E. David Crawford, MD, Editor-in-Chief
LEARNING CENTERS
Editor: J. Curtis Nickel, MD, FRCSC
Editor: Celestia S. Higano, MD
Editor: Seth P. Lerner, MD
LATEST CONTENT
Neal D. Shore, MD, FACS, Medical Director for the Carolina Urologic Research Center, discusses the physiological and economic factors impacting the ADT selection process. He particularly emphasizes the impact of the current volume-based and economically incentivized model of treatment and how this can restrict urologists. He also discusses the physiological impacts of drug-drug interactions, alternate modes of administration, and the complex prospect of an oral alternative.
Neil H. Baum, MD, Clinical Professor of Urology at Tulane Medical School, discusses the business of medicine and some important numbers that urologists need to know. Highlighting the need for doctors to improve their business skills in order to survive in today’s market, Dr. Baum goes over five important metrics that will help doctors truly understand the value of the service they are providing. These numbers include charges and receipts, accounts receivable, charge lag, denials, and new patient percentages. He talks about what these numbers look like in a perfect world versus reality and what doctors can do about them. Dr. Baum emphasizes that doctors need only spend five minutes every month monitoring these metrics in order to become more involved in the business of their practice.
Jens Rassweiler, MD, Professor and Head of the Department of Urology at Klinikum Heilbronn, the academic hospital of Heidelberg University in Germany, discusses the management of complicated cases of endourological stones. First, he defines what exactly makes a case complicated, and then goes on to detail the procedures involved. He compares various management methods, noting the pros and cons of each and emphasizing the importance of staying away from open surgery when possible. He does discuss the best techniques for open surgery when it is unavoidable, but emphasizes that a combination of robotic and laparoscopic surgery is best.
James L. Mohler, MD, Associate Director and Senior Vice President for Translational Research and Professor of Oncology at Roswell Park Comprehensive Cancer Center in Buffalo, New York, discusses the cause of and potential solutions to androgen receptor expression in castration-recurrent prostate cancer. He explains that prostate cancer tissue in a patient with castration-recurrent disease actually has greater levels of testosterone than benign prostate tissue and that castration-resistant prostate cancer relies on a backdoor pathway of manufacturing testosterone by which dihydrotestosterone (DHT) is made from androstanediol. Abiraterone is intended to inhibit CYP17A1 and therefore prevent the manufacture of DHT, but Dr. Mohler suggests that abiraterone inhibits CYP17A1 that is too far from DHT synthesis to achieve long term response by inhibition. He then discusses current research about a promising drug that targets the catalytic domain shared by the five 3α-oxidoreductases associated with DHT production.
Robert E. Reiter, MD, Bing Professor of Urology and Molecular Biology, Director of the Prostate Cancer Program, and Director of Urologic Research at the David Geffen School of Medicine at the University of California, Los Angeles, discusses the benefits of PSMA imaging in the context of biochemical recurrence. He reviews data from an Australian and an American study which both depict a positive correlation between PSA levels and PSMA prostate cancer detection rates, as well as high sensitivities for detection of recurrence based on pathologic confirmation. He then discusses the results of a study which compared PSMA with Axumin and found PSMA to be more than twice as effective in all areas but the prostate bed, which is most likely due to PSMA being excreted through the bladder. He argues that PSMA imaging can produce between a 29% and 76% change in prostate cancer management and allows for greater precision in treatment, resulting in fewer occurrences of unnecessary radiation therapy and long term systemic therapy.
Daniel P. Petrylak, MD, Director of Genitourinary Oncology, Professor of Medicine and Urology, Co-Leader of Cancer Signaling Networks, and Co-Director of the Signal Transduction Program at Yale University Cancer Center in New Haven, Connecticut, discusses data from recent chemotherapy trials for castrate-resistant prostate cancer (CRPC). Dr. Petrylak specifically examines trials evaluating drug combinations as treatment for CRPC patients. Additionally, he reviews the effectiveness of PARP inhibitors in patients with DNA repair mutations. Finally, he notes the apparent superiority of cabazitaxel to NG AA treatment after progression on docetaxel.
Michael S. Cookson, MD, MMHC, Professor and Chairman of the Department of Urology at the University of Oklahoma Health Sciences Center in Oklahoma City, gives an overview of the changing landscape of metastatic hormone-sensitive prostate cancer (mHSPC). He reviews the different treatment strategies that have undergone testing over the last eight decades, noting that although treatment options have progressed, there is still work to be done to continue improving results. He presents the findings of key studies that look to improve survival through the use of more potent androgen-targeting techniques, among other cutting edge treatments. These new treatments show promising results in lowering risk of spread and death, bolstering Dr. Cookson’s key point: that the landscape is rapidly changing, and urologists need to adapt quickly.
In Part 2 of his presentation on efficiency in the urologic practice, Neil H. Baum, MD, Clinical Professor of Urology at Tulane Medical School in New Orleans, Louisiana, offers five more ideas about how urologists can be more productive. He reviews the current problems facing urologists which make them less efficient. He explains why patients should complete their forms at home before coming into the office, as well as why it is important to obtain prior authorization. He emphasizes the benefits of using scribes and discusses the best way to use them. He also highlights how telemedicine can help improve efficiency by using it to fill no-show gaps in a urologist’s schedule. Finally, Dr. Baum talks about how important improving scheduling is and explains that the best way to stay on time is to build a 15-minute buffer into the schedule that can be used to deal with any emergencies that crop up.
E. David Crawford, MD, Professor of Urology at the University of California, San Diego, discusses the usefulness of adjustable needle sizes for prostate biopsies with Jelle Barentsz, MD, PhD, Professor of Radiology at the Nijmegen Medical Center of Radboud University in Nijmegen, The Netherlands. Dr. Barentsz agrees with Dr. Crawford that a needle that can be adjusted from 10 to 60 gauge would be useful in situations such as when the smaller needle sometimes needed to reach an area is unable to pierce through fat to take the needed core sample. Drs. Barentsz and Crawford then address the pros and cons of mapping biopsy of the prostate: Dr. Barentsz contends that the use of 180 needles to obtain only slightly more accurate results than MRI may not be warranted, and Dr. Crawford notes that mapping biopsies are usually reserved for patients with negative MRIs and negative biopsies.
In a conversation with A. Lenore Ackerman, MD, PhD, Section Editor of the Next Generation Microbiome and Urologic Infection Learning Center on Grand Rounds in Urology, Nicole M. Gilbert, PhD, an instructor in the Department of Pediatrics at Washington University School of Medicine, discusses her research linking urogenital microbes to recurrent urinary tract infection (rUTI). Although the bladder was long regarded as sterile in the absence of overt infection, recent research suggests that there is a urinary microbiome and that two commonly found bacteria in the bladder are Gardnerella and Lactobacillus, both of which are also common in the vagina. Dr. Gilbert and her colleagues wanted to investigate how those urogenital microbes affect the bladder, and determined that Gardnerella vaginalis causes urothelial exfoliation, a condition that has been associated with rUTI. Because Gardnerella vaginalis appears able to trigger rUTI even when it is cleared out of the bladder within 12 hours, Dr. Gilbert calls it a covert pathogen, and suggests that further research is needed to find stable indicators of repeat exposure to Gardnerella.
Michael A. Gorin, MD, a urologist at Urology Associates of Cumberland, Maryland, and Director of Medical Affairs for Perineologic, discusses the benefits of transperineal prostate biopsy over transrectal biopsy. He notes that transrectal prostate biopsy leads to infections in 5-7% of patients, and argues that transperineal biopsy is the best alternative for avoiding infection. Dr. Gorin acknowledges that the use of a grid-stepper unit for performing transperineal biopsy can be uncomfortable for patients, but suggests that new technology like the PrecisionPoint™ Transperineal Access System solves many of these issues. The presentation is followed by a Q&A in which Dr. Gorin discusses the importance of new coding for transperineal biopsy and the potential of variable length needles.
