surgical management of the “large” prostate: the robotic
TRANSCRIPT
NYU Langone Health Urology Case of the Month October 2020Surgical
Management of the “Large” Prostate: The Robotic Simple
Prostatectomy
Department of Urology Case of the Month
CASE PRESENTATION A 66-year-old man presented with acute urinary retention. He first sought medical care for an enlarged prostate about 10 years ago. At that time, he was experiencing a slow urinary stream and was started on an alpha blocker and a 5-alpha reductase inhibitor. He stopped taking the 5-alpha reductase inhibitor because of unwanted effects on his libido and mild breast tenderness. A year ago, he had an International Prostate Symptom Score (IPSS) of 24 and a Quality of Life (Qol) score of 3 (“mixed”). His lower urinary tract symptoms (LUTS) had progressed steadily over the years, but he became more concerned about 3 months ago when he started to have urinary incontinence. In addition to urgency incontinence, he felt an increasing pelvic pressure and thought his abdomen was more distended. He began sitting to void and was increasingly bothered by nocturia (3 times/night).
The patient’s past urologic history also included an elevated PSA, resulting in 2 negative prostate biopsies. The more recent biopsy was done 2 years earlier in conjunction with a prostate MRI (Figure 1). Although the MRI showed no lesion suspicious for prostate cancer, it did show benign prostatic hypertrophy (BPH) with a gland estimated to be 193 grams and a sizable median lobe.
Figure 1. MRI showing BPH, done before last prostate needle biopsy about 2 years prior to presentation. The prostate weight was 193 grams. There is thickening of the bladder wall.
The patient’s past medical history was notable only for Parkinson’s disease, which was mild and well controlled with medication. His past surgical history included appendectomy at age 16.
DC 12/7/2020
CASE OF THE MONTH
PHYSICAL EXAM AND EVALUATION AT NYU LANGONE HEALTH The patient was a well-developed man who appeared healthy. He had flat facial features and a mild shuffling gait, but he was otherwise neurologically intact. Digital rectal exam revealed normal tone and an enlarged but smooth prostate. Abdominal exam was unremarkable. Testicles were non- tender and no inguinal hernia was found.
Results of an attempted noninvasive uroflow were uninterpretable because of a low voided volume. The bladder scan residual at that time showed 850 mL.
Serum creatinine was noted to be elevated at 2.2 mg/dL from a baseline of 1.0 mg/dL a year earlier.
Renal ultrasound showed mild bilateral hydronephrosis, an enlarged prostate, and a thickened bladder.
PSA was 5.7 ng/dL (PSA was 6.2 ng/dL in 2018, just prior to MRI and subsequent biopsy).
Urodynamics showed a large bladder capacity (Figure 2) and a high amplitude terminal involuntary detrusor contraction with a small leak. On second fill, the patient was able to mount a high- pressure detrusor contraction (maximum detrusor pressure: 139 cm H2O) with poor flow.
IDC Void
MANAGEMENT The patient was acutely managed with clean intermittent catheterization but desired definitive management. He was counseled on the potential therapeutic options and elected to proceed with a robotic benign simple prostatectomy. This was done with a da Vinci Xi robot via a transvesical approach. An excellent enucleation plane was developed and the prostatic adenoma was removed in 2 large parts (Figures 3 and 4). Estimated blood loss was 100 mL. The morning after surgery, the patient was discharged home with a catheter for gravity drainage.
Figure 2. Pressure flow study showing a large bladder capacity. The patient’s involuntary detrusor contraction resulted in a small amount of leakage. On second fill, he mounted a detrusor contraction after being given permission to void with little to no urine flow. Fluoroscopic images (not shown) show little to no funneling of the bladder neck, consistent with obstruction from the prostate.
DC 12/7/2020
CASE OF THE MONTH
Figure 4b. Intraoperative photos showing: (Left) Transverse bladder incision. With this approach, the retropubic space is left intact. If the surgeon elects to utilize an inverted “U”, it can minimize the need for holding sutures thereby keeping the leaflet out fo the surgical field. (Right) After successful enucleation, the bladder was “re-trigonalized” by pulling the trigone down the cut urethral edge. This may aid in preventing circumferential bladder neck contracture, aid in hemostasis, and aid in the ease of urethral catheterization.
Figure 3. Port placement of the transvesical robotic (da Vinci Xi) simple prostatectomy. Two assistant ports allowed for retraction and suction to be performed simultaneously.
At his most recent 3-month visit, the patient remained elated with his urination. His IPSS was 4 and his Qol was 0 (“delighted”). He denied any leakage of urine and had been able to achieve and maintain erections sufficient for penetrative intercourse. His uroflow showed a voided volume of 450 mL/sec, a maximum flow rate of 32 mL/sec, and an average flow rate of 20 mL/sec, with a post-void residual of 0 mL. Follow-up ultrasound showed complete resolution of his hydronephrosis. His serum creatinine level was 0.8 mg/dL.
COMMENT This case brings up some of the issues involved in the management of the “large” prostate. It is well established that BPH with LUTS and benign prostatic obstruction (BPO) are common problems that urologists in the United States are frequently called on to manage. What is unique in this case is the enormous size of the patient’s prostate. This is an important consideration for
Figure 4a. Gross pathology of suprapubic prostatectomy specimen, microscopic examination (not shown) consistent with BPH .
DC 12/7/2020
CASE OF THE MONTH
urologic surgeons, because data suggest that we may be seeing a “stage migration” toward the large prostate. An example of this migration is the nearly 25% increase in Emergency Department visits for urinary retention attributable to BPH in a population of California men between 2007 and 2010.1 After the number of transurethral resections of prostates (TURPs) peaked in the late 1980s, there was a reduction that continued into the early 1990s. Around this time, the use of medical management significantly increased, as more pharmacologic agents became available, and guidelines encouraged a stepwise approach emphasizing medical management.2 Increasing medical comorbidities and population demographics (i.e., baby boomers) have also been suggested as reasons for this shift to an increased number of large prostates.
The benign prostatectomy is in no way new or novel, but has been considered to be the gold standard for managing the large prostate. In fact, it was first described in 1900 by Peter Freyer. Although the technique of open prostatectomy has been modified, it has continued to have significant morbidity, long hospitalization stays, and a significant transfusion rate.3
So, what are the viable surgical alternatives to the open simple prostatectomy? Laser enucleation was described in the 1990s. And since that time, some have touted the endoscopic technique of enucleating the prostate as the ideal way to surgically manage BPH, even in the setting of the large prostate, as some considered the technique to be “size independent.”4 However, historically this technique has had slow uptake and very low utilization in the United States.5 Undoubtedly, various factors contribute to the use of surgical tools and techniques, but one reason often cited for the low uptake of laser enucleation is the steep learning curve.6
On the other hand, access, comfort, and advancements with the robotic platform have led to the tremendous growth of robotics in the field of urology. Urologic surgeons have been eager to use the robots for a large array of indications. The robotic approach to benign prostatectomy may improve surgical outcomes for men with very large glands and significantly reduce morbidity. Sotelo et al. first published a description of robot-assisted simple prostatectomy in 2008.7 Although various approaches and techniques have subsequently been developed and described, overall the robotic simple prostatectomy shows excellent functional outcomes equal to those of open simple prostatectomy. The advantage of the minimally invasive robotic approach is unequivocally the reduction of blood loss, lower transfusion rates, and shorter hospital length of stay. Data suggest that these advantages come with only a marginal, often considered inconsequential, increase in short-term hospital costs. Even though the robotic approach may not be accessible to all surgeons, it has been established that its learning curve is substantially shorter than that of laser enucleation.8
The robotic benign prostatectomy offers a very effective treatment for the large prostate. Our patient did not have concomitant conditions, but inguinal hernia, bladder stones, and bladder diverticulum are all more common in these advanced cases. The robotic approach allows these conditions to be addressed easily. We continue to improve the technique, and new and better tools further minimize morbidity and improve outcomes here at NYU Langone. Although experts are needed to carry out robotic benign prostatectomy safely and efficiently, this procedure can be successfully implemented in a center with an established and strong robotic program.
Over many years of medical management, our patient had unfortunately experienced significant progression of his BPH with LUTS. Following robotic simple prostatectomy, his renal function returned to normal, his bladder contractility was preserved, and his voiding was successful again.
DC 12/7/2020
CASE OF THE MONTH
REFERENCES 1. Groves HK, Chang D, Palazzi K, Cohen S, JK Parsons. The incidence of acute urinary retention secondary to BPH is increasing
among California men. Prostate Cancer Prostatic Dis. 2013;(16):260-265
2. Filson CP, Wei JT, and Hollingsworth JM. Trends in medical management of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology. 2013;82(6):1386-1392.
3. McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, Foster HE Jr, Gonzalez CM, Kaplan SA, Penson DF, Ulchaker JC, Wei JT. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185(5):1793-1803.
4. Meyer D, Weprin S, Zukovski EB, Porpiglia F, Hampton LJ, Autorino R. Rationale for robotic-assisted simple prostatectomy for benign prostatic obstruction. Eur Urol Focus. 2018;4(5):643-647.
5. Robles J, Pais V, Miller N. Mind the gaps: adoption and underutilization of holmium laser enucleation of the prostate in the United States from 2008 to 2014. J Endourol. 2020;34(7):770-776.
6. Robert G, Cornu JN, Fourmarier M, Saussine C, Descazeaud A, Azzouzi AR, Vicaut E, Lukacs B. Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP). BJU Int. 2016;117(3):495-499.
7. Sotelo R, Clavijo R, Carmona O, Garcia A, Banda E, Miranda M, Fagin R. Robotic simple prostatectomy. J Urol. 2008;179:513-515.
8. Johnson B, Sorokin I, Singla N, Roehrborn C, Gahan JC. J Endourol. 2018;32(9):865-870.
BENJAMIN M. BRUCKER, MD Benjamin M. Brucker, MD, is associate professor of urology and of obstetrics and gynecology at NYU Grossman School of Medicine. He is director of Female Pelvic Medicine and Reconstructive Surgery (FPMRS) and of Neurourology at NYU Langone Health and program director of the FPMRS Fellowship. He is board- certified in urology and female pelvic medicine and reconstructive surgery. Dr. Brucker completed medical school at the University of Pennsylvania. He remained at the hospital of the University of Pennsylvania and completed his residency. He has been at NYU Langone Health since 2010. He has expertise in robotic surgery, pelvic organ prolapse, bladder dysfunction, incontinence benign prostate surgery and neurourology.
DC 12/7/2020
646-825-6387 [email protected]
Benjamin Brucker, MD Female Pelvic Medicine and Reconstructive Surgery, Pelvic Organ Prolapse-Vaginal and Robotic Surgery, Voiding Dysfunction, Male and Female Incontinence, Benign Prostate Surgery, Neurourology
646-754-2404 [email protected]
646-825-6318 [email protected]
Frederick Gulmi, MD* Robotic and Minimally Invasive Urology, BPH and Prostatic Diseases, Male and Female Voiding Dysfunction, Kidney Stone Disease, Lasers in Urologic Surgery, and Male Sexual Dysfunction
718-630-8600 [email protected]
646-825-6325 [email protected]
William Huang, MD Urologic Oncology (Open and Robotic) – for Kidney Cancer (Partial and Complex Radical), Urothelial Cancers (Bladder and Upper Tract), Prostate and Testicular Cancer
646-744-1503 [email protected]
212-263-6420 [email protected]
Herbert Lepor, MD Prostate Cancer: Elevated PSA, 3D MRI/Ultrasound Co-registration Prostate Biopsy, Focal (Ablation) of Prostate Cancer, Open Radical Retropubic Prostatectomy
646-825-6327 [email protected]
Stacy Loeb, MD, MSc** Urologic Oncology, Prostate Cancer, Benign Prostatic Disease, Men’s Health, General Urology 718-261-9100 [email protected]
Danil Makarov, MD, MHS*** Benign Prostatic Hyperplasia, Erectile Dysfunction, Urinary Tract Infection, Elevated Prostate-specific Antigen, Testicular Cancer, Bladder Cancer, Prostate Cancer
718-376-1004 [email protected]
646-754-2419 [email protected]
646-825-6348 [email protected]
646-825-6311 [email protected]
646-825-6326 [email protected]
Mark Silva, MD* Kidney stones, PCNL, Kidney Cancer, UPJ obstruction, Endourology, Robotic Renal Surgery, Ablation of Renal Tumors
718-630-8600 [email protected]
646-825-6327 [email protected]
Lauren Stewart, MD Female Pelvic Medicine and Reconstructive Surgery, Pelvic Organ Prolapse, Incontinence in Women, Female Voiding Dysfunction
646-825-6324 [email protected]
646-825-6321 [email protected]
James Wysock, MD, MS Urologic Oncology – Prostate Cancer, MRI-Guided Biopsy, Kidney and Prostate Cancer Surgery, Robotic Urological Cancer Surgery, Prostate Cancer Image-guided Focal Therapy (Ablation, HIFU), and Testicular Cancer
646-754-2470 [email protected]
Lee Zhao, MD Robotic and Open Reconstructive Surgery for Ureteral Obstruction, Fistulas, Urinary Diversions, Urethral Strictures, Peyronie’s Disease, Penile Prosthesis, and Transgender Surgery
646-754-2419 [email protected]
Philip Zhao, MD Kidney Stone Disease, Upper Tract Urothelial Carcinoma, Ureteral Stricture Disease, and BPH/Benign Prostate Disease
646-754-2434 [email protected]
*at NYU Langone Hospital – Brooklyn ** NYU Langone Ambulatory Care Rego Park ***NYU Langone Levit Medical †222 East 41st street; NYU Langone Ambulatory Care Bay Ridge, and NYU Langone Levit Medical
Our renowned urologic specialists have pioneered numerous advances in the surgical and pharmacological treatment of urologic disease.
For questions and/or patient referrals, please contact us by phone or by e-mail.
U1020
nyulangone.org 222 East 41st Street New York, NY 10017DC 12/7/2020
Department of Urology Case of the Month
CASE PRESENTATION A 66-year-old man presented with acute urinary retention. He first sought medical care for an enlarged prostate about 10 years ago. At that time, he was experiencing a slow urinary stream and was started on an alpha blocker and a 5-alpha reductase inhibitor. He stopped taking the 5-alpha reductase inhibitor because of unwanted effects on his libido and mild breast tenderness. A year ago, he had an International Prostate Symptom Score (IPSS) of 24 and a Quality of Life (Qol) score of 3 (“mixed”). His lower urinary tract symptoms (LUTS) had progressed steadily over the years, but he became more concerned about 3 months ago when he started to have urinary incontinence. In addition to urgency incontinence, he felt an increasing pelvic pressure and thought his abdomen was more distended. He began sitting to void and was increasingly bothered by nocturia (3 times/night).
The patient’s past urologic history also included an elevated PSA, resulting in 2 negative prostate biopsies. The more recent biopsy was done 2 years earlier in conjunction with a prostate MRI (Figure 1). Although the MRI showed no lesion suspicious for prostate cancer, it did show benign prostatic hypertrophy (BPH) with a gland estimated to be 193 grams and a sizable median lobe.
Figure 1. MRI showing BPH, done before last prostate needle biopsy about 2 years prior to presentation. The prostate weight was 193 grams. There is thickening of the bladder wall.
The patient’s past medical history was notable only for Parkinson’s disease, which was mild and well controlled with medication. His past surgical history included appendectomy at age 16.
DC 12/7/2020
CASE OF THE MONTH
PHYSICAL EXAM AND EVALUATION AT NYU LANGONE HEALTH The patient was a well-developed man who appeared healthy. He had flat facial features and a mild shuffling gait, but he was otherwise neurologically intact. Digital rectal exam revealed normal tone and an enlarged but smooth prostate. Abdominal exam was unremarkable. Testicles were non- tender and no inguinal hernia was found.
Results of an attempted noninvasive uroflow were uninterpretable because of a low voided volume. The bladder scan residual at that time showed 850 mL.
Serum creatinine was noted to be elevated at 2.2 mg/dL from a baseline of 1.0 mg/dL a year earlier.
Renal ultrasound showed mild bilateral hydronephrosis, an enlarged prostate, and a thickened bladder.
PSA was 5.7 ng/dL (PSA was 6.2 ng/dL in 2018, just prior to MRI and subsequent biopsy).
Urodynamics showed a large bladder capacity (Figure 2) and a high amplitude terminal involuntary detrusor contraction with a small leak. On second fill, the patient was able to mount a high- pressure detrusor contraction (maximum detrusor pressure: 139 cm H2O) with poor flow.
IDC Void
MANAGEMENT The patient was acutely managed with clean intermittent catheterization but desired definitive management. He was counseled on the potential therapeutic options and elected to proceed with a robotic benign simple prostatectomy. This was done with a da Vinci Xi robot via a transvesical approach. An excellent enucleation plane was developed and the prostatic adenoma was removed in 2 large parts (Figures 3 and 4). Estimated blood loss was 100 mL. The morning after surgery, the patient was discharged home with a catheter for gravity drainage.
Figure 2. Pressure flow study showing a large bladder capacity. The patient’s involuntary detrusor contraction resulted in a small amount of leakage. On second fill, he mounted a detrusor contraction after being given permission to void with little to no urine flow. Fluoroscopic images (not shown) show little to no funneling of the bladder neck, consistent with obstruction from the prostate.
DC 12/7/2020
CASE OF THE MONTH
Figure 4b. Intraoperative photos showing: (Left) Transverse bladder incision. With this approach, the retropubic space is left intact. If the surgeon elects to utilize an inverted “U”, it can minimize the need for holding sutures thereby keeping the leaflet out fo the surgical field. (Right) After successful enucleation, the bladder was “re-trigonalized” by pulling the trigone down the cut urethral edge. This may aid in preventing circumferential bladder neck contracture, aid in hemostasis, and aid in the ease of urethral catheterization.
Figure 3. Port placement of the transvesical robotic (da Vinci Xi) simple prostatectomy. Two assistant ports allowed for retraction and suction to be performed simultaneously.
At his most recent 3-month visit, the patient remained elated with his urination. His IPSS was 4 and his Qol was 0 (“delighted”). He denied any leakage of urine and had been able to achieve and maintain erections sufficient for penetrative intercourse. His uroflow showed a voided volume of 450 mL/sec, a maximum flow rate of 32 mL/sec, and an average flow rate of 20 mL/sec, with a post-void residual of 0 mL. Follow-up ultrasound showed complete resolution of his hydronephrosis. His serum creatinine level was 0.8 mg/dL.
COMMENT This case brings up some of the issues involved in the management of the “large” prostate. It is well established that BPH with LUTS and benign prostatic obstruction (BPO) are common problems that urologists in the United States are frequently called on to manage. What is unique in this case is the enormous size of the patient’s prostate. This is an important consideration for
Figure 4a. Gross pathology of suprapubic prostatectomy specimen, microscopic examination (not shown) consistent with BPH .
DC 12/7/2020
CASE OF THE MONTH
urologic surgeons, because data suggest that we may be seeing a “stage migration” toward the large prostate. An example of this migration is the nearly 25% increase in Emergency Department visits for urinary retention attributable to BPH in a population of California men between 2007 and 2010.1 After the number of transurethral resections of prostates (TURPs) peaked in the late 1980s, there was a reduction that continued into the early 1990s. Around this time, the use of medical management significantly increased, as more pharmacologic agents became available, and guidelines encouraged a stepwise approach emphasizing medical management.2 Increasing medical comorbidities and population demographics (i.e., baby boomers) have also been suggested as reasons for this shift to an increased number of large prostates.
The benign prostatectomy is in no way new or novel, but has been considered to be the gold standard for managing the large prostate. In fact, it was first described in 1900 by Peter Freyer. Although the technique of open prostatectomy has been modified, it has continued to have significant morbidity, long hospitalization stays, and a significant transfusion rate.3
So, what are the viable surgical alternatives to the open simple prostatectomy? Laser enucleation was described in the 1990s. And since that time, some have touted the endoscopic technique of enucleating the prostate as the ideal way to surgically manage BPH, even in the setting of the large prostate, as some considered the technique to be “size independent.”4 However, historically this technique has had slow uptake and very low utilization in the United States.5 Undoubtedly, various factors contribute to the use of surgical tools and techniques, but one reason often cited for the low uptake of laser enucleation is the steep learning curve.6
On the other hand, access, comfort, and advancements with the robotic platform have led to the tremendous growth of robotics in the field of urology. Urologic surgeons have been eager to use the robots for a large array of indications. The robotic approach to benign prostatectomy may improve surgical outcomes for men with very large glands and significantly reduce morbidity. Sotelo et al. first published a description of robot-assisted simple prostatectomy in 2008.7 Although various approaches and techniques have subsequently been developed and described, overall the robotic simple prostatectomy shows excellent functional outcomes equal to those of open simple prostatectomy. The advantage of the minimally invasive robotic approach is unequivocally the reduction of blood loss, lower transfusion rates, and shorter hospital length of stay. Data suggest that these advantages come with only a marginal, often considered inconsequential, increase in short-term hospital costs. Even though the robotic approach may not be accessible to all surgeons, it has been established that its learning curve is substantially shorter than that of laser enucleation.8
The robotic benign prostatectomy offers a very effective treatment for the large prostate. Our patient did not have concomitant conditions, but inguinal hernia, bladder stones, and bladder diverticulum are all more common in these advanced cases. The robotic approach allows these conditions to be addressed easily. We continue to improve the technique, and new and better tools further minimize morbidity and improve outcomes here at NYU Langone. Although experts are needed to carry out robotic benign prostatectomy safely and efficiently, this procedure can be successfully implemented in a center with an established and strong robotic program.
Over many years of medical management, our patient had unfortunately experienced significant progression of his BPH with LUTS. Following robotic simple prostatectomy, his renal function returned to normal, his bladder contractility was preserved, and his voiding was successful again.
DC 12/7/2020
CASE OF THE MONTH
REFERENCES 1. Groves HK, Chang D, Palazzi K, Cohen S, JK Parsons. The incidence of acute urinary retention secondary to BPH is increasing
among California men. Prostate Cancer Prostatic Dis. 2013;(16):260-265
2. Filson CP, Wei JT, and Hollingsworth JM. Trends in medical management of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology. 2013;82(6):1386-1392.
3. McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, Foster HE Jr, Gonzalez CM, Kaplan SA, Penson DF, Ulchaker JC, Wei JT. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185(5):1793-1803.
4. Meyer D, Weprin S, Zukovski EB, Porpiglia F, Hampton LJ, Autorino R. Rationale for robotic-assisted simple prostatectomy for benign prostatic obstruction. Eur Urol Focus. 2018;4(5):643-647.
5. Robles J, Pais V, Miller N. Mind the gaps: adoption and underutilization of holmium laser enucleation of the prostate in the United States from 2008 to 2014. J Endourol. 2020;34(7):770-776.
6. Robert G, Cornu JN, Fourmarier M, Saussine C, Descazeaud A, Azzouzi AR, Vicaut E, Lukacs B. Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP). BJU Int. 2016;117(3):495-499.
7. Sotelo R, Clavijo R, Carmona O, Garcia A, Banda E, Miranda M, Fagin R. Robotic simple prostatectomy. J Urol. 2008;179:513-515.
8. Johnson B, Sorokin I, Singla N, Roehrborn C, Gahan JC. J Endourol. 2018;32(9):865-870.
BENJAMIN M. BRUCKER, MD Benjamin M. Brucker, MD, is associate professor of urology and of obstetrics and gynecology at NYU Grossman School of Medicine. He is director of Female Pelvic Medicine and Reconstructive Surgery (FPMRS) and of Neurourology at NYU Langone Health and program director of the FPMRS Fellowship. He is board- certified in urology and female pelvic medicine and reconstructive surgery. Dr. Brucker completed medical school at the University of Pennsylvania. He remained at the hospital of the University of Pennsylvania and completed his residency. He has been at NYU Langone Health since 2010. He has expertise in robotic surgery, pelvic organ prolapse, bladder dysfunction, incontinence benign prostate surgery and neurourology.
DC 12/7/2020
646-825-6387 [email protected]
Benjamin Brucker, MD Female Pelvic Medicine and Reconstructive Surgery, Pelvic Organ Prolapse-Vaginal and Robotic Surgery, Voiding Dysfunction, Male and Female Incontinence, Benign Prostate Surgery, Neurourology
646-754-2404 [email protected]
646-825-6318 [email protected]
Frederick Gulmi, MD* Robotic and Minimally Invasive Urology, BPH and Prostatic Diseases, Male and Female Voiding Dysfunction, Kidney Stone Disease, Lasers in Urologic Surgery, and Male Sexual Dysfunction
718-630-8600 [email protected]
646-825-6325 [email protected]
William Huang, MD Urologic Oncology (Open and Robotic) – for Kidney Cancer (Partial and Complex Radical), Urothelial Cancers (Bladder and Upper Tract), Prostate and Testicular Cancer
646-744-1503 [email protected]
212-263-6420 [email protected]
Herbert Lepor, MD Prostate Cancer: Elevated PSA, 3D MRI/Ultrasound Co-registration Prostate Biopsy, Focal (Ablation) of Prostate Cancer, Open Radical Retropubic Prostatectomy
646-825-6327 [email protected]
Stacy Loeb, MD, MSc** Urologic Oncology, Prostate Cancer, Benign Prostatic Disease, Men’s Health, General Urology 718-261-9100 [email protected]
Danil Makarov, MD, MHS*** Benign Prostatic Hyperplasia, Erectile Dysfunction, Urinary Tract Infection, Elevated Prostate-specific Antigen, Testicular Cancer, Bladder Cancer, Prostate Cancer
718-376-1004 [email protected]
646-754-2419 [email protected]
646-825-6348 [email protected]
646-825-6311 [email protected]
646-825-6326 [email protected]
Mark Silva, MD* Kidney stones, PCNL, Kidney Cancer, UPJ obstruction, Endourology, Robotic Renal Surgery, Ablation of Renal Tumors
718-630-8600 [email protected]
646-825-6327 [email protected]
Lauren Stewart, MD Female Pelvic Medicine and Reconstructive Surgery, Pelvic Organ Prolapse, Incontinence in Women, Female Voiding Dysfunction
646-825-6324 [email protected]
646-825-6321 [email protected]
James Wysock, MD, MS Urologic Oncology – Prostate Cancer, MRI-Guided Biopsy, Kidney and Prostate Cancer Surgery, Robotic Urological Cancer Surgery, Prostate Cancer Image-guided Focal Therapy (Ablation, HIFU), and Testicular Cancer
646-754-2470 [email protected]
Lee Zhao, MD Robotic and Open Reconstructive Surgery for Ureteral Obstruction, Fistulas, Urinary Diversions, Urethral Strictures, Peyronie’s Disease, Penile Prosthesis, and Transgender Surgery
646-754-2419 [email protected]
Philip Zhao, MD Kidney Stone Disease, Upper Tract Urothelial Carcinoma, Ureteral Stricture Disease, and BPH/Benign Prostate Disease
646-754-2434 [email protected]
*at NYU Langone Hospital – Brooklyn ** NYU Langone Ambulatory Care Rego Park ***NYU Langone Levit Medical †222 East 41st street; NYU Langone Ambulatory Care Bay Ridge, and NYU Langone Levit Medical
Our renowned urologic specialists have pioneered numerous advances in the surgical and pharmacological treatment of urologic disease.
For questions and/or patient referrals, please contact us by phone or by e-mail.
U1020
nyulangone.org 222 East 41st Street New York, NY 10017DC 12/7/2020