What are the typical bread and butter cases that a Private practice Urologist would do??
What are your favorite type of operations/patient problems you deal with??
Sorry for the slow replies, as mentioned being a Urology resident does get quite busy.
I'd categorize bread and butter Urology procedures as follows:
Very common (e.g. office procedures performed up to multiple times per clinic day): diagnostic cystourethroscopy (using a flexible scope through the urethra into the bladder to look for any issues e.g. tumors, strictures, etc.), bladder biopsies, prostate biopsies, vasectomies.
Common (e.g. frequently will have on a typical OR day):
1. surgery for BPH: which ranges from in-office procedures like placing self-tensioning prostatic urethral implants to hold the urethra open (urolift) to using RF current to ablate prostate tissue (transurethral needle ablation or Rezum), to cystoscopic surgeries done under general anesthesia, which includes the gold-standard of transurethral resection of the prostate as well as laser vaporization or eunucleation of the prostate. Less common nowadays but still present is open or robotic simple prostatectomy for very large glands.
There has been talk about this part of urology diminishing significantly in volume because of medical therapy for BPH, but that really hasn't been the case and for good reason. We use a scale called the IPSS (international prostate symptom score), for which > 20 is severe urinary symptoms. Combination medical therapy, meaning taking 2 pills daily for the rest of your life, lowers, IPSS by 6 points (compared to 3-4 for placebo). One of the office procedures I mentioned lowers IPSS 10-11 points. One of the surgical procedures (TURP or laser procedures) lowers IPSS by ~15 points. Overall the rate of BPH surgery per person is mostly stable (~900/100,000/year), but the elderly population is increasing so that means more cases.
2. surgery for kidney stones: Includes shock wave lithotripsy, ureteroscopy and laser lithotripsy, which means running a tiny scope up the ureter or into the kidney, lasering the stone into pieces or dust, and removing any fragments, or percutaneous nephrolithotomy, which means making a tract through the back to the kidney, then using larger scopes through that tract to grind up large kidney stones using pneumatic or ultrasonic lithotripters. This is also a growing field as kidney stone incidence has been rising over the years.
3. Endoscopic surgery for bladder tumors: This involves transurethrally resecting a bladder mass, which can range from a 1cm lesion that takes a few minutes to resect and cauterize or a large mass filling most of the bladder that takes multiple surgeries to resect
4. Hydrocelectomy (excision of bothersome fluid containing sac around the testicle)
5. Varicocelectomy (ligation of bothersome dilated veins coming from the testicle)
6. If your practice involves pediatrics then inguinal hernias, circumcisions, and orchiopexies (bringing down undescended testicles) are very common. Typically in cities or places with peds hospitals, pediatrics is done by fellowship trained pediatric urologists, but if you're not near a big children's hospital/center, then this often falls on the private practice urologists.
7. If your practice includes female urology then bladder botox injections (usually done in the office) or mid-urethral sling placement are quite common
Relatively common (will have a case every week or 2)
Radical prostatectomy, usually robotic
Radical or partial nephrectomy, usually laparoscopic (or robotic for partials) sometimes done with hand-assisted laparoscopy, which is laparoscopy in which there is a special port that lets you place one hand into the insufflated abdomen to assist with your dissection (youtube this if you haven't seen it, it's pretty cool)
Surgery for urethral strictures. This typically involved endoscopic cases like urethral dilation or internal urethrotomy with a cold knife or laser, but the gold standard is a urethroplasty, either via excising the diseased segment, or more commonly by opening it up and laying on a graft of mucosa from the cheek or tongue. This is often done by fellowship trained reconstructive urologists, but I and many other current residents do so many of these we feel more then comfortable incorporating them into our general practice. Some Urologists will harvest the graft themselves, while others will get ENT to do it, personally I feel comfortable doing it myself.
Somewhat uncommon (may have a case every few months unless you specialize in that area)
Robotic pyeloplasty, which means fixing an area of obstruction at the uretero-pelvic junction. Often this comes from a crossing blood vessel, in which case you excise the area of blockage and reconstruct it on the other side of the obstructing vessel.
Other infertility procedures like vasectomy reversals or testicular biopsies
Placement of prosthetic implants like inflatable penile prosthesis or artificial urinary sphincters
radical cystectomy for bladder cancer with creation of urinary diversion (either an ileal conduit, continent diversion, or neobladder made of intestine)
This will vary significantly based on your referral patterns and what you are good at/want to do with your practice. Some Urologists choose not to do major oncology cases like prostates or nephrectomies because they either don't feel comfortable doing them solo or don't want the headache/risk from bigger surgeries. There is a regionalization effect where more of the cystectomies are being done at major centers and fewer by community Urologists (for good reason), as there is a volume-outcome relationship. If you're in a decent size group though, you could still keep the cystectomies in house and have more then enough volume to be on the right side of the volume-outcome curve.
