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Katie Mann:

Hello. My name is Katie Mann and I'm the nurse practitioner with the urology group at the University of Kansas health system, and today I present to you Stoma Bootcamp. And what we will be discussing will be what to expect before, during and after surgery.

Now, some things we'll talk about will be what is a urostomy, the steps of the cystectomy and ileal conduit surgery, and what to expect after surgery, like how long you will be in the hospital, what drains you may have, when will you get to eat again, pain control, your expectations for activity, as well as any new medications that you may be on.

Now, what is an ileal conduit? What this is is a urinary diversion which results in the creation of a urostomy. This is a surgically created opening for urine elimination. What we do is we use a small portion of the small intestine, usually about 10 to 15 centimeters, and we use that to create the stoma, usually on the right side. Now stomas vary in size, they protrude usually about an inch or less, they can be round or oval in shape, pink or red in color, and they look a little bit like a rosebud as you can see below. And there's no sensation to it so if it accidentally gets touched or bumped, you should not have pain.

Now, some things to consider before you have surgery. I think it's very important to think about whether or not you're set up for success before you go into the hospital and have the surgery. So you want to make sure that you're not having to go up and down stairs too frequently to go to the bathroom or get to the kitchen. So if you can set up a little area that's close to the bathroom and kitchen, that would be ideal.

I think it's also important to think about, is there someone available to help you once you go home? You're going to need help with getting to appointments, going to the grocery store, meal preparation potentially, so I think it's important to set that up prior to coming in.

Now, one thing I suggest to anyone that is intending to go home after surgery is getting home health set up, and we can do that for you while you're in the hospital. Now, what this entails is having a nurse come out to your house one to two times a week and they provide wound care, education about new medications you may be on, and assist with pouch changes. They should continue to educate you about how to change the pouch and this is important that you are very involved in this process because you want to be independent with pouch changes prior to them discharging you from home health. We can also set up physical therapy for you. They usually come out one to two times a week if you need this.

Now, in some cases, patients want to go to a skilled nursing facility and sometimes that is due to lack of assistance they may have at home, they may need additional therapy so that they can be independent after they go to the skilled facility. Now, they must complete one to two hours of therapy per day and you have to have a skilled need, which having this surgery does count as the skilled need because you have a new stoma and you will need to do pouch changes. We have to get insurance approval and we will work on that while you're in the hospital, if this is an option that you are interested in. But I do suggest if this is something that you are interested in, that you start looking at options prior to surgery and what this may mean is maybe touring a facility that you're interested in or talking to friends or family members that may have been in a skilled facility that they may be able to recommend a place that they've already been.

Now, when you come in for surgery, you will have general anesthesia. You will be asleep for approximately four to six hours, it's about average of how long it takes to have this surgery. We will remove your bladder. Now, for some individuals that have this surgery, it may not be for cancer so they may only be taking out your bladder, but if it is for cancer, we call this a radical cystectomy. And for men, we will take out the prostate and surrounding lymph nodes. For women, you may have your uterus, ovaries, a portion of the vagina that may be removed, as well as the lymph nodes. We do take that 10 to 15 centimeters of small intestine, and that's what we use to make the conduit, we sew up one end of that portion that we removed and then we bring the other end that's open to the surface of the abdomen to create the stoma. The ureters, which are the tubes that drain urine from your kidneys down into the bladder typically, we will take those tubes and we'll reimplant those into the conduit so that the urine will drain through the conduit. You will go from the operating room to the recovery room where there will be an anesthesiologist that will make sure your pain is controlled, your vital signs are stable and you're ready to go to the urology unit where you will be staying.

Now, occasionally, if you require more monitoring than what they can provide at the urology unit, some individuals may go to the intensive care unit to spend a night or two for closer monitoring. There, the nurses take care of one to two patients at a time. Whereas on the urology floor, the nurse may have four to five, so you really do have closer monitoring there.

Now, once they feel like you are doing well from a standpoint and can transfer out of the intensive care unit, you will go to the urology unit. It's nothing to worry about if you do end up going to the intensive care unit. Like I said, it's usually just for that closer monitoring.

People typically stay in the hospital about four to five days after surgery. You will have a drain called the Jackson-Pratt drain, or JP drain, and you can see the picture off to the right. It looks like a football or a hand grenade. The nurse will care for this while you're in the hospital and it's usually removed the day that you leave the hospital. You will also have a pouch over your urostomy that will cover two stents that will be coming out of your stoma. As you can see below, these tiny tubes are coming out of the stoma and they will be draining urine. They go through the conduit, through the ureters and up into the kidneys. Now, when they plug the ureters into the conduit, if we did not put those stents in, your body would create scar tissue and it would make it difficult for urine to drain out of your ureters through your conduit, so we place these and they will stay in for a couple of weeks after surgery. We will remove them at your followup appointment. This does not hurt. It usually just feels weird is what people tell me.

While the stents are in place, your urine may alternate from a yellow color to pink or even red. This will fluctuate while the stents are in place, but your urine should return back to a regular color after they are removed.

You may notice that mucus comes out of your conduit. Your conduit is made out of small intestine, which makes mucus, and it will continue to make mucus. It may lessen with time, but there will always be some amount of mucus in your urine after you have your conduit. Also, some individuals known as a stronger urine odor. This may be due to food or drink items that you consume, but it does not necessarily mean that you have an infection and this can be normal Some men, and even women, may have a pelvic drain. This looks a lot like a urinary catheter. We use this to help control bleeding in the area in which we did the surgery. It's usually removed within 24 to 48 hours after surgery.

Women will have vaginal packing. This is a packing that's made out of or has estrogen impregnated in the gauze, and we use this to help control bleeding in the area we did surgery. This is usually removed the morning after your surgery.

For most individuals, their bowels will begin working after one to two days after surgery. Occasionally for some individuals, it takes a little bit longer. The problem with this is that your stomach continues to make fluid, which is usually about one to two liters per day. If that's not going through, then it will just build in your stomach and it typically makes people extremely nauseated and even throw up, and this is not comfortable after you had a big surgery. So we will place something called a nasogastric tube. We put the tube in your nose and we thread it down into your stomach and then hook that up to suction. This really makes people feel quite a bit better after that fluid is removed. We'll leave that in place until your bowels begin working again, which is usually a day or two after that.

Pain control is important after your surgery. Your physician may decide to have anesthesia placed what's called a TAP block, which is where they will inject numbing medication around the anterior wall of the abdomen to block the nerves. Now, anesthesia will do this either before, during, or after surgery. It lasts about 18 to 24 hours. The benefit of this is that you don't have to be hooked up to any extra pumps or have any other catheters. They just put it in and it works.

Now, sometimes physicians may feel that an epidural is more appropriate. Anesthesia will place this before, during or after surgery. There is a catheter that's placed in your back and there's a continuous infusion of numbing medication and also, you are able to give yourselves additional boluses, what we call, if you're having additional pain. This is usually in place for one to three days after surgery, but it does require having the catheter in your back and it's hooked up to an IV pump. This can sometimes hinder mobility, but the benefit is that it's usually a non-narcotic medication that's infused so it does not slow down your bowels and cause constipation.

Now, if we're having a difficult time getting your pain controlled or perhaps you're not able to take oral pain medication, we may prescribe something called a PCA, or a patient controlled analgesia. We hook your IV up to an IV pump that delivers narcotic pain medication to you, you are able to hit the button when you have and it delivers a small amount of medication. Now, the benefit of this is that you are more in control of your pain and you get smaller amounts of medication so you may not take in as much of the narcotics as if your nurse is giving you medication because they typically give you a larger amount each time. The drawback is that narcotics will slow down your bowels and lead to more constipation.

Now, everyone will get some form of IV narcotic while they are in the hospital and usually around the time of surgery. We will transition you to oral pain medication when you're tolerating your fluids and food. Now, some examples of IV narcotics that we may give, they include fentanyl, morphine or even hydromorphone. We will transition you over to oxycodone, though sometimes individuals are not able to tolerate that and we may decide to use hydrocodone or even Tramadol. We usually use non-narcotic medications such as Tylenol and if you are a candidate, we will use something called Toradol, which is like an IV ibuprofen, but it really depends on how well your kidneys are functioning after surgery. We need for your pain to be under good control so that you're able to get up and walk around and meet your activity goals.

The night after surgery, you will go up to your room and if you're able to, we do encourage you to walk at least one time and perhaps even get up into the chair. Now, if you get back to your room late into the evening, this may not be a possibility, but if you are able to, we do encourage it. We will allow you to have a small amount of ice chips at that time.

Now, the day after surgery, what we call postop day one, we expect you to try to get up and walk at least three times and get up into the chair during the day. Dr. Taylor will let you have unlimited clear liquids, though I do encourage you to avoid carbonation. Now, the other surgeons will have you take in eight ounces of fluid every eight hours, which is usually water or ice. We will be giving you IV fluids so this will meet your nutritional requirements, but we don't want to give you too much fluid in your system before your bowels have woken up.

On postop day two, we encourage you to walk at least five times during the day and sit in the chair the majority of the day. Dr. Taylor will allow you to have full liquids and the other surgeons will allow you to have unlimited clear liquids at this time. On postop day three and day four, as long as your bowels are moving and you are comfortable and you are not nauseated, all surgeons will allow you to have a regular diet. Though I still encourage you to avoid carbonation and any gas producing foods such as beans or anything that you know makes you gassy because your bowels are still not working regularly and having extra gas will be very uncomfortable for you. We want you to walk as much as you're able to and be in the chair as much as you can. This will aid in your recovery and help with your pain.

We will also have you do breathing exercises. This machine is called an incentive spirometer, and this will assist you and opening your lungs after surgery and preventing pneumonia. We encourage you to do this 10 times an hour every hour while you're awake.

You will be on a bowel regimen, and what this is is we will prescribe medications to help stimulate your bowels and help you with constipation. You may be on milk of magnesia, Senokot, MiraLax or suppositories. We highly encourage to take your bowel regimen. This is not a situation where once you have one bowel movement, you are out of the woods. You will want to take medications throughout your recovery and even a month or two after surgery to help keep your bowels moving.

You will be prescribed a blood thinner unless you are on one prior to coming in. What we usually prescribe is something called Lovenox, which is an injection. You will take this while you're in the hospital and for 30 days after your discharge. You are at higher risk for getting a blood clot, and studies have shown that this Lovenox is really important for preventing blood clots from forming. This sometimes can be expensive, but we will work with you on finding out where it may be more affordable for you at discharge. Now, if you are on a blood thinner such as Warfarin, Eliquis, Xarelto or Pradaxa, you may resume that after surgery, but it really will depend on input from your surgeon at that time.

You will be on antibiotics while the stents are in place. We will have you on something called Keflex or Cephalexin, usually twice a day until the day before you have your stents removed. We will switch over to a stronger antibiotic and you will take that the day before, day of and day after stent removal.

After discharge, you will be alternating between diarrhea and constipation. I highly encourage you to play around with the medications we prescribe for constipation to keep your bowels moving. The goal would be looser than formed so that things continue to move through your bowels without issue. Most individuals experience a poor appetite, therefore we encourage you to take in smaller, more frequent meals, so perhaps five or six small meals per day instead of three larger meals. The poor appetite is usually due to slow moving bowels and taste changes related to the surgery that you had. If you're not taking in enough nutrition, I do suggest drinking between two to three supplements in between meals such as Ensure, Carnation, instant breakfast, or even a homemade protein shake. I encourage you to eat what sounds good and not start any new diets at this time. Remember, most people lose about 20 to 25 pounds after surgery and this is linked to higher complications. You are not losing fat, you are losing muscle.

As long as you do not have a medical condition that limits your fluid intake, I highly encourage you to drink eight to 12 cups of hydrating fluids daily. This could include lemonade, Powerade, juices and water, but the important thing is to take in enough fluids to keep you hydrated. We want you to continue to walk frequently throughout the day, taking several small walks will increase the amount of steps that you take and help with blood clot prevention and constipation. Continue to increase the amount of steps daily and think ahead on a plan of attack in case there's poor weather or other issues that may hinder being able to go outside.

Danielle

Hi, I'm Dani, I'm the local Hollister representative, and I cover the whole state of Kansas and a lot of Missouri and I cover every healthcare facility in both states, every healthcare facility, every home health agency, every rehab, every nursing home, et cetera. And I am here to provide support for you. I work very closely with KU Medical and they are the best hospital. They do the best urostomies, and they are amazing. They're state of the art. They're stoma bootcamp rivals ... No one else does this. So congratulations to you for picking such a great hospital to have your surgery done at. I am the representative of Hollister, which makes the ostomy products, and I am simply here to quickly tell you about a free program that they enroll you in called Secure Start services. And after they enroll you at KU, you'll get a gray box on your front porch, which looks like this, and it will arrive via Federal Express about 48 to 72 hours after KU enrolls you. We can also send it to a family's address or to a rehab facility if you prefer.

And this is just the first step in the whole life of the Secure Start services. So this box will contain lots of things, a little black bag that looks like this, and that's a little travel bag which will contain some scissors and a little magnetizing mirror. The kit will also contain free samples of urostomy pouches and lots of great education tools for you to read so that you can better understand how to live your life normally with your new urostomy patching system.

So the scissors are the ostomy scissors that were in that black bag, those are just used to help you cut out your wafers since you probably will be using a cut-to-fit type product for the first three months because after the first three months your stoma will shrink down and then we can send you samples of a pre-size product that you don't even have to cut anymore, to see if you'd like it before you actually place the order from your distributor for those. So that's what the scissors are for, they're ostomy scissors, and they just make it easier to cut the urostomy pouches.

And then the little mirror that I talked about, that also comes in the Secure Start kit in a black bag, that's magnetized so that if you're out and about, at a restaurant for example, once this whole covid-19 is over, let's say you're at a restaurant in the bathroom and you can just click that mirror on the back of the restroom stall door and that way you can easily see your abdominal area so that you can change your pouching system if you need to. That's all that mirror is for.

And then the kit also contains, like I said, lots of other things that look like this. This is used to give you a good measurement of what your stoma size is so when we do call you and we talk to you, we might say, "What's your stoma measuring at today?" and we'll ask you to put this right around the base of your stoma so that we know about what size it is so that we know what to send you, because we'll send you free samples until we get you to the right product. And what a right product looks like is that you're able to live your life normally. This should not handicap you in any way. So you should be able to shower every day with your product on, with your pouch on, you should be able to work out, you should be able to eat to, live your life normally and have the right product to where it feels good, it stays secure, your skin looks healthy around your stoma, and it doesn't break down. That's how we want you to live. And you'll get 20 of these a month through insurance, so you'll change them once to twice a week, and then the rest of the week it'll be fine. And that's called a predictable, secure wear-time. That's what we're looking for.

So you have to have the right fit and formulation in order to get that. We have hundreds of products and they're very customized, so that's why we're here is to help you get to that perfect product that best meets your lifestyle. So we will continue to send you free products until we get you there, so be sure you talk to us. We will call you from a 224 area code and it doesn't say Hollister on the caller ID so just make sure you pick up the phone when we call because we won't call more than three times if you don't call us back because we don't want to bug you. So we will talk to you however, as much as you want us to talk, once you do respond to us.

And five years from now if you're going on vacation and you're wondering what pouches you should wear at the beach, we can help you troubleshoot that as well. So we are here for the rest of your life if you want us to be, you can call us, you can email us, you can FaceTime us. Just make sure for those first three calls, at some point when we do reach out to you in that first couple of weeks post operatively, that you do talk to us.

And then also if you need anything locally, like if your home health wants some more education on how to take care of your urostomy, or your rehab facility, call me. My name is Dani, my number is (913) 636-2285, and I can help with that. The Secure Start number is, I need my glasses here, it's (888) 808-7456. And that's the Secure Start number so that's that service that I was talking about. They can also help you, once you're ready to place your order for your products, we can do the insurance matching tool, which is just a real easy way for us to help you find that cheapest place to buy your products that matches your insurance so that you hopefully don't have to pay out of pocket, because you should get 20 of these a month without really having to pay. So that's another great use of Secure Start that we are able to help you with.

I hope I've helped and good luck to you. I know that I will meet you one day soon, hopefully. And good luck, and KU is the best so you are in great hands in this journey. Take care.

Katie Mann

Thank you so much for watching this presentation. And let your surgeon know if you have any questions. Thank you.

I got a blood test for an insurance thing and my PSA had got high. They examined me, the rectal exam where they feel the prostate, they couldn't feel anything. And everybody said probably don't, but you should get it checked out. I went to my regular to begin with, because I was having some problem with the bladder, and they diagnosed as a prostate infection at first, and prescribed some medicine for that and it seemed okay for like a week, but then the symptoms came back again after that. I couldn't urinate, I mean it was difficult, I really had to push to urinate. It was getting progressively worse. My general practitioner originally thought it was prostate problems, was treating for that, wasn't helping. You really worry about it. It's something that you try to be the big touch macho man, and all this kind of stuff, and not pay attention to it. Yeah, it bothers you. And you start thinking well, how many days have you got left? They did the tests, and they found out I had a tumor in my bladder, and they thought maybe they could scrape that out to begin with. So they did small surgery of scraping that out, but the cancer had permeated into the bladder wall, so they had to remove the whole bladder. And then I was referred to Dr. Holzbeierlein. They'd been having to basically dilate me for my urethra about every six months. The waiting period is the hardest, when you wait between trying to find out whether you have something or not, that's always the hardest. After I would be dilated, I would be fine for a few weeks, then maybe after about a month I could feel that it's getting progressively you know, tighter, and more difficult. And by the time, the end of six months, I would literally be pumping it out in squirts. We came up here and Dr. Thresher wanted to do a biopsy, and it showed up that I had cancer in both sides of my prostate. [inaudible 00:02:10] You can't feel it, or anything else. And I didn't even have a real high PSA, it was in the upper fours. My urologist said he could do the surgery, but they've done so many here that he'd feel better if I came here. And he said, you know, it's ... This isn't working for you, you're too young for this. By the way, there's this doctor at KU Med who has this new procedure that I think might be what you need. So he referred me to Dr. Thresher. Dr. Thresher came in and introduced himself, and explained what the procedure would be and what further tests would be needed to determine whether or not I would be a good candidate for this particular surgery. It wasn't just I came in and I'm just somebody to cut on or anything like that, you know, he really card. All very professional, very caring, very to the point. Any question that I had about it, he had an answer instantly for me. Just real personable, you know, just eased your mind, made you feel like not just a patient. Like he cared about, like he cares about you as a person. He's one of the nicest guys to sit down and visit with and work with I've ever met. He makes you feel very comfortable, but more than anything else he gives you hope. Hope is the most important thing that you have going for you right now. And he is a wonderful, wonderful man when it comes to giving a person hope, and his staff and everything that they do, is geared towards that. After talking to Dr. Holzbeierlein I felt certain that he was gonna take care of the problem that I had. And he did. There's no pain when I urinate, and that's a good sign. The Dr. Thrasher and his residents, when they've looked at me have been very pleased and ecstatic, and have told me that oh boy, this is you know, this is turning out great. I went into surgery at seven o'clock in the morning, on Monday morning, and at nine o'clock, nine-thirty Tuesday morning I was up walking the halls of the hospital. It's great, I mean I've got the function of everything that they messed with, my bladder, I don't have a bladder I have a neo-bladder, but it works like a bladder does pretty much. And my erections are fine now, it took a while to have the nerve damage grow back, but they're all fine now. I can do anything I used to be able to do. The longest incision is about like this. There's several of them, they're small. I've never felt any pain from any of them. It basically was explained to me this way, that this surgery is 95% successful. If you're one that would fall into the 5% where it was not successful, you wouldn't be any worse off than where you were. You'd be doing the exact same thing, coming in every six months. So when you're looking at it from that perspective, 95%. Yeah, why wouldn't you want to do this? At home, I took it easy for two weeks like they advised, but I still worked. I have my own business. And I slept [inaudible 00:05:36] a bunch, but mentally and physically, I felt very good. Considering what my lifestyle was before, would I do it again? Yes. Yeah. I guess I was really surprised how fast I did recover. And I felt normal. I was really surprised. It gave me a whole new lease on life. I mean, my life is relatively normal, compared to what the options that I could have had. You know, with the coloscopy bag and all that. I don't have any of that, it all works pretty well like it's designed to. Actually, it's turned out much better than I expected. You've heard all the horror stories all your life growing up if you get your prostate removed, sex life destroyed, your drive and all that's gone and stuff. I've experienced none of that. Actually, Dr. Holzbeierlein had some patients that were thinking about having the same surgery, call me and discuss, you know, what the future holds in store for them and all that, and I've got no problem with recommending Dr. Holzbeierlein for any of that.

We have just witnessed a robotic prostatectomy. This essentially involves making very small incisions on the abdomen of the patient. And insufflating the abdominal cavity with carbon dioxide. After getting the working space. We dock the Intuitive da Vinci Robotic Platform to the patient. And then that assists us in doing the rest of the operation. The robot does give us better magnification, more precise use of our hand controls. And with the pneumoperitoneum, we'll have decreased blood loss. As you can see, our hands control the small controllers, which are one to one correlated with the movements of the robotic platform. Next, with the use of robotic assistance, we dissect free, the tissue surrounding the prostate. This allows us to come on top of the anterior surface of the prostate. Where we clear off this frowning fat. Here you can see where we have isolated the endopelvic fascia. We sharply cut the endopelvic fascia. And this divides the prostate from the levator musculature. And from the urethral sphincter. We then, take a staple to staple the dorsal venous complex, which is the large vain that drains the penis and lies right on top of the prostate. Once that has been divided, we then divide the bladder from the prostate, by taking down the anterior bladder neck. And then carefully taking down the posterior bladder neck, in order to get a nice division from the prostate. Next, you'll see us dissect out the seminal vesicals. These are structures that just store the semen and sperm and sit on the posterior side of the prostate. And the most important part of the procedure, which you will see here next. We free the neurovascular bundles from the lateral sides of the prostate. This involves incising, something called the lateral prosthetic fascia, and then carefully sweeping these nerves posterior and laterally away and off the sides of the prostate. The robot really helps in this step, because there's about a one millimeter margin of error between the capsule of the prostate and the neurovascular bundles. The neurovascular bundles will be responsible for the return of erectile function after surgery. We then re-approach the prostate anteriorly, and divide the apex of the prostate from the urethra. Again, we try to get a nice urethral stump here, in order to have adequate tissue to hook the bladder neck back up to. We dissect the urethra free. And then the prostate is freed within the pelvis. The prostate is placed in a small plastic back and set aside for later retrieval. Next, we will take the bladder neck and hook it back up to the urethral stump. This involves the running anastomosis, or the vesicular urethral anastomosis. Using two sutures, which are tied together, you can see us run the sutures in a circumferential manner to get a nice round and water tight anastomosis. We then test this anastomosis to make sure that there's no leakage of water and what would be urine in the post operative period. We then close the small incisions on the skin with some absorbable sutures to leave a nice appearing abdominal wall, with only five small incisions that will heal very nicely. So, a lot of the advantages of this procedure are, definitely decreased blood loss during the procedure, which makes patients recover quicker and feel better. We've also had very positive results with quicker return to urinary control. And excellent results with erectile function postoperatively after a short period of rehabilitation. In general, most patients stay overnight in the hospital and are discharged home the next day. And at three weeks, after surgery, they're able to go back to their normal activities. A lot of patients will actually go back to desk jobs within a few days after the procedure.

This particular patient that had his surgery today was a patient who had undergone a radical prostatectomy for prostate cancer. His prostate cancer was cured, but he was left with one of the unfortunate side effects that happen in a low percentage of people, and that is urinary incontinence. He presented today to get an artificial urinary sphincter in place. The prostate actually lies right next to what we call the genitourinary sphincter, which is the muscle that you use to control your urine. So, sometimes after a prostatectomy or a prostate removal you can actually have an injury to that muscle, where patients stat to lose control. That can be variable, from just a little bit of leakage to really quite dramatic leakage with someone using anywhere from eight to 10 pads a day. The incontinence that occurs is usually called stress incontinence. This occurs when people are doing heavy activity. They're lifting. They're playing golf. They're doing kind of the things in their day-to-day living. Simply getting out of a chair can cause a leakage, so it can be quite debilitating. It's difficult to go out to dinner if you're worried about having wet pants, changing multiple pads per day. Car trips are often difficult or leaving the house for long periods of time. It can really change someone's life. Basically, what we do is we make a small incision in the perineum, which is the space in between the legs, to locate the urethra or the tube that you pee through. So, what we're looking at here is we've split the fat layer over top of the urethra, and we're just now getting into the muscle that surrounds the urethra. Last loop. [inaudible 00:02:09] So, what we've essentially done here to start the case is we've made an incision through the perineum and dissected down through the subcutaneous fat. We've spread open the bulbospongiosus muscle, which is the muscle used for ejaculatory function, to expose the urethra, which is this blue midline structure, which we also have the blue tape wrapped around. This is the area where our artificial sphincter is gonna go and where we specifically size it and custom fit it to the patient's needs in terms of their degree of incontinence. So, this is the cuff that we're going to place here in the patient. This will provide the pressure support to help hold the urethra closed. Here you can see the cuff being put into place. We're just going to deploy this. Can I have a [inaudible 00:02:56]? There. All right. This is what the device looks like. You can see here the inflatable cuff is around. There's tubing that we're gonna pass into the abdomen, so the patient can activate the device, but this is essentially gonna provide coaptation of the urethra in order for him to help maintain his continence. What we're going to do now is just pack the wound with an antibiotic soaked sponge and then proceed to the abdominal portion of the operation. All right. What we've basically done here is we've made a series of sharp incisions down to the muscle layer of the abdominal wall. We're then entering the extraperitoneal space, which is the space outside the sac that holds the intestines and the bladder. We're just adjacent to the bladder. We'll be putting the reservoir, which holds the fluid, in order to make the device function. Again, same with the other incision. We copiously irrigate this in order to prevent an infection. What we have here is his device comes from ... this black and clear tubing comes from the reservoir. This yellow tubing comes from the cuff. We have a retractor or ring forceps in the scrotum right now, which is marking where we're gonna put our pump to. So, we'll place this device, and then we'll make the connections. Here you can see the device has been implanted into the scrotum. The pump has been subcutaneously tunneled down into the scrotum. This is what the patient will manipulate in order to use the restroom. All right. Now, what you can see here is we've made the connections and trimmed the tubing down, so it's an appropriate length. We're going to release these connections and bury the tubing. We'll pull the pump down into its appropriate spot within the scrotum, which you can see here, and the tubing disappears. We'll then begin to close our incisions. What we did today is we placed a small cuff around that urethra and then hooked it up to a device that goes into the scrotum, which we refer to as the pump. So, when the patient needs to urinate, he simply squeezes that pump, releases the cuff around the urethra. He's able to urinate. The device then resets, and he can go about his normal daily affairs, hopefully dry. This is an example of the device. Here we have a reservoir, which goes into the patient's abdomen. This stores the fluid to help make the device function. What I've illustrated here with this red catheter is the urethra or the peeing tube, if you will. We have a cuff or a balloon which goes around that. By this device squeezing, this is what's gonna help provide the patient continence. When the patient needs to urinate, this pump has been tunneled into his scrotum, in which case he just simply squeezes the base of this. This will then release the cuff around his urethra. He'll be able to urinate. Then the device automatically resets without having to do any manipulation.

Today, we performed a vasectomy reversal on a patient who was nine and a half years out from his vasectomy. What we did was a under the microscope, performed a bilateral vasovasostomy, which was indicated because of a fluid that was seen from each side under the bench microscope. And using the operating microscope that you saw. We used 9-0 and 10-0 suture, which was both smaller than a human hair to reconnect that the hole on each end of the vas and reinstate patency is what we hope. Patient will now recover and in about four weeks will get a followup semen analysis and evaluate him to see if he's had a patency of sperm and then hopefully then pregnancy thereafter. The success rates from a vasectomy reversal are very much based on the technique as well as the time from the vasectomy as well as some anatomical issues that are noted at the time of the reversal, both the fluid as well as the distance from the testicle as well as a a granuloma formation.

We're here today to see a robotic sacrocolpopexy. This is a robotic procedure planned for the treatment of apical prolapse in women who suffer from the feelings of pressure, pain, difficulty with urinating, having bowel movements due to the weakness in the pelvic floor. This is associated with their history of pregnancies and childbirth in addition to the lack of estrogen associated with menopause. This procedure will help in tacking the apex of the vagina to the sacral promontory to assist with adequate support, which will provide the patient relief of the symptoms that they present with. The first part of the robotic sacrocolpopexy is the opening of the posterior peritoneum over the sacral promontory. This can be tenuous as the middle sacral vessels run in the same space. In this portion, we're noting the dissected posterior peritoneum as flaps of the apex of the vagina. We utilize one arm of a Y-shaped piece of polypropylene mesh to lay on the anterior vagina. The mesh is attached to the apex of the vagina. We utilize six interrupted Gore-Tex sutures to hold the mesh in place on the anterior aspect of the vagina. Now, we see the other arm of the Y attached to the posterior aspect of the vaginal apex. Two Gore-Tex sutures are preplaced in the periosteum of the sacral promontory with care to avoid middle sacral vessels. With support of the vaginal apex to confirm appropriate tension, the preplaced sacral sutures are used to tack the mesh down to the sacral promontory. The posterior peritoneum is now pulled over the mesh tail and closed. The mesh, as you see, has been fully retroperitonealized, bringing this procedure to a close.

Today, we had a patient who had what we call Peyronie's Disease. It's a disease that have abnormal scarring of the penis. What it actually causes is an abnormal curvature of the penis. So, today we performed a penile plication. This particular patient had a curvature of approximately a 30 degree angle to the right, and basically it puts a hook in the penis, which can create a problem for the patient. This can be difficult for sexual intercourse for both him and his partner. Basically, it makes it difficult in order to perform vaginal penetration. It can cause discomfort during intercourse and essentially make it a problem to be intimate with his partner. This particular patient had a relatively mild form, in which we were able to correct with a simple plication surgery. Basically, the gist of that operation is that we take sutures on the lateral aspect of the penis. This patient's penis curved to the right, therefore out sutures were placed on the left, and by simply placing these sutures on the undersurface of the penis, we were able to correct the curvature and perform a penile straightening. The advantages to this operation is that it can be done as an outpatient basis. In addition, the sutures cause very little cosmetic changes. The patient also has low risk for erectile dysfunction and some of the other complications that can occur with complex Peyronie's surgery. What we've done here is we've induced an artificial erection, and so this demonstrates the patient's curvature. What he's developed is a scarring process on the right side of his penis, causing a bend. The left side's largely unaffected, and so he gets approximately a 30 degree curvature to the right. Our goal today is to do a straightening procedure, where we'll essentially be able to correct this curvature and allow him to have a more straight penis. What we're going to do is go through the patient's old circumcision scar. [inaudible 00:02:11] 21. [inaudible 00:02:16] So, what we've essentially done here is made an incision circumferentially around the penis through the patient's old circumcision scar. If you look here, there's a little bit of vascularity or bleeding. That's normal for a good, healthy penis. This is the main vein running here on the dorsal or the top part of the penis. This is the artery. This is the other artery. There's a whole network, which is probably difficult to see on camera, of nerves that run through here. We're trying our best not to manipulate or damage these nerves, because they're what allows the penis to have sensation. If we were to cut or transect these, the patient wouldn't have any feeling on the head of their penis, which would obviously be problematic. What we're going to do now is ... There is a little bit of an indentation or curvature on this side, and this is the area that we're looking to correct. What we're going to do is go to the opposite side of the curvature and make a series of stitches to correct this side of the penis. [inaudible 00:03:23] What we're incising here is Buck's fascia. This is another protective layer of the penis and kind of the final layer, until we get to the tunica albuginea, which is the layer in which the scarring occurs. You'll see as we get this further exposed ... I'll show it to you here in a moment. It's white tissue underneath, which we can see. What we're doing here is we're just marking the point of maximal curvature to give us a reference line on where we need to put our sutures. [inaudible 00:03:58] [inaudible 00:04:23] down. [inaudible 00:04:27]. Go ahead and hold this up. So, this is what the sutures look like once in place. You'll see how the purple line begins to disappear as we're infolding that or shortening this side of the penis. What that does is ... This is what I refer to as the long side of the penis or the outside of the curve. The short side is on the inside of the curve. Essentially what we're doing is making the penis equal length on either side. Once these sutures are in place and tied, the nice thing about this operation is that if we're not happy with the surgical correction, we can take these sutures out and replace them as needed. So, here you can see the patient's overall curvature has improved. He still has a little bit of right work curvature. Here you'll notice that there is a divot or defect here. This can't be corrected through plication surgery. A more intricate surgery could potentially reduce or remove this scare tissue. I think the patient may benefit from one more suture to complete the correction. The sutures that are placed in conjunction with another add a second strength layer. We're just putting some smaller stitches in this to correct the curvature and to get a nearly straight finish. Go ahead. The degree of erection's been corrected, and things look fairly appropriate. [inaudible 00:05:53] Sure. 12. [inaudible 00:06:11]. All right. I'm sorry. I lock every one by retying it. [inaudible 00:06:15] next one. Does this kind of make sense now? Yeah. [inaudible 00:06:32] stitch [inaudible 00:06:33]. Here you can see we've corrected the patient's penile curvature. He has a relatively straight penis and much more functional than previously, preoperatively.

We just finished doing a laparoscopic nephrectomy on this patient. He was a 91 year old male, who actually presented with a left renal bleed, and had a small renal mass consistent with a renal cell carcinoma that had bled into his kidney. We placed something called a trocar through the abdominal wall, in which our instruments are placed. We then begin the dissection to free up the kidney from the surrounding tissues. The first thing we'll do, is we'll drop the colon from the side wall, in order to let us get into that retroperitoneal space. Next we'll find the gonadal vein, and trace this up to the renal vein. Once we have the renal vein isolated, we then look for the renal artery. The renal artery is usually right behind the renal vein. We'll also identify this, and also clear it up from it's surrounding tissue. Using a stapler, which both staples and cuts both the artery and the vein, we first will divide the artery, and then we'll divide the vein. This will cut off the blood flow to that kidney, so we can remove it at a later time. After that is completed, we then need to free up the superior, anterior, posterior, and lateral sides of the kidney, which we'll do with a combination of electrocautery and blunt dissection. Eventually we will have the entire kidney freed within the retroperitoneal space, at which time we will insert a small plastic bag, of which we place the kidney in. The bag will help us remove the kidney through a smaller incision, and will also make sure that there will be no spillage of tumor cells, if there was any problems with a large mass, or with tumor up to our dissection margins. To remove the kidney, which is the size of a small Nerf football, we then begin the dissection to free up the kidney from the surrounding tissues, while leaving a nice rim of fat, in order to get a nice cancer surgery, to make sure we have negative margins. This would be considered, really, and advanced laparoscopic nephrectomy that we just completed. And I think the benefits of the patient will be, he'll have quicker recovery, less problems with his medical comorbidities, definitely less blood loss, and hopefully earlier return of bowel function. And, his hospital stay should be shorter. And then really, his return to normal activities should be much quicker. And we see that benefit most in patients who are elderly, obese patients, and patients with multiple comorbidities. And a lot of times those are the more difficult patients to do this type of surgery on, but I think since we were able to complete this laparoscopically, he will really benefit from that approach.

So the procedure that we just did today is actually repairing a deep bulbar urethral stricture. So deep in this particular patient, he had an area that was starting to narrow and was not allowing him to urinate. So what we did was take a piece of the inside of his mouth, harvested by one of our ENT colleagues. We de-fatted that on the back table here. Opened up the strictured area. So the strictured area came down, narrowed like an hour glass. So normally a urethra is up here. Move. Right in there. That's wide open. In fact, you can see how nice that looks, wide open. Then you can see it starts getting diseased right in here. Then you can actually see this little ... it's almost like a little cliff sitting in there, a little ledge. That's the strictured area and then it gets normal again right back here. You see it? Suck underneath here. So it's normal opening right there. What we're doing is, we're going to put the flap in right in here. So we're going to be putting this flap in right in here. You can see the little strictured area there. This is normal. This is normal. We're going to be suturing it all in here. We opened that up. Measured how much we needed. Sutured the inside of what's called buccal muco, which is the lining on the inside of the mouth. That lining, we measured and then sutured that with the skin side or the mucosa side which is the portion you touch with you tongue, into toward the urethra. We sutured all of that in and once that's sutured in we've now given a wider caliber to the urethra so this gentleman will be able to urinate. Now, that graft has take. In other words, it has to recruit its own supply so that's take two days or so while this patient is on bed rest. They have very little discomfort from it. There aren't many places doing this in the country. In fact, we have one of the largest series in the country. This is a specialty specific procedure that we do that I think has been very successful. We actually have a 96 percent success rate and we've followed our patients now for up to five years.

We just finished a radical cystoprostatectomy with bilateral pelvic lymph node dissection and the construction of an orthotopic neobladder. The patient had an invasive tumor of the bladder requiring removal of the bladder and prostate. After we removed the bladder and the prostate, we then harvested the patient's own small intestine, approximately 60 cm of that intestine, reconfigured it and then sewed it back down to the patient's urethra to create what's called a neobladder. This particular type of neobladder was called a Studer neobladder. We feel that this reconstruction most closely allows the patient to assume a normal life or as normal a life as he had prior to the surgery.

The way the procedure is done, the patient is brought to the operating room. They are actually awake. Although, we do give sedation and local anesthetics, so they're very comfortable while we're doing the procedure. What we do is we look for the specific landmarks. So, we look for the tailbone, and then we identify the bones by feeling through the skin. Once we've located the area where we believe the appropriate nerve root is, we actually take a small electrical conduction needle and place it through the skin that's been anesthetized and down into the opening in the bone, and that then sits down right alongside the nerve. Once that's in place, we test it electrically and we take some X-ray pictures to make sure that we're in the right position. Once we're sure that we're in the correct placement, we exchange this needle for an electrode that has four small contact points on it. That actually again goes through the bone and sits down right alongside the nerve. So, the nerve would be coming out kind of down in this area and that's what's going to give the electrical impulses to the nerve. The patient wears this for one to two weeks. It's connected to a little external wire that comes out of the skin, and the patient hooks it up to a small generator. It looks sort of like a pager, and they keep a diary for us about their symptoms. When they come back in one to two weeks, if it looks like they've had a good response and an improvement in their symptoms, then what we do is connect this lead to a small internal generator. So, it's basically like a pacemaker battery, and that is put just under the skin kind of in the lower part of the back kind of above the hip. It's very thin, and so for most patients they really don't even feel it unless they're pressing on it. Then, this has a small set of computer chips in it that allows the patient to program the device and adjust it based on their symptoms.

This was a patient who had had their bladder removed for bladder cancer. They had had a previous operation. He then unfortunately developed a stricture in his right kidney, which scarred down and closed off his kidney and the kidney essentially became nonfunctional. He had a recurrent tumor in the left ureter and he had a hernia at his previous urostomy site. This is someone that's perfect for me because it is a cancer case because he has a cancer in his distal left ureter, but it's also a reconstruction case and we have to rebuild a new urinary diversion and fix the hernia. This is something that I'm very interested in. It's also a difficult case because he's had previous operation. He's had multiple, multiple rounds of chemotherapy, which can cause scarring and desmoplastic reaction. Not many people want to do that case. It's something that gets me excited. It's nice to be able to have a passion for something that is also a great need within the community. With that case we went in, we started by taking out his right kidney because it was nonfunctioning, taking out the right ureter, finding those urinary diversion or ileal conduit and excising that. Then we fixed the hernia at that urostomy site. We moved to his left side and removed the distal left ureter and then harvested and new segment about and make another urostomy, or to make another ileal conduit and move that over to the opposite side where the hernia wasn't.

So basically this is a 75 year old female who has a large right renal mass that was found incidentally approximately a year ago. She decided that she wanted to do some alternative therapies but then represented due to pain a mass effect and blood in the urine. So, she was admitted into the hospital and then I saw here. We went ahead and looked and staged her with appropriate staging, including a chest CT and bone scan. It looks like she does have disease outside of the kidney. She has a large renal mass but she does definitely have disease in her retroperitoneum and potentially in her chest as well too. So the question most patients will ask is well if the disease is already outside of the kidney then why remove the kidney? So the answer is is that there are several randomized clinical trials that have really demonstrated a benefit of what we consider this as a cytoreductive nephrectomy. So basically you remove the kidney and as much bulky disease as possible knowing that there's metastatic disease and then treat them with systemic therapies to follow. The plan is to go ahead and do a midline incision. So we're going to go from an incision from right underneath the chest down to below the umbilicus. Essentially move her liver and her bowels out of the way so that we can approach the retroperitoneum, identify the artery and vein and clamp them. Once we do the nephrectomy we're also going to be approaching the retroperitoneal lymph nodes and seeing whether or not we're able to resect a lot of her retroperitoneal disease. So basically we did what we intended to do. We knew that this would be a very fixed tough mass and sure enough, her entire kidney looks like it's been taken over my a tumor. In the retroperitoneum there was also a lot of lymph nodes that looked to be positive to cancer. So, essentially we had to modify to a certain degree and go in between the vena cava and the aorta to find the right artery to the kidney. So we clamped it there and essentially then was able to remove the entire kidney. It was pretty fixed to the liver, it was fixed to the posterior wall and also to the muscle in the back part of her body. So the kidney is out and so we essentially we accomplished what we came into do, which was to remove the kidney. I am going to send it off for a frozen section so they'll give us a preliminary diagnosis.

We're planning to perform a right robotic partial nephrectomy. The patient's got a right side renal tumor about three and a half centimeters. She's had a lot of previous surgeries, so it's going to be a little bit challenging to get work around the adhesion and so on. Has a pretty large liver as we just saw, but the goal is going to be to remove the tumor, leave the kidney right where it is, render her cancer free, and leave her kidney functioning. We got the robotic console here that we're going to be working through, controlling the robot, that's the assistant's side of the table, where you got the robot docked, and an assistant surgeon on the side that's going to be controlling some instruments there. Clamps are off. That looks good. That was a tough one. The problems we had were the following. Number one, she had previous surgery, there were a lot of adhesions that we went in to take those down. Number two, which was the bigger problem, was that her liver was in the way, pretty much covering her whole kidney. So the whole kidney was basically underneath the liver. Third problem was a lot of blood vessels around the kidney, and then two renal veins, two renal arteries, and a tumor that was sitting right on top of the two renal veins. So it was pretty challenging, but we did it, and we had a lot of good help. So, hopefully she'll do well.

I saw a need for patients who had complications or difficult cases, whether it be strictures from previous surgeries or from radiation, fistulas or abnormal connections between different organs, hernias, or problems with their urinary diversions after they've had their bladder removed. I saw a need for these patients, they needed a physician who could handle all of their problems. I have a unique background. I [inaudible 00:00:42] completed urology and then after that completed a trauma reconstruction fellowship, following that completed a urologic oncology fellowship. So I have unique skillset that allows me to sort of treat difficult or complicated patients and, which is a big reason of why I'm here at KU, at an academic institution. Several years ago I had been diagnosed with prostate cancer through a biopsy, and I had a TURP along the way which is a procedure to clear up tissue. Things went well for several years, developed blood in my urine, was diagnosed with a minor stricture. From that point, I was referred by my urologist to KU Med Center. I love working at an academic center. I see myself probably always working at an academic center. There's three big reasons. One is I love to work with the residents. I love to teach the upcoming physicians that are going to take over our field and helping them develop their skillset. It's just amazing to watch them throughout their years, their five years with us develop and learn and mature into from just young medical students into excellent surgeons and good physicians, so I love that the most. I love being sort of on the cutting edge and sort of being with the complexes cases, dealing with the complicated surgical situations, and I also like the collaboration that we have with multi-specialties. We have good collaboration with radiology, with pathology, with our surgical oncologist, our gynecologic oncologist, so that ability to have like-minded people, who are also interested in similar complex cases, here to discuss with and to collaborate with and operate with. When you deal with KU Med, they're not just a local hospital. They're a regional hospital, and I know Dr. Wyre spends time dealing with other hospitals in the area. So, the working relationship between my urologist and Dr. Wyre and KU Med was very good, and I think that's what promoted the speed in getting things done. We're lucky that we are the major academic center for all of Kansas and certain parts of Missouri, certain parts of Oklahoma. So I see patients coming from all over the Midwest, and the hope is that with my unique skillset that we'll become a large referral center for the entire Midwest for those type of patients who have had complications or side effects from their previous surgeries, what I call oncologic reconstruction. I'm here to help them. I'm here to spend time with them and listen to their full story, get the full story and treat them as a person, not just a patient. Surgery is very, obviously, physically hard on the patient, but it's a lot of times more emotionally difficult on the family. They're the one that waits during the procedure for six to eight hours without news of what's going on, and so I think developing a relationship with them is very important. We left and I said, "This is really good." Dr. Wyre is unique in that he has a specialized set of skills, and the most impressive part about it is he has dedicated his life to making other people's lives more comfortable. If you have unique problems, specialized problems, this is a good place to go because they know how to treat those, and they treat you like a person. They're concerned about your well-being. I can't say enough positive things about Dr. Wyre in terms of his compassion towards people and his understanding.

As a medical student, I rotated here. I was a student [inaudible 00:00:15]. I came here as a med student and back then it was about maybe five, six people. I looked at it then kind of in the same way also, "Wow, these are some big, heavy hitters in the department. These are some of the thought leaders. These are some of the clinical, surgical leaders in our community and even across the nation." What Thrasher has done is really added to that. I'm number 11 or 12 in our department here at KU. It's an amazing thing to be a part of this. He had roots here and he came back after MD Anderson to come here to practice. That's a great tribute because he wanted to come back to Kansas to do his final work. To me, that makes a lot of sense. You find a person dedicated not only to your cause but to the cause of his family and the business that he works with. I'm from Kansas City. I was actually born in Chicago but we moved to Kansas City when I was seven years old. I've been here. I grew up north of the river. I know this city. I love this city. I want to raise my children in this city. Had a physical, my annual physical, and my doctor decided to do a PSA test. A PSA test to determine if I had the likelihood of cancer. The PSA test came back in December showing a 10.7. originally, three years prior, it had been two. My primary doctor suggested I get a biopsy of the prostrate to see if it was indeed cancerous. The biopsy was positive. Five out of the 12 probes were positive. That was enough to tell me that I had prostrate cancer. From there, I started looking for a urology department. We noticed that KU had a wonderful reputation for cancer hospital. That was one reason why we chose them. Dr. Eugene Lee was the eventual urologist that we started going to. It's very important obviously, to treat each patient individually, in terms of their cancer, in terms of their specific disease process and tailor each operation for whatever they have. I think the reason that research, especially at the basic science and the translational level is so important is that when you make a discovery in the lab that translates into either a new drug or new method of treating a certain cancer, that translates into affecting more than just that one individual patient. You have the potential to treat thousands of patients in a particular fashion. When people hear the word cancer, it's probably the most scary thing that they've ever heard in their entire lives up until that point. I think the most important thing to do is to make sure they understand the process and they have time to understand the process. Speak to them in terms that they're going to understand because what is more scary is when you don't understand what's going on. I like to think of cancer care as a big team and that it takes teamwork. I'm not afraid to bring in people, not only from my own department for different ideas and thoughts on complex cases, but also to make sure we have medical oncologist, pathologist, radiologist, psychologist involved in every aspect of their care. When you're in the darkness and you're not sure where you're going to be going next having somebody who can be empathetic to you and listen to you and explain to you what you might be going through and what you will be going through, I think is really important. If somebody can look you in the eye and tell you, "Yes, we're going to do this." But give you the confidence that he and his team and his support group can help you. I think that's the key. To me, I'm an old-fashioned guy. It's important that they have straight, in the eye type contact. Dr. Lee was that way with us the entire time. If you can win over my wife, you can win over me. He did a great job doing both. Anybody that comes through the door here at KU who needs urologic care, we can take care of anything. I think that's what's very important about, and what I'm most proud of being a part of.

From my perspective, I think really what we do well as a urology department is comprehensive patient care. Providing excellent care for patients, but also doing a lot of education and research. We have a very active education program with our residents, our medical students, our nursing students, and then we also do a lot of clinical research and basic science research that's related to urology. I really enjoy patient care, but I also have a real passion for teaching and I think that it's something that is very beneficial. It helps train other surgeons, other urologists who will go out and practice, whether that's in an academic center or in a community practice, but it really is teaching almost all of the time, both in the operating room, in our outpatient clinics, on the floors with our inpatients as well. For me, it's very rewarding. I really enjoy it and I think in some ways it's a way to give back to the people that help to train me and to our society in general. I think there are a lot of benefits at an academic medical center because you are being seen by a lot of different people who are all working as a team and it's really an expert team on that specific problem. And so I think that's a benefit. Most of the patients that I see are sent to me and with the specific question, often from a different provider, their primary care physician, other urologists, gynecologists, neurologists, for example. I think part of the reason is because of that specialized expertise. Again, my practice is focused very much in bladder dysfunction and in aging and geriatrics and in female urology. I see a lot of spinal cord injured patients and I also see a lot of people with chronic pelvic pain and problems like that that sometimes I think can be difficult, more perhaps challenging for other providers. And so we see people who have tried a number of different things before and are coming here for other options. Well I think really for patients it is a matter of being comfortable with your healthcare providers and really developing a relationship where you feel that you can tell the provider anything you know about your health and that they can be comfortable with that. As I said, we deal with a lot of very intimate and complex problems, urinary incontinence, sexual health and things like that. And I think we do a really good job of helping people to be comfortable with that.

There are numerous ... And we can count over 10 procedures that aren't done anywhere in the Midwest. Procedures that we do on a regular basis. You may say that there are places, from a spotty standpoint, in the Midwest that may do one or the other. But when you start talking about the full spectrum of care, and offering all that we have to offer, that's truly unique to this region. We, for instance if you start talking about having to have surgery for prostate cancer, this is the single institution in the entire area that this One Spot offers all three approaches: Perineal prostatectomy, robotic prostatectomy, retropubic prostatectomy. This is the place where we do major reconstructions of the urethra for people who can't urinate, males who cannot urinate. So we have a very unique perspective, and the nice thing about it is, One Spot is one stop shopping for the patients. And we offer all of that, as I said, in one department, and I think that that's not only good for our referring Docs, but that gives, what I would consider to be, a true benefit. It's very beneficial for the patients. Because you can come here, and have any problem addressed. I think that our philosophy is to provide state of the art sub-specialty care for all of our patients. And to do it with the best quality, in fact, above and beyond the best quality in the United States. So we want to deliver that care the best we possibly can for every single patient. So we're treating one patient at a time as if they're our family members. Sometimes, it's the people person skills that make all the difference. You can be the most talented person in the world, have hands that are just blessed, they just know exactly what to do, but if you can't relay that comfort level to your patients, if you can't do the hand-holding, if you can't show them the compassion ... And that's what I teach these residents, as well every one of the staff members here do ... Is if you can't teach them that, if they can't provide that at the bedside, they'll never be the doctor that you really want to go to. You want to go to a doctor who can sit down with you, spend the time, make you realize that they're particular disease ... I do this 30 times a day. They do it once in a lifetime. And they want to know that this is a special disease process, for them, that we care enough about them, spend the time, let them be able to express their concerns ... Do the hand-holding that we need to do, and make them feel comfortable with the care that we're going to provide. Yeah, I think that not only is the volume important, but the other thing that the patients come in and say, you go, "You know, we want someone that's in the cutting edge of what they do. We want someone who does the research also." And every one of us is published, extensively in our areas of expertise. You can go on and Google any one of us and find that out. The nice thing about it is, not only do you have the people that are doing the cutting edge research, you've got the people that are doing the cutting edge procedures, and you have teachers. We're all teaching the next generation of urologists. I think that's a pretty special group of people that have that passion to do all three. What you and many others should understand is that we have everything to offer at this institution. We feel that have put together a group of sub-specialty trained people. In every aspect of urology, we have extra training. They're doing the research, they're doing the teaching, they're staying on the cutting edge of their specialties. We do a lot of volume. Remember, we are the only urology program in the state of Kansas. We do a tremendous amount of volume. In fact, if you were to look at national numbers, the average resident getting out, graduating, has done an average of nine cystectomies, taken the bladder out for bladder cancer. Ours are getting out all three of them in each year, so that's a total of 15 residents if you're talking about five years of training. Each of them are getting out with about 55 cystectomies. Our volume is tremendous. A huge volume of patients. We do a lot of operating, and we do it very, very well. If you start looking at our databases where we can monitor how well we're doing compared to what's published in the literature, and the publishing we do ourselves, it shows that as a standard, we're exceeding the standard in almost all of our cases. And we're providing the best care, we believe, one of the best departmental cares in the country. So I think as a referring doctor, keeping that in mind, knowing that we have all young sub-specialty trained people at the peak of their careers in this program, and we cover the entire spectrum of urology. I think that's the very reason to refer to us. We always tell people jokingly, "Look, we can ski the Devil Diamond Black, so you know we can do the Greens," when you start talking snow skiing, so we feel we can do it all. And that's the main reason to get it to us.

The key thing about being in an academic institution is that all of us are specialists in our area. You're not getting someone who performs an operation once in a while. You're getting someone who performs this operation day in and day out. If it's an area that we're not comfortable with, we have someone who fills that spot, and so all of our department is well diversified in that we can cover almost every area. In addition, if you need ancillary services such as oncology, or pathology, or things like that, we have experts in those fields as well that we interact with on a day to day basis that help deliver the excellent care that we need. The sub-specialty aspect of our training allows us to refer patients to pretty much the expert in their field, and so if I run across a patient that may be in my area of expertise, but also has another problem in say something else, I can send them to one of my partners and be assured that they're getting excellent care. That's the unique thing about our department in general. I think we have almost every niche covered here at KU. We're able to handle just about anything. We get referrals of complex cases from out the city and throughout the state, even in the region. I think there's not much you can throw at us that we can't handle, because of our unique diversification amongst the faculty that are on staff here in our areas of sub-specialty expertise. Our goal is to build relationships with patients, and really be a part of their lives, and fix the problems they come with, but keep seeing them in the future, and really develop a great doctor patient relationship. My particular practice focuses on a lot of reconstructive techniques that not many people are trained to do, whether that be a urethroplasty, correction of Peyronie's disease, or urologic prosthetic surgery such as an artificial urinary sphincter to deal with, incontinence after prostate surgery, or a penile implantation to deal with erectile dysfunction after prostate surgery. My approach is one to make sure that the patients have a clear understanding of what their medical illness is, the ways that we're going to treat that, and how we can basically plan together, as a team, in terms of the direction that we're taking our care. We really want people to understand what the outcomes are going to be, and what their up against, and know that we're here to be a part of that, and help comfort them, and hold their hand, and help them through the process. We try to really get a plan together as quickly but as confidently as possible based on the information we have, and really as a team aspect, come together with a mutual decision that's going to benefit the patient. My goal is to make sure that people are comfortable with the medical system, comfortable with me, and that we get them to a stage in their life and in their medical care that we can really move forward in their treatment.

I think the whole research aspect of this place is incredible, especially in the field of reproductive medicine and people in Kansas City aren't completely aware of what we have at KU Med or University of Kansas Medical Center. There are over 100 researchers in the field of reproductive medicine. 50% of infertility is due to the male partner and it's essential that that partner be evaluated and hopefully treated because there are certain conditions that can be life-threatening and helping men who have just shown up in your office because of infertility may enlighten certain conditions that could help their general health, such as endocrine disorders, such as obstruction which is blockages of the ducts that provide sperm. Even testes cancer can present to you for the very first time in an infertility clinic, usually because the wife has dragged the guy in and said, "Look, we can't get pregnant. You need be checked out." Next thing you know, you've found a testes lump and then you've treated that and hopefully helped him with the cancer but yet you found them for infertility reasons. So I'm very, very much of the belief and the philosophy that male evaluation in couples who have infertility is essential. We're not doing this for the money. We aren't doing this for the money. Every one of us who ultimately is in academics is trying to help people because it's a niche in which we specialize. It's what we are very passionate about.

We really play a role as a tertiary referral center for the complex urological issues. Then, we're also a primary referral center just for the primary care physicians, the internal medicine doctors, all the other subspecialties who have even just run of the mill cases or difficult cases. I think if you want to send them someplace with a lot of experience who takes good care of their patients, has good outcomes, I think sending them to the University of Kansas is the best they could be. It's not the same cookie cutter textbook handout answer for every patient. Every patient's an individual. You really do need to get aquatinted with them, kind of know what their philosophy in life is, what they're looking for for long-terms plans and short-term goals as far as surgical outcomes and overall treatment of the urological health. Once you're able to kind of incorporate all of that, I think you can treat your patient a lot better according to what they would want. The elderly, those with a lot of medical comorbidities, overweight individuals all benefit the most if we can do things minimally invasive. I mean, the gentleman I had the other day was 91 and he went home three days after surgery really without any problems, and that's after having his kidney removed, which is a major operation. If we would have done an open approach, he probably would have been here anywhere from five to seven days and then may have had to go to a nursing home for some rehabilitation just to get his strength back.