What is Advanced Prostate Cancer

By: Scott Sellinger, M.D., F.A.C.S.

Advanced prostate cancer is a more aggressive form of prostate cancer that requires an intensification of treatment efforts.

However, advanced prostate cancer does not always mean metastatic prostate cancer, which is prostate cancer that has spread to other parts of the body. We consider five categories advanced, and I’ll discuss them shortly.

First, you should know the frequency of prostate cancer. Approximately 1 in 8 men will be diagnosed with prostate cancer in their lifetime, and about 20-30% of these men will be diagnosed with advanced prostate cancer at the outset. With advanced prostate cancer cases on the rise for the first time in 20 years, according to the American Cancer Society, it’s essential to understand what this diagnosis means.

How Advanced Prostate Cancer Progresses

The prostate is a small gland below the bladder and in front of the rectum. Prostate cancer occurs when abnormal cells in the gland begin to divide uncontrollably, forming an invasive tumor.

Frequently, prostate cancer is slow-growing and unlikely to cause a man any harm during his lifetime. However, for some men, the cancer cells are more aggressive.

Whether your prostate cancer is advanced will be something your doctor will determine based on the results of tests such as a prostate biopsy, imaging and PSA tests, and your personal medical history. These are the five categories we define as advanced prostate cancer, requiring an intensification of treatment.

• Very High Risk, Clinically Localized: While this type of cancer has not spread beyond the prostate, it is categorized as advanced because your physician believes it has a very high risk of doing so or reoccurring following a primary treatment.
• High-risk, Biochemical Reoccurrence (BCR): This is when a measurable and increasing PSA occurs following previous treatments.
• Non-Metastatic Castration-Resistant Prostate Cancer (nmCRPC): This cancer no longer responds to hormone treatment. It keeps growing even though the body’s testosterone levels have been reduced to very low levels. Non-metastatic means it is still localized.
• Metastatic Castration-Sensitive Prostate Cancer (mCSPC): Cancer has spread from the prostate into other body regions. It remains responsive to hormone therapy.
• Metastatic Castration-Resistant Prostate Cancer (mCRPC): Metastatic prostate cancer that no longer responds to hormone therapy.

How is Advanced Prostate Cancer Treated?

The treatments for advanced prostate cancer are progressing all the time. Hormone therapy medication is frequently used to block the production of testosterone. When prostate cancer cells are denied testosterone, the cancer cells are starved of their fuel source. It’s not a cure for prostate cancer, but it can slow cancer growth. Hormone therapy is frequently used in men with high-risk prostate cancer pursuing radiation therapy.

Evolving therapies include chemotherapy and immunotherapy (which boosts the body’s immune system to destroy cancer cells), as well as new drugs such as Radium-223 (which delivers radiation particles directly to bone tumors) and lutetium Lu 177 vipivotide tetraxetan, which delivers radiation directly to cancer cells.

Clinical trials for experimental new therapies are also an option for patients to consider.

Advanced prostate cancer often is not curable, but today’s treatments can help keep it under control and manage symptoms.

Prostate Cancer Awareness Month

September is Prostate Cancer Awareness Month. This year, we are stressing an important point—0.75. If your PSA increases by 0.75 or more in one year, it could be prostate cancer.

We are encouraging men to know their PSA level and better understand it, aiming to empower them with prostate health knowledge.

If you have questions about your risk or treatments for advanced prostate cancer, we encourage you to schedule an appointment with a urologist today. Professional advice and early detection can significantly improve your chances of successful treatment.

By: Jamey Sarvis, M.D.

It’s all fun and games until someone gets a kidney stone.

During the hotter months, it’s essential to be mindful of our health, especially when it comes to preventing kidney stones. Kidney stones are a common issue that can be particularly prevalent during summer due to dehydration caused by hot weather. And as Floridians we experience summer-type temperatures much longer than most other Americans. However, proper precautions and healthy habits can reduce the risk of developing kidney stones.

What is a kidney stone?

A kidney stone is a small, hard growth that develops in the kidneys when urinary minerals and salts crystallize and bind together.

What are common kidney stone symptoms?

The most common sign of a kidney stone is pain in the back, sides, groin, and/or testicles (for men).

The pain can be acute enough to cause nausea and vomiting, and blood may be present in the urine. Someone experiencing these symptoms should see a urologist. Small kidney stones may pass through the body naturally within days or weeks of formation, with the help of lots of water. A doctor can provide guidance. However, a stone must be removed if it causes complications, such as an infection or blockage.

Why do kidney stones increase in the summer?

One of the most crucial factors in preventing kidney stones is staying well-hydrated. Dehydration can lead to the formation of kidney stones, so it’s essential to drink adequate water throughout the day. Experts recommend consuming at least 8-10 glasses of water daily, but this may vary depending on individual factors such as activity level and climate.

How else can you prevent kidney stones?

In addition to staying hydrated, maintaining a balanced diet plays a significant role in kidney stone prevention. Certain foods high in oxalates, such as chocolate, nuts, and certain fruits and vegetables, can contribute to the formation of kidney stones. By moderating the intake of these foods and incorporating a variety of nutrients into your diet, you can help reduce the risk of kidney stone development.

Regular physical activity is another vital aspect of kidney stone prevention. Exercise helps maintain a healthy weight, reduces the risk of kidney stones, and contributes to overall well-being. Engaging in regular exercise routines can promote better kidney health and decrease the likelihood of developing kidney stones.

By prioritizing hydration, adopting healthy eating habits, and incorporating regular exercise into your routine, you can take proactive steps to prevent kidney stones, especially during summer. Remember to consult a healthcare provider for personalized advice and recommendations based on your health needs.

If you are experiencing symptoms of kidney stones, visit your AUI urologist as soon as possible.

Safe and effective technologies are available at Advanced Urology Institute to help diagnose, treat, and manage kidney stones.

By: Jenna Hurley, P.A.

Nearly 4 million Floridian women are 35 and older, and – based on national statistics – up to one in three of them is not in the mood.

Low sex drive among women is common, so much so that an estimated 21 million experience it nationally. Yet just four in 10 women who have difficulty with their sexual function ask about treatment, compared with 62% of men.

If you are among these women, you may simply be too busy or it may feel uncomfortable to seek a remedy. Causes of low libido include stress, body image insecurity, breastfeeding, and even some forms of birth control, including the pill.

However, underlying medical issues can also interfere with your sex drive. Some medical changes involve your stage of life as a woman, but others can stem from common urologic disorders. So, if you notice you have a low sex drive and it troubles you, it could be time to consult a urologist or urogynecologist for overall health reasons.

Why the Low Libido? 4 Mood-Lifting Solutions

Changes in your hormone levels or urinary function can make sex painful. Researchers estimate that 40% of all women have experienced pain during sex at one point or another in their lives. This can make it difficult or impossible for women to enjoy sex and can lead to decreased libido.

Here are four common causes behind reduced sex drive, and how you can treat them.

1. Vaginal discomfort – Hormone levels as well as physical events can make intercourse hurt. A drop in the female hormone estrogen, which stimulates desire and lubricates the vagina, can cause vaginal dryness. This typically occurs during menopause, but also can be due to certain medications or breastfeeding. Chronic vaginal pain, however, is different. Signs of this include persistent burning, aches, and itching in the vaginal area which can occur secondary to nerve damage, pelvic inflammation, muscle spasms, or a reaction to yeast.
   Mood-lifting treatments: You can improve general discomfort with intercourse by using an appropriate lubricant during sex. Dryness can also be alleviated by regularly applying vaginal lubricants or estrogen creams, or by using doctor-recommended laser treatments designed to reinvigorate vaginal tissue. Vaginal pain might be relieved by Kegel exercises to strengthen the pelvic muscles or medications, including nerve blockers. If your pain persists, our urogynecologists can surgically treat the vagina.

2. Pelvic organ prolapse– The muscles in your pelvis hold your bladder, uterus, and upper vagina in place. If those muscles weaken, these body parts can slip, or prolapse, toward the vaginal canal causing a budge or sensation of something “falling out”. This occurs in nearly half of all women between 50 and 79 to some extent, with symptoms such as pelvic discomfort, numbness, and pressure. This can make intercourse painful or physically difficult.
   Mood-lifting treatments: Minimally invasive approaches include Kegels which are pelvic floor exercises and pessaries which are small disc shaped devices used to hold the tissue in place when inserted into the vagina. If you choose surgery, your pelvic musculature can be reinforced using your vaginal tissue or medical grade surgical materials to resuspend anatomy back into an appropriate position.

3. Urinary leakage (incontinence) – Childbearing, menopause and nerve abnormalities can make it harder to hold in urine. The fear of an accident can shut down the idea of sex. The two most common forms are urge incontinence and stress incontinence. Overactive bladder (OAB) commonly causes urinary urgency, or the immediate, hard-to-control need to pee. Stress incontinence is a sudden urine leak from pressure to your abdomen, such as coughing.
   Mood-lifting treatments: You can relieve symptoms of OAB with medications that block some of the excess nerve signals that cause bladder muscles to contract. These medications include oral pills and bladder injections with Botox. The nerves can also be stimulated with electrical nerve stimulation to reduce urge incontinence. Your path to treatment for stress incontinence can involve Kegel exercises, bladder training, pessaries, and urethra-strengthening drugs or procedures.

4. Pelvic pain – Interstitial cystitis(IC) occurs when irritating substances in your urine leak through a compromised bladder lining. It can be quite painful even without sex, which is why it’s often referred to as painful bladder syndrome. Bacterial urinary tract infections can also cause pain in the bladder.
   Mood-lifting treatments: For IC, symptom-based treatments include pelvic floor physical therapy, bladder washes, nerve stimulation, medications including both oral options and Botox, and stretching the bladder with fluids while under anesthesia (called hydrodistension). We can help you relieve both acute and chronic urinary infections with medications as well.

Interested In Learning More? Sex Education is for All Life Stages

The urological conditions above are among the most likely to hamper your sex drive and other enjoyable activities. But other causes also exist. It’s tempting to ignore the symptoms, but try not to, as they can worsen over time without intervention.

If lifting your mood and improving your sexual health is important to your quality of life, call a specialist today for an appointment. Acknowledging your medical needs as a woman by seeking professional help for sexual dysfunction is an important step in feeling empowered to live your best life — and your journey to getting back in the mood can begin with that simple step.

The healthcare providers at Advanced Urology Institute are your partners in good overall health. You can read about all the women’s health conditions we treat, with symptoms and treatment options, on our web site: advancedurologyinstitute.com.

New Public Awareness Campaign from Advanced Urology Institute

During September’s Prostate Cancer Awareness Month, Advanced Urology Institute (AUI) wants to stress an important point—0.75.

If your prostate-specific antigen (PSA) level increases by more than 0.75 in one year, it could be prostate cancer.

“Your PSA number is important, and so is the rate at which it changes,” said Dr. Scott Sellinger, an Advanced Prostate Cancer specialist at AUI. “There are men with a PSA of 20 who don’t have prostate cancer and men with a PSA of 2 who do.”

High levels of PSA do not always mean cancer and normal levels of PSA do not guarantee cancer is not present.

“What’s crucial for men is having a baseline. Know your normal PSA level and have it tested annually to alert you to any unusual changes. Finding and treating prostate cancer early, when treatment might be more effective, saves lives,” said Dr. Sellinger.

Both noncancerous and cancerous prostate cells make PSA, but cancerous cells tend to produce more: the PSA blood test measures and screens for this. A PSA test, along with a digital rectal exam, remains the best way to detect prostate cancer.

If it’s been over a year since your last PSA test or you’ve never had your PSA level tested, now is the time to get it done.

By: Kristina Buscaino, D.O., M.S.

Sometimes, men can be pretty bad at talking about stuff that matters. For example, did you know that 44% of men are worried about erectile dysfunction, but only two in five will seek professional help?

Don’t worry, at Advanced Urology Institute we talk about this every day! Managing your sexual health is essential to protect your physical, mental, and overall long-term health. As physicians, we’re comfortable talking about sexual health issues with you, and we want to help you resolve them. So, today, let’s talk about some common male sexual health issues and treatments.

Erectile Dysfunction (ED)

What is it? ED is the inability to get or maintain an erection firm enough to have sex.

Who is at risk? Approximately 1 in 5 American men over 20 years old will experience ED in their lifetime. About 1 in 4 men face chronic health conditions, which can impact erectile function, too. These include diseases like diabetes, heart disease, hypertension, and obesity.

Common treatment options?

• Oral medications – Take about 1 hour to work and last for 4-36 hours
• Injections – Self-injected medications directly into the penis, which typically begin working within 5 to 20 minutes
• Penile prosthesis – The physician implants a bendable or inflatable device that can create an erection.
• Vacuum device – A hand or battery-powered pump creates a vacuum that pulls blood into the penis. Once an erection is achieved, an elastic tension ring is placed at the base of the penis to help maintain the erection.
• Low-intensity Shockwave Therapy (LiSWT) – Clinically validated to stimulate better blood flow.

Low Testosterone (Low-T)

What is it? A man’s body is not making enough testosterone, the primary male sex hormone.

Who is at risk? It is more common in men who are over the age of 80, have diabetes, high cholesterol, high blood pressure, or are overweight.

Common treatment options?

• Oral medications
• Topical agents such as gels or creams
• Injections
• Testosterone pellets placed under the skin

Peyronie’s Disease

What is it? A condition that causes penile curvature, indentation, or loss of length upon erection.

Who is at risk? It’s estimated that 10-15% of adult men experience some form of Peyronie’s disease. It is more common in men over the age of 40, and it can be caused by microscopic trauma that occurs during intercourse. The trauma leads to inflammation and then a penile scar or lump.

Common treatment options?

• Oral medications
• Penile traction
• Injections – Introducing injectable collagenase into penile plaques to break them up has dramatically broadened the options for safe and effective office-based treatment
• Surgery remains highly effective for correcting more severe or S-shaped curvatures.

The bottom line is that it is okay (and healthy!) to talk about sexual health. Talk about it with your partner and, most importantly, a physician. As urologists, we receive the most extensive training available in physiology, anatomy, and treatments associated with men’s sexual health issues. We can help you enjoy a more fulfilling sex life.

Find an AUI location near you and schedule an appointment today.

By: Matthew Sorensen, M.D.

Fun fact: Your bladder can extend from just two inches to more than six inches as it fills up. For those who have overactive bladder, each of those inches could feel like a yard.

That’s because overactive bladder (OAB) makes you feel like you have to go even if your bladder isn’t full. The tell-tale symptoms include the urgent, hard-to-control need to urinate, along with waking up having to go three or more times a night, and sometimes not making it to the bathroom on time (leakage).

If you’re experiencing these symptoms, you could be among the 40% of women and 30% of men who live with OAB. But you don’t have to “just live with it.” There are ways to manage your OAB and feel in control again, an inch at a time.

Your Bladder, Explained

The bladder is a hollow, muscular organ that stores urine until it’s full – typically, about two cups of urine.

As the bladder fills to that six-inch mark, your brain sends updates to a cluster of nerves (the sacral nerves) that control the bladder when it’s time to go. Ordinarily, the bladder muscles will squeeze when you are ready. But for people with OAB, the muscles start contracting before the bladder is full, triggering the sudden need to urinate.

OAB can be caused by complications from an underlying condition, such as diabetes, a urinary tract infection, a bladder obstruction, or nerve damage. With aging, your bladder muscles might weaken. Or OAB might be a communication error between your sacral nerves and your bladder.

Regaining “Full” Control, in 6 Steps

If you’re trying to manage OAB symptoms, read on. These following practices could help to eliminate triggers and strengthen your bladder.

1. Drink fewer stimulating beverages – When choosing your eight daily glasses of fluids, opt for water over caffeine, alcohol, and artificial sweeteners. Don’t drink anything two hours before you go to sleep.
2. Say “no” to acidic and spicy dishes – Avoid hot peppers, tomatoes, oranges, grapefruits, lemons, and limes. Research suggests these foods (and their juices) can irritate the bladder.
3. Make your pelvis stronger – Your pelvic muscles help hold in your urine, so the stronger they are, the more control you have. Try to perform five sets of 10 Kegels each day: squeeze like you’re trying not to pee, hold for a few seconds, then release.
4. Chronicle details of your “trips” – Write down all you eat and drink, how soon afterward you have urinate, and what you’re doing at the time. These details, including leaks, can reveal patterns and potentially be shared with a doctor.
5. Resist the urge to hurry – Don’t rush to the bathroom the moment you have to pee; the stress could make its worse. Instead, perform a few Kegels or do something soothingly distracting, like a puzzle.
6. Put bathroom breaks on a timetable – As you get better at waiting to go, you can start training your bladder to follow a schedule. Plan the times of day go, maybe once every two hours, and add more time as your gain control.

Your Doctor’s Office Is a Safe Place for OAB

Inch by inch, the above practices could relieve your OAB symptoms. If you don’t notice improvements, it’s probably time to talk to a urologist about treatment options.

Several medications can block misfired signals to the bladder, for example. Nerve stimulation treatments can modulate the nerves that control the urge to urinate, and Botox bladder injections can relax bladder contractions.

Together, you and your doctor can find the treatment that is right for you and your circumstances. Remember, OAB is not something you just have to live with.

Still have questions about managing OAB? Visit our OAB website to learn other causes and what to expect, or read our blog featuring the latest OAB treatments we offer.

By: Carlos Ramos, MD, FACS

Most Floridians know how to make a “go” bag in case of a hurricane. But what’s in your “go” bag in the case of prostate cancer?

In Florida, 113 of every 100,000 men are diagnosed with prostate cancer. It is the second most common cancer in men following skin cancer – a condition for which Floridians know how to prepare.

Sure, few men want to get ready for any cancer, including that of the prostate. But if you are among those men recently diagnosed, there are steps you can take to better adapt to your treatment and recovery.

Here’s what you can expect, and why.

Why Prostate Cancer Can Be Cured

Your prostate is a 1-ounce gland that helps make the fluid that carries semen. It’s located in an active part of your body, beneath your bladder and around the urethra.

Cancer occurs when an abnormality makes the cells grow out of control, without stopping, until they form a tumor. When this happens in the prostate, the cancer tends to grow slowly, so it is usually caught before spreading to surrounding tissue and bones.

Symptoms include difficulty urinating, blood in your urine or semen, unexplained weight loss, and pain in the groin area. If the cancer has spread, your bones might hurt.

Your chances of developing prostate cancer can vary based on age, race, family history, and lifestyle, but overall prevalence has risen 3% a year since 2014. The good news is that 99% of men diagnosed with localized prostate cancer today survive.

Choosing the Right Treatment for You

If you are diagnosed with prostate cancer, you’ll have a choice of treatments based on the stage and aggressiveness of the disease. In 40% of localized cases, men have their prostates surgically removed (prostatectomy). Other options include radiation therapy and, if the cancer is low risk, surveillance with repeat testing.

In cases where the cancer has spread beyond the prostate, your doctor could advise immunotherapy, chemotherapy, radiation, or hormone therapy to block testosterone production and slow the cancer.

Life After Prostate Cancer: Changes to Expect

During and after your treatment, you will experience some differences in your body and lifestyle. Following are the most common.

Scheduled time off of work – Men who have prostate surgery should plan to take three to four weeks off from work, depending on job physicality. If you work from home, you could return sooner.

Bathroom issues – A prostatectomy requires removal of one of the urinary valves (sphincters), resulting in incontinence in 6% to 8% of patients. This typically lasts a few months to a year. In some men, radiation therapy weakens the bladder. Kegel exercises can help.

Reduced drive in bed – Some procedures could affect the nerves and blood vessels that help you get an erection, but this could be treatable. Hormone therapy might temporarily weaken your sex drive. If the prostate is removed, you can still achieve orgasm, but will not ejaculate.

Limited activity and fats – You’ll have to take it easy after surgery – no strenuous exercise and heavy lifting for a month. You should be able to do Kegels and low-impact activities. And what you eat matters more: reduce fatty foods and red meat in favor of fruits and vegetables.

Therapy side effects – If you undergo chemotherapy, you might experience nausea, hair loss, and fatigue. Side effects of hormone treatments include thinning bones, hot flashes, and weight gain.

Get Your Prostate Cancer “Go” Bag Ready

Above all, your life after prostate cancer will require steps to remain cancer free. Expect to see your doctor every few months for a prostate exam and prostate-specific antigen (PSA) test, which detects cell abnormalities.

The better prepared you are now, physically and emotionally, the sooner you can enjoy the calm after the storm.

You can read more about our prostate cancer diagnostics and treatments on our website. Learn about clinical trials at AUI.

By: Scott Sellinger, MD, FACS

Although 1 in 8 men in the U.S. will be diagnosed with prostate cancer during their lifetime, Black men are 76% more likely to be diagnosed with prostate cancer than White men, and 2.2 times more likely to die from it compared to White men.

Get the facts about prostate cancer:

• About 6 in 10 prostate cancers are diagnosed in men aged 65 or older. Average age of diagnosis is 67, and it’s rare in men younger than 40.
• Prostate cancer is the second-leading cause of cancer death in American men, behind only lung cancer. About 1 in 44 men will die of prostate cancer.
• Ask your doctor when you should begin getting screened. But if your risk is higher (which it is for Black men), you should begin at age 40.
• Screenings include a prostate specific antigen (PSA) blood test. It’s simple, and it can make a difference in survival. When caught early, the survival rate is nearly 99%.

Follow these cancer-prevention tips, regardless of race:

• Pay attention to what you eat. Aim to eat primarily fruits, vegetables, and other foods from plant sources — such as whole grains and beans. Limit your intake of processed meats, refined sugars, and fat from animals.
• Eliminate bad habits. Don’t use tobacco, and if you drink alcohol, do so only in moderation.
• Exercise often. If you exercise regularly, you have a slightly lower risk of developing prostate cancer. Your chances improve with vigorous workouts. Plus, you’ll strengthen your bones if you exercise often, which is important if you have prostate cancer and are being treated with hormone therapy.
• Does it run in your family? If your father or a brother are diagnosed with prostate cancer, you’re twice as likely to be diagnosed with it, regardless of race. You should be tested regularly beginning at age 40.
• Don’t shy away from screenings. Ask your urologist when you should begin regular screenings for prostate cancer, and then be sure to follow your doctor’s advice.

If you are diagnosed with prostate cancer, know that there are many treatment options available and your urology team at AUI will work closely with you to determine the best treatment for you.

Remember, early diagnosis will improve your treatment’s success. Learn more about prostate cancer, prevention, and PSA screening options. Click to request an appointment to schedule your annual PSA screening.

By: John Lynam, DO, FACOS

Nocturia is not restful. It’s a condition that causes you to wake up twice or more each night to go to the bathroom. Nocturia impacts men and women and can be caused by anything from drinking too much before bed to certain medications that contain diuretics.

For men, one of the most common causes of Nocturia is a growing prostate.

The Prostate

The prostate gland sits at the base of the bladder, behind the penis. Through its center runs the urethra, the tube that carries urine out of the body. A man’s prostate grows throughout his life, but if it grows too large, it compresses the urethra and makes it hard to urinate.

About half of all men by age 60 will experience this issue, known as benign prostatic hyperplasia (BPH). In fact, BPH is the leading reason men visit a urologist.

Benign Prostatic Hyperplasia (BPH)

The good news for men is that BPH is not cancerous, hence the word “benign.” The bad news is that BPH causes many irritating symptoms, including:

• A frequent need to urinate both day and night
• A weak or slow urinary stream
• A sense that you cannot completely empty your bladder
• Difficulty or delay in starting urination
• An urgent need to urinate
• A urinary stream that starts and stops

Untreated BPH Can Progress

BPH is more than a nighttime nuisance. Untreated, it can progress with serious health consequences.

• Adult diapers. If the urethra is closed off, the bladder must contract harder to push urine out. Over time, this weakens the bladder and can lead to incontinence.
• Urinary catheter. If your urethra becomes too obstructed or if bladder weakness becomes too severe, a catheter may be needed to drain the bladder fully.
• Urinary tract infections (UTIs) and kidney stones. If your bladder isn’t fully draining, the residual urine left increases the risk of UTIs and kidney stones.
• Kidney damage. The kidneys are attached to the bladder through two ureters, the ducts through which urine passes. If urinary retention causes pressure on the bladder, it could eventually damage the kidneys. Also, if the bladder is infected, that infection could spread to the kidneys.

BPH Can Be Treated

The first place to start treating BPH is with conservative management and behavior modifications. This includes steps like limiting beverages in the evening, limiting caffeine and alcohol consumption, avoiding bladder-irritating foods, and avoiding certain medications that can impact urination.

Your urologist can prescribe medications to help urine flow better and shrink the size of the prostate.

For more severe urinary symptoms, minimally invasive procedures like UroLift® and Rezum® can significantly improve your urinary health and quality of life.

Do not ignore the symptoms of BPH. You’ll sleep more soundly and live more fully when you prioritize your urinary health.

Wondering if your symptoms could be BPH? Learn more about BPH symptoms, diagnosis, and treatment at Advanced Urology Institute of Florida.