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robotic surgery

Robotic Prostatectomy

Da Vinci prostatectomy (robotic prostatectomy, robot-assisted laparoscopic prostatectomy): Drs. Matsunaga and Paul launched the robotics program in 2006 when they performed the South Bay's s first ever robotic prostatectomy. With the addition of Dr. Lesser, SBU physicians have performed over 1000 robotic procedures to date. The most common robotic operation we do is the prostatectomy, which has become the standard of care for the surgical management of prostate cancer. This operation involves removing the entire prostate gland, the seminal vesicles, and a portion of each vas deferens. If indicated, we also remove the pelvic lymph nodes. In most cases we will elect to preserve the nerves for erection, though patient and cancer characteristics factor in to this decision. Additionally, we believe our advanced bladder neck sparing technique leads to a more rapid return of continence, with most of our patients completely dry by 3-6 months or sooner. Approximately 25% of our patients are continent immediately after removing the catheter.
Drs. Matsunaga and Lesser
Data has shown identical oncologic outcomes, less blood loss, shorter hospital stay, quicker return of continence, and a more rapid return to normal everyday activity. But data has also shown that experience is paramount in order to achieve these superb outcomes. Drs. Matsunaga and Lesser are the only two physicians in the South Bay who routinely perform the robotic prostatectomy procedure.

Click here for SBU' s Robotic Prostatectomy Instruction sheet

Click here to visit South Bay Urology's Robotics website

Robotic partial nephrectomy

Drs. Matsunaga and Lesser have extensive experience in robotic kidney surgery and routinely perform robotic partial nephrectomies for renal masses. This involves removing the kidney mass with a small margin of normal kidney. Like the prostatectomy, studies have demonstrated identical oncologic outcomes (cancer control), less blood loss, shorter hospital stay, and quicker return to regular activity when compared to open partial nephrectomy. Additionally, removing the entire kidney for renal masses has been shown to increase the long-term risk of kidney dysfunction and cardiovascular mortality. As a result, the partial nephrectomy - when feasible - has become the standard of care for the management of renal masses. The robotic partial nephrectomy allows for surgical management of renal masses that previously could only be approached with a traditional open operation. SBU physicians have experience with both the arterial clamping technique and the "zero-ischemia" partial nephrectomy.

Click here to visit South Bay Urology's Robotics website

Robotic pyeloplasty

Obstruction of the ureteropelvic junction (area where the kidney tapers into the ureter) is rare but is ideally suited to robotic repair. The 10x magnification and precision of both the dissection and the suture technique leads to excellent surgical outcomes and expedient patient recovery.

Click here to visit South Bay Urology's Robotics website

Robotic sacrocolpopexy

Vaginal vault prolapse can be repaired either through a vaginal approach or with a sacrocolpopexy, which involves securing the vaginal vault to the sacral bone. The latter approach is ideally suited to the robotic surgical technique with long term data demonstrating durability of cure.

Click here to visit South Bay Urology's Robotics website

Additional robotic procedures

SBU physicans have experience performing the following procedures: radical cystectomy, partial cystectomy, ureteral reimplantation, and complex ureteral reconstruction.

Click here to visit South Bay Urology's Robotics website

Female Urology

Incontinence

Female incontinence can result from behavioral factors, bladder and/or urethral pathology, pelvic muscle issues, or a combination of these.

Treatment is guided by complex and comprehensive evaluation with cystoscopy, urodynamic evaluation, and appropriate imaging. The results of these evaluations will direct treatment.

Urinary sling

A supportive material is placed underneath the urethra like a hammock to re-create the structural support. Dr. Morrisroe is able to perform the procedure using both the synthetic mesh material and autologous tissue (tissue from the patient's own body; i.e. meshless). She also is an expert at managing complications related to prior use of vaginal mesh or urethral sling procedures.

Sacral Nerve Stimulation (InterStim ®)

This implantable system sends mild electrical pulses through a lead to the sacral nerves to modulate the behavior of the pelvic floor, urinary and anal sphincters, and colon. Indications for treatment include urinary urgency/frequency, urge incontinence, non-obstructive urinary retention, and fecal incontinence.

Botox injections

Botox can be used to treat urinary incontinence, urinary urgency and frequency, non-obstructive urinary retention, and fecal incontinence. Neurologic conditions such as diabetes, cerebrovascular accidents (strokes), multiple sclerosis, and spinal cord injuries – among others – can lead to this condition. Botox treatment involves the injection of the medication into the muscle of the bladder during a cystoscopy (a scope to look inside the bladder). This results in the relaxation of the bladder muscle, thereby allowing the bladder to hold more urine and helping to treat symptoms of urinary incontinence and overactive bladder. In two clinical trials enrolling nearly 700 patients, Botox treatment significantly reduced the episodes of urinary leakage. The effect of Botox lasts an average of nine months.

Click here to learn more about Botox use in Urology

Physical therapy and biofeedback

Physical therapists who specialize in pelvic muscle and bladder pathophysiology play a critical role in the treatment algorithm for urinary symptoms. Sophisticated diagnostic and therapeutic evaluation with biofeedback and exercises targeted at re-training the neuromuscular axis for bladder function is often sufficient for curing many bladder issues. The physicans at SBU work closely with physical therapists who are experts in this field.

Vaginal Prolapse

Vaginal prolapse occurs when the vaginal muscles weaken which leads to a laxity in the structural support of the pelvic organs. This condition is most often associated with previous child birth and the hormonal changes following menopause. Patients with vaginal prolapse may first notice symptoms of vaginal pressure and may see a protrusion of tissue from the vaginal opening. It is not uncommon for women with prolapse to also experience leakage of urine with coughing ("stress incontinence") and/or urinary frequency and urgency.

Dr. Morrisroe offers evaluation of these conditions with sophisticated diagnostic techniques (cystoscopy, urodynamic evaluation, imaging). Treatment options vary depending on the severity and location of the prolapse. Dr. Morrisroe is adept at managing and surgically correcting the cystocele (fallen bladder), rectocele (fallen rectum), and enterocele (fallen intestine) via the transvaginal approach with or without the use of synthetic mesh. She is also adept at treating prolapse with the robotic sacrocolpopexy.

Neurogenic bladder

Though rare, the nerves that supply the bladder can be affected by a myriad of neurologic disorders and traumatic events. Dr. Morrisroe is trained in all surgical and medical techniques for management of this complex condition, including:
- Bladder augmentation: using intestine to make a larger capacity bladder.
- Sacral nerve stimulation (Interstim: ®) for neurogenic overactive bladder and incontinence.
- Botox: as a muscle relaxant for the bladder

Fistula disease

Vesicovaginal and rectovaginal fistulae require extensive evaluation to plan the surgical approach. Dr. Morrisroe is experienced and trained to repair both rectovaginal and vesicovaginal fistulae.

Female Sexual Dysfunction

Female sexual dysfunction can include a wide variety of symptoms including painful intercourse, poor sexual response, or poor desire. If you have persistent, recurrent problems with any of these issues that are causing distress or straining your personal relationships, you may benefit from evaluation and potential treatment. Physical conditions, hormonal imbalances, medication-related effects, or psychological/social factors may be contributing to your symptoms. Communicating your concerns and understanding your body and its normal response to sexual activity are important steps toward gaining sexual satisfaction. Treatments focus on the underlying cause, and can help eliminate or reduce the severity of these common problems.

Vaginal Aesthetic Surgery

Labiaplasty involves surgically reducing or reshaping the female external genital structures. More and more women are requesting this procedure to alleviate discomfort caused by large, thick, or asymmetric labia, which may interfere with biking, working out, wearing tight-fitting clothes, or sexual intercourse.

Vaginoplasty (vaginal rejuvenation) involves "tightening" and rebuilding of the vaginal muscles and the perineum. Childbirth, aging, and genetic factors often cause the vaginal muscles to become stretched and lose their strength and tone. Repairing the weakened muscles and lax vaginal tissue can help restore vaginal tone and sensation.

Advanced Laparoscopy

Laparoscopic Nephrectomy (removing the kidney with small incisions)

In situations where a partial nephrectomy is not technically or medically feasible, SBU MDs most often perform a laparoscopic radical nephrectomy.

Oncologic outcomes (cancer control) are the same as with traditional open surgery, but there is less blood loss, less pain, a shorter hospital stay, and a quicker return to everyday activity.

Laparoscopic Nephroureterectomy

When the cancer originates from the collecting system of the kidney (the renal pelvis) or the ureter, the appropriate operation is often to remove the kidney and the entire length of the ureter.

The laparoscopic approach again allows for identical oncologic outcomes with shorter recovery versus the traditional open approach.

Laparoscopic Partial Nephrectomy

With smaller and more peripheral renal masses where the dissection and suturing technique does not require the robot, a laparoscopic partial nephrectomy is performed. Oncologic outcomes (cancer control) remain optimal with all of the advantages with respect to recovery of laparoscopic surgery.

Laparoscopic Adrenalectomy

The adrenal glands are involved with hormone production and are situated just above each kidney. Whether for small, functional (i.e. hormone producing) masses or for larger adrenal masses, the pre-operative evaluation and surgical approach are critical for attaining good outcomes.

SBU physicians are experienced at the medical and surgical management of adrenal disease.

Other Laparoscopic Procedures

Varicocelectomy and renal cyst decortication are both amenable to the laparoscopy approach, with identical surgical outcomes and quicker recovery versus the open approach.

Urologic oncology

Bladder and urethral cancer

Treatment of bladder cancer depends on a variety of factors, including the aggressiveness (grade) and extent (stage) of the disease. SBU physicians provide appropriate treatment for the spectrum of bladder cancer disease, including transurethral options for superficial disease and exenterative surgery (radical cystectomy to remove the entire bladder) for invasive disease.

The radical cystectomy (or anterior pelvic exenteration) is the best curative option for invasive bladder cancer, and SBU physicians have performed far and away the most radical cystectomies in the South Bay. We are familiar with all of the reconstructive techniques. Using intestine, we are able to construct all of the types of urinary diversion, including the ileal conduit (Bricker), the continent cutaneous diversion (right colon pouch, Indiana pouch), and the orthotopic neobladder (building a new bladder out of intestine).

Prostate cancer

The management of prostate cancer involves the urologist, the radiation oncologist, and the patient working together to decide on the appropriate treatment. SBU physicians are experienced and adept at the da Vinci Prostatectomy , but this is not always the appropriate option. We routinely counsel our patients to meet with one of our radiation oncology colleagues to discuss the radiation option. Additionally, we believe very strongly in active surveillance for the management of prostate cancer, and many of our patients elect for this option to manage their disease.

Kidney cancer

The great majority of our patients have kidney masses that are best suited for the laparoscopic or robotic technique (either partial nephrectomy or nephrectomy). However, some renal masses are simply too large to approach laparoscopically, and we are well-versed in the open nephrectomy for large renal masses, even with extension into the renal vein or inferior vena cava.

Read about Dr. Paul and Lesser's Radical Nephrectomy in Torrance Memorial's Pulse Magazine
Renal pelvic and ureteral cancers

Similar to renal masses, most of these are able to be treated laparoscopically with the laparoscopic nephroureterectomy.

As with any laparoscopic operation, the size of the mass may necessitate an open operation, which SBU physicians routinely perform.

Testicular cancer

Testicular cancer is generally a disease of young men, and the diagnosis of cancer at a young age can be troubling. The radical orchiectomy for diagnosis and staging is a critical component of the management algorithm. Appropriate post-operative counseling for adjuvant (i.e. additional) treatment requires up-to-date knowledge of treatment protocols. SBU physicians are not only technically experienced but also knowledgeable and compassionate and will work together with the patient and family to outline a treatment plan.

Adrenal cancer

It is rare that an adrenal mass is large enough to require a traditional open operation; most are treated with the laparoscopic adrenalectomy. In the rare scenario that an open operation is necessary, our experience and knowledge of anatomy are essential for the appropriate management of the disease.

Penile cancer

Though exceedingly rare, SBU physicians are experienced at managing penile cancer. Like bladder cancer, the treatment depends on the aggressiveness (grade) and extent (stage) of the disease. Penile-sparing surgical techniques are offered when appropriate, and resection (partial or radical penectomy) is recommended when indicated. Inguinal (groin) lymph node dissection is also critical in the management of this potentially deadly disease.

benign prostatic hyperplasia

The management of BPH requires a complete knowledge of the medical and surgical options and a discussion with the patient about the goals of treatment. SBU physicians are up-to-date in all of the medical treatments and skilled at the surgical interventions. However, not every patient with BPH requires treatment; many men can be monitored for signs of progression or medical necessity. Again a discussion with your SBU physician is critical to formulating a mutual treatment plan.

The following are examples of the diagnostic evaluation offered by SBU physicians:
- American Urologic Association (AUA) Symptom Score Index Questionnaire
- Voiding diary
- Post-void residual measurements
- Uroflow evaluation
- Cystoscopy
- Urodynamic evaluation

The following are examples of procedures offered by SBU physicians:
- PVP laser treatment (also known as the "Greenlight Laser" or photovaporization of the prostate)
- Microwave Thermotherapy (also known as "the Microwave")
- TURP (transurethral resection of the prostate) - the "Gold Standard" for surgical management of BH
- Simple Prostatectomy (for large glands) - removes the central portion of the gland either open or robotically
- TUIP (transurethral incision of the prostate) - for appropriately-selected patients

kidney stones

Though common, kidney stone disease can be challenging to treat and even more challenging to prevent. SBU physicians recommend a full metabolic evaluation for certain patients in order to identify the cause of the stones and thereby potentially prevent future stones.

The great majority of stones are treated with minimally-invasive techniques, which include:
- Extracorporeal shockwave lithotripsy (ESWL): involves focusing sound waves onto the stones from the outside of the body in order to fragment the stones into smaller pieces which will pass more easily.
- Ureteroscopy: involves introducing a small scope into the ureter and using a high-powered laser to fragment the stones.
- Percutaneous nephrostolithotomy: involves opening a channel to the kidney to visualize the stones and then using pneumatic and ultrasound technology to break them up and remove them. This is reserved for larger stones and staghorn stones.

Guides for the prevention of kidney stones are available in the Patient Resources section.

Incontinence

Male incontinence

Whatever the cause for incontinence, SBU physicians have all of the diagnostic tools to direct appropriate treatment. Often these conditions can be managed with physical therapy alone.

In cases where surgery is required, we are experienced at placing the artificial urinary sphincter as well as the male sling.

Read more about the Artificial Urinary Sphincter for male incontinence

Female incontinence

Female incontinence requires extensive evaluation, and treatment depends on severity. Physical therapy, biofeedback, behavioral modification, Interstim ® placement, Botox injection, urinary slings, retropubic suspensions, and anterior repairs are all options available to patients.

Dr. Morrisroe has extensive experience with the evaluation, management, and surgical treatment of all types and severities of female incontinence.

pediatric urology

Congenital and behavioral abnormalities of the genitourinary tract are relatively common. Treatment is aimed at repairing whatever the condition might be while maintaining as normal function as possible.

The following are examples of some of the conditions that SBU physicians treat:

Undescended testicles (cryptorchidism):
This operation, called an orchidopexy, involves using suture to fix the testicle in position in the scrotum. Often an incision in the groin to allow for mobilization of the spermatic cord (arteries, veins, nerves, and vas deferens) is necessary as well as an incision in the scrotum. When the undescended testicle is not palpable (i.e. not able to be felt on exam), SBU physicians are adept at the diagnostic laparoscopy procedure to identify an intra-abdominal testicle.

Vesicoureteral reflux:
Reflux is extremely common and management depends on the severity and progression of the disease. In some cases, observation is the appropriate treatment, as this often will resolve on its own. Other options include injection of a bulking material around the ureteral orifice and ureteral reimplantation (surgery to relocate the ureteral orifice).

Hypospadias:
This condition is when the urethral opening (meatus) is not situated at the end of the penis after birth. Some distal cases are not necessary to correct, but many will require very delicate surgical intervention.

Voiding dysfunction and enuresis:
These are very common conditions of young boys and girls and can continue through the teenage years and even into adulthood. A combination of behavioral and pharmacologic intervention can help hasten the development of natural voiding.

Varicocele repair:
The left-sided varicocele is common, present in 15% of the normal male population. There are certain indications to correct the adolescent varicocele prophylactically, and when correction is necessary options include open excision and laparoscopic varicocelectomy . SBU physicians are trained at both techniques and will counsel appropriately.

male sexual dysfunction and infertility

Male Sexual dysfunction

The treatment of erectile dysfunction requires a step-wise approach, starting with the simplest modality and progressing to more invasive options should they become necessary.

Hypogonadism (low testosterone)

All SBU physicians offer comprehensive evaluation to confirm and determine the cause of low testosterone levels in men. When appropriate, we offer a variety of testosterone replacement techniques, tailored to the individual needs of the patient. Replacement strategies include:
- Daily cutaneous application (applied to skin daily)
- Testosterone replacement injection therapy (every two weeks)
- Slow-release testosterone implant (Testopel ®)

Erectile Dysfunction
Options include:
  • PDE5 inhibitors (Viagra ®, Levitra ®, Staxyn ®, Cialis ®): these will increase the blood flow to the penis and thereby potentially lead to an improved erection.
  • Penile injections: either in the side of the penis with a small needle (Tri-Mix ® or Bi-Mix ®) or in the urethra with a pellet (MUSE ®).
  • Vacuum Erection Device (VED): a cylinder is placed around the penis which suctions blood into it resulting in an erection, and a constricting band is placed around the base of the penis to maintain the erection.
  • Penile prosthesis: this is a surgical procedure to place a device inside the penis and thereby cause an erection. Two types exist: semi-rigid (hard all the time) and inflatable (inflate two cylinders using a pump in the scrotum).
Peyronie's disease

Acquired curvature of the penis can be cosmetically unattractive and functionally debilitating. SBU physicians offer counseling and treatment for patients with Peyronie's disease.

Male infertility

SBU physicians offer comprehensive evaluation for infertility, when appropriate.

Reconstructive Urology

Urethral stricture disease

A urethral stricture is a narrowing of the urethra that can result in difficulty urinating and even inability to void in extreme cases. It is essentially a scar, and often these are managed by a procedure through the urethra to open up the scar. Certain situations require a more definitive option with less chance of recurrence: the urethroplasty. This is a surgical procedure involving excision of the scarred segment and reconstructing the urethra. Larger segments of scar require the use of a buccal mucosal graft (skin from the inside of the cheek) to cover the area of scarring. Long term results are excellent and durable.

Urinary diversion

After removing a bladder (radical cystectomy ), a means for excreting urine from the body is necessary. Three categories of options exist:

1) ILEAL CONDUIT (Bricker):

Involves using a short segment of intestine like a pipe to direct urine into a bag that is affixed to the skin.

Click here to view the United Ostomy Assocation’s Urostomy Guide

2) CONTINENT CUTANEOUS URINARY DIVERSION (right colon pouch, Indiana pouch):

Involves reconstructing a spherical vessel using a combination of large and small intestine, then constructing a continent channel to the skin through which the patient periodically passes a catheter to empty the urine.

Click here to view the United Ostomy Association’s Continent Urostomy Guide

3) ORTHOTOPIC NEOBLADDER:

Involves using small intestine to construct a new bladder and attaching this to the native urethra, thereby allowing for a more normal urination.

Click here to view the United Ostomy Association’s Orthotopic Neobladder Guide

scalpel-less vasectomy

The vasectomy involves delivering the two vasa (one from each testicle) through a small opening in the scrotal skin, clamping a segment and removing it, then cauterizing both ends. The procedure is well-tolerated and can be performed as an outpatient procedure. All of the SBU physicians routinely perform vasectomies and have excellent operative technique to minimize the chance of pain and swelling after the procedure.

Click here to view SBUs Post-Vasectomy instruction sheet