Episode 27: Hernias & Your Prostate | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

All right. This is Hernia talk, another hernia talk Tuesday. My name is Dr. Shirin Towfigh. As you know, we have this every week where we talk about all different topics related to hernias. You can follow me on Twitter and Instagram at Hernia doc and also on Facebook on my homepage, Dr. Towfigh. After we are done with today’s Hernia talk live episode, this will be posted on YouTube and I’ll share the links with you on all of my different social media platforms. Today’s guest panelist is one of my favorite people in the world, Dr. David Josephson. He’s a urologist, which means he’s super fun at parties. You could tell we’re having fun already. You can follow him at Dr. Josephson. He’s a urologist, multiply trained for the prostate and cancers and robotic surgery. And welcome Dr. Josephson.

Speaker 2 (00:01:00):

Well, thanks for that introduction. I don’t think anyone’s used that word. Fun parties urologist, accolades, but

Speaker 1 (00:01:08):

As you know,

Speaker 2 (00:01:09):

I tend to think that I am fun at parties

Speaker 1 (00:01:12):

As urologists in general are the funnest people at the parties. And you in particular are especially fun because you’re a great guy and you’re just hilariously funny at the same time.

Speaker 2 (00:01:22):

Oh, thank you so much. And you have great, the pleasure being here. I love operating with you and certainly this is a great time to hang outside of the operating room and kind of talk about our patient population that overlaps.

Speaker 1 (00:01:34):

Yes. So you do a lot of different urologic procedures, but the prostate is your favorite organ in urology.

Speaker 2 (00:01:43):

One of, I think prostate and kidneys. So I dunno I tend to bounce between the two of them, but certainly the prostate has a lot more complexity in terms of outcomes that you need to be

Speaker 1 (00:01:55):

Aware of. Okay, that’s fair. I do hernia surgery, so a lot of my hernias are in the pelvis, so groin hernias as well as abdominal wall hernias. And so many of you don’t know, but I actually share a lot of patients with Dr. Josephson. Those of you have who’ve been to me I may have referred them to Dr. Josephson because people with hernias also need to make sure that other urologic issues are not causing their pelvic pain or what we’re going to be discussing today is if their prostate is going to somehow affect their hernia outcome. And that’s something we’re going to focus on. We’ve had a couple different hernia talks before and the topic of the prostate came up and tons of questions came. So I’m like, I need to get Dr. Josephson because he’s our expert to talk about everything he loves about the prostate. So what do you want to say as an intro and then I have tons of questions pre-prepared because they’ve been submitted and also I’m sure people will be submitting them as we talk to.

Speaker 2 (00:03:01):

Sure, sure. So where we trained at LA County, we used to call it the tri-county line because there is kind of this area in the pelvis where general surgery and orthopedics and urology all come together and just the upper end of the scrotum there could be some scrotal pathology, some inguinal or orthopedic pathology and certainly hernia. So that’s kind of how our world’s kind of come together. But certainly when you’re talking about pelvic pathology and pelvic pain, you have to consider the prostate and the bladder as part of the differential. Just a little bit of a background about myself, I trained in general urology, then I went on to do an open oncology fellowship and reconstructive fellowship with someone named Don Skinner was considered the kind of godfather of urologic Maxine invasive surgery. And then I went full schizophrenic to the other end and I went minimally invasive and did laparoscopic and minimally invasive surgery and robotic surgery at city vote.

Speaker 2 (00:04:07):

So I kind of have a hybrid approach to everything, minimally invasive and big open surgery for certain oncologic tumors. But as a result of certainly working with you and also being in somewhat of an acute community based practice, I do a lot of non-oncology based surgery and I think the thing that has pushed me to apply robotics is some of the complications that we’ve seen as it relates to maybe failed hernia operations or undiagnosed pelvic pain that involves the GU system. So I’m happy to talk mostly about the prostate, but I’m sure there’ll be other things that come about in terms of the questions that people come.

Speaker 1 (00:04:55):

Yeah, if you don’t mind, we’re just going to dive into it with some of these questions. Can I ask you to turn down your volume a little bit? There’s a little bit of a feedback, just a tad bit. Let’s see how that, okay,

Speaker 2 (00:05:05):

That better?

Speaker 1 (00:05:07):

Much better. Okay. Question number one. How do I know not, how do I know? Cause I don’t have a prostate. Just to be clear, only men have prostates, correct? Correct. Okay. How does a man know if they have an enlarged prostate?

Speaker 2 (00:05:22):

So that’s typically a symptom-based issue as we age, our prostate glands grow. I think kind of the first sign of prostate enlargement may be urinary symptoms. So typically I think the earliest, you know, start seeing people developing some prostate problems is maybe in their early forties but typically it’s an older patient population issue and the presenting signs is some sort of obstructive symptoms. So getting up to go to the bathroom at night, having a weak urine flow, having frequency of urination or urgency of urination are typically the presenting signs. So having an enlarged prostate by itself is not very dangerous. You can have a massive prostate and have no symptoms and you can certainly have a small prostate in overall size, but the inner channel of the urethra may be compressed by the prostate growing inward and subsequently developing symptoms. So it’s perfectly normal for someone to have a large prostate.

Speaker 2 (00:06:37):

I tell people it’s something that you’re born with, it’s not like something you can really act upon with diet or exercise or activity. So it’s like some people are born with big noses or big breasts or big heads. Prostates are the same way. They come in all size and shapes and sometimes they can be symptomatic and sometimes it can be completely asymptomatic. But I think the most common question about prostate enlargement is the fear that it involves some sort of malignancy. And that’s typically not true. So in fact, very large prostates tend not to have malignancy. I typically see more aggressive cancers in smaller glands. So if you want to explore whether you have a big prostate, you can go see a urologist or even a general practitioner can do an exam on someone. And we do advocate for screening for prostate cancer at a certain age group not in all men, but certain age group. And then as part of that workup, the patient can get a PSA, which is a prostate specific antigen as a blood test to see if they’re at risk for having [inaudible]

Speaker 1 (00:07:51):

Prostate. Okay, great. So PSA is a blood test, correct? Right, correct. So as part of the screening, men are asked to get a PSA, at what age should they start checking a PSA?

Speaker 2 (00:08:04):

So this is a very controversial topic and for years we’ve had some conflicting recommendations. The US preventative Task force, which is kind of the authority for family medicine and internal medicine has changed their position on this. And their most recent recommendation is that they actually recommend against routine screening. Okay. So the American Urologic Association, which is the body of all urologists actually has modified their statement. So you have to take into consideration a patient’s age, their life expectancy and their core morbidity. So if they don’t have a life expectancy of 10 to 15 years, then you shouldn’t be checking for prostate cancer. We also don’t routinely recommend checking for prostate cancer for men under the age of 40 sometimes men over 70, it’s kind of a risk benefit ratio. If they have a lot of comorbidities, they’ve had a stroke, a heart attack, pulmonary hypertension they’re expected life expectancies, let’s say less than 80, we would advocate against its routine screening. So the sweet spot is maybe people between 55 to 69 and certainly in people who are 40 to 55 who have some risk, maybe a family history or some underlying prostate symptoms. But it’s a shared decision making process because we know that just a routine blood test can cause some harm because it may be falsely elevated and lead to unnecessary biopsies and the biopsies can cause an unnecessary infection. So it kind of involves a shared decision making with the patient.

Speaker 1 (00:09:52):

So you don’t want to over treat

Speaker 2 (00:09:54):

Over treat or over screen because you may as we grow older, our chances for developing prostate cancer certainly increases. So men over the age of 80, I’d say 40 to 50% of them may have some form of prostate cancer and it’s typically what we call indolent. It’s not going to kill them, it’s going to grow with them and not cause their death, but they will die of another cause. So what’s the point of diagnosing ’em with something that’s not going to ultimately kill them and subject them to unnecessary biopsies and testing and exams and so on and so forth.

Speaker 1 (00:10:31):

But there are non-cancer reasons why a PSA may go up, right? That’s

Speaker 2 (00:10:36):

A little absolutely true. So a prostate a PSA can be elevated, not just related to cancer, it can be related to an enlarged prostate. Anytime someone has any manipulation, so instrumentation, let’s say they’ve had a catheter in because of inability to urinate or they’ve had a recent spine operation and a catheter was placed or a urinary tract infection even maybe a rigorous prostate massage for prostatitis can elevate the PSA. So I don’t like to act on one level alone. So a knee jerk reaction, someone comes in and you check a PSA and it’s elevated, we don’t automatically jump to do a biopsy. I tend to take the history context. Did they have sexual activity, masturbation, intercourse? Did they have a recent infection? Maybe they had a very long bike ride, they did a century bike ride and maybe sat on a very hard bike seat.

Speaker 2 (00:11:37):

All these things need to be taken into consideration. And in most cases, if I don’t have a prior level to compare it to, then I would say, okay, we’re going to repeat this. Historically, some people have advocated for using antibiotics to decrease the inflammation and recheck it, and we’ve kind of moved away from that. So I just give it a little bit of time and then recheck it. And we use eight specific ranges. So if someone is in their forties and they have a PSA of four, that would be considered abnormal. But if someone is in their seventies and have a PSA of four, that would be considered to be totally normal. So you have to take age specific range, family history and then velocity. So the growth of PSA over time, and as we grow because our prostates grow in size, the PSA will go up as well. So anywhere between 0.5 to 0.7 points. It’s not uncommon for me to see someone that I saw 10 years ago and their PSA let’s say was two, and then they get back sent back to me 10 years later, and their PSA is four and their primary care physician is concerned. But if you plot over a 10 year period 0.5 points per year, you can assume that their PSA can certainly go up to six or seven. So it’s the rate of increase that is something that you need to work

Speaker 1 (00:13:04):

On. So most of the patients that I see, prostate cancer is not the issue is an enlarged prostate. Correct. So the same way that I want to make sure that my hernia repair heals well, there’s no infection and that there’s no recurrence. I always screen for constipation, chronic coughing, nicotine use, is their diabetes well controlled? Are they obese? Those are all known risk factors. But I think one risk factor, which a lot of people don’t look into is someone’s prostate health. In other words, are you having symptoms from an enlarged prostate? And how is that going to adversely affect your current hernia? So can you just briefly let us know what’s the risk of having an enlarged prostate? What can that imply in some patients?

Speaker 2 (00:13:51):

So the primary risk is really age, and of course being a male, so your female population doesn’t have a prostate. So as you get older, your risk of having an enlarged prostate goes up.

Speaker 1 (00:14:04):

What’s the clinical implication of having an enlarged prostate? What symptoms?

Speaker 2 (00:14:09):

So symptoms, so what we call ’em obstructive symptoms. So most common I would say is getting up in the middle of an IT urinate, and the reason is the prostate grows and it can grow outward and also inward. So the inward growth ends up pinching the urethra. So the channel is reduced. So imagine the analogy I like to use with patients and they get it is a sewer line. Imagine your sewer line has roots growing into it and the flow of water going out is going to be constricted. So water is going to back up. So when a patient

Speaker 1 (00:14:46):

Donuts, I always use a donut as my analogy. Am I doing that?

Speaker 2 (00:14:51):

I don’t know. I mean sewer line, it’s kind of like a bodily habit. Urine, the house, I don’t know, I guess you can use a donut, but there’s no water going through a donut. There’s certainly fluid going through the sewer line, or let’s say just a pipe in the house, like a drain pipe. But the water ends up backing up. So the process of urination, the bladder tries to contract and release as much as possible from the bladder to empty it. And if you have a constricted channel most men with an enlarged prostate can’t empty completely. So let’s say an average capacity of a bladder is 400 to 500 ccs. In younger patients or those who don’t have an enlarged prostate, I’d say 400, 450 ccs get evacuated and only 50 ccs at most will stay behind. Okay, well, people within large prostates end up having 150 to 200 ccs.

Speaker 2 (00:15:55):

So as a result, within a couple of hours, the person that can’t fully empty will have, again, 500 ccs of a full bladder and they’ll need to go evacuate again. So the most common symptoms are frequency and nocturia or nighttime urination, and then decreased force of stream. So instead of a fire hose, it’s like a slow trickle. Sometimes you’ve may not been aware of this, but you go to a ball game like a Laker game or a Dodger game, and you’re sitting in this kind of communal bath toilet bathroom with these stalls, and you hear guys sitting there literally straining and taking a very long time to urinate, where two people have already gone and urinated and they’re back at their seats and this guy’s still trying to empty. So that’s kind of the presenting symptoms. And the reason that that comes in handy in your world is they’re straining, which puts a lot of pressure on their inguinal canal. And if they’ve had a hernia repair or they have an underlying hernia, exacerbates the commission.

Speaker 1 (00:17:05):

I ask my patients if they strain and they’ll say no. And then I say, okay, do you have a slow urinary strain? Yeah, it’s slower. Okay. Does that mean that you’re straining to make it go faster? Some say yes. Does that mean that you have to wake up in the movement? How many times do you wake up at night to urinate? And they’ll say three times. So usually after two, I think that’s abnormal, right? Like one

Speaker 2 (00:17:28):

Or two. It’s also, again, it’s age dependent because as we get older, and this is not related to the prostate, it’s actually related to physiology of how we make urine. So nocturia is a common thing in older patients, women and men, but you have to kind of differentiate whether this is more urine production or a problem with emptying of the bladder, right? And there are tests that you can do to kind of determine that.

Speaker 1 (00:17:56):

And then the other question I ask is, do they feel like they’re completely emptying? Because what happens is that they don’t empty, like you said, because it’s against the back pressure from an enlarged prostate. And then they feel like they have to strain at the end of that urination. They’re really completely empty. So that is straining. Yes. And then they come in with all these symptoms from their hernia, and as you know, hernias don’t all need to get repaired. If you’re symptomatic and have pain or other symptoms from your hernia, then that’s a good time to have your hernia repaired in the groin, especially in men. And so if I can get their prostate checked out and get them from having to strain, then maybe their hernia symptoms will go away and I just save them from a hernia surgery.

Speaker 2 (00:18:41):

Correct. And frequently what I see is people that have not been evaluated for BPH and they do get a hernia operation, and not only do they not stop straining but actually get a hernia operation and they get worse, they get more pain, and their hernia repair kind of fails.

Speaker 1 (00:19:01):

Yes. I’d like to look into that really. Well. Before we do that, we have one question from Facebook, which is, what are your thoughts on the usefulness of 4K score or pH I score or multi-parametric MRI instead of a needle biopsy?

Speaker 2 (00:19:16):

Oh, great question. That’s

Speaker 1 (00:19:18):

A great

Speaker 2 (00:19:18):

Question. Great question. I dunno what that

Speaker 1 (00:19:20):

Means at

Speaker 2 (00:19:20):

All. Yeah, so PSA is not a great test. It’s not a perfect test. It’s a good screening test, but there’s a lot of false positives. So big glands can have a elevation PSA. So 4K score is one of the many, many markers that we have. 4K score looks at kallikrein markers, the genetic alterations P H I is another index that takes into context complex PSA, free PSA, total PSA. There’s actually urine based markers, select MDX. Another one is exosome, which look at genetic alterations in the RNA in urine that’s expressed from the prostate. And probably another one that other ones that I haven’t covered. There’s actually new XSO marker by a company called Mirror Scientific that not only can tell you whether someone is at risk for prostate cancer, but it can actually differentiate between low intermediate and high risk prostate cancer. Whoa. And so the ultimate goal is to avoid the needle biopsy altogether.

Speaker 2 (00:20:31):

Out of all the things that I just mentioned I think probably the most reliable thing in my practice is the use of MRI. Okay. So there’s, there’s something called a promise trial, which looked at the utility of MRI guided versus non MRI guided prostate biopsies. And the detection rate for cancer and high risk cancer was significantly better with MRI. It hasn’t become kind of standard of care throughout the states. We are still dealing with a lot of insurances that won’t approve it. They’ll want to have a traditional biopsy or an ultrasonic biopsy, and if that fails, then they’ll approve an MRI. But in the UK, their system is actually favored a process where if someone has an elevated PSA before they even see the urologist, they get an MRI. And if that MRI is normal, then they’re told you don’t need any follow up. We’ll recheck your PSA in a year to two years.

Speaker 1 (00:21:30):

And that’s that sensitive,

Speaker 2 (00:21:32):

It says. Yeah. So the sensitivity of MRI, and it depends on the reading. So it’s a pyrad score. So the radiologist looks at the way that the prostate takes up the contrast and based on it’s called diffusion weighted imaging, the way the contrast is taken up and then gets excreted from the gland, A score is applied. So a score like a five out of five is 85 to 95% sensitive for having underlying cancer. Four out of five is like 70 to 85, 3 out of five is a 50 50 chance, and a two out of five is essentially a benign reading. So I love to use MRI in my practice as part of the next step in screening. And again, I don’t use it in everyone. I kind of use age specific ranges how fast that it’s gone up. And then if the MRI, if I’m suspecting something, then I always get an MRI if I can get one. They don’t have a pacemaker, they’re not claustrophobic or anything like that. I always try to get an MRI before I do a biopsy. And

Speaker 1 (00:22:43):

That’s a, that’s non-contrast. MRI prostate,

Speaker 2 (00:22:47):

It’s a contrast. Contrast, multi-parametric three Tesla prostate MRI. So it’s different than a pelvic MRI.

Speaker 1 (00:22:58):


Speaker 2 (00:22:59):

It. It specifically looks at the prostate.

Speaker 1 (00:23:01):

Okay. There’s a comment about, wow, Dr. Josephson knows his stuff. I mean, that’s who I bring to hernia attack, guys, come on. I don’t associate,

Speaker 2 (00:23:09):

This is my bread and butter.

Speaker 1 (00:23:10):

I don’t associate with people that don’t know more than that. Don’t know more than me. So let’s then discuss how it relates to hernias. Lot of questions about enlarged prostate, hernia pairs, et cetera. So what’s the risk to my hernia repair? We already discussed that if you’re straining because you’re trying to urinate against the pressure of an enlarged prostate in men, then that can exacerbate hernia symptoms. I don’t believe it causes a hernia. You should already be prone to hernia before these things happen. But it can make it worse. It can make it more obvious. Bigger hernia or more symptoms.

Speaker 2 (00:23:52):

It can certainly exacerbate correct a preexisting hernia and make it a lot worse. Certainly if you’re using what’s called Valsalva.

Speaker 1 (00:24:02):

Yeah. Multiple times a day, right? Yeah. So then you come to my office and you say, all right, I have this hernia. Let’s say you need hernia repair. I’m always make sure I send you back to your urologist to get your prostate treated for two reasons. One is I don’t want you to strain after surgery, right? Because the same issue is there now you have a fresh hernia repair and you’re straining against my hernia repair. Sorry, you have, yeah. And then you’re going to bust my sutures or pull my Mesh off or whatever the situation is. And so the risk of recurrence is higher if you have an enlarged prostate that’s not treated. The other thing I’d like you to know discuss Dr. Josephson, is what’s the risk to during surgery? So let’s see, is that here? Hold on. What are these questions? Okay. Right. So after hernia surgery, so you get either general anesthesia or local anesthesia may be a catheter during surgery if you have a large prostate that increase your risk of urinary retention or not being able to pee after surgery.

Speaker 2 (00:25:18):

Yeah, so exactly. So even before you talk about exacerbating your hernia repair, it’s the immediate kind of perioperative issues that we want to make sure that people don’t have a bad outcome. So outside of hernia surgery, any kind of operation, whether it involves a general anesthetic, spinal anesthetic, sedation puts people at risk of going into retention or not being able to urinate, or certainly having a difficult time to urinate. So in general, I think the risk of retention after any type of surgery is about 3 to 5%. So in all comers, we get called about this all the time in the hospital, but there are certain specialties, and you’re one of the lucky ones, that these patients are more at a risk of going into retention. So orthopedic procedures, joint replacements, knee replacements are probably at the highest risk. Colorectal procedures because it sometimes impacts the sympathetic, parasympathetic inversion to the bladder.

Speaker 2 (00:26:28):

And then certainly hernia operations. And in the literature it’s anywhere from 10 to 40% of patients after hernia surgery can have or be at risk for acute urinary tension. So naturally men are at the highest risk, probably probably double the risk of women because they have a prostate. And age is another predisposing factor. So as we get older part of it is related to having a prostate. Part of it is just related to maybe decreased activity of the bladder, the muscle to be able to push the urine out. Those patients are also at risk. Other things,

Speaker 1 (00:27:04):

It’s a big deal though, having, first of all, if you can’t urinate after surgery and you need to have that addressed very quickly because your bladder’s going to get bigger and bigger and bigger. Right. And in extreme cases, it can even burst if you don’t address it after what, a couple liters or something? How big?

Speaker 2 (00:27:22):

Yeah. I mean, I’ve rarely seen someone have a bladder perforation from not being able to urinate after an operation. The bladder perforations typically happen in people that have maybe been intoxicated or traumatic had trauma. Most people that have operations or they’re observed after surgery to make sure they’re able to urinate and they’re comfortable before they leave. So we catch this before it causes real harm, but it does cause a lot of stress and unnecessary pain if they’re not able to urinate. And

Speaker 1 (00:27:58):

Then if you let it go too long, your bladder gets overstretched, right? Correct. And loses ability to work normally until you give it some rest.

Speaker 2 (00:28:07):

Correct. So the smartest thing you can do as any surgeon, not beyond hernia operation, is to screen patients. And if they have underlying BPH or urinary symptoms make sure that they’re kind of optimized. So if they have already seen a urologist and they’re already on some medication for the prostate, and typically those medications are called alpha blockers like Flomax, Rapaflow, many different names, we want to make sure that they do not stop taking their medication prior to surgery, especially the night before, because it will protect them the next day. And I’d say probably decreases the risk of retention by at least 50%.

Speaker 1 (00:28:57):


Speaker 2 (00:28:59):

And if they’ve never been to urologists, and as part of your review systems, you kind of pick up that they have some obstructive symptoms, then certainly get them to see a urologist to evaluate them and make sure that their kind of symptoms are optimized or they get put on an alpha blocker before they get to surgery.

Speaker 1 (00:29:14):

So my issue is sometimes they do have a urologist and the urologist feels like that amount of symptoms is minimal and they don’t care. And they were not put on medications and I said, no, you need to go back because you have a hernia. That’s difference. If you’re walking around with some of those symptoms, maybe it’s okay, but now that you have a hernia and or need hernia surgery, I need that more tightly controlled, better controlled symptoms from your prostate than if you were just a run in the mill guy. So I almost have to force some of the urologists to treat patients because they feel like, oh, the symptoms aren’t that bad, but I would hate to have a patient get a catheter after surgery for no reason. If that can be prevented, it’s very painful.

Speaker 2 (00:30:01):

So we’ve talked about this. Even people that may be coming into to see you from out of town, they don’t have a urologist that they have an established rapport with. As an MD, you’re qualified to give them some alpha blockers. And I would strongly encourage all hernia specialists and all pelvic surgeons for that matter, orthopedists, colorectal surgeons, general surgeons, to consider putting men who are older who have some underlying symptoms, at least on some alpha blockers for a couple of days before their operation. And then maybe a dose right afterwards. Certainly if they have any difficulty afterwards to decrease the chance O of retention. But there’s other things that can be modified as well. So as the length of surgery increases, so the mound of time under anesthesia

Speaker 1 (00:30:57):

And maybe narcotics,

Speaker 2 (00:30:59):

And certainly narcotics. So use of narcotics, length of anesthesia, spinal anesthetic, more than general anesthesia time of or time and volume. So distending the bladder over distending the bladder, maybe not having a catheter in will probably put them at higher risk of going into retention. So those things need to be taken into consideration. And then once the patient comes out of surgery and they go to recovery again, use of narcotics should be minimized. So for abdominal surgery, I love to use a tap lock. I know you use a tap lock as well to minimize their use of narcotics, and that would also decrease the chance of retention early ambulation. So getting the patient up and about as early as possible will decrease the chance of retention. And on some people actually use a hot pack over the bladder. Yeah, I mean there’s some reports of it. I don’t typically use it, but it can’t hurt. I mean it can’t hurt. There are some of these anecdotal things that I’ve heard of over the years. Some people say, especially when I get called after hours, someone isn’t able to urinate. Trying to whistle and taking a hot bath sometimes helps them whistle

Speaker 1 (00:32:28):

While you’re taking a hot bath,

Speaker 2 (00:32:30):


Speaker 1 (00:32:31):

Whistle while

Speaker 2 (00:32:32):

You’re whistling, use whistling as one and also sitting in a warm bath. Okay. I can’t explain how it works.

Speaker 1 (00:32:42):

It works. Who cares? Yeah. Yeah. So here’s a patient who is on an alpha blocker and their question is, while on treatment, what’s an acceptable post avoiding residual, especially for someone who’s contemplating hernia surgery? Are there any cutoffs as to the retained urine after urinating that will predict whether you will have problems after hernia surgery such as retention?

Speaker 2 (00:33:10):

So there’s no absolute number. Okay. It’s really how big your bladder capacity is. If your bladder capacity is 700 ccs and you retain 250 ccs, it’s about a third. It’s not that big of a deal. I mean, it’s a high, but it’s not going to cause damage. But if your bladder capacity is 300 ccs and you’re retaining 250 ccs, that’s almost 80 90% of your lot of capacity. That’s probably concerning. And the reason retention outside of surgery or hernia surgery is concerning is that retention may be a precursor to damage to the upper tracts. So there’s a couple of things that I like to talk about with my patients when they come in for their prostate issues. One issue is quality of life and symptoms. So if they’re retaining, it probably means that they’re getting up frequently to go to the bathroom both during the day and at nighttime.

Speaker 2 (00:34:15):

Okay, no big deal. So they get up if it doesn’t bother them, not a big deal. But in an older patient population, if they’re getting up in the middle of an night to urinate, that’s going to put ’em at risk for maybe having a fall. Someone’s groggy, they’re getting out of bed, it’s dark, they don’t want to wake up their partner, they walk into the bathroom, they sit there for a while, they’re finally woken up and they slip on their way back out. And so forget the quality of life, you’ve actually caused a potentially life threatening issue. They hit their head trauma and stuff like so. Good point. That’s one thing that you have to keep in mind. So quality of life and maybe putting ’em at risk for other issues. Outside of the quality of life issues and symptoms is having obstructive symptoms that are go undiagnosed or untreated for a long period of time results in bladder wall thickening, it causes detrusor abnormalities. So part of urination is the outlet, which is the prostate. A part of urination is the bladder and the muscle. So if you’re putting a lot of pressure on the bladder, it has to build up muscle to be able to urinate, to push all that urine out against the blockage. And so what that does, it causes thickening of the bladder wall, which doesn’t go away when you fix the blockage.

Speaker 2 (00:35:40):

So I tell people, don’t consider your issue one of those. You come in, we unblock your prostate and you’re symptom free for the rest of your life. It’s not uncommon for people to relieve their blockage symptoms, but they continue having urinary frequency and urgency because their bladder is overactive.

Speaker 1 (00:36:01):

Oh, got it.

Speaker 2 (00:36:01):

Got it. So it’s almost like a preventative thing. So that’s the thing that you have to keep in mind with residuals being high. And the last thing is when it’s really high, it will back up into the kidneys and cause kidney damage. So historically, before the advent of alpha blockers and prostate surgery, many people who were retaining a lot of fluid would either get infections or bladder stones or bleeding from the prostate. But one of the other things that would happen is that retention or residual would back up into the kidneys and cause hydronephrosis or blockage and the blockage would ultimately cause kidney failure failure. Yeah. So long answer for a question about what’s acceptable residual, I certainly think less than 200 ccs is acceptable, but it needs to be monitored over time. And if patient comes back, it’s one 50, then it’s 200, then it’s two 50, then it’s 300, then it’s three 50, and then you get an ultrasound of their kidneys blocked time to do something about it.

Speaker 1 (00:37:09):

True. Another question, this one is a really good question. It’s a little bit complicated, but it’s very good question. So this patient had an open angle of hernia repair with Mesh. I believe it was a Mesh plugin patch, but that part doesn’t matter. They had a recurrence after their open angle hernia repair with Mesh. They also had some prostate issue. It’s called a hole up surgery. What is a hole up surgery?

Speaker 2 (00:37:31):

It’s a home laser prostate enucleation.

Speaker 1 (00:37:37):

Okay. For cancer or

Speaker 2 (00:37:38):

For any? No, for BPH for benign large

Speaker 1 (00:37:42):

Gland. So they have this known history of severe process prostate enlargement that’s being treated with this holdup surgery. Then they had an open-angle hernia repair with Mesh that’s recurred for whatever reason their urologist said, and I don’t agree with what they said, which is I was told not to have more Mesh placed as it will affect my ability to have an open prostatectomy. That’s old

Speaker 2 (00:38:11):

School. That is very old school. So you may recall maybe like 10 to 15 years ago when robotics came into play that some people in the general surgery world, hernia surgeons that only did open surgery and didn’t do any laparoscopic surgery, were advocating against the use of Mesh because if the patient developed prostate prostate cancer, it would be almost impossible to do their prostate surgery, whether it’s prostate cancer or let’s say even what’s called a simple prostatectomy for a very, very enlarged gland, yes, that’s not amenable for endoscopic treatment. And that’s not true. It, it’s true that it makes it harder if you want to do an open prostate operation. But for the most part, this day and age for prostate cancer, if someone’s going to have surgery, I’d say 80 to 90% of most urologists now that have come out of training would do it robotically. And when you do it robotically, you actually go right underneath the Mesh. So that doesn’t cause any issues with being able to complete an operation, whether it’s for cancer or for a very big gland for a simple prostatectomy. So

Speaker 1 (00:39:26):

If you have an enormous prostate, can that be done robotically too?

Speaker 2 (00:39:30):

Yes. So that’s called a -So a lot of people don’t feel comfortable with you yet, but I think more and more robotic surgeons do it. And you can certainly do non robotic surgery or non abdominal approaches. So [inaudible] is a perfect example. There are people that are very comfortable doing homeolaser enucleation for glands over 200 grams. There’s something called a green light laser, which I’m not a big fan of because it causes some irritation. But homeo laser I mean green light laser vaporization of the prostate can be done for glands above 200 grams. But I don’t think that this day and age a Mesh repair will complicate or be a contraindication for someone to have a robotic approach for their prostate cancer or for BPH.

Speaker 1 (00:40:30):

So I agree, we actually looked at that problem because I don’t want to and do an operation that will hinder someone’s ability to have some type of lifesaving prostate surgery in the future. So we actually looked at that. Cedar Sinai is probably one of the busiest hospitals for urology in terms of robotic surgery as I mean prostate surgery as well as for laparoscopic surgery and hernia surgery. So we looked at the data, we never published it, we probably should relook at it and publish it, but that question’s kind of outdated now. But when I first got to Cedars around 2008, we looked at this, I looked at all the prostates done robotically to see if any could not be done because there was a Mesh there, zero. And I looked at all the laparoscopic hernia repairs done that could not be done because they had a robotic prostatectomy also zero, so or basic close to zero. So it’s a fallacy that you can’t have good prostate surgery if you’ve had a prior hernia repair, whether Mesh or without Mesh, laparoscopic or open number one. And number two, it’s true, open prostatectomy is complicated. If you’ve had Mesh in the plane where you have to go after the bladder prostate,

Speaker 2 (00:41:51):

That’s more difficult.

Speaker 1 (00:41:53):

And there have been situations back in the early two thousands, there was a publication from I think him at train with him at UCLA where he published that there were patients where they had to stop surgery and were not able to do surgery, had to do radiation because they couldn’t do open prostatectomy on the patient. No one really does open anymore. Correct. And numbers that I’ve seen is something like 92 or 96% of prostate surgeries by urologists is done robotically. Something like huge number

Speaker 2 (00:42:28):

90% for cancer and certainly maybe 70, 80% or open simple because it’s a more complicated technique to do a simple prostatectomy for benign glands. But more and more people are becoming comfortable with that

Speaker 1 (00:42:45):

Technique. So I think the statement was made by someone who is maybe of an older generation or is more aware of the older data. There’s no new data that supports that at all.

Speaker 2 (00:42:57):

Correct. I agree with that.

Speaker 1 (00:43:00):

Okay. I have another question. This one.

Speaker 3 (00:43:05):

Oh, where’d it go?

Speaker 1 (00:43:08):

Sorry. So this is about a patient who has had urethral resection of the bladder and

Speaker 2 (00:43:18):

Bladder or prostate,

Speaker 1 (00:43:20):

Sorry, TURP, trans urethral resection of the prostate. And for an enlarged prostate, once they’ve had the surgery, the whole goal is to kind of shave the inner part of that donut or clear off that sewage line like you’ve mentioned, to allow for better urine flow. Should they still be on prostate medications like an alpha blocker or can they be off of it afterwards?

Speaker 2 (00:43:42):

They should ideally be off of it. So we do a TURP when medic medical therapy fails. So first line of therapy for an large prostate is typically behavior modification, believe it or not. So I can’t tell you the number of guys that come and see me. They got some, maybe even a large prostate, but they’re getting up four times a night. And I say, okay, well how much water do you drink during the day? Average, and how about at night? Well, I like to drink a glass of water every time I go to the bathroom.

Speaker 1 (00:44:13):

Oh, <laugh> counterproductive.

Speaker 2 (00:44:16):

Very counter. So I mean common sense stuff. Some people forget it. So first thing is behavioral modification. So cut out fluids after a certain time limit caffeine or alcohol intake before going to sleep or even during the day. So got it. Above that, it’s medication. So there’s two classes of drugs, alpha blockers. We told Tamsulosin rapiflow hyran, and then the five alpha reductase inhibitors, which shrink the gland. So alpha blockers work on the alpha channels. They open up the smooth muscle within the prostate. Five alpha reductase inhibitors actually shrink the gland by blocking the effects of testosterone on the prostate.

Speaker 1 (00:44:56):


Speaker 2 (00:44:57):

Five alpha reductase inhibitors typically work in bigger glands, so 40 grams and above. When those fail, and you can only increase alpha blockers to a certain point because they can drop the blood pressure. The next step is some sort of operative intervention. There’s minimally invasive ones, there’s lasers, there’s clips that can be done in the office. There’s heat ablation, and then there’s different forms of resection of the prostate TURP. But the goal of all of these is to get people off medication. So I like to keep people on the medication because there’s a lot of swelling and healing. We’re about maybe four to six weeks after their operation, but after that they should ideally be off

Speaker 1 (00:45:38):

Of is there any benefit to stay on?

Speaker 2 (00:45:41):

I mean, the whole point of doing an operation is to get off the medication. So what’s the point of keeping someone on medication and doing a surgery?

Speaker 1 (00:45:50):

Got it. Okay. Another question. This is a younger male, 20 years old, he keeps needing to urinate in small amounts. Is this because of a prostate problem?

Speaker 2 (00:46:01):

Very good question. So the first thing that stands out in this is 20 years old. Usually 20 year olds do not have a big prostate, but there are other things that can mimic enlargement or constriction of that channel. So on 20 year olds, it can be a urethral stricture. So having trauma as a child like skateboarding or biking pelvis rams on top of the tube of the bicycle or skateboarding and they end up perineal getting some damage or an STD gonorrhea. What these things can cause scars and those things can cause constriction of the prostate of the urethra.

Speaker 2 (00:46:49):

Beyond that, it could be a bladder issue, so over activity of the bladder. So we like to call it pelvic floor dysfunction or neuromuscular pelvic floor dysfunction where this, there’s no coordination of the nerves and the muscles, the bladder is contracting, but at the same time, instead of the channel opening up, the channel constricts, so instead of being able to empty, you retain fluid. So that may be an issue prostatitis inflammation of the prostate because of either bacteria or just chronic non bacteria infections. And this is an overlap of where we see a lot of patients young who come in with pelvic pain. It could be their prostate, it could be an inguinal hernia, it could be a neuromuscular pelvic floor dysfunction. But typically it’s not a prostate enlargement issue. That patient should definitely get evaluated. And if I had to guess what the primary treatment would be, it would probably be some sort of physical therapy in the pelvis.

Speaker 1 (00:47:54):

So one thing that is something that I’ve learned, which is hernias can cause pelvic floor spasm as some other things we talked about. Even hip problems can cause pelvic floor spasm, but the spasm of the pelvic floor can make it feel like you need to urinate and either have frequency where you’re urinating a lot or this urgency to urinate, but there’s not much to urinate and then you fix the hernia and then the bladder issues go away. It’s not very common, but I’ve seen it in extreme cases. One lady I think was peeing 10 times at night and 40 times during the day, it was ridiculous. You fixed her hernia and she was like normal. That was the most extreme case that I remember.

Speaker 2 (00:48:38):

And the bladder can sometimes go into a hernia. So it’s not uncommon to see the bladder actually go into the hernia canal and get kind of stuck in there.

Speaker 1 (00:48:45):

True. And then yes, that’s very true. Very correct. Let’s see, there’s another interesting question, which was had to do with this kind of injury to the fassa navicularis. Is that the tip of the penis?

Speaker 2 (00:49:06):


Speaker 1 (00:49:07):

Okay. So this gentleman had TURP, the trans urethral resection of the prostate, basically what we call the roto-rooter had damage to his urethra at the tip of the penis because of the catheter that was used for the irrigation. And then I guess they need recons. It’s a question of whether or not they need reconstructive repair. What do you know about that? And what his urologist is able to pass a

Speaker 2 (00:49:35):

16 fr cytoscope

Speaker 1 (00:49:36):

Through. So they’re like, well, you don’t need to a right

Speaker 2 (00:49:39):

Any so urethral stricture, typically 50% of em are iatrogenic. They’re caused because of maybe having a catheter from a non urologic procedure. So like a spine operation or a general surgery operation just traumatic placement of a foreign body through the urethra can cause some scar tissues. So people have to be very careful, use lots of lubrication, have good technique, blow up the balloon in the appropriate place. But it’s not uncommon. I tell my residents all the time, what’s probably the most common complication outside of bleeding after a TURP, and it typically is urethral restricted disease. And the most common part is actually obicularis, which is the tip of the penis. And the second location is the bulbous urethra where kind of the urethra goes like this, and then it makes a little L and then goes into the prostate bladder. And the second part is that little angulation between the penile urethra and the prostate.

Speaker 2 (00:50:47):

And so a stricture, again, causes constriction. And typically the symptoms are decreased stream, so dribbling out or very high pressure flow coming out very thin stream or maybe a split stream. So if someone is not symptomatic, so if you’re not having any symptoms of the stricture, then you definitely don’t need it to get it fixed. If you have good flow, you’re not retaining fluid, you’re not having obstructive symptoms, getting up in the middle of the night and feeling like you’re not emptying, a little bit of narrowing should not be enough to warrant an operation. Certainly if you’re able to easily pass a 16 French cystoscope, which is the size of this camera, yeah, kind of like the size of this pen, probably smaller than that, I don’t think that would warrant an operation. And if someone had a fossa navicular restrictor that was tight enough to cause symptoms and it wouldn’t accommodate a cystoscope historically, it’s a difficult place to cut endoscopically because you need a fulcrum to be able to put the cystoscope and then use knife, an endoscopic knife to cut.

Speaker 2 (00:52:15):

So because it’s at the tip, you don’t really have a fulcrum. It’s easy to fall out and cause more damage. So these things actually are treated by dilation where you use a succession of sounds, we call ’em these instruments that passively just stretch. Yeah, stretch the urethra. But now some people are actually using what’s called a Urethroplasty using grafts. So the mucosa of the inside of the lining of the mouth, like a buccal mucosa graft. Sometimes they use the skin from the penis and then flip it on a pedicle to make a tubular eye segment to open up very kind of creative reconstructive methods. But those are usually hindered by reconstructive experts. This I definitely don’t think, pardon, the outcome is pretty good. The outcome is good, but you got to understand that this part of the penis is probably the most prone to recurrence of stricture because of it’s fixed in place. It’s kind of locked in between the corpora of the penis and it’s it’s got a lot of kind of fibrotic tissue. So it’s hard to mobilize it well, and it’s certainly at risk for recurrence. So that’s why I would advocate if someone needs to have that done they get it done by an expert.

Speaker 1 (00:53:49):

So these are all things that I learned, I learned so much every time I speak with you those of you that are watching you heard me say that I do share a lot of patients with Dr. Josephson, but often I just call him <laugh> that I have questions and he’s either in OR a meeting or something, always tries to respond to my calls. And it’s mostly just like, I have a patient here and I think this is what’s going on. What do you think? And we just had a recent patient, some really cool situation where she had a bulging in her abdomen on the side, and I’m like, that’s not a hernia. But I learned from you this thing called ptosis of the kidney where the kidney can move around and move up and down or rotate around his axis. I never knew such a thing existed until I heard it from you. I forget why there was some, we had another patient many, many years ago, and I’m like, that’s what it is. So I called you, I’m like, what do I do? I think this is what it is. And you saw her. And so we have these kind of cool,

Speaker 2 (00:54:54):

That was very cool. I have to admit, I was, after doing this for 20 years, every patient is exciting in a certain way. But that was really exciting because you don’t see that too often. And you can practice some old school, very old traditional physical exam to diagnose the problem where you actually feel the kidney move as the patient moves. And it’s kind of like some, it’s like a Dr. House kind of scenario. And yeah, I definitely got a kick out of that case.

Speaker 1 (00:55:30):

We had another patient too. She was allergic to nickel, nickel on the earrings, you know, can’t wear certain jewelry because of it. And then she had this diagnosis, which I’m not even sure if she actually had this diagnosis of pelvic congestion syndrome, congestion

Speaker 2 (00:55:48):


Speaker 1 (00:55:50):

So we had to operate, she had these coils put in to get rid of the vessels, but the coils had nickel in it. So she had this huge, massive burn and inflammation in it was kind of an interesting operation because she came to me because of the pelvic pain, but then this was really her problem. And so from that, I learned from you all the different kidney reasons or renal reasons, urologic reasons why you can get pelvic congestion syndrome. So for those of you, we’ll discuss this in the future, but there are different reasons for pelvic chronic pelvic pain, especially in women. And one of the rare ones is called pelvic congestion syndrome, where there’s like it’s varicose veins of your pelvis, a lot of vein pooling of blood. And what you do is the same way you do for varicose veins, the leg, you strip the vein. So you strip the vein. But what’s interesting, and which I look for sometimes because I like that whole Dr. House like feeling is look to see why they have it. Sometimes they have it because they just have bad veins, but sometimes they have it because there’s a blockage by the kidney called the Nutcracker syndrome, the renal artery nutcracker syndrome. And I’ve seen some patients with Nutcracker syndrome since then. It’s just really cool that there’s all these urologic disorders that

Speaker 2 (00:57:16):

There’s a lot of overlap. And that’s kind of cool about the way we practice sometimes we get a gynecologist in the mix and an orthopedic surgeon, and it’s a true multidisciplinary approach, which I truly enjoy. You were talking about pelvic congestion syndrome in men, a lot of guys you see have some scrotal pain or inguinal pain. And one of the most common things that I see is probably varicocele, and I’m sure you’ve talked about it with Paul in the past, but varicocele can also be related to congestion from where they enter in the renal vein. So if someone has a very prominent varicocele, especially on the right side, because right sided barica seals are not as common as the left side of varicocele, and it’s because of the drainage. So the left renal vein crossing, left gonadal vein goes into the left renal vein, the right gonadal vein should go into the vena cava. And if you have a very prominent right sided varicocele, you need to mention someone does not have a mass. Yeah. So I’ve picked up probably three kidney cancers because of a varicocele presentation. And again, somewhat old school medicine listening and taking a history and doing an exam and kind of doing the hot Dr. House

Speaker 1 (00:58:39):

Kind of, I love it. That’s what I love. I love this because it’s a lot of discussion and back and forth, and I love doing the same thing with my patients. Just the history. The story is so important and it kind of gives you so much insight. One thing we didn’t discuss, and we have one more minute, is to quickly review the fact that some people may have inguinal hernias, groin hernias that they never knew they had, and then they have prostate surgery and that exposes or exposes an inguinal hernia that they didn’t have before. So they have a great prostate surgery. And then after surgery, what’s this bulge <laugh>, right. And can you just discuss that really quickly? I don’t want to take

Speaker 2 (00:59:24):

Mean, this was a very big thing when we used to do open surgery for prostate cancer, especially undiagnosed inguinal hernias and then the UR operation. And then, I don’t know, something like 20% of people after open surgery would now present with a symptomatic inguinal hernia. Hernia, yeah. It’s not as common now. So if the patient complains about a hernia or has some bulging preoperatively, I pick it up on some imaging because of staging. I get a CAT scan to make sure the cancer has not escaped or an MRI for staging purposes. And I see the hernia and they’re symptomatic. I’ll talk to them about fixing it at the time of their prostate operation because I want to make sure they recognize the risks and benefits and the use of Mesh. We don’t want to typically use Mesh when there is urine, probably potentially leaking out and infecting Mesh.

Speaker 2 (01:00:19):

So if we kind of cover all the bases, I think it’s a good idea to do it ahead of time. But if it’s a small hernia, they’re asymptomatic, and at the time of surgery it does not look like it’s going to be a big issue postoperatively. I typically leave it alone because a lot of times they do not get bothered by it. I will say though, I have stopped, it’s not an inguinal hernia, but an umbilical hernia and one I learned this from you is I modified the way we put in our ports. So rather than going right through the belly button and going up and down on my incision, kind of make a semicircular kind of incision or to the laterally, but I don’t take my specimen out of that incision because that’s the weakest part. So I typically make a small incision like a little baby fan and steel. Yeah. And my hernia rates as a result of that have,

Speaker 1 (01:01:11):

Yeah. Yeah. Both colorectal and prostate surgery they have learned to try not to take the specimen out of the belly button, but to take it out through a C-section scar because they hernia rate is much lower from that. So I’m very happy that you guys are that. Okay. Dr. Josephson, thank you so much. This has been an amazing hour. I don’t want to take up too much more of your time.

Speaker 2 (01:01:35):

I had a blast. Thanks for inviting me and thank you

Speaker 1 (01:01:37):

So much. Helpful. Thank you. So that’s the end of Free Talk today. I will post a copy of the link to the YouTube final YouTube video of this on all my different social media outlets. And I will see you next week on Tuesday for another Hernia Talk live. Thank you, Dr. Josephson. Hope you’re all welcome. Oh good.

Speaker 2 (01:02:02):

Thank you.

Speaker 1 (01:02:02):

Bye-bye. Bye.