Department Profile: Urology

The field of urology is vast in scope. As the discipline responsible for all aspects of the urinary system in females and the urogenital system in males, it studies and treats a wide range of conditions – including infections, obstructions, dysfunctions, and malignancies – in patients of all ages.

“Urology is unique,” says Dr. Richard Norman, Head of Dalhousie’s Department of Urology. “From a surgical perspective, it’s the only discipline that operates via so many parts of the body...we perform procedures from the front, side and back of the abdomen, pelvis, chest, urethra...and even from across the room.”

The Department provides a variety of clinical services and conducts research within every one of its clinical programs. It strives to continually improve its practice in surgical, medical, dietary, and educational interventions.

The Department is particularly well known for its Kidney Transplant Program, the only in Canada certified by the American Society of Transplant Surgeons. This program recently pioneered the laparoscopic removal of kidneys from living donors, an advance that will help solve the problem of donor shortages. “Moving from open surgery that requires a week long hospital stay, to small incisions that allow the donor to walk out within 48 hours, removes huge barriers for people considering giving a kidney,” Norman explains.

Kidney stones affect about one in eight people, mostly men. The Capital Health Stone Clinic sees more than a thousand patients each year, using advanced techniques to break up and remove stones, and working with patients to evaluate and modify their diets to prevent future stones. Recent research conducted in the Stone Clinic showed dietary changes can reduce the chance of recurrence from 50 to 10 per cent.

“Our findings were somewhat paradoxical,” notes Norman, “We found that reducing dietary calcium actually increases the risk of stones – formed when calcium binds with oxalate – probably by increasing oxalate absorption. Now we know patients should consume adequate calcium, not only to keep their bones strong, but also to prevent kidney stones. This is a complete reversal of earlier thinking and emphasizes the importance of dietary evaluation in these patients.”

The Stone Clinic is about to publish a study that could change how stone cases are managed in Canadian emergency departments. Currently, many people presenting with stones are sent home to pass the stone – an excruciating process that can take two weeks or more. The Dalhousie researchers found that almost half of these patients return to emergency in pain – some as many as six times – and are urging prompt intervention to remove the stones.

Prostate disease is another major focus of the Department, with an emphasis on research related to men with benign prostatic hyperplasia, prostate cancer and prostatitis. The Department offers patient education, advanced urodynamic assessment and various medical and surgical treatment options – including the opportunity to participate in clinical trials.

Surgeons in the Department play a major role in treating cancers of the prostate, bladder, kidney and testicles. Prostate cancer is the most common cancer in men, eventually affecting as many as one in six. Though this cancer can often be cured through removal of the prostate gland, the surgery can lead to permanent difficulties with sexual function. The Department conducts leading research about prostate cancer treatment and how loss of sexual function affects men’s self-perception, relationships, and quality of life.

“Our research has shown that open discussion with men and their partners about prostate removal and how it may affect their lives and sexual health makes a significant difference in their decision-making and how they cope with the consequences of surgery,” says Dr. Lorna Butler, a PhD nurse cross-appointed to the Department. With help from the Halifax Prostate Support Group, Butler and her team developed www.caprostate.ca. Currently a research site, it will be re-launched in an educational format for patients once funding comes through, and will become the first online oncology course in Canada.

Also in the area of sexual health, the Department of Urology runs an erectile dysfunction clinic and has participated in numerous clinical trials, including pre- and post-market studies of Viagra and several other drugs. In terms of reproductive health, the Department opened its Male Infertility and Andrology Clinic in 1991. This clinic is unique in Canada in that it treats couples as a reproductive team. The Clinic is located at the IWK Health Centre, where its director, Dr. John Grantmyre, works side-by-side with reproductive gynecologists to help couples conceive a child.

“Seeing couples together reduces blaming and fosters a team approach to problem solving,” Grantmyre says. The reproductive team at the IWK has been a key player in making the revolutionary procedure known as ICSI – intracytoplasmic sperm injection – an accepted and effective way to overcome male infertility. The team is now studying surgical sperm retrieval as a way to help men with extremely low sperm counts. And for men with vasectomies who now wish to conceive, Grantmyre performs reversal surgeries, effective in returning sperm about 90 per cent of the time.

Although many urological problems affect only men, about 40 per cent of the patients Dalhousie urologists see are women. Post-partum and post- menopausal bladder incontinence is extremely common, as is interstitial cystitis, an inflammation of the interior bladder wall that leads to urinary frequency and pain. The Department is involved in numerous basic science investigations and drug trials for interstitial cystitis, and hosts regular public education forums on this troublesome condition.

The Department works with patients of both sexes with serious voiding disorders, often due to spinal cord injury or neurological diseases such as multiple sclerosis and Parkinson’s disease. Patients with compromised nervous systems may be unable to control their bladder function, or incapable of voiding without a catheter. The Department is involved in numerous clinical studies, as well as basic research into the neurological mechanisms of bladder and urethral function and dysfunction.

Adults aren’t the only ones who experience urological problems, and the Department runs an active and growing pediatric service that corrects such congenital conditions as urinary reflux and obstructions within the urinary system. Dalhousie graduate

Dr. Dawn MacLellan will soon be joining pediatric urologists Dr. Robert Schwartz and Dr. Peter Anderson at the IWK.

MacLellan has just completed three years of fellowship training at Harvard Medical School, and will be launching a proteomics-based research program to improve early diagnosis of kidney obstruction in children.

The wide range of urological conditions and procedures are taught through both clerkship and residency programs at Dalhousie Medical School. Both programs have longstanding reputations for top-quality training, and attract medical students and residents from across Canada.

The clerkship training is particularly important in that most common urological problems present in primary care, but urology is not taught by specialists in many postgraduate family medicine training programs. Thus, medical students who don’t plan to specialize in urology have their best opportunity to learn urology fundamentals, and how to perform prostate exams, catheterization, urinalysis and other procedures, at the undergraduate level. However, currently the urology clerkship isn’t mandatory. The Department is confident its clerkship will be returned to its former mandatory status once the Clerkship Review Committee completes its current assessment.

“This would be a major boost for urology in the region,” says Grantmyre, Director of the clerkship program. “When the clerkship was switched from mandatory to selective status a few years ago, our numbers dropped from 100 per cent of Dalhousie medical students to 15 per cent. We now have more clerks from other schools than our own, which means a minority of our graduates get adequate exposure to urological problems. We end up with fewer local urology residents and, ultimately, fewer urologists in the region.”

Dalhousie’s urology residency is recognized for excellence nationwide, attracting top candidates to its two annual positions. Residents gain tremendous experience through the large volume and variety of patients they see, and participate as valued members of the team in this close-knit Department. “Our residents get a lot of hands-on experience that’s not always available in larger centres,” notes Dr. Peter Anderson, Director of the residency program. “They also gain exposure to pediatric urology at the IWK and to community practice through rotations at smaller health care centres in the Maritimes.” He adds that roughly half of Dalhousie’s urology graduates go on to fellowship training in one of the field’s many subspecialties.

The DofU celebrates its 80th anniversary next year, and expects a large turnout to the reunion. In 2006, the Department will host the annual meeting of the Canadian Urological Association – preparations are already well underway. “It’s a great honour to have this meeting in Halifax,” says Norman. “We’ve been building our reputation in patient care, teaching and research for a long time, and will continue to be national leaders in urology.”