BackTable Urology

In this episode of BackTable Urology, Dr. Jose Silva interviews Dr. Peter Steinberg, director of quality and safety in the Division of Urology at Beth Israel Deaconess Medical Center, about practical tips and his personal experience in improving quality and safety.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/dyLGud---SHOW NOTESFirst, Dr. Steinberg explains how he found quality and safety as his niche in academic medicine. He was named in a malpractice lawsuit as a resident, which encouraged him to think about safety and complications in OR. Furthermore, he became interested in root cause analysis at his institution and discovered that he was skilled at improving the efficiency and results of a process.Next, he and Dr. Silva define and discuss quality, which they agree is delivering safe and effective outcomes in efficient time and lower cost to patients. Quality includes getting rid of waste processes, such as patients waiting for too long, not utilizing physician talent, extraneous movement within a system, and extra steps in a process in general. Dr. Steinberg explains that although surgeons already think in an efficient and high quality manner, they are underrepresented in quality and safety discussions. If solutions are simple, he encourages members of a healthcare team to deal with issues themselves or within their direct teams. For bigger problems with more complex solutions, challenges arise if higher administration needs to get involved to implement solutions. However, he gives a few tips for speaking with administration, such as speaking administrative language and performing an impact effort matrix to find high impact projects with low effort. Additionally, he shares acronyms for quality improvement projects, like SMART goals (specific, measurable, achievable, relevant, timely) and PDSA cycles of improvement (plan, do, study, act ).Next, he defines safety as the process of minimizing errors in order to meet a promised standard of care. Safety events can include preventable harm, adverse events, and near misses. Some big areas where safety may be compromised are medications, universal protocols, support staff and equipment, patient selection, use of techniques/maneuvers, and fire safety. To ensure the correct patient and side for operations, he encourages the use of two identifiers and time out procedures, even for in office procedures. He always reads labels and sticker labels for his medications. Furthermore, he encourages private practice doctors to engage in some form of M&M boards to categorize their complications, like in academic centers. Finally, he summarizes that safety issues are often systemic and undetectable instead of the result of a single action.

In this episode of BackTable Urology, Dr. Jose Silva interviews Dr. Jonathan Clavell, a men’s health specialist, about workup and treatment options for Peyronie’s disease.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/6wT7AR---CHECK OUT OUR SPONSORReviveRXhttps://reviverx.com/urology/---SHOW NOTESFirst, Dr. Clavell explains that Peyronie’s patients have extremely variable presentations. They can have distal or proximal curvatures, penile shortening, pain, hourglass deformities, and calcified plaques. However, Dr. Clavell believes that listening to the patient is the most important thing a urologist can do, as most patients take years to seek treatment and may be very distraught about their diagnosis. He notes that most men he sees are already in a stable phase (3 months of no change in curvature), as they are referred to him by other urologists. He also notes that penile pain is not unique to Peyronnie’s disease; patients need to also have an acquired penile deformity as well to be given an accurate diagnosis.Dr. Clavell emphasizes that the treatment option and duration should be based on the degree of bother and degree of erectile function, instead of by the degree of curvature. Then, Dr. Clavell summarizes the surgical and non-surgical options for Peyronie’s disease. He notes that medications, such as pain medication and Cialis are always available. Additionally, non-pharmacological penile rehabilitation therapies, such as traction therapy and vacuum therapy have helped some of his patients. He notes that traction therapy combined with Xiaflex injections can be useful in patients who can still maintain good erections; however, injections should not be used in men with erectile dysfunctions or calcified plaques. In these patients, a penile prosthesis is indicated.Other complex cases that will require surgery are Peyronie’s patients with severely calcified plaques, severe deformities, two points of angulation, corporal wasting, and an unstable penis. Besides penile implantation surgery, two other surgical options for Peyronie’s disease are grafting and plication surgery. The risks of all surgeries should be discussed with patients. Finally, Dr. Clavell explains his advanced surgical techniques for penile implant surgeries, such as alternative incision sites and the modified sliding technique.---RESOURCESDr. Clavell’s Youtube Channel:https://www.youtube.com/@clavelluroDr. Clavell’s Website:https://houstonmenshealth.com/

In this episode of BackTable Urology, Dr. Angie Smith (UNC Chapel Hill) and Dr. Rena Malik (University of Maryland) discuss practical tips for developing a growth mindset in medicine.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/jkLckg---SHOW NOTESFirst, Dr. Malik defines growth mindset as the belief that you can do something or accomplish something that you don’t know how to do yet. Both doctors agree that adopting this mindset also requires expecting failures along the way, asking for help, and sharing your vulnerabilities with colleagues and trainees. Then, both of them share personal experiences about when developing growth mindsets were difficult for them and how they overcame self-doubt.Dr. Malik suggests journaling to think about long-term goals and assess personal obstacles. Dr. Smith encourages doctors to set aside time for self care and reflection.Next, the doctors discuss how to cultivate a growth mindset in situations they might not wholeheartedly enjoy all the time, like seeing patients in the clinic instead of being in the operating room. Dr. Smith shares how meaningful conversations with her patients brought her joy in the clinic and advocated for more time to engage in these conversations. Dr. Malik was able to streamline her charting through a detailed intake form and utilizing dot phrases so she could spend less time charting in the office and at home.Finally, the doctors discuss ways to encourage their colleagues to adopt a growth mindset as well. Both agree that encouraging colleagues to question their negative attitudes and stopping the propagation of negative attitudes and stories is helpful to building a more positive workplace environment.---RESOURCESMindset by Carol Dweckhttps://www.penguinrandomhouse.com/books/44330/mindset-by-carol-s-dweck-phd/Chatter by Ethan Krosshttps://www.ethankross.com/chatter/Dr. Malik’s Websitehttp://www.renamalikmd.comDr. Malik’s YouTube Channelhttps://www.youtube.com/channel/UCV66hp0qxx2Xq273N0bo7uQDr. Malik’s Twitterhttp://twitter.com/RenaMalikMD

In this episode of BackTable Urology, Dr. Bagrodia discusses cultivating a healthy culture inside and outside of the operating room with Dr. Chris Kane, Dean of Clinical Affairs at UCSD and CEO of the UCSD Physician Group.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/rVQG40---SHOW NOTESFirst, the doctors discuss the definition of culture, which Dr. Kane defines as the norms of behavior and relationships within an organization. Culture can include dress code, meeting rules, and punctuality. Most of the time, institutional culture is established in an unspoken way. Dr. Kane emphasizes the importance of having a conscious strategy to create a healthy culture and reiterates that trust is a crucial foundation for motivating cultural changes.Next, the doctors discuss helping team members find meaning in their work. Dr. Kane recommends that surgeons share patient gratitude with their other colleagues who are not frontline medical workers. He acknowledges his staff’s contributions during meetings and expresses his gratitude through written notes. He also recommends communication training for everybody on his team. Then, he shares tips for assessing organizational culture. He believes that it is most important to ask team members what they think the overarching goal of the institution is and to assess the attrition rate through exit surveys. He emphasizes that behavioral norms matter most, as department leaders often lead by example. One detrimental practice is favoritism, which Dr. Kane regards as disrespectful to other team members. Additionally, he shares his personal experiences with changing cultures at different institutions and utilizing change management theories.Finally, Dr. Kane shares general leadership advice. He highlights the importance of creating a patient-centered environment, leading by influence rather than authority, and the power of positivity.

In this episode of BackTable Urology, Dr. Jose Silva and Dr. Stephen Nakada, chair of urology at the University of Wisconsin, discuss indications and benefits of extracorporeal shock wave lithotripsy (ESWL).The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/Ebk55a---CHECK OUT OUR SPONSORReviveRXhttps://reviverx.com/urology/---SHOW NOTESFirst, the doctors discuss ideal candidates for ESWL. Dr. Nakada considers 2 centimeters as the maximum stone size for ESWL. The stone must be low density (<1000 Houndsfield units) on CT, and the skin-to-stone distance must be less than 10 centimeters. Other contraindications to ESWL include patients with coagulopathy and patients with a solitary kidney. Dr. Nakada mentions that PCNL and a trial of passage are more common treatments for kidney stones. He also emphasizes the importance of continual stone analysis because stone composition can change over time, thus changing the probability that ESWL will work. He prefers to observe patients in their 70’s / 80’s and patients with calyceal stones. He also mentions that it is important to mention the higher failure rates of ESWL when compared to other treatments in the initial discussion with the patient.Next, Dr. Nakada describes his ESWL technique. He continues to deliver shock waves to the stone until he cannot see it with fluoroscopy. For obstructing stones, he gives contrast to check for complete fragmentation. Additionally, he mentions that urologists might have to wait 6-8 months after the procedure for the patient to pass their stones, so the conventional 3 months is not a good benchmark for re-treatment. If there is one fragment that is too large to pass, he will perform a second lithotripsy. He states that there is no role for a third lithotripsy.Next, Dr. Silva and Dr. Nakada discuss why ureteroscopy has eclipsed ESWL. They come to the conclusion that more residents are trained to do PCNL, there is a strict criteria for ESWL, and heavier patients usually cannot meet the skin-to-stone distance. The doctors then discuss imaging for kidney stones and Dr. Nakada notes that ultrasound is unreliable to gauge stone size. Although he always gets a CT scan without contrast before the procedure, a postoperative CT scan may be difficult to obtain because of cost limitations.Finally, the doctors discuss their post-procedural recommendations. Dr. Nakada sends all his patients home with Flomax and a single dose of antibiotics. He avoids narcotics and NSAIDs and recommends Tylenol. FInally, he schedules a follow-up KUB 2 weeks after the procedure.

In this episode of BackTable Urology, Dr. Bagrodia and Dr. Jay Raman, the chair of urology at Penn State Health, discuss advancements and future directions of medical education for trainees.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/s82N5z---SHOW NOTESFirst, the doctors discuss the need for medical education to incorporate multimedia and active learning into residency curriculums and CME courses. Dr. Raman notes that although the copious amounts of articles and videos online may be overwhelming, integrating quality videos, textbook chapters, and journal articles into a standardized curriculum for urology residents can teach them the fundamentals of urology. Additionally, he notes that this approach takes into consideration different learning styles.Dr. Bagrodia emphasizes how the AUA core curriculum has leveled the playing field for trainees, as it has standardized education across all training programs. He suggests a model of having residents do pre-work by learning from the AUA curriculum on their own time and then using valuable in-person time with attendings to review case examples. Dr. Raman agrees that meeting in person for resident lectures or conference courses should be interactive and incorporate active learning exercises. They then reflect on the social value of getting together in order to network and discuss cases casually, but concede that virtual meetings can be more convenient for family life and comfort.Next, the doctors discuss the role of simulation in education. Dr. Bagrodia notes that simulation increases practice opportunities for residents, which makes them safer and more competent surgeons. Dr. Raman is excited about virtual reality technology, which makes simulation more feasible and realistic for many training programs. The doctors then discuss the possibility of incorporating simulation into board exam certifications. Dr. Raman explains the traditional arc of residency training and proposes changes to this arc to help align resident education better with their future practice types and meet the current need for more general urologists. Finally, they end the episode by addressing the need to expand resident and CME education beyond clinical education to include topics like social determinants of health, time management, wellness, and environmental stewardship.

In this episode of BackTable Urology, Dr. Bagrodia and Dr. Jay Simhan, director of reconstructive urology at Fox Chase Cancer Center, discuss how to demonstrate value at a private or academic physician job.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/DU5Nmx---SHOW NOTESThe doctors first briefly discuss the process of obtaining a physician job. Dr. Simhan believes that physicians should negotiate their contracts only out of necessity. He encourages new attendings to demonstrate their own value to the administrators who create their contracts. Next, the doctors move onto advice for the first 3 months in a new job. Both doctors agree that the goal should be to learn who people are and earn their respect, whether they are residents, trainees, other attendings, nurses, MAs, or administrators. Dr. Simhan also emphasizes the importance of building your own cultural philosophy and deciding what you care about. Then, the doctors discuss the traditional 3 A’s: available, affable, and able. Dr. Simhan notes that for a new physician, availability and affability are probably more heavily weighted for new hires. Dr. Bagrodia believes that accountability should be the 4th A because physicians should know when to accept their mistakes and move forward. Finally, Dr. Simhan explains how he had to learn the landscape of his new department at Fox Chase Cancer Center in order to figure out how he could build and fit in his reconstructive urology program.Finally, the doctors discuss how to engage in tactful self-promotion to demonstrate your value. Dr. Simhan explains that recognition is not a negative result to seek, as it can fuel your passion (e.g. bigger patient base, support for funding, etc.). He encourages doctors to have a personal website, to always update referring doctors after clinical visits and surgeries, and to be available to trainees and nurses. Additionally, Dr. Bagrodia advises physicians to meet with their department chairs and mentors to discuss progress and ask for help. He discourages physicians from giving unsolicited advice to their colleagues.Finally, the doctors share some of their miscellaneous tips for demonstrating value within a hospital system. Dr. Bagrodia notes that it is helpful to be prepared with talking points, ideas, and solutions when meeting with hospital administrators. Dr. Simhan adds that it is important to fully commit to the responsibilities that you agree to take on.

In this cross-specialty episode of BackTable OBGYN, Dr. Amy Park chats with Dr. Jose Silva, a board certified urologist and co-host of BackTable Urology, about the workup, counseling, and management of urinary incontinence and pelvic organ prolapse.---SHOW NOTESThe co-hosts begin by briefly discussing the workup for pelvic organ prolapse (POP). Dr. Park identifies common symptoms of prolapse and special exams (e.g. Pelvic Organ Prolapse Quantification System or POP-Q and urodynamics) that may be utilized for initial evaluation. She then explains the clinical indications for treatment of isolated POP, in addition to POP with concomitant urinary incontinence.Drs. Park and Silva then transitioned to cover the management of urinary incontinence. The two co-hosts reveal the benefits of pelvic floor physical therapy and other conservative management options, such as core-centric exercises and weight loss. In length, they elaborate on the benefits and takeaways of using sling procedures versus urethral bulking agents (e.g. Bulkamid). When discussing these topics, the co-hosts bring to light the possible differences in approach between Urogynecologists and Urologists. In regard to urethral bulking agents for treatment of urinary incontinence, Drs. Park and Silva highlight the potential role for stem cell injections. In addition, Dr. Park provides a tip to maximize patient comfort during in-office periurethral injections for urethral bulking. When focusing on sling procedures, Dr. Park highlights her preferred approach and encourages listeners to become proficient in the approach of their choosing.Lastly, they describe their approaches to treatment of stress urinary incontinence. In their discussion, Drs. Park and Silva consider factors such as patient age, desire for future fertility, and pregnancy. When wrapping up the episode, Dr. Park emphasizes the importance of patient counseling when it comes to management of these conditions, as well as practicing shared decision making to determine the best next steps for her patients.---RESOURCESNager CW, et al. Design of the Value of Urodynamic Evaluation (ValUE) trial: A non-inferiority randomized trial of preoperative urodynamic investigations. Contemp Clin Trials. 2009 Nov;30(6):531-9. doi: 10.1016/j.cct.2009.07.001. Epub 2009 Jul 25. PMID: 19635587; PMCID: PMC3057197.Erin A. Brennand, Shunaha Kim-Fine. A randomized clinical trial of how to best position retropubic slings for stress urinary incontinence: Development of a study protocol for the mid-urethral sling tensioning (MUST) trial, Contemporary Clinical Trials Communications, Volume 3, 2016, Pages 60-64, ISSN 2451-8654, https://doi.org/10.1016/j.conctc.2016.04.004.M. Abdel-Fattah, D. Cooper, T. Davidson, M. Kilonzo, M. Hossain, D. Boyers, et al. Single-Incision Mini-Slings for Stress Urinary Incontinence in Women New England Journal of Medicine 2022 Vol. 386 Issue 13 Pages 1230-1243. DOI: 10.1056/NEJMoa2111815 https://doi.org/10.1056/NEJMoa2111815.Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP-Q) - a new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar;4(1):75-81. Epub 2011 Feb 25. PMID: 21505577; PMCID: PMC3056425.

In this episode, guest host Dr. David Canes interviews Dr. Matthew Allaway about PrecisionPoint, his medical device for transperineal prostate biopsy, and his journey towards changing the paradigms of prostate cancer diagnosis.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/0Lmsku---SHOW NOTESDr. Allaway starts by outlining his path to medicine. The choice to pursue urology was largely influenced by his personal cancer diagnosis. He cites cancer as the greatest lesson in his life, since it brings an enhanced level of empathy to his patient care and inspires him to contribute to the field of urology. Throughout his career, he has always examined his procedures for logical sense – if a process was inefficient, he tried to devise ways to make improvements for patient care.In 2013, Dr. Allaway decided to switch from the transrectal to transperineal approach for prostate biopsies. With the traditional transrectal approach, he found unacceptably high rates of infection and failure to detect cancers in the anterior prostate region. He started performing transperineal biopsies with a freehand technique, using ultrasound in one hand and a biopsy probe in the other. He built a database of his own patients, which showed an increased cancer detection rate. His technique eventually evolved into the PrecisionPoint transperineal access system. He originally started marketing the device at American Urological Association (AUA) meetings, through booths and video competitions. Although Dr. Allaway works in private practice and not academia, he was able to form connections with institutions and key opinion leaders to encourage adoption of the transperineal approach. PrecisionPoint has been accepted by early adopters, and his team is now working to capture a larger share of the biopsy market. Importantly, they are also marketing the device to patients, since patients can also recognize the safety and diagnostic benefits, and being the ultimate consumers of healthcare, can influence urologists to adopt the device.Dr. Allaway also gives advice for budding entrepreneurs. He highlights the need to link the device to a specific clinical need, research existing devices, check the your device’s feasibility and pricing strategy, and find good mentors who will allow you to learn from their mistakes. In terms of product marketing, he encourages entrepreneurs to look beyond the United States and explore worldwide markets to increase the chances of product adoption. His confidence in PrecisionPoint grew when he received positive feedback from other urologists about the simple elegance of the device. Finally, Dr. Allaway discusses the importance of truly believing in your product. He says that if you are ashamed of your product’s price, you have priced it wrongly. He encourages entrepreneurs to focus on their product’s benefit to society, rather than profitability.---RESOURCESPrecision Point:https://perineologic.com/precisionpoint/American Urological Association:https://www.auanet.org/Zero to One by Peter Thiel:https://www.amazon.com/Zero-One-Notes-Startups-Future/dp/0804139296

In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with two fellow urologic oncologists, Dr. Timothy Clinton (Brigham and Women’s Hospital) and Dr. Eugene Pietzak (Memorial Sloan Kettering), about the management of BCG-refractory non muscle-invasive bladder cancer.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/h8YiBe---SHOW NOTESFirst, the doctors define BCG-refractory cancer from the clinical and FDA viewpoint. They emphasize the importance of determining the difference between BCG-resistant cancer and residual tumor from the primary resection. Blue light cystoscopy can help in confirming that the original tumor was totally resected. The doctors warn that although the initial response to BCG may be promising, there is still a chance of cancer recurrence. The success rate of BCG depends on the patient and tumor characteristics.Next, they discuss BCG-intolerant patients. BCG has many side effects such as frequency and urgency symptoms and bladder spasms. Some patients will have a systemic immune response resulting in flu-like symptoms. However, most of these side effects are self-limiting and should resolve after the induction course. They also discuss how to deal with the current BCG shortage. They first prioritize starting an induction course and view the maintenance course as a secondary priority.An erythematous and inflamed bladder can either be a result of BCG cystitis or a carcinoma in situ (CIS). The doctors agree that if the bladder is inflamed and the patient has a positive cytology, they would obtain a bladder biopsy to look for recurrent high-grade cancer. If the biopsy is positive, they would start a second induction course of BCG and introduce another form of therapy, like intravesical gemcitabine or an immune checkpoint modulator. If the bladder is inflamed and the patient has a negative cytology or a negative biopsy, they would continue with a BCG maintenance course and follow up.Cystectomy is a curative option for BCG-refractory bladder cancer. Patients with tumors with high risk features such as lymphovascular invasion and varying histology are good candidates for cystectomy. Patient comorbidities, age, and willingness are also important factors in the decision. Dr. Bagrodia also recommends getting a CT scan to check for nodal metastases. Both Dr. Clinton and Dr. Pietzak agree that it is beneficial to introduce the idea of cystectomy early and explain that the procedure does not prevent patients from living a fulfilling life.Finally, the doctors discuss recent BCG and gemcitabine clinical trials as well as new research about non-BCG therapies.