Office Procedures: Office procedures such as vasectomy, cystoscopy, and transrectal ultrasound and prostate biopsy (TRUS and biopsy) are common procedures at Denton Urology. This page will help assist you in preparing for them, and knowing what to expect.
Vasectomy | Cystoscopy - Male | Cystoscopy - Female | TRUS/Biopsy
Click link above to go to information about each procedure.
Vasectomy:
Vasectomy is a common procedure for permanent sterilization in men. It is a procedure done in the office under local anesthesia. Typically men who desire this procedure will make an appointment when they can take off from work a couple of days afterwards (commonly done on a Friday.) On the day of the procedure, the patient is asked to eat a normal breakfast (there's no need for an empty stomach, and having something on board prevents "low blood sugar".) We can no longer prescribe or provide you with Valium or any other sedatives to be used during the procedure due to Texas State Law prohibiting the administration of "Conscious Sedation" in our office with our level of medical licensure (this is a recent change -- sorry for any inconvenience). You will be asked to shave the upper part of your scrotum (the part nearest the penis) and the lower pubic (lower groin area) hair prior to arriving. You will speak with the doctor (the "consult") first, and then will immediately have the procedure if you desire it.
The consult visit lasts between 5-10 minutes, and wives/significant others are encouraged to come. The process of vasectomy will be discussed, and benefits and potential complications will be discussed as well. If you have gone over this page, the consult will be directed at any questions that this page does not cover. Complications (potential) from vasectomy include bleeding, infection, injury to other structures such as nerves, arteries, or veins, and regrowth of the vas deferens resulting in regaining fertility. Swelling at the site of the surgery or down around the testicle (epididymis) can occur immediately or in a delayed fashion--say after 6-24 months of being "normal." This last phenomenon is likely due to a combination of congestion (sperm having nowhere to go) and to autoimmunity (where antibodies are attacking sperm as if they are "invaders".) All complications are usually minor and respond to taking it easy a few days and perhaps anti-inflammatories. Antibiotics may be necessary for infection if that were to occur.
A vasectomy is a procedure designed to interrupt sperm flow, and should not affect sexual function, sexual desire, erectile function, or anything else other than fertility (the ability to impregnate a partner) once the swelling has subsided, and recovery is over. Sex is usually delayed for about a week after vasectomy. The first 48 hours are "couch potato" days relegated to laying around with ice packs (an instruction sheet will be given at your visit) and taking it easy. No heavy lifting, strenuous activity, or sexual activity is recommended for about a week after the procedure. You may begin showering the evening of your procedure, but tub baths, or swimming/hot tubs should not be used for about 48-72 hours afterwards. You will be asked to bring specimens (semen) at 6 and 8 weeks after the procedure to make sure there is no sperm in the specimen. Prior to that, another form of contraception should be used. Remember, a vasectomy DOES NOT protect you from sexually transmitted diseases (STDs). Also remember, a vasectomy should be considered a permanent solution as vasectomy reversals (not done at Denton Urology) are not always successful, are quite expensive, and are often not covered by insurance.
The procedure itself lasts about 15 minutes and starts with a surgical scrub of betadine on the scrotum. First one side will be worked on and then the other. The vas deferens will be grasped between the doctor's thumb and forefinger, and the skin overlying will be infiltrated with lidocaine ("numbing") solution via a small needle. Once the skin is numb, a small (1 cm) incision is made and dissection is done until the vas deferens can be reached with an instrument. A loop of vas is pulled up (the 'tugging') and a section is removed. The ends are then cauterized with a heat-producing cautery instrument, and each end is clipped with a titanium clip. The the two ends are replaced, now disconnected and separated in space. The skin is then closed with an absorbable suture--no sutures will ever need to be removed. The other side is done in a like fashion. After completion, a gauze dressing will be placed, and the patient will be ready to depart. Pain medication will be called in or a prescription given, and the instructions for recovery are to be followed.
Cystoscopy - Male
Cystoscopy ("cysto") for men is done with a flexible fiber optic telescope. The scope is about the same diameter as a catheter (or if you've never had a catheter, it is roughly the same diameter as a pencil). By necessity, the scope is quite long as the male urethra is about 25-27 centimeters (about 10 inches). The indications for cystoscopy include the evaluation of blood in the urine (hematuria), evaluation for strictures (scar tissue in the urethra), removal of stents, and various other reasons, including evaluation of prostate anatomy before consideration of prostate surgery.
Flexible cystoscopy is done in the office with local anesthesia (lidocaine gel). We can no longer prescribe or provide you with Valium or any other sedatives to be used during the procedure due to Texas State Law prohibiting the administration of "Conscious Sedation" in our office with our level of medical licensure (this is a recent change -- sorry for any inconvenience). The patient need not refrain from eating the day of the procedure, and in fact, we recommend eating a hearty breakfast that day. Upon arrival to the office, a urine for analysis or testing may be obtained (come with a full bladder), and then the patient will be escorted to the procedure room, and be asked to undress from the waist down. The procedure will then follow.
First of all, a urinary cytology may be obtained if indicated (this is a test of the urinary bladder to test for cancerous cells that may not be visible to the naked eye.) This is done by the doctor who first cleanses the penis and surrounding area with surgical scrub soap, and then inserts a rubber or latex catheter. This catheter allows a "wash" of the bladder with about 2 ounces of sterile saline that is then retrieved and sent to the lab for cytologic evaluation. The results are usually back in about a week. Immediately following the cytology (bladder wash) the cystoscopy will ensue. The area will already be prepped, and the doctor will instill the lidocaine gel local. This is kept in place with a small clamp while the remainder of the equipment is set up.
The flexible cystoscope is connected to water irrigant, and a light source. The doctor will then view the inside of your urethra and bladder with his eye (we have no camera equipment.) The urethra is first entered and inspected, and then the bladder is entered. The doctor will survey all areas of the bladder and inspect the urine coming out of the ureteral openings (where urine from the kidneys enters the bladder). The entire procedure takes less than 15 minutes, and more often about 10. Although uncomfortable, most men do not find cystoscopy with the flexible scope to be particularly painful, though pain tolerance is widely variable among men.
The findings will be discussed with the patient immediately. If nothing is seen, the patient will be called with his cytology results in a week or so, if a cytology was indicated and done. After the procedure, the patient will still have a full bladder as the irrigant is not able to be withdrawn through the flexible scope, and the patient will be asked to get dressed/cleaned up and to urinate. He will then be able to depart the office after being given a short course of antibiotic samples to make sure no infection develops. Anti-spasmodics can be given on a case-by-case basis for those who may need it.
Patients having cystoscopy can expect to have some blood in their urine for a few days or even up to a week or so, and may have a slight bloody urethral discharge. This is all normal and should improve. Some patients experience spasms, or a frequent/urgent need to void. All this is normal and should also go away soon. Serious infections or other complications are exceedingly rare after office cystoscopy, although very infrequently infections and bleeding can be serious. Other potential dangers such as development of scar tissue are theoretically possible, but highly unlikely after a simple office cysto.
If something was detected on the cystoscopy, this will be discussed with the patient, and further follow-up treatment outlined right away. If the cytology returns suspicious after a week or so (the lab takes a while to process these specimens) then further testing may be necessary in the operating room.
Cystoscopy - Female
Cystoscopy in women is done for various reasons. Blood in the urine, irritative voiding symptoms, certain other conditions such as frequent and/or urgent voiding, and incontinence are just a few of the reasons cystoscopy may be needed. Cystoscopy in the female is somewhat easier than that for men since the urethra in women is substantially shorter (5 cm vs. 27 cm). Cystoscopy is done in the office with local anesthesia (lidocaine gel). We can no longer prescribe or provide you with Valium or any other sedatives to be used during the procedure due to Texas State Law prohibiting the administration of "Conscious Sedation" in our office with our level of medical licensure (this is a recent change -- sorry for any inconvenience). The patient need not refrain from eating the day of the procedure, and in fact, we recommend eating a hearty breakfast that day. Upon arrival to the office, the patient may be asked to give a voided urine specimen (arrive with a full bladder, please) and then will be escorted to the procedure room, and be asked to undress from the waist down. The nurse will then assist the patient in preparing. The patient will lay flat with legs up in stirrups, and the nurse will prep the vaginal/urethral area with a surgical scrub soap. Drapes will be placed to ensure sterility of the area (to avoid infection) and a cotton tipped swab coated with 4% lidocaine gel will be instilled in the urethra to provide local anesthesia to the area. After all the equipment is prepared, the nurse will call in the doctor for the office cysto.
First of all, a urinary cytology may be obtained if indicated (this is a test of the urinary bladder to test for cancerous cells that may not be visible to the naked eye.) This is done by the doctor who inserts a rubber or latex catheter into the bladder through the urethra after removing the numbing swab. This catheter allows a "wash" of the bladder with about 2 ounces of sterile saline that is then retrieved and sent to the lab for cytologic evaluation. The results are usually back in about a week. Immediately following the cytology (bladder wash) the cystoscopy will proceed.
The doctor will insert the "sheath" of the cystoscope, which is the last instrument that will go into your urethra. The sheath is a rigid steel tube especially designed to be inserted in the urethra. All of the other instruments will go through this first instrument. The doctor will then look with a narrow angle and a wide angle lens, and in this way will be able to visualize your entire bladder lining including the ureteral openings (where the urine comes in from the kidneys) and the urethra. The bladder will be emptied through the rigid cystoscope prior to completion of the procedure. The entire procedure typically lasts 10 minutes or so.
If something was detected on the cystoscopy, this will be discussed with the patient, and further follow-up treatment outlined right away. If the cytology returns suspicious after a week or so (the lab takes a while to process these specimens) then further testing may be necessary in the operating room.
Occasionally, a "urethral dilation" may be done in a female at the same setting as cystoscopy. This is done to enlarge the urethral opening to aid voiding. This is rarely necessary, but helpful in some who really require it.
The patient will then be able to depart the office after being given a short course of antibiotic samples to make sure no infection develops. Anti-spasmodics can be given on a case-by-case basis for those who may need it.
Patients having cystoscopy can expect to have some blood in their urine for a few days or even up to a week or so, and may have a slight bloody urethral discharge. This is all normal and should improve rapidly. Some patients experience spasms, or a frequent/urgent need to void. All this is normal and should also go away soon. Serious infections or other complications are exceedingly rare after office cystoscopy, although very infrequently infections and bleeding can be serious. Other potential dangers such as development of scar tissue are theoretically possible, but highly unlikely after a simple office cysto.
TRUS/Prostate Biopsy
(Transrectal Ultrasound)Transrectal ultrasound and prostate biopsies are most often done to evaluate an elevated PSA (Prostate Specific Antigen) level and/or an abnormal DRE (digital rectal examination.) This is most commonly done to rule out prostate cancer, but occasionally TRUS without biopsy can be done to evaluate benign prostatic diseases.
At home prior to a TRUS/Biopsy, the patient may be asked to use a Fleet's Enema prep to cleanse the rectum of stool. The day of the procedure, the patient will arrive and be asked to void his bladder, and then be escorted to the procedure room for the TRUS. Denton Urology uses a Technician (Jason) who operates our Ultrasound machine, and provides the service of performing the preliminary sonogram, and will image the bladder and prostate and make notations about the size and character of the prostate in preparation for the biopsy, which the doctor himself performs with the aid of the tech. The technician initially will describe the procedure from his standpoint and prepare the patient (position the patient, etc.) and begin the procedure, and as mentioned, the doctor will then be called for the actual biopsy part of the procedure.
The procedure consists of the insertion of a narrow cylindrical ultrasound probe into the rectum. This probe allows the technician to visualize the prostate and seminal vesicles on a monitor (TV screen). The ultrasonographic characteristics of the prostate will be noted by the technician, and images will be obtained. After the survey looking for abnormalities and for the size of the prostate is done, the doctor will be called into the room for the biopsies if these are to be done. If all that was ordered was the TRUS, then the results will be transmitted to the doctor.
Both Dr. Casey and Dr. Admire provide a local "prostate block" to deaden the prostate prior to biopsies. This is done with 1% lidocaine injected into the tissues surrounding the prostate with a very fine needle. About 10 mL (1/3 ounce) of numbing medicine is injected into 3 different areas of the periprostatic (surrounding the prostate) tissue. The technician will then position the probe such that the doctor can obtain biopsies from several locations of the prostate. Anywhere from 6 to 12 biopsies may be obtained depending on prostate size, abnormalities, and other factors. The biopsies are obtained with a biopsy needle loaded into a specially designed spring loaded biopsy gun. The needle will be visualized on the ultrasound monitor, and a button on the biopsy gun allows a 15-22 mm fine strip of prostate tissue to be obtained with the gun. There is a loud snapping noise as the gun fires. This is NOT the patient's body making the noise, but the spring within the gun. The tissue thus obtained is then retrieved and saved. Each biopsy is obtained from a different area of the prostate so that all areas of the prostate gland are sampled. This is done due to the fact that most prostate cancer looks no different than normal tissue sonographically, and in fact sonographically "abnormal" areas are only cancerous about 35% of the time. After all biopsies are obtained, and sent to the lab, the probe will be removed, and the patient allowed to clean up and dress.
During the procedure, some discomfort may be noted at the time the local is instilled, and at the time of the biopsies. The discomfort of a prostate biopsy is usually fleeting and minor, though different men have different pain tolerances. Although not usually needed, and not commonly prescribed, we formerly would occasionally prescribe a sedative for the particularly anxious patient having a TRUS/biopsy. We can no longer prescribe or provide patients with Valium or any other sedatives to be used during the procedure due to Texas State Law prohibiting the administration of "Conscious Sedation" in our office with our level of medical licensure (this is a recent change -- sorry for any inconvenience).
After the biopsy, men can expect some blood in their urine, stool, or semen for up to 2-3 weeks, although most men have it only a few days. It is not abnormal, though for it to be there several weeks later. Antibiotics are provided after the biopsy to prevent infection, and with our prep, infections are rare.
Severe bleeding or serious infection are the biggest potential complications, but these are exceedingly rare, but can occur. High fever (above 102.5 F or 37.5 C) should be reported to the doctor or office.
The results of the prostate biopsy will return to the office anywhere from 3-10 days after the procedure, and the patient will be called promptly to be notified of the results. Remember that a negative biopsy does not absolutely rule out prostate cancer as a small tumor may be present but simply not be "hit" with a biopsy so some men may require more than one trip for a biopsy. The timing of any repeat biopsy is individualized by the doctor and by a specific patient's characteristics. Overall, TRUS/Biopsy, though not particularly pleasant, is hopefully not to be feared.
Remember, if you have an emergency, the ER is always available. True medical emergencies should be reported by calling 911. If you need to speak with the on-call physician for a surgically urgent question, please dial (940) 387-2241. Please note the Email Rules regarding such calls.Dr. Casey can be reached for less urgent questions via Medem's Secure Messaging/Online Consultation (link on CV Page)
This page was authored by Dr. David L. Casey. It reflects his practices/experiences with these procedures, and Dr. Admire's instructions and/or precautions may be somewhat different.Back to the TOP
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This site created 4/22/2002
Site updated 11/20/2007
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