BackTable Urology

We talk with Dr. Jeff Cadeddu about workup and treatment options for patients with localized prostate cancer.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/L8oz83---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Jeff Cadeddu, professor of urology at UT Southwestern, about the management of localized prostate cancer.First, the doctors discuss important considerations for an initial evaluation, such as lower urinary tract symptoms, a Gleason score, comorbidities, and a thorough family history. Dr. Cadeddu emphasizes that the main goal of the initial evaluation is to risk-stratify the prostate cancer patient. Although he does not consider any anterior surgeries as contraindications, he notes that abdominal perineal resection surgery may be challenging for surgeons.For patients who have low-risk disease, he strongly advises choosing surveillance over surgery and radiation therapy, regardless of age. For him, active surveillance does not start until a second confirmatory biopsy, and his patients receive MRI at the beginning of every year as well as a PSA every month. Some triggers for ending the surveillance period and entering treatment are: a PSA over 10 or upstaging on an MRI or biopsy.In patients with intermediate-risk disease, Dr. Cadeddu will either proceed with radiation therapy or prostatectomy. He notes that neither radiation nor surgery are risk-free. Although radiation does not involve pain, post-treatment incontinence, and or peri-operative risk, it can result in irritative symptoms as well as side effects from androgen deprivation therapy used in conjunction with radiation therapy. Radiation also presents a higher delayed risk of cancer recurrence, especially in younger patients. In contrast, surgery presents with more upfront perioperative risk and post-surgical complications but provides more long-term security, as post-surgical salvage radiation is possible. Although many patients have anxieties about post-surgical stress incontinence and sexual function, Dr. Cadeddu notes that 95% of patients will regain continence post-operatively by 6 months. Any incontinence after 6 months is correctable via a male urethral sling or an artificial sphincter. He explains that recovery of post-operative potency depends on the stage and volume of disease, pre-operative sexual performance, patient age, and the skill of the surgeon. If the patient experiences long-term sexual dysfunction, medicines and surgical intervention could possibly resolve the problem. For high risk patients, Dr. Cadeddu makes sure his patients are mentally prepared for multimodal therapy and recurrence.Dr. Cadeddu is excited to see the future direction of the management of localized prostate cancer and advises surgeons to educate themselves about new studies and technologies associated with prostate cancer.

We talk with UTSW Program Director Dr. Steve Hudak and UTSW Urology Resident Dr. Blake Johnson about what it takes to get into Urology Residency these days, and pearls for a successful Urology rotation.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Wsf47h---SHOW NOTESIn this BackTable Urology episode, Dr. Steve Hudak, UT Southwestern residency program director, and Dr. Blake Johnson, PGY-1 at UT Southwestern, give advice on how to successfully match into urology residency.The doctors first discuss their personal journeys to urology, noting that many medical students may discover a passion for the field late into their medical education during their fourth elective rotations. Then, they review the necessary components of an application, such as: excellent performance on all clinical rotations, away rotations, research experience, strong letters of recommendation, and a strong STEP I score. They briefly discuss the transition to a pass-fail STEP I score and its effect on future applicants.Then, Dr. Hudak explains the difficulties involved in the resident selection process. Because the urology match is competitive, he strongly assesses resilience, teamwork, and work ethic in each applicant. He notes that overcoming hardships should be noted in personal statements, as it is a salient demonstration of these qualities. Similarly, Dr. Johnson evaluates applicants based on their attitude and contributions in the clinic/OR.Finally, the doctors share their advice for medical students on away rotations. Both agree that medical students should always remain professional, punctual, and helpful over the course of the rotation. Dr. Johnson also advises medical students to develop situational awareness by knowing when to ask questions and to anticipate residents’ needs.

Urologist Dr. Francisco Gelpi discusses surgical treatments for BPH with a special focus on the minimally-invasive GreenLight Laser prostatectomy. Listen to hear more about Dr. Gelpi’s transition from an oncology-focused practice to a BPH-focused practice, initial BPH patient workup , using prostate anatomy to choose a BPH surgical treatment, GreenLight Laser postoperative care, and the importance of BPH patient involvement and expectations.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/MtP5TT---SHOW NOTESIn this episode of BackTable Urology, Dr. Jose Silva interviews urologist Dr. Francisco Gelpi about GreenLight laser therapy and other BPH surgical treatments.Although he was originally trained in urologic oncology, Dr. Gelpi decided to expand his expertise and incorporate BPH treatment into his medical practice as well. He also explains his decision to enter private practice and his role as a Boston Scientific proctor for Rezum and GreenLight.When initially evaluating a male patient with voiding issues, Dr. Gelpi emphasizes the importance of lower urinary tract imaging. Although he goes through the basic questionnaire to assign the patient an AUA symptom score, he usually performs a pelvic ultrasound on the first visit. In subsequent visits, he will perform an in-office cystoscopy and teach the patient about his urinary tract anatomy simultaneously. His main goal in evaluating patients is to find ways to preserve bladder health and function.Dr. Gelpi uses individual prostate anatomy to guide his decision on BPH treatment for each patient. If there is a substantial median lobe, he prefers to use GreenLight laser therapy. He notes that overtreating patients with GreenLight laser therapy may cause irritative symptoms post-operatively. He also acknowledges UroLift and Rezum as two very good options for patients without substantial median lobes and presents different surgical complications for each treatment. His post-operative medication regimen (pyridium, meloxicam, and colace) is identical for all three BPH treatments.Finally, because some BPH treatments may result in post-operative pain and/or reduction of ejaculation ability, Dr. Gelpi prioritizes having transparent and honest conversations with his BPH patients. He always presents all relevant treatment options to his patients and allows them to share their expectations and priorities before reaching a decision about BPH treatment.---RESOURCESBoston Scientific GreenLight Laser Therapy: https://www.bostonscientific.com/en-EU/health-conditions/enlarged-prostate/our-treatments/greenLight-laser-therapy.html

UT Southwestern endourologist Dr. Jodi Antonelli shares her tips and tricks for difficult ureteroscopy cases. Listen to learn about pre-op and post-op medication, dealing with large prostates and narrow ureters, variations in baskets, access sheaths, and ureteroscopes, dusting vs. basket retrieval, and performing ureteroscopies on pregnant women.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/ZcHovN---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia interviews UT Southwestern endourologist Dr. Jodi Antonelli about her tips and tricks for difficult ureteroscopy cases.First, the doctors discuss the treatment of acute patients presenting with flank pain in the emergency department. In these cases, it is important to obtain a comprehensive patient history complete with vitals, temperature, bloodwork, urinalysis, and appropriate imaging. Indications for intervention include: febrile state, hemodynamic instability, severe pain, and a combination of tachycardia and hypertension. Dr. Antonelli advises urologists to avoid relying solely on urinalysis, as a patient with inflammation may present similar results to one with ureteral stones. In patients who require drainage, Dr. Antonelli prefers to use a nephrostomy tube instead of a stent if the ureteral stone exceeds 1.5 centimeters or if she encounters difficulty in the prostate or bladder anatomy.For non-acute patients, a trial of passage is recommended if the stone has not occupied an obstructive position for more than 6 weeks. For stone passage patients, Dr. Antonelli prescribes NSAIDS, which she has found to be more effective than narcotics in pain management. If she decides that medical expulsive therapy is appropriate for a ureteral stone patient, she prescribes alpha blockers for both proximal and distal stones. Finally, she notes that relying on the disappearance of symptoms to confirm stone passage is insufficient; before declaring a patient stone-free, imaging, such as a KUB X-ray, must be performed.If the trial of passage fails, surgical intervention is the next step. Ureteroscopy is an ideal minimally invasive method of extracting ureteral stones. Dr. Antonelli’s pre-operative regimen consists of obtaining a urinalysis and urine culture at least 2 weeks before surgery. She recommends at least 5 to 6 days of culture-specific antibiotics if the patient has a positive urine culture. In the context of the ureteroscopy procedure, Dr. Antonelli emphasizes the importance of being very thorough with ureteroscopy to find tumors in the bladder. Furthermore, Dr. Antonelli discusses her approaches to getting a wire past a difficult stone and dealing with anatomically complex cases that involve large prostates and narrow ureters. She acknowledges that in some cases, the best option is to place a stent to dilate the ureter and attempt the surgery again in the next week.One method of surgically removing ureteral stones is through the use of a basket. Dr. Antonelli discusses the different basket shapes and manufacturers she prefers to use. However, if the stone is too big or positioned at an unfavorable angle for basket retrieval, dusting the stone is a possible alternative. Although Dr. Antonelli addresses the rapid advancement of dusting laser technology, she also discusses potential risks of dusting--the creation of small stone fragments increases the likelihood of stone recurrence and reduces intraoperative visibility.The post-operative medications Dr. Antonelli prescribes are: NSAIDS, anticholinergics to help with LUTS, alpha blockers to relax ureter, urinary tract anesthetic, and stool softener. She recommends ordering a post-operative metabolic evaluation, an ultrasound, and a KUB six weeks after surgery.

We talk with Dr. Yahir Santiago-Lastra, director of the Women's Pelvic Medicine Center at UC San Diego Health about the management of cystitis and pelvic pain syndromes. She shares her insights on genitourinary syndrome of menopause, pain evaluation and treatment, and procedural options including botox and sacral neuromodulation.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Glx2AL---SHOW NOTESIn this episode of BackTable Urology, Dr. Jose Silva discusses cystitis and pelvic pain syndrome with Dr. Yahir Santiago-Lastra, a urogynecologist and director of the Women’s Pelvic Medicine Center at UC San Diego Health.The initial evaluation of a pelvic pain or cystitis patient must address the patient’s detailed symptoms and pain. On the first visit, Dr. Santiago-Lastra emphasizes the importance of discussing the frequency of symptoms, past treatments sought by the patient, and qualitative descriptions of the pain. She notes that some urologists will forget to consider genitourinary syndrome of menopause (GSM) as a cause for recurrent UTIs. Then, she outlines her 5-step pelvic examination procedure: vulvovaginal examination, urethral examination, classic pelvic examination, vaginal/cervix examination, and anal examination. If she finds something abnormal during the pelvic exam, she will use a hand mirror to show patients the anatomical location of their pain.Next, Dr. Santiago-Lastra discusses the kinds of medical treatment for patients presenting with recurrent UTIs and consistently positive urine cultures. She prefers to prescribe vaginal estrogen over long-term antibiotics, but acknowledges that some patients, such as premenopausal breast cancer patients, may refuse vaginal estrogen. In these cases, she recommends Refresh cream, methenamine, prophylactic post-coital/nightly antibiotics, and sometimes intravesical gentamicin instillation. Aside from medical treatments, Dr. Santiago-Lastra also recommends pelvic floor therapy and sometimes additional holistic treatment, as pelvic pain may originate from sexual trauma.Dr. Santiago-Lastra then discusses different options for treating pelvic pain and cystitis. For her, opioids play an extremely limited role for pelvic and bladder pain. She typically uses injections (nerve blocks), neuromodulation, pyridium, vaginal diazepam, vaginal lidocaine, gabapentin, and vaginal/systemic cannabis to treat pelvic and bladder pain. She does not usually prescribe NSAIDS because of their adverse effects from long-term use. For patients with confirmed localized bladder pain, she notes that IC cocktail (instillations) can provide some pain relief. In the rare case that all medical options have been exhausted, urinary diversion, an open surgery that removes the bladder completely, is a possible option.Finally, Dr. Santiago-Lastra and Dr. Silva discuss Botox and InterStim (sacral neuromodulation), two new treatments for patients who have both pelvic pain and incontinence/urgency symptoms. Although Botox and InterStim are equivalent treatments, there are certain indications for each treatment. For instance, InterStim is recommended for patients with voiding dysfunction and severe bowel symptoms because Botox only directs its efficacy to the bladder.To conclude, Dr. Santiago-Lastra emphasizes the importance of taking time to listen to pelvic pain and cystitis patients’ concerns and desires, as they commonly become long-term patients.

Dr. Aditya Bagrodia interviews urologist Dr. Steve Hudak from UT Southwestern Medical Center about post-prostatectomy incontinence. They cover an array of topics including, incontinence evaluation, managing patient expectations, kegel exercises and pelvic floor therapy, and slings vs. artificial urinary sphincters.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/pk6zeG---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia discusses post-prostatectomy incontinence with UT Southwestern urologist Dr. Steve Hudak. Urinary leakage is very common after the post-prostatectomy catheter is removed. Although the majority of men will regain continence in the long-term, 10-20% will need further treatment for their incontinence.First, Dr. Hudak emphasizes the importance of comprehensive incontinence evaluation in the clinic. He prefers to schedule two different appointments to make incontinent patients feel more comfortable; he will only take a good medical history in the first appointment and save the cystoscopy and more provocative maneuvers for the second appointment. Dr. Hudak's clinical evaluation consists of a variety of quality of life questions as well as specific questions about pad weight, pad quantity, and pad size.Further incontinence treatment can be non-surgical or surgical. Among the non-surgical therapies, Dr. Hudak suggests Kegel exercises and pelvic floor physical therapy. Dr. Hudak encourages urologists to explore these non-surgical options with their patients first. When deciding to move onto surgical intervention, Dr. Hudak explains that the trajectory of improvement is more important than a generalized timeframe because surgery is most effective in the time period in which a patient’s progress plateaus.Pelvic slings and the artificial urethral sphincter (AUS) are the two most common surgical techniques for resolving urinary incontinence. Urologists must take into account their incontinence patients’ medical status, progress, goals, severity of leakage, and age before deciding whether to place a pelvic sling or an AUS. Dr. Hudak notes that the AUS is preferable in patients with severe arthritis, patients who have received radiation therapy, and patients with gravity incontinence. Two possible complications with the AUS are infection and erosion, as the AUS is a mechanical device with a half-life of seven to ten years. The sling is preferable in patients with mild incontinence, as it is a less invasive surgical technique and has a minimal risk of infection.In some cases, it is possible that post-prostatectomy patients will also need post-operative radiation, so it is crucial to time the incontinence surgery correctly. Dr. Hudak recommends performing sling surgery before radiation, but concedes that radiation treatment should not be delayed solely due to incontinence surgery. His rule of thumb is: perform surgery if radiation is presumed, but not planned. If he has to perform surgery after radiation therapy, he waits at least 3-6 months after radiation to do so, allowing his patients to restore to their baseline levels of health.

Dr. Aditya Bagrodia interviews Dr. Vitaly Margulis, professor of urology at UT Southwestern Medical Center, about locally advanced kidney cancer. They discuss various topics including classification of locally advanced kidney cancers, various imaging modalities for staging cancer, special considerations for tumor-thrombus formation, targeted therapy vs. checkpoint inhibitors, and robotic vs. open nephrectomies.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/EaNoop---SHOW NOTESIn this episode of BackTable Urology, Dr. Vitaly Margulis, professor of urology at UT Southwestern Medical Center, joins Dr. Aditya Bagrodia in a thorough discussion about locally advanced kidney cancer.First, the doctors classify locally advanced kidney cancers and discuss various imaging modalities used in staging this type of cancer. Dr. Margulis uses MRI, chest CT, and direct radiographic imaging to visualize patient anatomy. He notes that PET scans have a very limited role in staging.Although extensive metastasis is not present in locally advanced kidney cancer, small metastases--such as pulmonary nodules and small pancreatic/liver metastases--may be present. In these cases, Dr. Margulis emphasizes the importance of collaboration with interventional radiologists to choose the optimal site to biopsy, as biopsy can trigger a hemorrhage of the primary tumor site. He notes that the easiest site to access may not be the best site to biopsy.Next, Dr. Margulis discusses pros and cons of the two broad types of general systemic therapy: targeted therapy and checkpoint inhibitors. In his clinical practice, he uses a combination of both therapies and continues until the maximal response is reached. He notes that pseudoprogression, or the process of the tumor initially swelling and then shrinking, may be possible.Furthermore, Dr. Margulis discusses general surgical considerations for other types of locally advanced kidney cancers, such as the necessity of performing a lymph node dissection and whether to take an open or robotic surgical approach. Dr. Margulis also shares special surgical considerations in locally advanced kidney cancers that cause the formation of a tumor-thrombus. He first categorizes these thrombi into two categories--bland thrombus vs. pulmonary emboli--and explains how they can make surgical intervention more complicated. When operating on these cases, he always has a multidisciplinary team with echocardiogram capabilities.Finally, he shares his clinical opinions about neoadjuvant and adjuvant therapies, two new approaches to locally advanced kidney cancer. He notes that neoadjuvant therapy may be useful, as it can shrink the primary tumor pre-operatively, but he does not use post-operative adjuvant therapy because of its inability to increase survival rates. However, he notes that using checkpoint inhibitors in an adjuvant setting may improve outcomes.

Dr. Margaret Pearle, the Vice Chair of Urology at UT Southwestern Medical Center, joins us to discuss percutaneous nephrolithotomy (PCNL). Dr. Pearle shares advice on pre-operative urine culture analysis, CT scans, percutaneous access, and placing a ureteral stent vs. a nephrostomy tube---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/TdxUCi---SHOW NOTESIn this episode of BackTable Urology, Dr. Margaret Pearle, an endourologist specializing in complex kidney stone cases, joins Dr. Aditya Bagrodia and Dr. Jose Silva to share her preoperative, intraoperative, and postoperative advice on the percutaneous nephrolithotomy (PCNL) procedure.First, the doctors discuss preoperative considerations such as absolute indications for PCNL, preferred imaging modalities and urine culture analysis. Dr. Pearle notes that, although every kidney stone patient is a potential candidate for PCNL, PCNL is ideal for patients with large and complex stones and/or patients with no other access options besides percutaneous access. Her preferred imaging modality is CT imaging without contrast, and she emphasizes that a surgeon must study the patient’s collecting system anatomy extensively before operating. Dr. Pearle also adopts an aggressive preoperative antibiotic regimen in patients who present with positive urine culture analyses at least two weeks before the operation.Then, Dr. Pearle discusses the PCNL operation in the context of achieving percutaneous access, her tools of choice, and operating red flags. She advocates for urologists to learn how to gain percutaneous access without the assistance of an interventional radiologist, but still acknowledges that working with an interventional radiologist is helpful, especially in cases where ultrasound-guided access is needed. She then delineates the type of guide wire, introducer set, sheaths, and nephroscopes she uses and explains how to distinguish the posterior calyx from the anterior calyx using balloon dilation and contrast. Some signs to abort the PCNL procedure are: a significant amount of bleeding, the presence of pus, and a significant perforation of the collecting system.Finally, Dr. Pearle discusses postoperative decisions, such as whether to place a ureteral stent or a nephrostomy tube. She advises urologists to check the kidney with a flexible nephroscope and to get a postoperative contrast-enhanced ultrasound to confirm that patients are really stone-free. Also, she always gets a chest CT that includes lung bases to check for the presence of a hydrothorax.---RESOURCESJeffrey Wire Guide Exchange Set (Cook Medical):https://www.cookmedical.com/products/ir_jwge_webds/Shockpulse Stone Eliminator (Olympus):https://medical.olympusamerica.com/products/shockpulse-seSwiss LithoClast Trilogy (Boston Scientific):https://www.bostonscientific.com/en-US/products/lithotripsy/swiss-lithoclast-trilogy-lithotripter.html

Dr. Jose Silva interviews Dr. Jonathan Clavell, a high-volume prosthetic urology surgeon and assistant professor of urology at UT Health Science Center Houston, about erectile dysfunction counseling and penile implants. Dr. Clavell goes into detail about his journey as a men’s health specialist, ED workup and medical counseling, advantages and limitations of different penile implants, implants for complex ED patients (diabetics, cancer patients, etc.), and post-operative care for penile implant patients---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/GC1TnY---SHOW NOTESIn this episode of BackTable Urology, Dr. Jonathan Clavell, a high-volume prosthetic urology surgeon and assistant professor of urology at UT Houston, joins Dr. Jose Silva to discuss his journey to becoming a men’s health specialist. He also shares advice on erectile dysfunction counseling and penile implant procedures and complications.First, Dr. Clavell shares his approach to starting a successful urology private practice. Early on, he invested in marketing himself and his prosthetic services through a professional website, a Spanish radio show, an informational Youtube channel, and social media. His diverse marketing strategy succeeded in Houston, a large urban city with a sizable Hispanic population.Next, Dr. Clavell and Dr. Silva talk about penile implants for patients with erectile dysfunction. Dr. Clavell emphasizes the importance of asking patients about their personal goals and having a partner in the room, if possible. Dr. Clavell then discusses the advantages and limitations of the two main penile implants, the AMS 700 and the Coloplast Titan. Special considerations may be given to patient age and penis size. Then, Dr. Clavell summarizes different approaches of complex ED patients needing penile implants, such as those with urinary incontinence, pump incompatibility, prostate obstructions, and diabetes.Finally, Dr. Clavell shares his postoperative care regimen for penile implant patients. He always prescribes a week of antibiotics to prevent infections and, if needed, pain medication. He also instructs his patients on how to cycle their implants properly after 4-5 weeks if the incision site has healed.---RESOURCESDr. Clavell’s Youtube Video on Cycling the Coloplast: https://www.youtube.com/watch?v=o1t3YuJ_zz4&t=106sDr. Clavell’s Youtube Video on Cycling the AMS 700: https://www.youtube.com/watch?v=07gyeibMieUDr. Clavell’s Youtube Video on the Mini-Sling: https://www.youtube.com/watch?v=HpjJZuhA2uoDr. Clavell’s Radio Show, Sí Se Puede: https://houstonmenshealth.com/posts/events/new-radio-show/

Dr. Aditya Bagrodia and Dr. Jose E Silva interview Brad Hornberger, PA-C in the UTSW Urology department, about bringing advanced practice providers (APPs) into your practice, and how to do it successfully. Brad goes into detail about his journey as a urological PA, advice for on-boarding new APP’s, and training PAs to do in-patient consults and assist in the OR.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/kwiMKe---SHOW NOTESIn this episode of BackTable Urology, Brad Hornberger, PA in UT Southwestern’s Urology department, joins Dr. Aditya Bagrodia and Dr. Jose Silva to discuss how to successfully incorporate advanced practice providers (APPs) like physicians’ assistants and nurse practitioners into your urology practice.First, Brad shares tips for onboarding new APPs. He emphasizes that onboarding depends on the experience of the new hire, as there is a difference between training a new graduate versus an experienced APP. He suggests a time period of 6 months for onboarding, which includes 6-12+ weeks of shadowing. He also notes the need to identify a champion who can take responsibility and set expectations for the new hire. Additionally, Brad explains two models of clinical supervision for APPs--the shared visit model, where the APP presents the patient to the urologist, versus the independent provider model, where the APP sees the patient autonomously. Determining which model works best depends on the experience of the new hire, state laws, and billing logistics.Brad also briefly explains how to train APPs to assist in the operating room. He recommends a gradual apprenticeship system, where APPs are able to scrub in one-on-one with an experienced APP or a urologist. OR onboarding often depends on whether the APP has laparoscopic or robotic operating experience. Brad emphasizes that exposure to both clinical and surgical environments may be very professionally and intellectually enriching for APPs, who in turn will be more likely to stay at a practice for longer.