BackTable Urology

In this episode of BackTable Urology, Dr. Aditya Bagrodia invites Dr. Yair Lotan, professor of urologic oncology at UT Southwestern, and oncologist Dr. Suzanne Cole to discuss types of adjuvant treatment for high risk bladder cancer, including chemotherapy, radiation therapy, and immunotherapy.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---SHOW NOTESFirst, they discuss the benefits of neoadjuvant chemotherapy for bladder cancer, which includes a 5-10% absolute advantage and a 20% reduction in likelihood of dying. They also discuss potential barriers to neoadjuvant chemotherapy and the importance of having a discussion with a medical oncologist to determine eligibility for cisplatin-based treatment, such as MVAC chemotherapy. Next, they explore the differences between adjuvant and salvage therapy, as well as how to approach post-operative complications and counseling; it is important to discuss the risk of disease recurrence and initiate conversations about future chemotherapy early in treatment.Then, the doctors explore when to consider immunotherapy instead of cisplatin-based chemotherapy, the success rates of chemotherapy treatments, and the potential of cell-free DNA testing to predict outcomes. They consider the implications of false negatives and false positives and agree that clinical trials are important to gain a better understanding of the technology and how it could be used in personalized medicine. They also discuss when radiation therapy is appropriate for recurrence in the retroperitoneum and the use of metallic clips to create a target zone for radiation oncologists.Finally, they consider the difficulty of convincing patients to accept additional therapy and the lack of level 1 evidence for adjuvant therapy. However, they remain optimistic about the progress being made with upper tract studies, innovative new treatments, and the potential of biomarkers to predict response.

In this episode of BackTable Urology, Dr. Silva invites Dr. Ronald Cadillo to speak about the realities of reconstructive surgery and bladder neck reconstruction and explore the challenges of transitioning from performing oncologic surgeries to reconstructive surgeries.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/plWnX7---SHOW NOTESFirst, Dr. Cadillo shares his journey from being a urologist in Peru to coming to the United States in search of a better opportunity to help his family. Then, he discusses his experience of transitioning from open to robotic surgery. He discusses his experience with interviewing at programs and how he felt in the moment of being accepted into the robotic program at the University of Pennsylvania. Next, he describes the experience of completing a robotic boot camp.Dr. Cadillo faced challenges when returning to Puerto Rico, where there was a greater need for oncology and reconstructive surgeries. He learned that having a healthy obsession when learning new techniques is important, as well as having adequate resources, such as videos and mentors. In his opinion, practice and experience are the most important components of successful reconstructive surgeries. He then shares how he used mentorship and collaboration to deal with complex cases. Finally, he explains how the field of reconstructive urology in Puerto Rico has changed in the past four years with the arrival of a new generation of young urologists.

This week on the BackTable Urology Podcast, Dr. Jose Silva invites Dr. Seth Bechis onto the show to discuss the diagnosis and treatment of BPH with Rezum, a minimally invasive surgical that uses water vapor to dissolve prostate tissue.---CHECK OUT OUR SPONSORBoston Scientific Rezum Water Vapor Therapyhttps://www.bostonscientific.com/rezum---SHOW NOTESFirst, the doctors emphasize the importance of establishing a relationship between primary physicians and urologists to improve the referral times of patients with BPH. They also discuss how involving patients in the cystoscopy process can help them with the decision-making process and maintaining better bladder health in the long run.Then, Dr. Bechis summarizes current BPH treatments, and how to effectively manage post-treatment patient expectations. He emphasizes the importance of over preparing patients for the potential side effects of BPH treatments, and strategies for adjusting their expectations. They also discuss the ideal candidates and prostate sizes for Rezum therapy. Additionally, Dr. Bechis discusses the technical aspects of the procedure, including his anesthesia regimen, needle placement, antibiotic prophylaxis, and postoperative care.Finally, they explain the importance of following up on a PSA test annually after a prostate procedure and how to manage anxious patients who may be checking their PSA too frequently. As urologists, they have to counsel patients upfront about all of their options, so having flexibility to take different paths is helpful if their priorities change. Lastly, they touch on the idea of performing prophylactic procedures as a preventative measure.

On this episode of BackTable Urology, Dr. Jose Silva and Dr. Jay Simhan, director of reconstructive urology at Fox Chase Cancer Center, discuss how urologists can demonstrate their value to hospital systems.---SHOW NOTESFirst, Dr. Simhan explains the changing nature of urology practice. He opts for the term “health systems urologist” over “private practice urologist” because many urologists are managed by smaller medical groups that are owned by larger hospital groups. He notes that this multi-tiered system of management can cause tension around decision making and increase senior leadership turnover when hospital finances change.Then, Dr. Simhan explains the four ways that doctors can generate value, which is clinical productivity, departmental service, academics or research, and teaching. Clinical productivity is often measured by the RVU system, which assigns a certain number of value units to a procedure. Hospital systems may encourage urologists to choose surgical procedures over office-based procedures to increase RVUs. Although RVUs are arbitrarily set by the Centers for Medicare & Medicaid Services (CMS), each hospital or medical group can increase the number of RVUs per procedure to their own discretion. Dr. Simhan believes that urologists should band together to negotiate fair RVU systems.Finally, they end the episode by discussing concrete ways to demonstrate value as a urologist. Generally, minimizing complications and maximizing RVUs is helpful. Dr. Simhan advises urologists who are joining a new system to build their name and referral network to earn a long term contract. Usually, there is no RVU requirement in the first employment contract. In the later years, he recommends putting in the effort to understand productivity metrics and downstream costs and revenues in order to maximize earnings and potential.

On this episode of BackTable Urology, Dr. Jay Shah (Stanford University) and Dr. James McKiernan (Chair of Urology, Columbia University / New York Presbyterian Hospital) discuss practical tips to develop and maintain successful mentor-mentee relationships in medicine.---SHOW NOTESFirst, Dr. McKiernan explains how he started his mentorship journey, which started when he began to build a research team. He explains that the residents and medical students received advice from him while working on his team. He notes that forced mentor-mentee relationships never work because both sides need to have shared priorities and values. His decision to take on a mentee depends on whether the trainee in question could potentially benefit him and the field of urology as a whole. For a mentee to fulfill these criteria, they must show interest in projects, have willingness to put time into the relationship, and complete all tasks to the best of their ability.Next, Dr. McKiernan discusses how organizations can develop successful mentorship programs. He suggests building in structured, recurring meetings for both sides to prioritize the relationships. He also notes that hiring faculty members who want to mentor and who prioritize using their protected time for education can greatly increase the ease of establishing a mentorship program. He also discusses the importance of racial and gender diversity in leadership positions, but does not think that they should be barriers to mentorship. Finally, he emphasizes that mentorship meetings are not performance evaluations, as discussions should focus on the future goals and priorities of the mentee.

On this episode of BackTable Urology, Dr. Jose Silva invites endocrinologist Dr. Rodrigo Valderrabano onto the show to discuss the impact of testosterone replacement therapy on hypogonadic patients and prostate cancer survivors.---SHOW NOTESFirst, Dr. Valderrabano explains the role of testosterone in the body, which is to create the male phenotype and to maintain sexual function and muscular strength. There is a strong relationship between bone building and testosterone, as testosterone is converted to estrogen to maintain bone density. He then explains what constitutes low testosterone, which is difficult to define due to testing imprecision, fluctuating hormone levels throughout the day, and other comorbidities, like obesity. To be diagnosed with hypogonadism, patients will need at least 2 lab tests and display clinical symptoms as well. For all patients who are interested in starting testosterone replacement therapy (TRT), Dr. Valderrabano measures total and free testosterone, sex hormone binding globulin, and LH and FSH to determine if the patient has primary hypogonadism or secondary hypogonadism.Next, the doctors discuss different methods of testosterone delivery, such as injections, gels, patches, pellets, pills, and intranasal sprays. Dr. Valderrabano prefers to use gel, as it mimics the natural daily release of the hormone and results in less pituitary interference. However, he notes that the patient must be careful not to transfer the gel onto household contacts. Dr. Silva prefers to give testosterone injections. Then, the doctors discuss how recent literature disproves the claim that testosterone replacement therapy causes BPH/LUTS symptoms.Finally, Dr. Valderrabano speaks about his research trial focused on giving TRT to prostate cancer survivors who have hypogonadism. His patient cohort includes prostate cancer patients who have a low risk of disease recurrence are at least 2 years into remission, have normal PSA levels, and are on no other hormone therapy treatments. His main outcomes are physical and sexual health. He also explains his data collection methods and collaboration with other institutions. Lastly, he emphasizes that physicians must collaborate with their patients to balance the risk of disease recurrence and their quality of life to determine if TRT is a good option for them.

On this episode of BackTable Urology, Dr. Aditya Bagrodia, Dr. Ranjith Ramasamy, and medical student Farah Rahman discuss effective and meaningful ways to build a productive team in medicine.---SHOW NOTESFirst, Dr. Ramasamy recounts his journey to becoming a mentor for medical students. Initially, he found difficulty in finding peer relationships in academic medicine, so he started mentoring medical students. After seeing one of his mentees help out another student, he saw a benefit in building his own team in order to indirectly help more students outside of the traditional one-on-one mentoring model. He explains which qualities are most important for team members to have and has an open door policy and open communication with every team member. Farah adds that including many stages of trainees in the team with different skill sets is also useful. She emphasizes the importance of collaboration as the foundation for a productive team.They also discuss ways to resolve conflicts, like communicating expectations about professional duties and checking in periodically and frequently with team members. Farah adds that mentors should know their mentees’ strengths and weaknesses and steer them away from opportunities that are not helpful. Dr. Ramasamy notes that having a good work life balance and encouraging students to do the same is also beneficial. Finally, they discuss the value in branding a team and the power of social media to reach out to new team members and patients.

On this episode of BackTable Urology, Dr. Aditya Bagrodia, Dr. Matt Allaway (Perineologic Biopsy), and Dr. Juan Javier-DesLoges (UC San Diego) discuss benefits and procedural tips for the transperineal prostate biopsy.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/6Pc55q---SHOW NOTESFirst, the doctors discuss why they invested in learning to perform transperineal biopsy. Dr. Allaway explains that transrectal biopsy can lead to rectal bleeding, infections, and sepsis. He also believes that the perineal approach offers the proper trajectory to sample the prostate appropriately. Next, they discuss the equipment required for transperineal biopsies, such as probes, ultrasounds, grid steppers, and needle sheaths. They weigh the pros and cons of performing the procedure in the office versus in the clinic. Additionally, they discuss different costs and features of different probes.Next, they discuss their techniques for obtaining the transperineal biopsy, including tips for patient positioning, probe maneuvers, and local anesthetic injections. Dr. Javier-DesLoges uses a local injection of lidocaine, normal saline, and sodium bicarbonate. Dr. Allaway then shares his advice on how to deal with obstacles, such as stool burden and rectal gas. They end the episode by highlighting the importance of collaboration and learning from others’ techniques. Dr. DesLoges strongly recommends the AUA course on transperineal biopsies as an educational resource.---RESOURCESPerineologichttps://perineologic.com/aboutpl-2/

On this episode of BackTable Urology, Dr. Mike Hsieh (UC San Diego) interviews Dr. Larry Lipshultz (Baylor College of Medicine) about his journey to becoming a renowned specialist in male infertility and reproductive medicine.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---SHOW NOTESFirst, Dr. Lipshultz explains how he became interested in urology through working in a basic sciences surgery laboratory with a urologist. He became passionate about doing research in male infertility as an intern after hearing a Grand Rounds lecture. Before his residency ended, he was sent to El Paso, Texas by the military, where he was able to start his own semen analysis laboratory to treat male infertility patients. He then accepted an AUA fellowship and followed a mentor to UT Houston for training in male infertility. He eventually transitioned to Baylor College of mEDICINEand stayed after fellowship to join the faculty.Next, Dr. Lipshultz reflects on major events in his life, such as the opportunity to perform trailblazing surgeries, like gender-affirming surgeries and vasovasostomies, and graduating productive male infertility fellows. He gives advice on balancing clinical duties and research, the importance of goal setting, and mentoring junior faculty.Finally, the doctors discuss the future of men’s health. Dr. Lipshultz disagrees with the concept of direct-to-consumer marketing and “low T clinics”, as he believes they do not exist to serve the patient’s best interest. He is excited about new research implicating that testosterone may have other health benefits besides treating erectile dysfunction and that male infertility may be an indirect measure of men’s health. He encourages urologists to explore running their own IVF clinics and incorporate biotechnology into their practices as well.

On this episode of BackTable Urology, Dr. Aditya Bagrodia, Dr. Daniel Costa (UT Southwestern), and Dr. Xiaosong Meng (UT Southwestern) discuss patient selection and procedure for TULSA-PRO, a new transurethral ultrasound ablation system that incorporates real-time MR imaging, as a focal treatment option for prostate cancer.---CHECK OUT OUR SPONSORProfound Medical TULSA-PROhttps://profoundmedical.com/---SHOW NOTESFirst, the doctors discuss the benefits of using MRI with transurethral ultrasound ablation (TULSA), which include direct visualization of anatomy, margins, and boundaries. They compare TULSA to other forms of focal management, such as cryoablation, brachytherapy, stereotactic body radiation therapy (SBRT). Compared to these methods, TULSA has lower risk of rectourethral fissures and preserves the posterior plane better, making salvage procedures more viable.Then, the doctors discuss ideal candidates for TULSA therapy, which include patients with intermediate risk and localized disease, patients with lesions in lateral or anterior portion of prostate, patients with medium sized prostates, low risk patients with lower urinary tract symptoms (LUTS) who do not want to undergo active surveillance. Patients with large calcifications may not be ideal candidates for TULSA, as the calcifications can be a shield for the ultrasound beam. The doctors recommend ordering a CT/MRI scan first to identify if calcifications are present to assess their sizes and locations. During imaging, it is also important to make sure the tumor is not close to key anatomical elements, such as the neurovascular bundle. When deciding between different focal therapies, it is important to balance oncological outcomes and quality of life preservation. Thus, the treatment decision should be a collaboration between patients, their families, the radiologist, and the urologist. The doctors also discuss special considerations for salvage therapy patients, brachytherapy patients, patient with urethral strictures, and patients with a prior history of TURP.Next, the doctors explain how to prepare patients for TULSA. The patient’s colon has to be emptied in order to reduce MRI noise during the procedure. Additionally, the doctors help patients understand the immediate side effects of the procedure, which can include reduced semen volume, urgency incontinence from bladder and prostate irritation, and temporary erectile dysfunction, and semen retention. After the procedure, the urinary catheter will have to be left inside for five days to two weeks, depending on the volume of the prostate removed. There is a 20-25% chance of recurrence.Finally, they discuss specifics of the TULSA procedure. Dr. Costa and Dr. Meng perform these procedures at the university hospital, as they need access to MRI and anesthesia. They discuss the optimal MRI window for the procedure, patient positioning, as well as their two sweep method. The total procedure time is dependent on the volume of ablation and number of sweeps, but the average total time is 3 hours. Patients are discharged on the same day, and no narcotics are prescribed. Finally, they discuss the progress of a new prospective multi-center randomized trial comparing focal TULSA therapy to surgery for intermediate risk prostate cancer patients.---RESOURCESTULSA Procedurehttps://tulsaprocedure.com/tulsa-procedure/about-tulsa-procedure/Profound Medicalhttps://profoundmedical.com/