Shin, Paul R, MD

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Mon - Fri:	9:00 am - 5:00 pm

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Additional Specialties: Urological Surgery

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Extra Phones: Fax: (202) 223-2152
Payment method: master card, visa
Neighborhoods: Connecticut Avenue - K Street, Dupont Circle, Northwest Washington
Other Link: http://dcurology.net
Categories: Physicians & Surgeons, Mental Health Services, Physical Therapists, Physicians & Surgeons, Dermatology, Physicians & Surgeons, Emergency Medicine, Physicians & Surgeons, Family Medicine & General Practice, Physicians & Surgeons, Gastroenterology (Stomach & Intestines), Physicians & Surgeons, Gynecology, Physicians & Surgeons, Nephrology (Kidneys), Physicians & Surgeons, Nuclear Medicine, Physicians & Surgeons, Obstetrics And Gynecology, Physicians & Surgeons, Oncology, Physicians & Surgeons, Plastic & Reconstructive, Physicians & Surgeons, Psychiatry, Physicians & Surgeons, Radiology, Physicians & Surgeons, Sexual Dysfunction, Physicians & Surgeons, Surgery-General, Physicians & Surgeons, Urology, Physicians & Surgeons, Weight Loss Management, Skin Care, Surgery Centers
Other Information: Specialties: Urological Surgery

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Phone: (202) 223-1024

Address: 1147 20th St NW, Washington, DC 20036

Website: http://dcurology.net

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Shin, Paul R, MD

General Practitioners

Cryotherapy
If you have been diagnosed recently with prostate cancer, Dr. Engel (robotic prostatectomy, cryotherapy) would be happy to have a consultation with you in our office. We will make sure we review your case with you, make sure you understand the problem first thoroughly, and will then go over all treatment options before zeroing in on the right one for you.
Medical Weight Loss
Primary Care
Ndidi is highly experienced with a 17-year nursing career, eight of which were as a Registered Nurse in the Critical Care unit and Medical-Surgical units at Cook County Hospital in Chicago (one of the oldest and most innovative teaching hospitals in the US on which the show ER was based). Ndidi also has eight years of experience in dialysis care and as a nurse practitioner in Pain Management and Primary Care.
Emergency Care
Every patient that would otherwise have gone to a generic urgent care for their urologic can now be seen at a specialist-level urologic urgent care with same-day appointments. Online Appointments Learn More
Colonoscopy
A group of physicians working for the federal government called the US Preventative Task Force reviewed the data generated by all screening tests in America, including most notably PSA, but also mammogram, colonoscopy and others. They determined the usefulness of a screening test by estimating the number of patients screened or biopsied to save a life. Since that organization, which did not include an Urologist or an Oncologist, performed their work before 2010 and thus was reviewing the data generated by early usage of PSA, it should be no surprise that PSA was the worst performing screening test of them all, with mammograms in women between 40 and 50 also producing similar results. In the era where our government was/is promoting paying for treatments based on “evidence based medicine”, you might remember the first attempt at limiting payment for screening based on this idea when our government considered the performance of mammograms in younger women. It was not soon after that this same report was used as justification for a campaign against PSA screening in America.
Erectile Dysfunction
Urinary Incontinence
Overactive Bladder (OAB) is a common urinary condition affecting men and women alike. Symptoms include the uncontrollable urge to urinate, frequent daytime urination and getting up at night to urinate. It is common for these symptoms to be accompanied by leakage of urine (urinary incontinence). These symptoms can cause undesired changes in the work environment, social settings and lead to an overall decrease in quality of life.

Pelvic Pain
Many men struggle with chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS). CP/CPPS is defined as long standing symptoms of pelvic pain or discomfort not attributed to an infection, cancer, neurologic disorders or anatomic abnormalities. In addition to these symptoms of pain, patients can experience urinary and sexual dysfunction, causing a severe impact on their life. CP/CPPS necessitates a complex analysis and treatment plan to alleviate symptoms as studies have not supported the use of a single therapy. The comprehensive approach includes appropriate urologic consultation and discussion of the options outlined below.
Labor and Delivery
Male urinary incontinence is a much less common problem than female incontinence, and the causes tend to be quite different. Let’s talk about the different causes for urinary incontinence. In women, there are generally two types – stress and urge incontinence. Stress incontinence is most commonly a result of vaginal laxity, a structural problem where the bladder gets less and less supported by the anterior wall of the vagina. This can be caused by previous childbirth, menopause or simply aging. With this in mind, the strategies behind addressing this type of incontinence center around adding more support to the pelvic floor or vaginal wall. This is accomplished either by exercises, often called Kegel exercises, or by procedures designed to provide a backboard for the bladder to push against during times of increased abdominal pressure – an act previously performed by the vagina.

Bladder Cancer
Bladder cancer is the second most commonly treated cancer by an Urologist, and should therefore be considered common. Of course any time a person is informed that they harbor a cancer it is a frightening time, but it should be noted that the vast majority of cases of bladder cancer are low risk, and thus have a low likelihood of spread. Such cases are in many ways analogous to suspicious colon polyps that, if monitored by regular scope procedures and addressed at an early stage, can be very effectively managed with minimal impact on one’s life. However, perhaps 10-20% of cases of bladder cancer are far different and are aggressive. As such, these cases will need to be treated that way. The main risk factor for development of bladder cancer, or cancer of the lining of the urinary tract at any location, is smoking. However, not all patients with bladder tumors are smokers. It is largely accepted that environmental exposure to some chemicals also causes bladder cancer, but an exact list of all causative agents has not been completely outlined.
Urology
Dr. Engel has been in practice in Washington, D.C., since 1999. He is a local who grew up in Wheaton, Maryland, and ultimately graduated from Landon School. Then came the University of Virginia for his undergraduate degree with high distinction, the University of Pennsylvania for his M.D. (inducted into Alpha Omega Alpha, recognizing the top 10% of his class), followed by his surgical and Urology residency at Northwestern University in Chicago.
Kidney Cancer
The most common cell type found in kidney cancer is called clear cell renal cell carcinoma, but variants such as papillary, sarcomatoid, medullary and others are seen. Transitional cell carcinoma (TCC) is not uncommon, is typically found in smokers, and arises from the lining of the kidney rather than the functioning kidney tissue itself. TCC of the renal pelvis is more similar to bladder cancer than kidney cancer, carries a higher metastasis risk, and if found, typically necessitates removal of not only the entire kidney but also the entire ureter as well. Thus, if TCC of the renal pelvis or collecting system is found, a patient is offer a “nephro-ureterectomy”, also performed laparoscopically by Dr. Engel.
Kidney Stones
In the adult population, the presentation of an UPJ obstruction is quite different. The most common situation is that a young adult, perhaps a college student or similar age, will begin to have pain in the back or kidney. This pain is usually worse in situations where a lot of urine is made (such as binge drinking of alcohol), and many such patients will state that they do not drink much alcohol because historically it “makes them feel bad.” If the pain becomes worse enough, or if another problem develops such as kidney stones or infection, medical help will be sought. Here, an initial imaging study, most commonly a screening ultrasound, will show a dilated kidney. Kidney dilation is termed hydronephrosis, and this hydronephrosis can be very severe when found. It is usually at this point that a patient is referred to an Urologist.
Urinary Tract Infection
Blood in the urine can often accompany urinary tract infection in women. However, it must be proven as such. Blood in the urine can also be a dangerous situation that can be the first sign of urologic malignancy or kidney stones. These problems deserve urologic management specifically.
Prostate Cancer
Prostate cancer is a unique but common medical problem, and a very difficult one for the lay person to fully comprehend. The greatest challenge to the patient first diving into the topic, especially on the internet, is what Dr. Jason Engel calls the great paradox. On the one hand, prostate cancer is now often presented as always slow growing, not particularly dangerous or harmful, and that eventually every man gets prostate cancer. On the other hand, the fact remains that prostate cancer can be as aggressive and deadly as any other cancer, as it is the number two cause of cancer mortality in men in the United States today. So which one is true?

Anxiety

Ultrasound
A specific type of kidney obstruction that is seen not uncommonly in the adult population, and is common in the pediatric population, is called a ureteropelvic junction obstruction, or UPJ obstruction. We will not spend too much time here discussing the problem of pediatric UPJ obstruction other than to say it is usually found on pre-natal ultrasound, is the most common cause of a baby having a dilated kidney on such an ultrasound, and often requires surgery to correct it. In the pediatric population, almost always the cause of an UPJ obstruction is that the ureter, or the tube that connects the kidney to the bladder, is malformed where the ureter meets the kidney at an area called the renal pelvis. Since the muscular ureter propels urine towards the bladder with a rhythmic motion called peristalsis, this area of malformed ureter does not squeeze and thus in essence serves to obstruct the normal flow of urine.
MRI
The incidental discovery of a mass on the kidney has become a commonplace occurrence now that imaging modalities such as ultrasound, MRI and particularly CT scanning is so prevalent. It is of course very scary to be told that by accident a mass or lesion has been found on one’s kidney, and almost always in such a circumstance a patient will be referred for counseling or perhaps even surgery to remove the mass. It is important to remember however that many masses or suspicious lesions may not need to be removed, may not be cancerous, and even if cancerous are usually cured with removal alone.
Radiology
When coming for your consultation, please bring all pathology, radiology, and lab reports with you. As well, we encourage you to bring your spouse, family or significant other as usually these people are also integral to your education and decision process.
X-Rays
Nuclear Medicine
At the Urologic consultation, the patient must bring their imaging study. Here, we will not only look at the degree of hydronephrosis, but also get a sense as to whether chronic obstruction has led to kidney damage. Sometimes the damage is so severe that a determination must be made if the kidney is worth saving at all. The next study that will be ordered is called a renal scan, a nuclear medicine study that will allow us to quantify the degree of function in the affected kidney, as well as the exact degree of obstruction. Sometimes the degree of function will be borderline, the pain mild, or the kidney without damage. Such patients at times are followed with another renal scan to track the situation. Those where pain is severe, severe obstruction is found, or where the kidney is being damaged, are offered treatment.
Computed Tomography
However, some cysts can be classified as “complex”, and such cysts do carry some risk of malignancy. A CT scan with IV contrast is mandatory if at all possible in such circumstances so that the Urologist can assign a “Bosniak score”. This scoring system uses specific characteristics of the cyst like wall thickness, internal septations, calcifications and whether the cyst “enhances” to generate a score that predicts malignancy risk. A Bosniak 1 cyst is a simple cyst and would not be followed. A Bosniak 4 cyst is considered an enhancing renal mass and must be assumed to be malignant and thus treated accordingly. It is the intermediate grade complex cyst that requires judgment and counseling as to proper next steps. A Bosniak 2 cyst has a less than 1% chance of being malignant. They may or may not be followed based on the clinician’s judgment. A slightly more suspicious score is a Bosniak 2F, which will be malignant 5% of the time. These complex cysts are typically followed until complete stability is demonstrated over time. A Bosniak 3 cyst will be cancerous 50% of the time and unless there are co-morbidities that preclude surgery are usually dealt with in a similar fashion to solid renal/kidney masses.
Chemotherapy
If a primary tumor is found to be deeply invasive, there is at least a 50% chance of metastasis that has occurred, even if it cannot be found. Such tumors that are invasive into the deep muscle will necessitate removal of the bladder. Contemporary thinking is that giving chemotherapy prior to bladder removal may be beneficial in such cases (neoadjuvant chemotherapy). Dr. Engel will always arrange a visit to an oncologist to be offered this approach, but sees logic in some cases in proceeding with surgery directly and offering chemotherapy after the surgery based on the pathologic findings (adjuvant chemotherapy). Removal of ones bladder is a very involved, major operation done in specialized centers in most cases. Dr. Engel performs such operations regularly. He is one of a few Urologists in the area that performs complex urinary tract reconstruction to handle urination in a continent manner after bladder removal. In men, Dr. Engel performs a Studer ileal neobladder, whereas in women his preferred reconstruction is called an Indiana pouch. Many patients will opt for a simpler approach called an ileal conduit whereby the urine will flow into an ostomy bag placed on the patient’s abdomen. In men, removal of the prostate is usually also performed when removing the bladder, but in selected cases Dr. Engel will perform a prostate sparing cystectomy in an effort to preserve erectile function and potentially retain ejaculation. Feel free to view a video of Dr. Engel performing such a surgery found in the common procedures section of this site.
Radiation Therapy
Another urologic condition we see and treat regularly is urethral strictures. A stricture is primarily a problem of the male urethra, or the tube that carries urine through the prostate and penis. A stricture is essentially a scar that limits urine flow. The male urethra has several distinct anatomic segments, and it is valuable to go over them here briefly. Technically speaking, the urethra starts at the bladder base or neck, and travels through the prostate as the prostatic urethra. The most common cause for prostatic urethral strictures would be previous radiation therapy for prostate cancer or previous TURP. Just beyond this point, in the area which includes the voluntary urinary sphincter, is the membranous urethra. This can also be narrowed or scarred by radiation therapy, but is most commonly injured as a result of pelvic trauma or pelvic fracture. Repair of the membranous urethra is complicated, often resulting in incontinence, and will not be discussed further here.

Minimally Invasive Surgery
Urologic Surgeons of Washington (USW) has been providing the highest quality urologic care for patients from Washington, DC, Maryland, and Northern Virginia for over 20 years. Dr. Engel spent the earlier portion of his career introducing advanced minimally invasive surgery to the DC area. He founded the robotic surgery program at George Washington University Hospital, the first of its kind in the entire Mid-Atlantic region. Dr. Engel served as Vice Chairman and Clinical Director of Urologic Robotic Surgery at GW, and has authored over 20 papers and book chapters relating to his experience. To date he has performed nearly 3000 robotic procedures.
Vasectomy
In more recent years, Dr. Engel has not only maintained his penchant for robotic surgery and oncology as well as complex urologic reconstruction as applied to urethral strictures and Peyronie’s Disease, but has also expanded his robotic expertise to vasectomy reversal. He has added significant focus to the minimally invasive treatment of BPH and helping men with and without a history of prostate cancer treatment with erectile dysfunction and their incontinence with contemporaneous reconstructive techniques.
Robotic Surgery
Office procedures have distinct advantages. In our practice, most patients will choose these over more aggressive options, as part of the step-wise approach that we employ. However, as stated, office procedures have a lower success rate. In men where these fail, where a patient demands a higher success rate, or if there are anatomic considerations or medical complications of BPH that demand a more aggressive approach, there are several options in this category. We call these operating room procedures, and these will typically offer at least a 95% success rate and durability of 7 years or more. However, these will require anesthesia, and the preparation that goes into that, will have an approximate 1% chance of incontinence after the procedure, and will almost certainly create a situation where there will be no semen with ejaculation. Other risks would include bleeding and infection. The gold standard here is called the TURP, or trans-urethral resection of the prostate. Although the instrumentation is far more advanced and safe now, the TURP has been the mainstay operation in this category for over 50 years. When the prostate is quite large, perhaps 80 grams or higher, Dr. Engel will offer his patients a Robotic Simple Prostatectomy as the safest, quickest solution. HOLEP, or Holmium laser enucleation of the prostate, is employed by a few Urologists in this same setting, but due to Dr. Engel’s skill with robotic surgery, he does not find this to be the safest solution here. Laser procedures, such as Greenlight laser, HOLEP, and others, are included in this category because they require anesthesia, but typically produce inferior results to the TURP with more irritative symptoms unless the prostate is quite small. We usually see office procedures as better solutions in this setting. Again, please go to our Procedures section of this site to learn much more.
Laparoscopy
The contemporary mainstay of surgery for renal masses is laparoscopy, the act of performing abdominal surgery by inflating the abdomen with carbon dioxide, inserting a camera and several instruments that allow for surgery through small incisions with a rapid recovery. Once it is determined that treatment of a kidney mass is necessary, the next step is to review the actual films, usually a contrast CT, to determine if removing only the tumor is feasible. This is always the desired approach, and in Dr. Engel’s hands will always be attempted. In cases however where the tumor is in a central location, invades deeply into the center of the kidney, or if negative margins cannot be assured in the operating room, the entire kidney will be removed. One only needs one healthy kidney, so in such a circumstance the patient is not usually adversely affected.
Reconstructive Surgery
Finally, the area of the urethra just under the glans, just before the meatus, is called the fossa navicularis. Strictures in this area are seen often after a catheter or scope has been placed in a man’s urethra, for instance after a TURP. These strictures often respond to simple dilation, and if recurrent can easily be managed by self-dilation, although on rare occasion a reconstructive surgery is indicated.

Plastic Surgeons

Botox
Another type of incontinence typically seen in women, but at times in men also, is called urge incontinence. Urge incontinence is really just an end stage of the progression of overactive bladder. Here, the bladder is irritable perhaps due to vaginal wall atrophy, menopause in general, stress/anxiety, prostate obstruction in men, or for reasons unknown. What is happening is the bladder is deciding to squeeze on its own, and if the contraction is forceful enough, the patient simply cannot stop it and leaks on the way to the bathroom. Urge incontinence is primarily a medical problem, although we now also have botox injections or even implanted nerve stimulators than can be used as procedural alternatives best applied if oral medicines fail.

Cyst
Lesions
If a kidney lesion is a solid mass, particularly one that picks up blood and thus “enhances” on contrast CT, it is considered malignant until proven otherwise. In the era of CT scan however, masses are found at a much smaller size than ever before. Now, if a mass is small, less than 2 cm, up to 20-25% of such lesions may be benign. The most common benign renal mass is called an oncocytoma. Oncocytomas have a typical appearance when large, but when small look similar to malignancy. Another common benign renal mass, more common in fertile women, is called an Angiomyolipoma. Such masses often contain fat that can be demonstrated on CT allowing for a definitive diagnosis by X-Ray alone. Angiomyolipomas are usually followed unless greater than 4 cm in largest dimension. Such lesions are usually treated with percutaneous embolization and not surgery.

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