The editorial team at the Leading Medicine Guide spoke to Dr Robert Hefty, Head of the Department of Urology and Pediatric Urology at Kliniken Heidenheim, which is conveniently located between Stuttgart, Munich and Frankfurt. You’ll be surprised at just how varied and fascinating urology is – a medical speciality that is completely underestimated by the general public!
Urology – an underestimated diversity in medicine
The term ‘urology’ derives from the Greek word οὖρον (pronounced ‘ouron’) and means ‘urine’. A urologist deals with diseases of the kidneys, the bladder, the ureters and the urethra in both women and men. In the case of men, this also includes conditions affecting the testicles, epididymis, vas deferens, seminal vesicles, penis and prostate. This therefore also covers areas of andrology, the male counterpart to gynecology.
If we look at the history of urology, we have to go back a long way, as bladder catheters were already in use in Egypt around 1000 BC. And while there was almost a standstill in the further development of urology during the Middle Ages, progress advanced significantly in the early modern period, before really gathering pace in the 19th and 20th centuries.
“Today, of course, we are talking about entirely different dimensions when it comes to urology. Innovative laser procedures and a focus on minimally invasive techniques are setting the tone and paving the way for much more comfortable treatments for patients,” explains Dr Hefty, who gained experience with laser methods in Wrocław during his training back in the 1990s.
“Major prostate operations, for example, which used to be performed via an abdominal incision and required the patient to stay in hospital for ten days or longer, are a thing of the past. Now, only a tiny puncture in the skin is needed to carry out such a procedure, and the patient is ready to be discharged after three days,” says Dr Hefty with pride in his voice.
From urinary urgency to incontinence: “No diagnosis through your trousers!”
Many people suffer from bladder problems and cope with everyday life using all sorts of tricks to manage them. Bladder infections or stress incontinence (where those affected involuntarily leak urine as soon as they put pressure on their abdomen through physical exertion such as coughing, laughing or heavy lifting) make life difficult.
Going to the toilet becomes a torment with bladder infections, because the few drops of urine produced cause pain in the urethra and there is a constant feeling of needing to go. Incontinence turns many people, both men and women, into experts on panty liners, sanitary towels or nappy pants. Certain items of clothing, such as short skirts or tight trousers, are avoided.
“Women are significantly more likely to be affected when it comes to urinary tract infections or bladder weakness. On the one hand, because their connective tissue is generally weaker than that of men, and on the other, because the pelvic floor muscles are put under considerable strain, for example as a result of childbirth, and can no longer provide optimal support for the urethral sphincter. Age-related weakness of the tissue and muscles is also one of the causes,” explains Dr Hefty. Most people find incontinence embarrassing. They feel ashamed and try to hide their problem for as long as possible. Yet many patients can help themselves through targeted pelvic floor exercises and regain control over their urge to urinate, or at least improve it.
Men generally react with even greater embarrassment and delay visiting the doctor for as long as possible, as examinations ‘down there’ are usually more unfamiliar to them and their sense of shame gets the better of them. Dr Hefty’s motto here is: “No diagnosis through your trousers!”, and with his humorous manner, he tries to allay people’s fears about the examinations and help them overcome their embarrassment.
“There is hardly a man over sixty without a few drops of leakage,” declares Dr Hefty. Many men suffer from stress incontinence, meaning they leak urine when laughing or lifting something heavy. No man needs to feel ashamed of this. As well as weakened pelvic floor muscles, the prostate can also be responsible for this, as this organ grows throughout a man’s life and its size can eventually put pressure on the bladder. “In men, if in doubt, one can always consider an artificial sphincter,” explains Dr Hefty, adding: “The advantage of necessary procedures on the urethra in men is essentially that the urethra is many times longer than in women. While the urethra in women measures only about 3.5 cm, that of a man is around 12–15 cm long.”
The new Urolastic therapy for women
Women for whom pelvic floor exercises are not sufficient can now be helped with a new therapy, the so-called “Urolastic procedure”. “The Urolastic procedure is a minimally invasive procedure carried out under local anesthetic and takes only about 15 minutes,” says Dr Hefty, adding: “A two-component filler is injected into four small reservoirs around the urethra. Within just a few minutes, this forms flexible implants, which in turn cause the urethra to narrow, thereby stabilizing it and thus stabilizing the closure mechanism.” The ‘cough test’ performed after the procedure demonstrates immediate success.
State-of-the-art technology is essential for examination and diagnosis
“In cases of stress incontinence, there is also the method of placing slings beneath the urethra to stabilize it. However, our new method has the clear advantage that it does not create a sensation of a foreign body,” says Dr Hefty, adding: “Tapes are inserted via surgery and under general anesthesia. The new method requires only a local anesthetic. And simply because it has not yet been approved for outpatient use, the patient must be admitted to hospital for one night,” he adds. This new procedure is particularly exciting for patients who wish to have children. This is because the filler used is long-lasting, does not fuse with the tissue, is easily replaceable and does not cause pain during sexual intercourse – a complaint frequently voiced by patients who have had slings fitted.
“Keep an eye on the toilet!”
Bladder infections have a bacterial etiology. As far as bladder infections are concerned, the cause is often excessive hygiene using harsh soaps in the genital area. “The environment inside the bladder offers protection.
If the bladder lining is compromised, chronic resistance can develop,” explains Dr Hefty, adding: “Urine and stools should be checked regularly. Blood in the stool or urine should always prompt a visit to the doctor. In such cases, women should see a gynecologist, as the presence of blood in the urine is often treated solely as an infection. However, a referral to a urologist makes sense here, as only a urological examination can detect conditions such as bladder cancer.”
If a bladder infection is present, a drinking regimen often helps, involving the consumption of three to four liters of water a day, so that as many bacteria as possible can be flushed out. A quick tip: after sexual intercourse, women should always empty their bladder, as this helps flush many bacteria out of the body.
Bladder cancer grows slowly at first following exposure
Don’t panic – if you have blood in your urine, you don’t need to immediately think of bladder cancer. To diagnose bladder cancer definitively, a cystoscopy is necessary. “In most cases, these are flat tumors that can only be detected during a cystoscopy. An ultrasound, a CT scan or an MRI may be required to determine the stage,” reports Dr Hefty.
However, it is important to know that bladder cancer develops very slowly. “It can take between 15 and 18 years for a cancerous tumor to form in the bladder,” explains Dr Hefty, adding reassuringly: “The success rate of treatment and the chances of recovery are very high. Most tumors, around 75%, are superficial in nature and can be removed endoscopically. The challenge here is that with bladder cancer we are dealing with tumors that recur quickly, and regular follow-up checks are essential.”
If bladder tumors are very deep-seated, a cystectomy is often unavoidable. “The potential for spread in bladder tumors is quite high. Imagine a rampant plant that can attach itself to blood and lymph vessels. The risk of metastasis is therefore high,” explains Dr Hefty, who therefore advises taking follow-up examinations seriously.
The neobladder – a blessing
If the bladder can no longer be treated endoscopically, it must be removed. However, without a bladder, going to the toilet is not possible. Fortunately, there is a replacement option here too: the neobladder. This is an artificial bladder formed from the patient’s own small intestine tissue. This allows urine to flow from the kidneys into the replacement bladder via the ureters, which are connected to the neobladder. It is connected to the urethra above the sphincter muscle, which has been preserved during surgery, and enables normal urination.
“Neobladder surgery is a major challenge and requires a high level of expertise,” explains Dr Hefty, who performs a great many operations himself and criticizes the lack of surgical training within urology. “As a consultant, it is therefore important to me to pass on my experience to my younger colleagues and to teach them how to perform these operations,” says the renowned specialist in urological surgery. “In many hospitals, bladder-preserving surgery is performed simply because the expertise is lacking, even though removal and the use of a neobladder would make more sense,” says Dr Hefty.
A positive outlook on the future of urology
Dr Robert Hefty, a native of Heilbronn with family roots in the USA, lives by the motto: Information – Innovation – Motivation. “I am very optimistic about the future of urology. The treatment of kidney stones, urethral strictures or prostate changes, and surgery for urological tumors is carried out to a high standard, thanks in particular to the modern laser technology used. Drug therapies will certainly increase in the future, and cell structure analysis will also become more widespread, enabling even more personalized treatment to be developed for patients,” he explains optimistically.
He advises young doctors not to lose sight of urology. “There is hardly any other medical speciality as diverse as urology. Urology encompasses, among other things, andrology, radiological diagnostics, proctology and tumor therapy,” he enthuses. Urology is indeed a key discipline when one considers demographic trends. “In the future, we will need twenty to thirty per cent more urologists than we do today, as people are simply getting older and many urological conditions only manifest in later life,” Dr Hefty concludes. A specialism with a bright future!
We thoroughly enjoyed this informative and refreshing conversation, which has given us a completely new perspective on the field of urology. Thank you very much, Dr Hefty! Would you like to find out more about Dr Hefty? Then visit the Leading Medicine Guide profile of urology specialist Dr Hefty – with a direct and secure way to get in touch!
