Observant Jews are bound to recite many blessings – before eating bread, wine, other beverages and foods, upon waking up in the morning and going to sleep at night, when seeing a rainbow or smelling fragrant spices, after hearing thunder and many other situations.
But few people know that religious Jews also say a blessing after using the toilet. A bathroom blessing? Strange! Not really.
Blessed are You, Lord our God, King of the universe, who fashioned man with wisdom, and created within him many openings and many cavities. It is obvious and known before Your throne of glory, that if but one of them were to be ruptured, or but one of them were to be blocked, it would be impossible to survive and to stand before You. Blessed are You, God, who heals all flesh and acts wondrously
Urologists and proctologists who deal with body parts below the belt know that functioning of these bodily systems is vital, and when they break down, life is in danger. Their working in good order should not be taken for granted.
A two-hour series of free lectures on urology was recently held at Jerusalem’s Sha’are Zedek Medical Center – the 14th in its Shishi Bari (Healthy Friday) talks open to the general public. So many people – mostly middle-aged and elderly men and women – interested in the urinary problems packed the Hedi Steinberg Auditorium that some sat on the steps.
Prof. Jonathan Halevy, the growing medical center’s director-general, greeted the audience by saying that Shaare Zedek tries to educate the public about preventing and coping with disease. Urology is especially touchy, as many people are too embarrassed to talk about such problems, even with their family doctors.
The specialty of urology is constantly advancing, as many problems that were once treated by open surgery can now be performed making small incisions and using a laparoscope. As much of this change has been due to improved technology, it will become increasingly important for urologists to learn new skills and gain experience in using the surgical microscope.
Prof. Boris Chertin, a pediatric urologist who is how head of the hospital’s urology departments for adults and for children, said Shaare Zedek is the only hospital in Israel with separate departments for babies, children and youths up to the age of 18 in addition to one for adults, where advanced robot surgery is available for those who need it. Not only are congenital and other problems treated in youngsters but also bedwetting.
Among the various conditions treated in the department are benign and malignant tumors, as well as fluid-filled cysts, kidney stones, infections, problems in control of urination. Specialists working with Prof. Ofer Shenfeld also treat sexual function disorders.
Urination is a complex process that involves not only the kidneys, bladder, the ureters and the urethra but also the brain. The firing of neurons causes the wall of the bladder to contract; as a result, a sudden, sharp rise in intravesical pressure occurs. Voiding begins when a voluntary signal is sent from the brain to begin urination, and it continues until the bladder is empty. At a certain level of activity, the conscious urge to void becomes difficult to ignore. When the external urinary sphincter is relaxed, urine is released from the urinary bladder as pressure forces urine to flow out of the urethra.
Dr. Ilan Kafka, head of the endourology service and robotic surgery who moved to Israel from Mexico, explained that the field refers to a specific specialty in which small internal endoscopes and instrumentation are used to see into the urinary tract and perform surgery. Although urology is technically a surgical specialty, a urologist has to know about related fields including internal medicine, pediatrics and gynecology because of the wide variety of clinical problems that the urologist deals with.
Endourology – also known as minimally invasive urologic or laparoscopic surgery – is different than traditional urology in that all procedures are done internally, without any large incisions.
Kidney stones, which occur in 5% to 15% of the population, are very common in countries with “hard” water (with high mineral content, as in Israel) and in people who don’t drink enough water. Even eating red meat and fish can cause the formation of stones in some patients. Avoid consuming too much table salt; coffee, chocolate and peanuts may increase the tendency to develop kidney stones as well.
Years ago, stones were pulverized by putting people in tubs of water and using ultrasound shock waves. Today, the tubs are hardly used, as the shock waves can be passed directly into the kidneys or other parts of the urological system without the use of water. If stones are small enough and don’t cause much pain, they can be flushed out of the body without treatment. But if they are larger, they can cause a lot of problems until they are removed.
Stones are usually composed of salts. Kafka noted that getting too little calcium in your diet can cause oxalate levels to rise and cause kidney stones. To prevent this, make sure to take in an amount of calcium, in the form of dairy products, lentils, sardines or vegetables, appropriate to your age. Ideally, get calcium from foods, since some studies have linked taking calcium supplements to kidney stones themselves. Drinking a lot of water, even if it is rich in minerals, also helps prevent stones.
Genetics and certain medications, as well as drinking vodka and certain energy drinks, may also have a role in the formation of kidney stones, he said. All stones are x-rayed and examined after their removal from the body.
Stones may be removed out or fragmented using tiny instruments inserted into the body through such areas the urethra, bladder and ureter. Thin, flexible instruments including lasers, graspers, miniature stone retrieval baskets, special scalpels and cautery can be used to perform surgery without creating any incisions at all. Percutaneous nephrolithotripsy involving the making of a small tunnel through the hip, is also used to vacuum out stones over two centimeters wide. Nearly all endoscopic procedures can be done on an outpatient basis.
In addition to treatment, doctors can help determine what is causing the kidney stones and help identify ways to prevent further stones from forming.
Dr. Ala Eddin Natsheh heads the hospital’s outpatient urology clinic, which deals with many cases of patients with the inability to control urination; about a fifth to a third of them have to be hospitalized as inpatients to get the necessary treatment for being unable to urinate normally or being unable to control urination.
The bladder, where urine is stored until eliminated, becomes smaller as people age. Lack of normal urinary control commonly results from benign prostate hyperplasia (an enlarged but not cancerous prostate) is a common condition as men get older and can cause many uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder. It can also cause bladder, urinary tract or kidney problems.
In women, a weakened pelvic floor is also a cause of inadequate urinary control. Laughing, coughing, sneezing, picking up a heavy object or even a child can cause stress urinary incontinence in women and in men. Obesity and smoking are both risk factors for urinary incontinence.
Various treatments are also available for urinary incontinence; if all else fails, one can wear a discreet bag for the collection of urine or adult diapers. “Don’t be ashamed, Natsheh concluded. The staff are always ready to help you.”
Among the treatments for difficulty urinating are taking alpha blocker drugs (which may cause side effects), injecting Botox into the bladder every few months, the insertion of catheters (even disposables, inserted by the patient daily) or stents, and surgery (including the use of robots).
Difficulty urinating can be a result of anatomical abnormalities within the genitourinary tract. In men, enlargement of the prostate gland, due most commonly to benign prostatic hyperplasia (BPH) and less commonly to prostate cancer, can cause difficulty urinating. In both men and women, difficulty urinating can result from neurological or muscular conditions that affect function of the bladder. When it becomes difficult to urinate, other symptoms such as dribbling (leaking or mild incontinence) and a weak urine stream may also be present. Certain medications can also cause problems with urination. Scar tissue from surgery or trauma can also cause problems with the flow of urine. Infections of the urinary tract or of the nervous system can also cause urine retention.
Dr. Dmitry Koulikov, an expert in uro-oncology and robotic surgery, explained that prostate cancer is a disease of cells that grow fast and die slowly. Malignant cells can metastasize (spread) through blood vessels or lymph glands. Fortunately, prostate cancer usually grows slowly, but it can kill. In Israel alone, there are more than 2,200 new cases in men each year (or 84 per 100,000). Nearly 450 die of it in an average year.
The symptoms include frequent urination; painful urination; a weak or interrupted urine flow or the need to strain to empty the bladder; the urge to urinate frequently at night; blood in the urine; blood in the seminal fluid; new onset of erectile dysfunction.
As some of these symptoms are caused only by BPH, the urologist must do a careful diagnosis and patients should not ignore symptoms. Among the methods used is a rectal examination, tests for prostate-specific antigens (PSA), tests for biomarkers and advanced scanning.
PSA testing, said Koulikov, started in the 1980s. However, the results are often misleading. “One can have prostate cancer – about 15% of cases – even with a low PSA count. Inflammation, trauma to the prostate, herbal or hormonal supplements or even a rectal exam can trigger a high PSA count. Having a large but healthy prostate can cause a high PSA level. There is no PSA level at which there can’t be prostate cancer.”
PSA counts rise as one gets older. Other influences are race and family history. Even a rectal exam (with a finger) does not result in a diagnosis every time. MRI scans and ultrasound can raise the accuracy of diagnosis, yet about 40% of cancers cannot be detected with ultrasound.
“We take everything into account before we decide about performing a biopsy using a local anesthetic,” said Koulikof.
A cancerous prostate can be removed in an operation, during which the surgeon tries not to hurt the nerves affecting sexual function and urination.
Fortunately, the Da Vinci Surgical System – a robotic surgical system made by the US company Intuitive Surgical and approved by the US Food and Drug Administration, is available at Shaare Zedek and numerous hospitals around the world. It is expensive, each robot costing about $2 million. The company says it chose the name because the artist and inventor, Leonardo da Vinci, conducted a study of human anatomy that eventually led to the design of the first known robot in history.
Although some patients tell Koulikof, “OK, turn on your robot and let it do the surgery,” the computerized device does not work by itself. “It is not autonomous, but controlled by a surgeon console who is assisted by several team members.” The system is commonly used not only for prostatectomies, but also increasingly for cardiac valve repair and gynecologic surgical procedures.
The console controls four interactive robotic arms, three of which are for tools that hold objects and can also act as scalpels, scissors or graspers. The instruments’ jointed-wrist design exceeds the natural range of motion of the human hand; motion scaling and tremor reduction further interpret and refine the surgeon’s hand movements.
By providing surgeons with superior visualization, enhanced skills, greater precision and ergonomic comfort, the da Vinci robot makes it possible for more surgeons to perform minimally invasive procedures involving complex dissection or reconstruction. For the patient, a da Vinci procedure can offer all the potential benefits of a minimally invasive procedure, including less pain, less blood loss and less need for blood transfusions, said Koulikof, and patients usually need shorter hospital stays, recover more quickly and return faster to their normal daily activities. “It is now clear that robotic prostatectomy is the winner, and that it is the standard of care.”
Taking care of urinary problems – and preventing them – will surely be a blessing.