BackTable Urology

We talk with Dr. Siamak Daneshmand, Director of Urologic Oncology at USC Institute Of Urology, about the management of muscle-invasive bladder cancer. Listen to the full episode to learn tips for successful transurethral resections of bladder tumor (TURBT) and cystectomies, using imaging to stage bladder cancers, deciding between a cystectomy vs. trimodality therapy (TMT), and comparisons between neobladder procedures and urinary diversions.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/hEi42s---SHOW NOTESFirst, the doctors discuss the initial workup of a referred bladder tumor patient. Because almost all bladder cancers are malignant, a transurethral resection of the bladder tumor (TURBT) is the first step. Dr. Daneshmand notes that imaging may be helpful in patients with complex anatomy. He prefers to perform a CT over an MRI scan due to patient discomfort and costs.Next, Dr. Daneshmand shares his tips for a TURBT procedure. His main goal is to perform a complete resection of the tumor. He often uses blue light enhancement to visualize the edges of tumors better, improve the educational experiences of his residents, and stage smaller tumors more easily. He notes that doing an extensive TURBT does not lead to a higher likelihood of bladder cancer metastasis. Although uncommon, bladder perforation during TURBT is a possible and serious complication. To prevent seeding in the scenario of a perforation, he advises urologists to stop high-pressure irrigation immediately. Furthermore, he trains his residents to be vigilant of the amount of fluid going in and out of the abdomen.Another important aspect of bladder cancer care is accurately staging the bladder cancer after the TURBT. Dr. Daneshmand usually orders a CT scan of the abdomen, chest, and pelvis in order to check for metastases. He prefers not to order a PET scan, as it results in too many false positives and false negatives. In the case of the discovery of suspicious pelvic lymph nodes, he will move on with neoadjuvant therapy and keep assessing the lymph nodes via imaging. He does not usually biopsy these lymph nodes due to their precarious location between the external and internal iliac arteries.After staging the bladder cancer, a treatment modality must be chosen. Two common options are a cystectomy or trimodal therapy (TMT). Both Dr. Bagrodia and Dr. Daneshmand agree that variant histology results do not immediately indicate one treatment over the other—a patient’s tumor must be evaluated holistically. TMT is very effective in patients with T2-T3 unilateral, muscle-invasive bladder cancer. For patients who do not meet this narrow criteria, cystectomy remains a valid option.Next, Dr. Daneshmand gives advice for performing a successful cystectomy. He notes that the surgeon should always handle the urethra with great care, as meticulousness can lead to a lower risk of post-surgical incontinence. Also, he notes that nerve-sparing techniques for male bladder cancer patients can help with post-surgical incontinence and erectile dysfunction. However, he warns urologists to be careful not to accidentally leave tumor tissue behind during female cystectomies involving gynecologic organ preservation.After a cystectomy, patients can either choose to undergo a urinary diversion procedure, in which the surgeon creates a different way for urine to leave the bladder, or a neobladder (ileal conduit) procedure, in which the surgeon creates a new bladder from the small intestine. Dr. Daneshmand emphasizes that having a standardized and specific approach to the patient conversation about these treatment options is very important. He encourages urologists to be clear about the consequences of each of these options on incontinence and catheter usage.

En el primer episodio en español de BackTable Urology, yo y Dr. Francisco Gelpi discutimos los tratamientos mínimamente invasivos para HPB, específicamente Urolift, Rezum, y GreenLight. Escucha el episodio completo para aprender más sobre la transición de Dr. Gelpi desde práctica oncológica académica a práctica privada enfocada en HPB, evaluación inicial de los HPB pacientes, factores importantes en la toma de decisión de un tratamiento de HPB, y beneficios y complicaciones de cada tratamiento.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/yzxjDf---SHOW NOTESEn el primer episodio español de BackTable Urology, Dr. Jose Silva y Dr. Francisco Gelpi discuten los tratamientos mínimamente invasivos para la hiperplasia prostática benigna (HPB), específicamente Urolift, Rezum, y GreenLight.Primero, los doctores hablan sobre la transición de Dr. Gelpi desde práctica oncológica académica a práctica privada enfocada en HPB. Tomó la decisión para tener mas autonomía y libertad. Dr. Gelpi cuenta que mucho de su aprendizaje de los procedimientos de HPB ocurrió durante su trabajo después de la residencia debido al hecho de que no existía tanto tecnología para HPB hasta los años recientes.Seguido, Dr. Gelpi habla sobre la evaluación primaria de un paciente con HPB. Es importante tomar en consideración las expectativas del paciente, la edad del paciente, y la anatomía única de cada próstata antes de escoger un tipo de intervención. Resume los métodos de imagen y análisis diferentes, como la ecografía pélvica y el examen urodinámico. También, Dr. Gelpi menciona que la situación económica de un paciente podría ser un factor importante en la selección de un procedimiento.Entonces, Dr. Gelpi resume sus consejos para los procédures de Urolift, GreenLight, y Rezum. Además, los doctores charlan sobre la embolización de la próstata como otra opción. Usualmente Dr. Gelpi opera en un centro ambulatorio, pero para los casos de GreenLight, prefiere operar en un hospital debido al riesgo alto de infección y con los pacientes con catéteres crónicos.Finalmente, los doctores hacen una comparación de los beneficios y complicaciones de cada opción quirúrgica. Ambos están de acuerdo de que solamente son generalizaciones porque cada paciente responde a tratamientos diferentes y puede presentar síntomas diferentes después de la cirugía. Dr. Gelpi termina el episodio animando a los urólogos hispanos a explorar, leer, aprender sobre otras cosas nuevas cada día para mejorar su conocimiento y práctica medical.

Dr. Aditya Bagrodia and Dr. Aaron Fritts talk with Dr. Phillip Pierorazio from Penn Urology about his Operate with Zen podcast and tips for surgeon wellness. They cover Dr. Pierorazio's motivation for starting a wellness podcast, preventing physician burnout, achieving work-life balance, and managing healthy competitiveness.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/A9shzj---SHOW NOTESIn this crossover episode of BackTable Urology and BackTable VI, Dr. Aaron Fritts and Dr. Aditya Bagrodia speak with Dr. Phil Pierorazio about surgeon wellness and his mindfulness podcast, Operate with Zen.First, Dr. Pierorazio discusses his motivation for starting the Operate with Zen podcast. During the pandemic, he crafted a new goal for himself: to be happier in surgery. He defines mindfulness as taking a moment to enjoy his livelihood and being more present at work and at home. Next, the doctors tackle the topic of physician burnout. All three doctors agree that burnout is not a badge of honor and are glad that the culture of medicine is progressing towards one that reprimands toxic attitudes early in training.As for managing work-life balance, Dr. Pierorazio explains that once he started creating boundaries for his work schedule, he expanded what he could do. He encourages other surgeons to trust that their colleagues can handle emergencies, even if the patients are not their own patients. Collaboration with colleagues also leads to healthy competitiveness, a concept in which physicians stop comparing themselves to each other and instead celebrate their fellow colleagues. Dr. Pierorazio recommends channeling toxic competitive energy towards a drive to better a broader institution and patient care.Finally, Dr. Pierorazio shares two of his personal tips for wellness. He avidly journals each day in order to exercise gratitude, reflect on his day, and set priorities for the next day. Finally, he emphasizes the importance of finding a wellness mentor or counselor in order to expand surgeon wellness and talent.

Dr. Jose Silva brings Dr. Jonathan Clavell back onto the show to discuss complex penile implant cases. They cover how to deal with mechanical complications of AMS700 and Coloplast Titan, penile implants in Peyronie's disease, penile implants in priapism, tips for successful revision surgery, and how to manage post-operative infections.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/rPlXUn---SHOW NOTESFirst, the doctors discussed mechanical complications with three-piece inflatable penile implant devices. Dr. Clavell always directs post-operative patients to his Youtube videos where he explains how to cycle penile implants. Because older patients may have trouble finding and operating the pump, Dr. Clavell prefers to place an AMS 700, as it is easier to deflate. Additionally, he tries to place the pump as anteriorly as possible for ease of patient usage. If he notices that the tubing of the implant is too long at the time of surgery, he cuts the tubing and reconnects it again at the appropriate length. Finally, to avoid autoinflation, he takes great care in making sure that the lock-out valve of the Coloplast Titan does not hit the pubic bone.Next, Dr. Clavell discusses different approaches to placing penile implants in complex patients. First, he tackles patients with chronic priapism, a common consequence of sickle cell disease. With priapism patients, he emphasizes the importance of severity and timing; waiting a longer time period since the patient’s last priapism episode means that there will be more scar tissue in the corpora. For these complex patients, Dr. Clavell encourages surgeons to set proper expectations with their patients, try to operate as soon as possible, and encourage their patients to use a vacuum erection device to keep corporal space open and maximize the size of implant. Additionally, he recommends coming into the operation with adequate tools that are able to drill through the fibrosis and being ready to use a counter incision or to extend the incision distally.In patients with Peyronie’s disease, Dr. Clavell always assesses the degree of curvature first. For patients with mild curvature (under 45 degrees), he places the penile implant and uses manual remodeling techniques intraoperatively to straighten the penis. For patients with more severe curvature (more than 60 degrees), he performs a plaque incision with grafting (PIG) through a ventral non-degloving incision to avoid the risk of glans ischemia. In these severe Peyronie’s patients, he will do the PIG first and then place the implant in order to minimize implant exposure time and infection risk.In the event where a revision surgery is necessary, Dr. Clavell orders a CT scan if the problem cannot be found upon physical examination or if he was not the surgeon who placed the original implant. He usually takes some fibrous tissue out around the pump and then places the pump in a different pocket to make sure there is no contact between the capsule and the new pump. Although he tries to take the reservoir out, he simply drains and retains reservoirs that have migrated too deep in order to avoid damaging major structures.In patients who develop post-operative penile implant infections, Dr. Clavell usually completely removes and replaces the implant if pus is present. He notes that it is important to swab the biofilm at the time of implant removal in order to culture and identify the type of bacterial infection. He prefers to administer culture-specific antibiotics and antifungal for 2-3 weeks. Also at the time of removal, he will irrigate the patient’s corporas with Irrisept and an antibiotic solution. Research has shown that patients who develop a post-operative infection will have a 50% chance of success with another 3-piece implant.Dr. Clavell also discusses other post-operative complications, including impending erosions and glans ischemia.

Urologist Dr. Claus Roehrborn and Interventional Radiologist Dr. Sandeep Bagla discuss the pros and cons of Prostate Artery Embolization (PAE) compared to other Minimally Invasive Surgical Treatments (MISTS) for Benign Prostate Hyperplasia (BPH). They also discuss the importance of a collaborative, multidisciplinary approach when offering these treatment options, including agreeing on the best treatment for the patient.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Daw1w2---SHOW NOTESIn this episode, urologist Dr. Claus Roehrborn and interventional radiologist Dr. Sandeep Bagla discuss benign prostatic hyperplasia (BPH) and prostate artery embolization (PAE) in the context of counseling patients and cross-specialty collaboration.Dr. Roehrborn starts by reviewing the history of BPH treatment, from medications like alpha-blockers and anticholinergics, to minimally invasive options like UroLift, Rezum, and PAE. He emphasizes that the latter options are growing in popularity, since they provide treatment alternatives for patients who are concerned about side effects from medications, or have not experienced symptom relief from medications.Dr. Sandeep Bagla describes Prostate Cancer USA’s philosophy on IR/Urology partnership and how it can ultimately benefit patients. This model provides the patient with both an IR suite for the PAE procedure and a urology clinic for diagnostic assessment, determination of PAE candidacy, and follow-up assessment.Both doctors describe ideal patients for PAE. These are usually patients with a gland size above 60 g, confirmed bladder function, and a desire to preserve ejaculation function. Contraindications include urinary retention, chronic prostatitis, and heavily calcified glands.Finally, they describe how they manage minor short-term complications such as frequency and dysuria with medication. They track symptom relief using the International Prostate Symptom Score (IPSS), Dr. Bagla notes that the largest drop in IPSS usually occurs about 4-5 weeks post-procedure.---RESOURCESProstate Centers USA: https://www.prostatecentersusa.com/“The Role of Novel Minimally Invasive Treatments for Lower Urinary Tract Symptoms Associated with Benign Prostatic Hyperplasia”:https://bjui-journals.onlinelibrary.wiley.com/doi/abs/10.1111/bju.15154

We speak with Dr. Zamip Patel about the different causes and treatments of male infertility. Listen to hear more about genetic vs. environmental causes of infertility, hormone tests, hormone replacement therapy, and varicoselectomies.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/HIkLi7---SHOW NOTESIn this episode of BackTable Urology, Dr. Zamip Patel discusses the assessment and treatment of male infertility with Dr. Silva.Initial fertility consultations are usually made for couples who have not had success in conceiving for over a year. Dr. Patel will start with an initial semen analysis. He notes that cell differentiation depends on the quality of the lab performing the analysis. The presence of round cells and leukocytes may be indicative of a bacterial infection, and prednisone and antibiotics may be administered. Besides bacterial infections, Dr. Patel notes that there are 4 main factors for male infertility: genetic, environmental, anatomical, and hormonal.Globozoospermia and azoospermia are two consequences of genetic mutations resulting in irregular sperm morphology and inadequate sperm production, respectively. Attribution of infertility to genetic mutations can be difficult, as microchip arrays only test for 10% of genetic defects. Sex chromosome aneuploidy can also result in male infertility, but can easily be identified via karyotyping.Environmental factors may also contribute to male infertility. Dr. Patel notes that improving diet, exercise, and sleep is the most common solution for infertility. Additionally, he observes that supplementing diet with vitamin coenzyme Q10 has been shown to improve infertility. Finally, he explains that prolonged marijuana usage and THC intake may contribute to infertility on an individual and dose-dependent basis.Next, Dr. Patel considers anatomical reasons for male infertility. Irregularities in vas deferens morphology and small testicular size can be observed through physical examination. A varicocele, or an enlargement of veins in the scrotum, can also cause low sperm production and quality. Patients with varicoceles will usually elect to undergo a varicocelectomy, a surgical intervention with minimal downtime and complications.Lastly, low testosterone levels can cause male infertility. To get a clearer picture of testosterone levels, Dr. Patel recommends combining a free testosterone test with SHBG and albumin tests, which calculate bioavailability of testosterone. He will also measure TSH levels, but notes that measuring prolactin levels, which can vary individually, may potentially cause more confusion and lead to unnecessary further imaging. Although clomiphene and anastrozole can both increase testosterone concentration, Dr. Patel warns listeners about osteoporosis as a side effect of anastrozole. Additionally, he has had success with increasing testosterone levels using pituitary stimulation via hCG supplementation. Testosterone levels can also be naturally increased through healthier diets, daily exercise, and adequate sleep.

Dr. Daniel Hoffman, a urogynecologist specializing in voiding dysfunction, discuss the use of Botox, sacral neuromodulation, and bulking agents in treating overactive bladders. Listen to hear more about patient selection criteria for each treatment, botox and neuromodulation procedure techniques, and treatment side effects and complications.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/cWymN6---SHOW NOTESThis week on the BackTable Urology Podcast, Dr. Jose Silva and Dr. Daniel Hoffman, a urologist specializing in voiding dysfunction, discuss the use of Botox, sacral neuromodulation, and bulking agents in treating overactive bladders.First, Dr. Hoffman explains his procedure for Botox, which he suggests as a treatment option for patients with neurogenic bladders. He uses Urojet as anesthesia and injects the Botox in 0.5 cc injections following a grid template. Additionally, he saves 1 cc for the trigone of the bladder. He uses 200 units of Botox in patients with neurogenic bladders and 100 units in those with urge incontinence. Additional considerations should be made for patients with additional comorbidities, such as benign prostate hyperplasia and cystitis. For cystitis patients, increased caution around vascularized areas should be exercised. Additionally, Dr. Hoffman recommends assessing the degree of obstruction in BPH patients before treating their incontinence with Botox.Next, Dr. Hoffman discusses his procedure for sacral neuromodulation, a procedure that he recommends for younger patients with urinary retention. Although he notes that rechargeable and battery-operated devices have equivalent functions, a patient’s ability to use and maintain the device and MRI-compatibility should be considered. He recommends allowing the patient to undergo a percutaneous nerve evaluation (PNE) before inserting a permanent device. After permanent device insertion, some patients may experience chronic pain down the leg. Dr. Hoffman recommends reprogramming the device before performing a lead revision. If a lead is fractured and lost during surgery, he advises urologists against going after the fractured lead—neurosurgery should be consulted instead. Finally, he notes that fecal incontinence may also be mitigated through sacral neuromodulation.Lastly, Dr. Hoffman notes that bulking agents as a potential therapy for women with stress incontinence because they have little to no side effects compared to the pelvic sling. Because he has noticed that coaptite does not have the same longevity as Botox, he considers Bulkamid as a better choice. Like Botox, bulking agents can be quickly injected in the office and result in minimal patient down time.

Dr. Ranjith Ramasamy explains the known effects of the COVID-19 virus and the pandemic on testosterone levels, vasculogenic erectile dysfunction, male fertility, and sexual practice patterns. Additionally, Dr. Ramaswamy uses evidence-based medicine to debunk myths about the adverse effects of the COVID-19 vaccine on men’s health.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/7hBgDv---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Ranjith Ramasamy discuss the effects of the COVID-19 pandemic and COVID vaccines on various men’s health topics, including testosterone levels, erectile dysfunction, and male fertility.First, Dr. Ramasamy discusses the effects of COVID-19 on hypogonadism. He notes that in the initial stages of the pandemic, many providers attributed low testosterone levels as result of a sedentary and less active lifestyle because of the lockdown. However, it was later discovered that the SARS-CoV-2 virus binds to the ACE2 receptor, an important receptor present on the surface of testosterone-producing Leydig cells. Thus, temporary testosterone deficiency is a direct impact of COVID-19 infection. Dr. Ramasamy advises his recovered patients to naturally increase their testosterone levels by eating, exercising, and sleeping well.COVID-19 is also linked to higher rates of erectile dysfunction. Dr. Ramasamy explains that the cause of ED may not be psychogenic, as the SARS-CoV-2 virus affects endothelial cells lining blood vessels. Studies have also shown that the virus can be present in penile tissue seven to 9 months post-infection. As a result, Dr. Ramasamy urges urologists to differentiate between psychogenic and vasculogenic erectile dysfunction.Next, the doctors discuss the impact of COVID-19 on fertility. Research has shown that a COVID-19 infection may decrease sperm count in semen three to six months post-infection. Most patients have normal sperm counts after 6 months. Although birth rates have declined due to the uncertainty during the pandemic, Dr. Ramasamy notes that more male patients have requested fertility consultations with him as a proactive family planning measure.Finally, Dr. Ramasamy uses evidence-based medicine to debunk myths about the mRNA COVID-19 vaccination on male sexual and gonadal function. He cites his most recently published article, “Sperm Parameters Before and After COVID-19 mRNA Vaccination” (JAMA) and emphasizes that there is no link between the vaccine and declining sperm count.

We finish our discussion with Dr. Angie Smith from University of North Carolina at Chapel Hill about peri-operative optimization of radical cystectomies. She discusses pre-operative incentive spirometry, opioid and NSAID regimens, post-operative drains and stents, and the importance of multidisciplinary collaboration.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/TafjXx---SHOW NOTESIn this episode of BackTable Urology, Dr. Bagrodia and Dr. Angie Smith finish their discussion on optimizing radical cystectomy outcomes using peri-operative measures.First, Dr. Smith emphasizes the importance of getting her cystectomy patients actively invested in their pre-operative and post-operative care. Pre-operatively, she recommends nutrition counseling, as carb loading and amino nutrition within 3-5 days before surgery have been shown to promote tissue healing. She also recommends engaging patients in pre-operative incentive spirometry, giving them a chance to learn to use their post-operative spirometers correctly. However, she does not have her patients undergo bowel prep before surgery.Post-operatively, she emphasizes the importance of involving a multidisciplinary medical team in the patient’s recovery process. First, she recommends collaborating with anesthesia for pain management and to reduce post-operative nausea. She notes that although Tylenol is effective in mitigating post-operative pain, she sometimes sends patients home with a small opioid prescription for 1 week. She also continues to consult nutritionists and aims to have her patients on a regular diet two days after the surgery. Because long-term drains have a higher susceptibility to infection, she removes them after the first post-operative week. Finally, she involves physical/occupational therapists in the post-operative care of patients. One practice she has incorporated into her post-operative counseling is explaining to the patient why physical therapy is important, in addition to explaining general instructions, in order to increase patient compliance.Patients who experience dehydration, acidosis, and nausea have a higher chance of readmission. Once her patients return home, she and a triage nurse monitor their hydration and sodium bicarbonate levels closely. Lastly, she invites cystectomy patients back for a survivorship care visit 6 weeks after surgery to look for pending obstructions with ultrasound.

We talk with Dr. Angie Smith about perioperative measures to optimize radical cystectomies.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Ajr24g---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Angie Smith from UNC School of Medicine discuss peri-operative measures to optimize radical cystectomy outcomes.First, the doctors start by explaining their approaches to initial cystectomy discussions with bladder cancer patients. Dr. Smith usually provides a walkthrough of the surgery and discusses complication rates with her cystectomy patients. Because sexual dysfunction and infertility are possible long-term complications of the procedure, she emphasizes the importance of transparency and expectation management in patients.Next, the doctors discuss the optimal timing for a cystectomy. Dr. Smith and Dr. Bagrodia usually wait at least 4 to 6 weeks after chemotherapy to perform a cystectomy. However, because Dr. Smith believes that timing is the most crucial factor in a cystectomy, she prefers to perform surgery sooner rather than later. For this reason, she performs both open and robotic surgery, depending on which approach can be done sooner. Furthermore, to anticipate a patient’s post-operative regimen, Dr. Smith uses the comprehensive geriatric assessment because she prioritizes the functional status of a cystectomy patient most. In addition to this assessment, she will evaluate a patient’s activities of daily living, hearing and vision deficits, and fall risk.Finally, Dr. Smith emphasizes the importance of involving multiple interdisciplinary health professionals, such as medical and radiation oncology, nutritionists, wound/ostomy/continence nurses, geriatricians, and pelvic floor physical therapists. She notes that “prehabilitation”, or using physical therapy to improve a patient’s strength and fitness before surgery, is a new feasible pre-operative strategy, but its effects on distal post-operative outcomes have not yet been determined.