BackTable Urology

In this episode of Legends in Urology, Dr. Manoj Monga, chair of urology at UC San Diego, interviews Dr. Ralph Clayman, a world renowned minimally invasive urologic surgeon, about his path to medicine and perspectives on the future of urology.---SHOW NOTESFirst, Dr. Clayman speaks about his childhood in New Jersey and his extensive family background in medicine, which encouraged him to pursue a career as a physician. He attended Grinnell College in Iowa for undergraduate, then UC San Diego for medical school. Dr. Clayman then went to the University of Minnesota for his surgical residency. During his intern year, he decided to do a urology rotation and was drawn to the specialty instantly. He also explains how he met his wife in medical school and elements of a successful relationship.Next, he defines success, which he believes is the ability to solve problems creatively and with humility. Dr. Clayman also speaks about the future direction of urologic surgery, which he believes points towards improving and expanding upon minimally invasive surgery and medications to treat common conditions, such as kidney stones.Finally, he shares his life lessons he has learned, such as taking advantage of mentorship opportunities, delineating the separation of work and home life, and the importance of resilience.

In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Ruchika Talwar, a urologic oncology fellow at Vanderbilt University Medical Center, discuss her personal journey to becoming an advocate and how other urologists can get involved in policy making.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/wWaqJd---SHOW NOTESFirst, Dr. Talwar explains how she got interested in advocacy. Before college, she had always been interested in issues and causes, so she originally wanted to be a politician. After participating in a summer program, she realized she didn’t want to be a politician and instead pursued undergraduate majors in biology and legal studies. To her, medicine and politics were always intertwined. She was active in the American Medical Association (AMA) in medical school and the American Urologic Association (AUA) in residency.Next, Dr. Talwar explains what advocacy means to her, which is picking a topic and trying to make a broad impact. She chooses to advocate through organized medicine because she believes that organized medicine creates a unified voice necessary to guide politicians in making correct policy decisions. Although she participates in advocacy at a national level through AUA conferences and Capitol Hill visits, there are also other levels of advocacy to engage in, such as advocacy at the department or state level. She emphasizes that advocacy has helped her fight burnout, as she feels like she has a voice in the larger medical system.Dr. Talwar cites many historical examples of the benefits that advocacy from urological societies has brought to patients. For example, organized urology has done much to improve insurance coverage of PSA screenings and Medicare policies. During these times, she notes that updating and checking emails from the AUA and forwarding emails to colleagues is critical. Another way that urologists have been able to advocate for health equity is to share patient stories with lawmakers, which may make a bigger impact than sharing research statistics. She mentions that the AUA policy arm is able to connect urologists with their specific congressional representatives and sends out legislative priority surveys to AUA members. She encourages other trainees to get support from their program leadership to pursue advocacy by sharing tangible ways that they can improve their department and relaying patient stories. The doctors also discuss differences in generational perspectives when it comes to advocacy. Older generations of urologists may not think the AUA should play an active role in policy making, but younger generations think AUA should be more active in policy making. Dr. Talwar encourages younger urologists to apply for leadership positions, especially female and minority urologists.Finally, the doctors discuss the upcoming AUA Summit, an annual fly-in advocacy event. During this conference, urologists will be able to decide the AUA’s legislative policies for the year, such as coding and reimbursement, retention and diversity of workforce, and research funding. Urologists will be able to meet with their congressional offices and representatives as well.---RESOURCES6th Annual AUA Summit Registration:https://www.auasummit.org/AUA Public Policy & Advocacy Committees:https://www.auanet.org/about-us/aua-governance/committees/public-policy-and-advocacy-committees

In this episode of BackTable Urology, Dr. Aditya Bagrodia, Dr. Ari Hakimi (Memorial Sloan Kettering Cancer Center), and Dr. Nirmish Singla (Johns Hopkins University), discuss the value and indications for germline testing in renal cell carcinoma (RCC).---SHOW NOTESFirst, the doctors explain basic information about germline mutations and kidney cancer. Although historical data has shown that 5% of kidney cancers are inherited, recent efforts to increase testing through commercial testing and large scale efforts at cancer centers have proven that 8-10% of kidney cancers are inherited. Von Hippel Lindau (VHL) syndrome is the most prototypical kidney cancer predisposition syndrome, but there are other less common ones as well. Extrarenal manifestations of VHL syndrome include pancreatic tumors, pancreatic cysts, pheochromocytomas, retinoblastomas, and CNS hemangioblastomas. These tumors have a variable penetrance, but African Americans and women are more likely to have hereditary RCC. The doctors recommend asking newly diagnosed RCC patients about a broad spectrum of their family history that includes cancer and non-malignant conditions, such as uterine leiomyomata. Dr. Hakimi notes that some patients will confuse germline testing with somatic tumor testing, so urologists will have to explain to patients that the VHL mutation was found in their tumor, not in their blood or saliva.Extended physical exams to look for syndromic conditions can also be performed. A thorough cutaneous exam to look for fibrofolliculomas, leiomyomas, facial angiofibromas, and cafe-au-lait spots can help indicate the presence of a familial syndrome. According to guidelines, all patients diagnosed with RCC under 46 years of age should be recommended to have germline testing. Dr. Bagrodia mentions that having experienced genetic counselors and setting up thorough dot phrases to send to patients explaining their results is helpful for him. Dr. Singla adds that medical geneticists have the ability to counsel the patients more extensively on the risks and benefits of giving consent to go forward with genetic testing. They can also provide psychosocial support and education for the patients.The doctors then move on to discuss how germline mutations may lead to different treatment modalities. Precision surgery, or utilizing pretest probability information about a tumor to guide surgical approach, may be possible with germline testing. Additionally, testing may help surgeons to decide whether to perform a retroperitoneal lymph node dissection (RPLND). Next, the doctors discuss belzutifan, which is an oral drug used to treat VHL familial syndrome tumors. Finally, they discuss the use of tumor sequencing for research purposes and share what they are most excited for in the field of RCC research.

In this episode of BackTable Urology, Dr. Aditya Bagrodia, Dr. Kara Watts (Montefiore Medical Center), Dr. Minhaj Siddiqui (University of Maryland), and Dr. Arvin George (University of Michigan) discuss active surveillance for prostate cancer.---SHOW NOTESFirst, the doctors discuss workup for prostate cancer. They usually obtain an MRI prior to the diagnostic biopsy, but this decision may change in the face of inadequate infrastructure, insurance, and resources. Dr. Siddiqui notes that patients may be distressed when first hearing about their diagnosis, as prostate cancer may be the first serious illness they’ve been diagnosed with. Dr. George recommends discussing the diagnosis in person after pathology is confirmed. Additionally, Dr. Bagrodia uses the WellPrept app to send patients educational material about prostate cancer before they meet with him again.Next, they discuss the general regimen for active surveillance patients within the first year of diagnosis. Dr. Watts orders an MRI 6 months after the diagnostic biopsy because inflammation from biopsy may be present in the first couple of months. Dr. Minhaj believes that deciding on when to do an MRI scan also depends on the patients’ preferences and personalities. They also discuss different types of biopsies and the use of confirmatory biopsies. The doctors also agree that removing the term “cancer” from grade group 1 prostate cancer could potentially minimize financial toxicity and patient anxiety. For patients who still want to pursue treatment, Dr. Bagrodia believes that urologists should have the refusal to treat patients who push for inappropriate treatment.Finally, the doctors consider additional factors that may encourage them to consider treatment in low grade prostate cancer, such as a family history of cancer, BRCA mutations, lower urinary tract symptoms, and select molecular biomarkers and pathology characteristics. Dr. George states that the designation of high versus low volume cancer does not matter and should not be a trigger for treatment. Dr. Minhaj notes that for him, younger age is a stronger indication for active surveillance in order to avoid the morbidity of treatment.Finally, the doctors explain their personal active surveillance regimens and tips for transitioning patients with more serious conditions off of active surveillance once their prostate cancers have been proven to be stable.---RESOURCESWellPrepthttps://wellprept.com/

In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Todd Morgan, chief of urologic oncology at the University of Michigan, about benefits and indications for germline testing in prostate cancer patients.---SHOW NOTESFirst, the doctors discuss the formal definition of germline testing, which is identifying inherited DNA mutations known to be pathological. This is different from molecular testing, which detects molecular markers specific to tumor cells. The term “genomic testing” is a broad and vague term that may confuse patients. Germline testing may be beneficial to patients and their families by notifying them to undergo cancer screening earlier. 12% of metastatic prostate cancer patients and 5 to 10% of localized prostate cancer patients have a germline mutation.Next, they discuss critical criteria for germline testing besides having a high grade and high stage cancer. Dr. Morgan recommends germline testing for all prostate cancer patients with metastatic cancer. He also believes that taking a thorough family history is fundamentally important in deciding whether or not to order testing. He emphasizes the importance of collecting information about other family members with other types of cancer, their age of diagnosis, their relationship to the patient, and their mortality from cancer. Patients may not know family history well, but he has a low threshold of testing if he suspects a pattern of heritability.Then, Dr. Morgan explains how germline testing may affect decision making. For patients with localized and low risk disease, he notes that prompt treatment may be beneficial in patients with a BRCA2 mutation, but there is still not enough evidence to eliminate active surveillance as an option. For high-risk disease, he always recommends treatment over active surveillance, regardless of germline mutation. For patients who have a BRCA2 mutation but no diagnosis of prostate cancer, he counsels them in his high risk prostate clinic. These patients receive close screening measures, such as lower PSA level thresholds, identification of urine biomarkers, and MRI scans.Additionally, the doctors discuss various testing companies. They do not recommend using 23 and Me as a comprehensive screening panel because it is exceedingly limited in the germline mutations it tests. Dr. Morgan also emphasizes that as the ordering physician, he is responsible for giving the patient the result of the test. If there is a positive result on germline mutation testing, he refers the patient to genetic counselors, who are equipped to deal with conversations regarding mutations that have non-urological implications as well. Finally, they end the discussion by chatting about different research trials about germline testing.

In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. David Penson, professor and chair of urologic oncology at Vanderbilt University, about the indications and benefits of surgery for high risk prostate cancer.---SHOW NOTESFirst, Dr. David Penson gives the traditional definition of high-risk prostate cancer, which is a PSA level over 20 ng/mL, a Gleason grade greater than 10, and a cancer staged at T2 or higher. However, he notes that in recent years, a more heterogeneous criteria has developed, so some patients with a Gleason grade greater than 8 and a T3 stage can also be considered high risk. Dr. Penson believes that pathological analysis is the best criteria to use when assessing risk and also uses MRI to distinguish between T2 and T3 patients and look for the median lobe before surgery. In his personal experience, he has noted that some patients will find online information about prostate cancer as a relatively benign chronic disease. For patients with high risk cancer, it is important to emphasize that the conventional active surveillance approach for low risk prostate cancer will not be beneficial. Both doctors agree that sending their patients curated, quality information is important and recommend using the WellPrept app. The doctors also discuss different imaging modalities involved in staging, such as PSMA PET scan, a bone scan, and prostate MRI. Before surgery, patients may receive neoadjuvant treatment. In the past, GnRH agonists were used, but long term data showed that patients receiving this type of therapy in addition to surgery had the same recurrence rate as patients who underwent surgery alone. Recently, newer neoadjuvant treatments, like PARP inhibitors, have been developed.Next, Dr. Penson speaks about choosing surgery versus radiation therapy (RT) as a primary treatment. The main risk of prostatectomy is its impact on continence and sexual dysfunction. The downside of radiation therapy is that the possibility of surgery as a therapeutic option is eliminated and its side effects, such as irritating urinary symptoms. Dr. Penson also notes that nerve sparing prostatectomies may be cancer sparing. In his opinion, if patients have impotence at baseline, nerve sparing surgery is not beneficial because of the risk of leaving positive margins. Contraindications to surgery include rectal involvement, a history of multiple abdominal surgeries, severe heart disease, bladder neck involvement, and a high volume nodal disease. Ideal prostatectomy patients are ones who have high grade disease contained in the prostate (T2) and patients with preexisting lower urinary tract symptoms (LUTS).Finally, the doctors discuss the use of nomograms to determine the extent of cancer control and the need for additional therapy. Dr. Penson has limited use for nomograms. He believes that they can generally be used to predict mortality, but not cure rates. He prefers to base prognosis on postoperative results. If the postoperative pathology report comes back with widely positive margins or bladder neck involvement, he discusses RT as an adjuvant treatment with his patients. For this reason, he emphasizes the need for collaboration with radiation oncologists and multidisciplinary tumor boards.---RESOURCESWellPrept App:https://wellprept.com/

En este episodio de BackTable Urology, Dr. Jose Silva entrevista a Dr. Ramphis Morales sobre su trayecto de ser urólogo reconstructivo y su práctica privada de cirugía de afirma de género en Puerto Rico.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/GRW13w---SHOW NOTESPrimero, Dr. Morales discute términos básicos en la comunidad transgenero desde el punto de vista médico. Prefiera usar el término “afirmación de género”, en vez de "reasignación de género” o “cambio de género”. Tambien, enfatiza la diferencia entre el sexo y el género. Entonces, explica por qué escogió un programa de urología reconstructiva en Temple University. Aunque ocurrió la pandemia de COVID-19 en 2020, recibió la oportunidad de aprender sobre la cirugía de afirma de género bajo la tutela de buenos mentores.Próximo, él discute el proceso gradual de establecer su propia práctica privada dedicada a ayudar a los pacientes transgéneros. Se dio cuenta de que había una falta de urólogos en Puerto Rico y quería ofrecer un servicio discreto pero muy necesario a la isla. Adicionalmente, explica su proceso de evaluación inicial de sus pacientes. Primero, un paciente necesita un diagnóstico de disforia de género. La mayoría de sus pacientes ya empiezan la terapia hormonal antes de pedir la cirugía. Dr. Ramphis nota las preferencias del paciente, diferencias anatómicas, y niveles de hormonales anormales antes que la cirugía también. Adicionalmente, los médicos discuten la colaboración con otras especialidades. Dr. Morales opina que la reconstrucción genital es el trabajo del urólogo, debido a su conocimiento profundo de la anatomía. Sin embargo, explica que hay un rol para la cirugía plástica en reconstrucción de otras partes del cuerpo y también en microcirugías involucrando los “free flaps”.Finalmente, Dr. Morales refleja las complicaciones que ha visto como resultado de reconstrucción genital, como estenosis de canal después de vaginoplastia y vaginectomía incompleta. Menciona también la importancia de cuidar la salud de la próstata, porque los hombres transgéneros pueden desarrollar cáncer prostático también. Por eso, es importante educar a médicos y pacientes sobre este tema importante. Los doctores terminan el episodio con una discurso sobre el futuro de la práctica privada de Dr. Morales y la posibilidad de establecer un programa educativo de reconstrucción genital para los residentes médicas.

In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Marc McGuire and Patrick Scheffler about their personal experiences with prostate cancer, from diagnosis to remission.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/y6LGqe---SHOW NOTESFirst, Marc and Patrick share how they were initially screened for prostate cancer using PSA levels. When both of their labs showed elevated PSA levels, they were surprised because they had no symptoms of cancer. Then, they share how they felt while awaiting consultation with a urologist after their lab results. Both of them tried to educate themselves about PSA levels and prostate health and spoke to different medical professionals in the meantime. Although Dr. Bagrodia notes that many men hold back abnormal PSA results from their families because of uncertainty or stigma, both men agreed that their families were their biggest support system during this time.Then, Marc and Patrick discuss receiving the results of the prostate biopsy. Both men emphasize the importance of having a positive attitude and being proactive about making treatment plan decisions. Marc encourages patients and their families to have a list of questions ready for the urologist in order to stay organized. Dr. Bagrodia adds that he sends resources to patients before meeting with them, so they can educate themselves before he has the first discussion about their diagnosis. He also emphasizes the importance of vetting educational materials before sending them out.Next, the men reflect on how they chose a treatment option for their prostate cancer. Both of them decided to enroll in clinical trials and also underwent nerve-sparing prostatectomies. They both agree that different specialties have different opinions on how their cancer should be treated, so multidisciplinary teams at tumor boards often come up with the best approach to present to patients. Marc emphasizes that patients should be proactive and not push decision-making onto their physicians. Patrick also discusses how he mentally prepared himself for the side effects (i.e. urinary incontinence, erectile dysfunction) after his prostatectomy.Additionally, Patrick and Marc explain how they felt when receiving various follow up PSA draws and scans after surgery. Dr. Bagrodia notes that follow up measures may cause patients lots of anxiety as well. Marc and Patrick both emphasize the importance of a positive attitude during the post-operative period. Lastly, they discuss germline testing for familial conditions and agree that it provides more knowledge and preparation for their children, who may benefit from earlier screenings and treatments.

In this episode of BackTable Urology, Dr. Esther Han (USMD Hospital) and Dr. Richard Santucci (Crane Center) discuss genital gender affirming surgery techniques and postoperative management.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/ij2MdK---SHOW NOTESFirst, Dr. Santucci discusses his career pivot from academic trauma reconstruction to private practice gender affirming reconstruction. After 17 years at Detroit Medical Center as director of trauma reconstruction fellowship, he left his position to learn gender-affirming surgery at the Crane Center in Austin, Texas. He was drawn to gender affirming surgery because of the dynamic techniques and novel research in the field. Next, the doctors review of vocabulary for transgender patients. Dr. Crane notes that vocabulary is always changing and advises doctors to not assume a patient’s gender or surgical preferences based on appearance. Additionally, Dr. Han explains why using the word “normal” over medically correct terms can confuse and cause discomfort in patients.Next, Dr. Santucci summarizes the gender affirming surgeries he performs. He explains trans women surgeries, such as full vaginoplasty and vulvoplasty. In trans men, he performs metoidioplasty and phalloplasty. However, Dr. Santucci emphasizes that patients are given the freedom to customize their own surgeries by picking which anatomical parts they would like to keep, change, or remove. Complications, such as urethral strictures and infections may occur in all these surgeries. Additionally, he emphasizes the need for addressing fertility with trans men, as some of them would like to keep their ovaries for egg harvesting.Then, the doctors discuss the recent change in World Professional Association for Transgender Health (WPATH guidelines), which now only require one letter from a therapist instead of two in order to receive genital surgery; however, insurance companies may require more letters. The doctors also contemplate the presence of post-operative regret, since gender affirming surgery is difficult to reverse. Dr. Santucci explains that regret is often tied to postoperative complications.Then, he delves deeper into the management of phalloplasty complications, such as postoperative incontinence, postoperative infections, and erosions. He also emphasizes the importance of prostate cancer screening for trans women. Although it is rare, the prostate cancer they develop is testosterone independent, making it more difficult to treat and more aggressive.Finally, Dr. Santucci shares what a typical week in his life looks like and reflects on how multidisciplinary collaboration in the OR has made his operations more efficient and effective.

In this episode of BackTable Urology, Dr. Jose Silva and Dr. Petar Bajic speak about various ways that the men’s health field is evolving, such as the rise of direct-to-consumer services, the need for more community urologists, and ways to de-stigmatize common men’s health conditions.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/AcDjsu---CHECK OUT OUR SPONSORReviveRXhttps://reviverx.com/urology/---SHOW NOTESFirst, the doctors discuss the popularity of direct-to-consumer (DTC) healthcare. Both doctors agree that this option may seem appealing to some patients because of anonymity, privacy, and convenience. However, Dr. Bajic notes that DTC services may be dangerous because DTC services do not routinely identify red flags of other major medical issues and do not provide preventative health care or routine screenings. Additionally, Dr. Silva and Dr. Bajic reflect on their own experiences of treating patients who have experienced avoidable complications after receiving DTC treatments and prescriptions. Furthermore, they brainstorm ways to educate patients about dangers of DTC medications without proper medical consultations. They agree that spreading awareness to patients and families and breaking down boundaries that men may have about incontinence and erectile dysfunction may be good places to start. However, Dr. Bajic notes that there is a beneficial role in integrating licensed medical care with the use of e-pharmacies to lower the cost of medications for patients.Next, they discuss the growing need for community urologists in rural and urban areas. They weigh the pros and cons of a shorter surgical residency and the creation of purely medical urology fellowships. Then, they discuss potential a need for advanced practice providers and implications for the scope of urological practice.