Nesbit Plication, as surgery used to treat curvature of the erect penis caused by Peyronie's Disease. We first discussed Peyronie's Disease in episode 72 of this podcast. Question #1. Doctor, what is my diagnosis? Can you describe it? Peyronie’s disease is a scarring process of the penis that creates a classic triad of symptoms: curvature, pain, and palpable deformity on the penis. It can also create erectile dysfunction. Its incidence is estimated at around 1 in 10 men. Peyronie’s disease can affect a man’s penis with severe symptoms of pain or curvature with erection that affects his ability to be sexually active. Most men have mild to moderate symptoms that may hinder, but not prohibit, sexual activity. Why does the penis bend? The curvature of the penis is due to the fact that scar tissue does not stretch as well as normal tissue, so with erection that area of the penis does not expand with the blood filling the corpora. The penis is then pulled towards the scar tissue. Most men will have a bend upward. Peyronie’s disease usually presents as a rather sudden onset of pain and curvature during erection that, like any scar tissue, changes over time. We usually think about Peyronie’s having two phases, the active and the stable phase What we call the active phase of Peyronie’s, the sudden onset of symptoms and the changing curve afterwards, may last up to 18 months or more as the scarring continues to change the shape, size, and curve of an erection. The stable phase of Peyronie’s disease is when the scarring has stopped shaping the penis and a man is left with a stable, unchanging deformity that no longer is painful. Determining the phase of Peyronie’s Disease is critical prior to a surgery. Surgery on the penis to correct its shape or curvature can be considered when a patient has reached the stable phase of erectile dysfunction, when there is a stable curvature--no pain, no progression. Question #2: What is the procedure you are recommending? Describe the procedure. The Nesbit plication “tucks” or plicates the tunica albuginea of the penis on the side opposite of the curvature. Think about putting a pleat in a pair of pants or alternatively altering a suit. The surgeon can simply place a suture in the tunica to pull it together, like a pleat or alternatively, the plication procedure can remove a piece of the tunica and sew the edges back together, like fitting a suit. The plication pulls the penis back to straight equal and opposite to the formed Peyronie’s plaque. The procedure is done as an outpatient, in the hospital or surgery center, under general or spinal anesthesia. While a patient is asleep the surgeon exposes the tunica albuginea of the penis, creates an artificial erection to expose and measure the curvature, places the appropriate suture to correct the curvature, and then closes and bandages the incision. The man then wakes up and goes to the recovery area to prepare for going home the same day. Question #3: What are the goals and benefits and what can I expect to gain from this procedure? The goal is to create a straight and firm penis for sexual activity. The goal is not a cosmetic result. This is important. Many men are concerned about and how their erection looks, but it’s the function that the surgeon cares about. A man with a small curve of the penis that does not inhibit sexual activity should not be considering this procedure. Question #4: What are the risks? As with any surgical procedure bleeding, infection, and anesthetic risks exist but there are three unique risks to this procedure that should be discussed: failure to correct the curvature, penile shortening and subsequent erectile dysfunction. Failure to correct the curvature can happen when the artificial erection created intraoperatively doesn’t simulate the actual erection a man gets during normal sexual activity. Subsequently, there is potential for over-correction or under-correction of the curvature or failure to identify a secondary curve. Fortunately most all men have a very good result from this procedure. Erectile Dysfunction can also occur. The tunica albuginea of the penis is the part of the penis that gets firm during an erection. The tunica is responsible for the trapping of the blood. Peyronie’s can affect the ability of the penis to trap blood but so can sutures placed into the tunica result in erectile dysfunction. Finally let’s discuss penile shortening can occur as well. The peyronie’s disease limits the stretch to the penis on the one side of the penis. By tucking or plicating the side opposite we have effectively shortened the overall length of the penis. This is a major potential drawback to the procedure. Alternative procedures exist that can maintain length, but are more complicated and carry greater risk. Question #5: Are there alternative procedures? Yes, there are alternatives to a Nesbit plication: Xiaflex injections, traction therapy, excision and grafting techniques, and penile prostheses. Question #6: Is this a common procedure? The Nesbit plication is a common procedure. Question #7: Why now? Can I wait to have this procedure? Timing of a Nesbit plication is critical. There are two phases of Peyronie’s disease. There is an active phase, usually the first 6 months to 2 years of the problem where a man has ongoing curvature and discomfort. The plaque at this time is evolving and even has some ability for the curvature to correct itself. We do not want to operate in this phase. If we correct curvature in the active phase then the penis may develop more deformity after the surgery. In the second phase of Peyronie’s the scarring is what we call “stable” and there is no further curve or deformity developing within the penis. A man should wait to have surgery until he knows the curve is stable. Question #8: How do I prepare for this procedure? There is no special preparation for this procedure. Get preoperative clearance by your primary care physician for the anesthesia. Stop blood thinning medication at an appropriate time before surgery. Follow your surgery center guidelines for NPO status. Get to the surgery center on time. Have plans for your care after and for going home on the same day of your procedure. Question #9: How do I recover from this procedure? Recovery from this procedure takes a full six weeks before you are allowed to be sexually active. This is probably the most important part of this procedure. Resuming sexual activity too early can cause disruption of the suture line resulting in failure of the procedure. The initial phase of recovery takes a full two weeks. There will be some pain, especially with erection. Swelling and bruising are common and begin to resolve in 7-10 days. Ice packs can help reduce swelling. You will be able to shower. The incision line needs minimal dressing with antibiotic ointment. There are no dietary restrictions. You will most likely be able to stay on or resume all medication as prior to surgery, including any blood thinners. Most men can go back to light activity right away, taking care to protect the penis during physical activity, and resume heavier physical activity within a week or two. Your individual surgeon and postoperative needs will determine your postoperative care. Question #10: How do I pay for this procedure? Is it covered by insurance? Most insurance carriers will cover this procedure. Some do not. As with any procedure verify your coverage prior to your operation. Your insurance carrier will want to know the specifics of what the procedure is, who is performing it, where, and on what date. Insurance companies like to authorize a specific event for surgery, not just a general procedure type.
16 minutes | 2 months ago
Bladder Cancer: Ten Questions about Transurethral Resection of Bladder Tumor ep 104
This is episode number 104 of this podcast that I started as a personal exploration into podcasting, the field of urology, and how we can combine the two to educate a general listening audience about different topics in urology. Today’s topic is bladder cancer, and I want to focus specifically on a procedure that is the first step for most patients in their bladder cancer journey after they are diagnosed with a suspicious bladder tumor, the transurethral resection of bladder tumor or TURBT. The format of this episode is to walk through the ten questions to ask your surgeon about any surgery or procedure and to apply it to the transurethral resection of bladder tumor. The ten questions is a set of questions that I have come up with that I think can apply to any surgical procedure. It is meant to be a general framework for discussing any surgery or procedure with your surgeon. You can hear that episode of this podcast at https://whyurologypodcast.com/ten-questions-to-ask-your-surgeon-before-an-operation-ep-97
42 minutes | 3 months ago
Enlarged Prostate or BPH and HOLEP or Holmium Laser Enucleation of the Prostate: A conversation with Dr. Andrew Bergersen ep 103
In this episode I discuss the HOLEP (Holmium Laser Enucleation of the Prostate) with Dr. Andrew Bergersen. The HOLEP procedures is used for men with very large, obstructive prostates causing urinary symptoms. You can find Dr. Bergersen at https://mnurology.com/physicians/andrew-bergersen/ Connect with me at www.whyurologypodcast.com
58 minutes | 4 months ago
Applying for Urology Residency and Podcasting during COVID-19: an interview with medical student Parker Adams
In this episode I interview medical student, Parker Adams. Parker is in his final year of medical school and applying for a urology residency training program. His match day for Urology this year is Feb 1st. Parker is also a podcaster. His podcast, Rod Squad, is aimed at medical students learning urology. Find his podcast at rodsquadpod.com Parker is passionate about using technology to improve medical and patient education. You can find me at whyurologypodcast.com
54 minutes | 4 months ago
Erectile Dysfunction: Using Shock Wave Therapy, an interview with Dr. Alex Tatem ep 101
Welcome to the Why Urology Podcast. This is episode number 101, an interview with Dr. Alex Tatem about shock wave therapy (SWT) for treating men with erectile dysfunction. Shock wave therapy is a developing technology within the field of urology, a technology not universally endorsed, encouraged, or employed in urologic practices today. Dr Tatem is a urologist in Indianapolis Indiana specializing in men’s health with a special knowledge about using shock wave treatment who uses it within his own practice. Dr Tatem is also content creator, posting videos on YouTube and Vidscrip for patient education. Whenever I want to see what I should be doing on YouTube, I take a peek at Dr. Tatem’s videos. I was doing this recently and I came across his video on using shock wave therapy for erectile dysfunction. I was immediately interested because this is a controversial technology within the field of urology and I was interested to see what Dr. Tatem had to say. I was impressed, not only with the quality of video, but with the depth and honesty of his presentation. https://www.youtube.com/watch?v=DS1XqgLHOvc If you are a man with erectile dysfunction considering shock wave treatment, I would encourage you to listen to this podcast or watch his video. You will not only learn about shock wave treatments for erectile dysfunction but you will hear or see how a young, innovative physician employs a new, maybe unproven technology in his practice with the highest possible standards of care. This was a long conversation between Dr. Tatem and I and, even edited, it's a long interview. I chose to keep it long because there is such good content I did not want to cut out too much of it simply for the sake of time. Here are the takeaway points from this interview: Shock wave therapy is an easy to apply in office treatment being used to treat men with erectile dysfunction. Shock Wave Treatment will give the best results to men with mild to moderate ED. Long term benefits of Shock Wave Treatment are still being studied. There are different kinds of shock wave machines on the market, so buyer beware regarding what type of shock wave is being delivered to the penis. As of this date, the end of December 2020, there is only one shock wave machine on the market in the U.S. that delivers that kind of penetrating shock necessary to get the results equivalent to the medical research. The Storz Duolith SD1: https://www.storzmedical.com/en/disciplines/urology/product-overview/duolith-sd1-ultra-uro.html Thank you for listening to my interview with Dr Alex Tatem. I you have questions, thoughts or concerns please reach out to me. www.whyurologypodcast.com.
44 minutes | 6 months ago
A Thousand Stories, A Big Orange Bucket, and A Little Help From My Friends ep 100
Thank you for listening to this episode of the Why Urology Podcast. This is episode number 100, a milestone in my podcasting journey. This podcast started with a single question, “Why Urology?” In this podcast episode, at the very end, I give you the answer. Just a heads up this episode is the last episode for 2020. I am taking a break for the holiday season and to do some planning for next year. I will put an episode out if I feel so inspired before January, but don’t count on it. If you want to take the time to listen to any of the old episodes of this podcast please go to whyurologypodcast.com. On this episode I have a special guest, my girlfriend Susan who has been a key player in this podcast for many of the 100 episodes. I couldn’t have gotten to 100 without her help. A couple of months ago I had commented to her that I would be hitting 100 episodes sometime before the end of the year and I was starting to wonder if I should make it a thing. Her reply was a pleasant surprise. “I am going to be your 100th episode,” she said. On a cool Sunday morning here in Minnesota, with the kids still asleep and a freshly brewed pot of pumpkin spice coffee, we cleared a spot on a table in her basement where I set up a couple of microphones and hit the record button. Her idea was that she would interview me, a transfer of host duties from me to her, about my podcast journey. You will hear that our interview starts that way, but I can’t help myself and I begin to ask her about her job in surgical nursing before we swing around to podcasting again at the end. A surgical nurse is just one of the many people who play a critical role in keeping a patient safe as they go through their journey from diagnosis to treatment. There’s a lot to unpack in that conversation and I hope you enjoy it. What struck me about this conversation was my dependence on so many others in my personal and professional life who help me actually be a urologist. The list is very long, too long to get it all correct. I can diagnose your prostate cancer and take your prostate out robotically. But that is the end of a long chain of people and events that help you and I get there safely and with the opportunity to create the best possible outcome. To steal a line from the Beatles, we get by with a little help from our friends. So, this is a special thanks my friends and to those of you who help me on a daily basis take care of my patients. I can’t do it alone. You are needed. You are appreciated. Thank you.
22 minutes | 6 months ago
Aequanimitas: Why Poetry Matters in Medicine ep 99
Kidney cancer is most commonly a Renal cell carcinoma (RCC). Renal Cell Carcinoma, with its various subtypes, will be diagnosed in an estimated 73,750 adults (45,520 men and 28,230 women) in the United States this year. Kidney cancer is the sixth most common cancer for men, and it is the eighth most common cancer for women. A Renal Cell Carcinoma begins in what I call the meaty portion of the kidney, the renal parenchyma. It grows slowly most of the time, forming a mass somewhere in the kidney. If the mass is less than 7 cm and there is no spread to lymph nodes or distant organs it is a stage 1 tumor. If it is larger than 7 cm, but still no spread, it becomes a stage 2 tumor. Treatment for a Renal Cell Carcinoma, when it is large enough, approaching 2 cm or greater is to either remove or ablate the tumor. If possible, we can remove to tumor from the rest of the kidney leaving a large portion of the kidney intact and functional. A stage 3 tumor is one of several subtypes. It can invade into the fat around the kidney, called Gerota’s fascia, or into nearby lymph nodes, or, somewhat unique to kidney cancer, RCC has the ability to locally invade the veins of the kidney with tumor thrombus that can propagate distally from the segmental renal veins to the main renal vein, then into inferior vena cava (IVC) and all the way up to the heart into the right atrium. Around 5 % of cases of RCC are reported to have some level of venous invasion, most commonly into the segmental renal veins still within the kidney. Medicine, they say, is both an art and a science. The science part slowly removes the veil of mystery about disease. And once the mystery is gone, the art of medicine is at risk of fading in the background. It’s a tug of war, and science is always winning. Because science is so powerful, there is a constant effort within medical education to make sure we are accepting and training young physicians who are caring, kind, and compassionate to balance the science with the art of medicine. It is a worthy goal. In this episode I tell you how poetry can help.
11 minutes | 6 months ago
Aequanimitas, Keystone Habits, and Four Things That Can Make You a Better Doctor ep 98
The idea of a keystone habit I think is attributed to Charles Duhigg in a book called, The Power of Habit. As I understand the concept, a keystone habit is a habit that leads to multiple other behaviors, and positive outcomes in your life. A keystone habit sparks a chain reaction. When you focus on, when you become intentional about, building keystone habits those few habits that will have a ripple effect. The Four Habits Model are four simple keystone habits a doctor can employ during a clinic visit to improve communication, outcomes and patient satisfaction. The Four Habits are invest in the beginning, elicit the patient’s perspective, show empathy and invest in the end. Identifying and being intentional about developing these keystone habits can have a major impact in the lives of our patients. Here is the Wikipedia link to Aequanimitas https://en.wikipedia.org/wiki/Aequanimitas You can find more information about the Four Habits Model at http://www.thepermanentejournal.org/files/Fall1999/habits.pdf
19 minutes | 7 months ago
Ten Questions To Ask Your Surgeon Before An Operation ep 97
Consider this a top ten list of things to ask your doctor about your upcoming surgery or procedure. 1. What is my diagnosis? 2. What is the name of the procedure you are recommending? 3. What are the goals and benefits and what can I expect to gain from this procedure? 4. What are the risks? 5. Are there alternative procedures that I should be considering? 6. Is this a common procedure? It is a procedure you commonly perform? 7. Why now? What happens if I wait? 8. How do I prepare for the procedure? 9. How do I recover from the procedure? 10. How do I pay for this procedure? Is the procedure covered by insurance? Thank you for listening. You can connect with me at whyurologypodcast.com
14 minutes | 8 months ago
The Ureter ep 96
The ureter is the long thin little muscular structure that transports urine from the kidneys to the bladder. The ureter is a relatively small player in the urinary system but a very important one. It doesn’t get talked about enough because it is often thought of as just a transport tube from the kidneys, the star of the show where the urine is made, to the bladder, the supporting actor, where the urine is stored. What is most striking to me as a surgeon is how delicate the ureter is to have such a critical function to getting waste products out of the body, , how small it is and occasionally hard to identify within the body, how easily it can be injured during an operation, and how delicate we have to be when we operate. There’s a lot relying on these little guys to do their job. The ureters are long, usually 20–30 cm (8-12 inches) long and around 3–4 mm (1/8 to ¼ inch American) in diameter. From the renal pelvis, they descend on top of the psoas major muscle to reach the brim of the pelvis. Then they cross in front of the common iliac arteries down along the sides of the pelvis, and finally curve forward and enter the bladder at the back of the bladder, tunneling through the bladder wall before opening into the bladder on its back surface at the level of the trigone of the bladder at small openings called the ureteral orifices. The inner lumen of the ureter is lined by transitional cells, the same type of cells that lines the urinary bladder. The transitional cell urothelium stretches in the ureters, appearing as a layer of column-shaped cells when relaxed, and of flatter cells when stretched and distended. Below the epithelium sits the lamina propria, a connective tissue layer with many elastic fibers, blood vessels, veins and lymphatic channels. The ureter’s outer layers are two muscular layers, an inner longitudinal layer of muscle, and an outer circular or spiral layer of muscle. The lower third of the ureter has a third muscular layer. Because of it’s length along the body the ureter’s blood supply (arteries and veins), lymphatic drainage and nerve innervation come from many different sources at the levels along it’s path. The ureters can be affected by a number of diseases. Kidney stones are the most common problem. The ureters are so narrow it doesn’t take a very big stone to get stuck in the middle. Stones even as small as 1-2 mm may get stuck in the ureter (although some ureters can pass stones as large as a centimeter). When the stone gets stuck the urine cannot pass. The urine backing up stretches the ureter and renal pelvis behind it causing hydronephrosis or hydroureteronephrosis. The muscular renal pelvis and ureter try to push the urine out with peristaltic waves of muscular contraction. The pressure buildup and stretch receptors in the renal pelvis and ureter cause pain. The pain often comes in waves and is referred to as renal colic. Because the nerve innervation comes from several levels along the course of the ureter the pain can be felt sometimes in the back, sometimes in the flank, or sometimes radiating around to the front lower abdomen and down into the testicle, scrotum or labia. To get a stone that is stuck in the ureter out of the body often requires a scope procedure called ureteroscopy to look into the ureter and pull out the stone and/or to break it up using a holmium laser. The ureter can also be blocked by obstruction. Obstruction of the ureter can occur intrinsically, as a result of narrowing within the ureter, or extrinsically, compression or fibrosis of structures around the ureter pushing on the ureter to narrow it. Intrinsic blockage can come from strictures, congenital or acquired, and ureteropelvic junction obstruction from abnormal development at that junction or from obstructive ureteroceles. Extrinsic compression can come from cancer, endometriosis, tuberculosis and schistosomiasis, and retroperitoneal fibrosis. A narrowed ureter leads to hydronephrosis and hydroureteronephrosis similar to a kidney stone but it does not always lead to pain because the conditions are usually more chronic. Other symptoms may be blood in the urine, infection, or a loss of kidney function. Often the condition is found incidentally, when an x-ray, ultrasound or CT scan is done for another condition. Treatment of any of these obstructions may involve treatment of the underlying conditions as well as ureteral stenting or nephrostomy tube, ureterolysis in the case of retroperitoneal fibrosis, or reinserting the ureters into a new place on the bladder called reimplantation. Another class of ureteral problem is congenital abnormalities that affect the ureters, which can include the development of two ureters on the same side with subsequent obstruction and/or reflux, or abnormally placed ureters, called the ectopic ureter. Variants of ureteral anatomy such as duplication occur when the ureteric bud, an outpouching from the mesonephric duct, which forms the ureter, develops abnormally, sometimes duplicating completely or incompletely or budding from an abnormal position so the ureter drains not on the trigone of the bladder but higher or lower in the bladder, in the prostate, urethra or vagina. Congenital abnormalities can present with a number of symptoms and may need to be treated very early in life in some cases. Another condition commonly seen in children is vesicoureteral reflux. Reflux is when urine is pushed back into the ureter during urination. In the normal situation the ureter tunneling through the bladder creates an area of the ureter that prevents urine from going back into the ureter during urination. Many children with this vesicoureteral reflux have the reflux resolve as the bladder develops through childhood. The amount of reflux can be mild, going just to the end of the ureter, or severe, going to the renal pelvis and dilating the system from the backflow. Symptoms are most commonly recurrent infections. Occasionally surgery is needed to reimplant the ureter and correct the reflux. Lastly, I would like to mention ureteral cancer. Ureteral cancer is most often cancer of the cells lining the ureter, the transitional cells, and is called transitional cell carcinoma This is a similar cancer to most bladder cancers. Bladder cancers are more common that ureteral or renal pelvic tumors, but the risk factors are largely the same, including smoking and exposure to dyes such as aromatic amines and aldehydes. The most common symptom is blood in the urine. Diagnosis is made radiographically and through visual inspection called ureteroscopy. Treatment most often requires removal of the entire ureter, renal pelvis, and kidney on that side. For more information on that you can listen to the last episode of this podcast, an interview I had with Dr Mikhail Regelman about a procedure called nephroureterectomy. Find more episodes and connect with me at whyurologypodcast.com.
31 minutes | 8 months ago
Kidney Cancer: Upper Tract Transitional Cell Carcinoma with Dr. Mikhail Regelamn
Transitional Cell Cancer forms in the renal pelvis and ureter as well as in the bladder. In this episode Dr. Mikhail Regelman and I discuss how we diagnose and treat this disease
10 minutes | 9 months ago
Aequanimitas: Henri Matisse and The Road Not Taken ep 94
This episode is about how, as we make choices in life, we often have to choose between two equally attractive paths with incomplete information and uncertain outcomes. Career choices are like that; life choices are like that. And often the choices feel limiting, like we are boxing ourselves in, closing off opportunities for our future selves. “Two roads diverged in a yellow wood/And sorry I could not travel both,” wrote the late poet Robert Frost in his poem, The Road Not Taken. But life’s a marathon, not a sprint. We have long careers and long lives. There may be several segments to our careers, so we don’t have to do everything all at once. We can, make small iterative changes. We can experiment, test, and correct course. We can focus on developing your abilities in the direction of your talents. We can stop worrying about winning awards or being high profile and instead focus on being so good we can’t be ignored. Finally, we can remember to have fun. Life is short, after all. If it’s not fun, why do it?
12 minutes | 9 months ago
"Are You Busy?": Steve Martin, Aequanimitas, and the Path to Success ep 93
What is success? What does a successful life look like? What does it mean to be a success? For too many urologists including myself the primary way we measure our lives as successful is through the building of a large and lucrative practice. For the record, I believe these are important things to measure. A medical practice is after all a business and we must always pay attention to the bottom line. Ultimately, it’s not about how many patients did you see, but about how many patients received excellent medical care. In 1889, William Osler called the “Father of Modern Medicine”, who would himself become a world-famous physician and educator by working long days and nights, had this to say to graduating medical students at the University of Pennsylvania in his most famous Speech “Aequanimitas.” Remember, this was in 1889… “…I would warn you against the trials of the day soon to come to some of you—the day of large and successful practice. Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.” There is a book I read by an author called Cal Newport. The title of the book is “so good they can’t ignore you.” The book is about how to build a career that you love through skill development, not by pursuing of a “passion.” The title comes from a Steve Martin quote. Here is his simple message. Focus on being good. Really good. Undeniably good. The rest will probably follow. The successful physicians, the ones I look up to, seem to be able to juggle the demands of being both “good” and “busy”. They possess that certain “Aequanimitas” that William Osler describes in his famous speech. They have developed skills through years of deliberate practice that allow them to be efficient and effective. They do not forget what makes life worth living. Here is a poem written in 1904 by Bessie Stanley of Lincoln Kansas as an entry into a magazine contest. The requirement of the contest was to define success in 100 words or less. He achieved success who has lived well, laughed often, and loved much; Who has enjoyed the trust of pure women, the respect of intelligent men and the love of little children; Who has filled his niche and accomplished his task; Who has never lacked appreciation of Earth's beauty or failed to express it; Who has left the world better than he found it, Whether an improved poppy, a perfect poem, or a rescued soul; Who has always looked for the best in others and given them the best he had; Whose life was an inspiration; Whose memory a benediction
11 minutes | 9 months ago
Jumping Back Into the Water After COVID 19 ep 92
I have spent half of my life as a physician, beginning as an intern just before my 26th birthday. It began in an inauspicious start on July 1st as an intern at the VA hospital. On our first day we spent most of the day in orientation, but at the end of the day I reported to my assigned general surgery team, currently on rotation at the VA hospital and doing afternoon rounds. When I arrived, I was informed I would be taking call that night, was shown to my call room at the end of rounds, and was given a few basic orientation tips. I will never forget being handed the “code” pager for the first time. The chief resident explained to me that carrying the code pager as a surgery resident wasn’t a big deal. Be professional; be prompt; stay relaxed; work with the team; do your job. Basically, he said, you have to run to the code blue, announce that “surgery” was there. Surgery’s responsibility was to make sure tube and lines, things like IV access were present and functioning well and, if needed, to perform whatever bedside procedures needed to be done. I nodded my head and said goodbye for the night to my fellow residents and medical students. No sooner had I sat on the bed in the call room than the pager went off for a code blue. Code Blue. Intensive Care Unit. Room 9. Up I jumped, and made my way quickly to the intensive care room 9. There I found a number of doctors and nurses already gathered around a patient and performing CPR and delivering medication. This ICU patient had plenty of tubes and IVs but I was there and I thought I should let people know just in case. “Surgery is here!” I said as I entered the room. “What?!” said the nurse standing at the bedside, “Who are you kidding? Get out of here!” I took a look around the room, decided that surgery was not needed during this particular code blue, and slowly backed out of room 9 in the ICU and back to my call room. Such began my life as a physician. I learned two things that night You are not as important as you might think. Be professional; be prompt; stay relaxed; work with the team; do your job. And there are many days where I feel about as relevant as I did that night. But, like Sysiphus, I keep pushing my rock up the hill. And I have been doing so over the last 26 years. Enter 2020 and the abrupt halt to what I have come to know over the last half of my life. Clinics and surgeries cancelled, telehealth and video visits replacing in person interaction, time spent at home in isolation, wearing a mask not only the OR but many other places as well. Our practice faced the challenge head on, adopting telemedicine quickly, shutting down clinics and cancelling unnecessary surgery in preparation for the COVID-19 surge. Our changes felt and still feel like the right answer. We were ahead of the curve, if only slightly, still we were ahead. At first it was a break. An unwelcome break, but a break nonetheless. I vowed to take the time for personal development, hoped to make a few podcasts and videos, and, to be honest, did not expect our hiatus to last too terribly long. My positivity waned a bit after a few weeks as I personally began to feel more and more distanced from my family, my friends, and actually more concerning for me, my work. Without patient interaction, without the ability to touch people, either with a handshake or a scalpel, the practice of urology just isn’t as fun…at least for me. But it’s summer, which has always allowed me one of my life’s simplest pleasures. I live on and grew up on body of water called the St. Croix River, on section of the river called the Lake St Croix because it widens into an area that is the size of a very large lake. The river is designated as a National Scenic Riverway, and it is fantastic in the summer. A near nightly ritual for me in the summer is to put on a bathing suit at the end of the day and wash away the cares of the day with a dip in the water. This is not a workout. I usually have a beer in hand. Think of this almost as a nightly baptism, and I emerge refreshed. I often think about a quote from an ancient philosopher as I go on my nightly swims. "A man cannot jump into the same river twice. It is not the same river, and he is not the same man." I am old enough now to know, and feel, that as I approach the river each night both the river and I have changed, if ever so slightly. The quote comes from Heraclitus who lived around 500 B.C. in the city of Ephesus, in modern-day Turkey and then part of the Persian Empire. His philosophy was characterized by Panta rhei or impermanence. He was most famous for his insistence on ever-present change, or flux or becoming. He wrote a single work, On Nature, which remains only in fragments. He was called “The Obscure” because he spoke, wrote, and taught in ways difficult to understand. He was also called "The Weeping Philosopher” because he was prone to depression. As we look on the tragedies of men we have a choice if we want to turn away from anger. We can laugh, or we can cry. Heraclitus apparently chose to cry. Our current state of affairs has been a tragedy on so many levels. Over the last few months I have been angry; I have laughed; and I have cried. Fortunately, we have flattened the curve in Minnesota and we are beginning slowly, at least for the moment, to open back up. Even one of my favorite places, my local public library, is allowing a limited amount of traffic. I went there the other night to pick up some books. The library was eerily quiet as I walked through the stacks of books. Where once would be families with kids, high school and college students studying, middle aged and elderly people reading magazines or looking for a novel now there was empty chairs and echoes. We are ever so slowly dipping our toe back into the water. But the river has changed; the world has changed; and, of course, we have changed. But what strikes me about it all is that life still feels familiar. As I begin to see patients in the office again, and operate again we know that medicine has changed and will continue to change, but it still feels much the same. People still need their medical care because, well, life is short, and it keeps moving on. Life is short; the art is long is attributed to Hippocrates, who lived 400 BC and is considered the father of Western medicine. Hippocratic medicine was notable for its strict professionalism, discipline, and rigorous practice. Hippocrates recommended that physicians always be clean, honest, calm, understanding, and serious. I suspect he would tell us this whether we were in an operating room, the clinic, or at home on our computers trying to tell patients how to unmute their microphones or maybe they could move the computer a little bit so the camera would show all of their face. Here is my point. I am a bit reflective as I face my 52nd birthday. Half of my life has been spent as a physician. Which feels appropriate since I only half define who I am as a physician. The other half has been the guy in the swimsuit with the beer in his hand. This Great Reset has come at an interesting time in my life as I ponder the next 26 years, the third half of my life. What will I bring forward? How have I changed? How has the world changed? What is the best response to avoid anger, should I laugh or should I cry? I do not have the answers, by the way, but I continue to explore for the answers. Which brings me to a line I remember reading back in high school, it’s from a poem by T.S. Eliot. “We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time.” Each day, whether I return to the clinic, or the river that I have been jumping into since I was a kid I arrive at the place and I know it for the first time.
12 minutes | 10 months ago
Kidney Stones: Cystinuria and Sir Archibald Garrod ep 91
This episode is another in the long line of podcast episodes I have done about kidney stones. In this episode we are going to talk about a less common form of kidney stone called a cystine stone, and a metabolic disorder called cystinuria. Cystine stones comprise about 1% of all stones in adults and about 6% to 10% of stones in children. Cystinuria is as you would expect by its name is disease that is characterized by high concentrations of cystine in the urine. Because cystine is highly insoluble in urine, frequent kidney stones are the result. Patients with cystinuria are at risk of forming many, many stones over a lifetime. And the stones begin to form very young in life. Elevated cystine excretion can even be seen in infancy and symptoms of this disorder typically begin between 10 and 30 years of age. The average age at first presentation for cystinuria and kidney stones is around age 12 or 13. Cystinuria is an inherited disease, one is born with it. It’s an autosomal recessive genetic mutation, which means that you have to get the gene from both your mother and father. The disorder is relatively uncommon, but far from rare. The disorder occurs in approximately 1 in 7,000 to 1 in 10,000 people in the United States. The prevalence of cystinuria varies in different countries and ethnicities. The Swedes, for instance have a low incidence of 1 in 100,000. Cystinuria affects males and females in equally. There are two gene locations that are involved in creating cystinuria, mutations form in the genes SLC3A1 and SLC7A9, which code for the 2 subunits of a transporter that mediate nearly complete reabsorption of cystine and other dibasic amino acids in the renal proximal tubule and the intestine. The dibasic amino acids are cystine, ornithine, lysine and arginine (C O L A, cola). In cystinuria all those amino acids can all be found in elevated amounts in the urine. But cystine is the only one that matters to a great deal because it is the one that forms kidney stones. Ornithine, lysine, and arginine are soluble and do not form stones and are merely lost in the urine. Cystinuria was first correctly described in 1908 by Sir Archibald Garrod, describing it along with three other metabolic abnormalities that he classified as inborn errors of metabolism. The tetrad comprises four inherited metabolic diseases: albinism, alkaptonuria, cystinuria, and pentosuria. In any young person with a new diagnosis of kidney stones, cystine stones must be considered. Kidney stones are sent for analysis to determine their composition. Cystinurics tend to form stones that are 100% cystine. Cystine stones may be pink or yellow in color after removal, but later they turn to greenish due to exposure to air. People with cystinuria typically produce jagged stones that are small, though some form very large stones. Stones may be accompanied by urinary “gravel,” which consists of yellowish-brown hexagonal crystals. If a stone cannot be analyzed a suspicion for diagnosis can be made based on other clinical parameters. As I said any young patient presenting with stones should be suspect. The crystals of cystine are easy to distinguish from other crystals in the urine under the microscope. They are hexagonal, translucent, and white. The urine of a cystinuric may be identified by a positive nitroprusside cyanide test. When urine cystine excretion is greater than 75 mg/L, this spot test will turn the urine purple in color. Quantitative testing is then recommended, such as 1) 24hour urine cystine measurement or 2) Random spot urinary cystine, ornithine, arginine, and lysine excretion normalized by creatinine excretion. Cystine stone show up only faintly on standard xray of the abdomen due to the sulfide group. Calcium based stones show bright white, uric acid stones usually are radiolucent. Cystine stones can be seen with imaging techniques now more common, such as renal ultrasound and CT scans Treatment options for a cystine stone depends on the size of the stone as in any other stone. Small stones may pass spontaneously on their own with high fluid intake and, if needed, pain medications. If spontaneous stone passage is unsuccessful, stones may be removed using one of three options: ureteroscopy or extracorporeal shock wave lithotripsy, leaving percutaneous nephrolithotomy for the largest of stones. Treatment of a single stone episode is not a cure and the patient with cystinuria must focus on prevention to try to decrease the risk of future stone formation. There are three core principles in the prevention of cystine stones. Hydration Alkalization Medications The first principle is adequate hydration. Crystals precipitate when the concentration of cystine in the urine is above 250 mg/L. The primary objective of treatment for cystinuria is to reduce the cystine concentration in the urine. Consumption of large amounts of fluid–both day and night–maintains a high volume of urine and reduces cystine concentration in the urine. Reducing the concentration of cystine in the urine which prevents cystine from precipitating from the urine and forming stones. What high fluid intake means in this context is a recommendation of at least 4 liters (roughly 4 quarts) per day. That’s essentially a gallon. More is better. The fluids must be spaced out as well, including through the night. It has been said that people with cystinuria must realize that "for them, water is a necessary drug." Secondly, cystine is more soluble in urine that has a higher pH. Cystine precipitates if the urine is neutral or acidic. Making the urine more alkaline (alkalization) with medication such as potassium citrate, sodium bicarbonate and acetazolamide helps cystine to dissolve more readily in the urine. Alkalization is not without risk because a urine with a high pH is at risk of form calcium phosphate stones. A brief mention here that efforts at urinary alkalization can be hampered by diets too high in salt or proteins so cystinurics should try to reduce salt and protein. If hydration and alkalization fail then patients are usually started on chelation therapy. Chelating drugs containing a thiol group which exchange a disulfide with cystine. The result is the formation of a drug‐cystine complex which is soluble. The orphan drug alpha-mercaptopropionyl glycine, also known as tiopronin (Thiola) has been approved as a treatment for cystinuria. D-penicillamine and captopril have also been used.
10 minutes | 10 months ago
Cancer: How a Cancer Starts and Grows ep 90
Where does a cancer come from? One cell. Cancer begins with one cell. A normal cell has cell membrane, a cytoplasm with lots of working parts within it, and a central nucleus. The nucleus contains the instructions, the DNA, that tells the cell exactly what it needs to do. A cell has a specific purpose, become a prostate cell for instance or skin or a brain. Our DNA is incredible. Using the nucleobases adenine, cytosine, guanine, and thymine base pair nucleosides of adenine-thymine and cytosine-guanine can be stacked, one on top of another, into chromosomes, long chains of coiled double helix code that is read by the cell as the ultimate instruction manual. The instructions contained within a single cell is more complex than any how-to book you have ever read. The full set of instructions is so long that it would take more than 3,000 books to print all of the instructions assuming that each book would have 1,000 pages. If you could take the DNA out of a single cell and stretch it into a line, it would be more than six feet long. To grow a prostate or skin or a brain, a cell must replicate itself over and over. Cell division and replication happens in a process called mitosis. During mitosis a cell’s DNA needs to be replicated exactly to form a duplicate cell. One cell into two, two into four, four into eight and so on. The cells must then all work together to create a prostate or skin or a brain. Here is the origin of a potential cancerous cell. Any loss of integrity to the DNA causes the entire cell to be dysfunctional, either completely or partially. The new imperfect DNA contains an imperfect set of instructions. Most often the mutation will be fatal to the cell. That cell dies. No big deal. nfrequently, a mutation will form a non-lethal cell change and the abnormal cell will not follow the normal growth pattern. A cell that continues to grow and does not get the appropriate instructions for growth eventually becomes a problem. It continues to grow and divide, replicating its own DNA. One to two, two to four, four to eight and so on until there is a mass of cells, a tumor, that is not following normal instructions. An individual cancer cell, depending on the type of mutation within it, will have its own unique growth pattern. When we look at a cancer cell under the microscope we can predict how aggressively it will behave by how undifferentiated the cell is. Each cancer has its own grading system. Cancers start within one organ. Prostate cancer starts in the prostate cells, breast cancer from the breast, skin cancer in the skin, and colon cancer in the colon. Then it spreads to other parts of the body. Cancers metastasize. Cancers spread in one of two ways They grow 1. by local spread and 2. By distant spread, travelling hematogenously (through the blood) or lymphatically (through the lymph system). A metastatic cancer is one that has spread to other organs through either local invasion or through the blood or lymph. A cancers stage is often classified in a staging system we call TNM. T, tumor. What is the tumor doing? Is it confined to the organ or has it advanced locally? N, lymph nodes. Are there any swollen lymph nodes that would indicate that a cancer has spread to the lymph system. M, metastases. Is there evidence of cancer in other parts of the body? TNM each are given a number. An overall stage is often a number as well and is a consolidation of the TNM classification. How does a cancer do this, grow such that the body doesn’t fight it off? Your body often does not recognize the cancerous cell as abnormal, or just downright turns its head away and ignores it until its too late. Our immune system detects and kills bad stuff through a complex interplay of B cells, T cell, Natural killer cells, humoral immunity and cellular immunity working together to detect the abnormal and destroy it. The body has the ability to detect self from non-self. Our bodies tissues have normal markers on the cell surface that tell our immune system, “hey, we are one of the good guys.” Cancer cells evade the normal immune signals that would otherwise find and destroy it. They confuse it, or exhaust it, or disrupt it. And the cancer cells grow, spread and destroy. We must get rid of it to survive.
15 minutes | a year ago
Uric Acid Kidney Stones: The Little Sister of the Kidney Stone Family
80% of all kidney stones are calcium-based stones, mostly calcium combining with oxalate or phosphate to make calcium oxalate or calcium phosphate stones. This episode is about another kind of kidney stone mineral called uric acid. Uric acid stones makeup about 15 % of all kidney stones. Calcium based stone and uric acid stones make up the vast majority of stones that we treat. What I want to do for the this episode is highlight 5 areas where uric acid stones differ from calcium based kidney stones in diagnosis, treatment and prevention. If you want to hear all of the episodes on kidney stones there is a link in the show notes to the category list of kidney stones on the website at whyurologypodcast.com. http://whyurologypodcast.com/category/Kidney+Stone
12 minutes | a year ago
World No Tobacco Day May 31, 2020, 100%, and the Golden Gate Bridge ep 88
May 31 is world no tobacco day sponsored yearly, since 1987 by the Member States of the World Health Organization. World No Tobacco Day every year informs the public on the dangers of using tobacco, the business practices of tobacco companies, what the world Health organization is doing to fight the tobacco epidemic, and what people around the world can do to claim their right to health and healthy living and to protect future generations. This year’s theme is prevention of smoking by our youth and awareness of how tobacco companies market to younger generations. This year, the World Health Organization is encouraging efforts that empower young people to stand up to big tobacco companies by resisting their ads and marketing and refusing to use any tobacco or nicotine products including e-cigarettes and other vaping devices. Here are 5 reasons your urologist may tell you not to smoke according to the Urology Care Foundation: Bladder Cancer: May is bladder cancer awareness month. This year over 80,000 will be told they have bladder cancer. Smoking causes harmful chemicals to collect in the urine. These chemicals affect the lining of the bladder and significantly raise your bladder cancer risk. Erectile Dysfunction impacts 20-30 million American men. Erectile Dysfunction is most commonly a result of poor blood flow to the penis. Smoking harms blood vessels, mostly arterial health, which impacts the blood flow to the penis with the result in not being able to get or keep an erection firm enough for sexual intercourse. Kidney Cancer. Kidney Cancer is in the top ten most common cancers for men and women, combining for more than 70,000 cases of kidney cancer expected this year. When smoking, carcinogens are drawn into the lungs and then into the bloodstream where they are filtered by the kidneys. The harmful chemicals increase your risk of getting kidney cancer. Incontinence, urine leaking, and Overactive Bladder (OAB), impact more than 33 million men and women. The chemicals from smoking and vaping bother the bladder and can contribute frequent urination. Smoking can also cause coughing spasms that can lead to urine leakage. Smoking can harm the eggs in the female and sperm in the male. The infertility rate for smokers is twice the rates for those who do not smoke. You don't have to do it alone. Your family, your friends, and your doctors will help you. Get ready. Set a date to quit. Get support and seek help. The national tobacco quit line: 1-800-QUIT NOW (1-800-784-8669). Free smartphone and tablet apps are available. Try the National Cancer Institute's QuitPal. Websiters such as Smokefree.gov offers a ton of support and resources including a text messaging program called SmokefreeTXT.
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