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Building Your Urologic Castle: Barriers to Exit (Part 2 of 2)

In the second part of this two-part series, Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, gives suggestions on how urologists who have already successfully attracted patients by removing barriers to entry can then keep those patients in their practice by building barriers to exit. He explains that the goal is for each patient to have a stellar experience and then share their feedback with others. Dr. Baum emphasizes the importance of a robust, regularly updated website and active social media pages. He also highlights the importance of practice accessibility, from having online scheduling and communication via email and text, to having same-day appointments available, keeping office wait times as short as possible, and supplying accessible, validated parking. He suggests that doctors call patients at home after they have had a procedure, both to demonstrate care and to reduce incoming calls from patients. Dr. Baum also notes the importance of having transparent pricing and insurance assistance, and of providing translators for patients who do not speak English. He concludes by encouraging urologists to make their USP (unique service proposition) visible and obvious to patients, by noting that there are riches in the niches, and by reiterating the importance of eliminating negative barriers and fortifying positive ones in a medical practice.

Neoadjuvant Immune-Checkpoint Inhibition for Muscle-Invasive Bladder Cancer

Petros Grivas, MD, PhD, Associate Professor of Oncology at the University of Washington School of Medicine in Seattle, argues for the use of immune-checkpoint inhibition over cisplatin-based chemotherapy for muscle-invasive bladder cancer (MIBC) based on promising level 1 evidence. He begins with an overview of the PURE-01 trial, which found that single-agent pembrolizumab safely achieved a pTO of 42% and a down-staging rate of 54%. Dr. Grivas continues by discussing the possibility of imaging endpoint use, reaching the conclusion that more validation is necessary before progress can be made in this area. He then returns to the PURE-01 trial, reviewing the surgical safety data which demonstrate high-grade complications post-pembrolizumab in 34% of patients, a significant minority. Dr. Grivas follows this by looking at the wider landscape of phase 2 trials in MIBC beyond just PURE-01, noting that they have shown promising pathologic complete response rates and rates of pathologic downstaging to non-muscle invasive disease. He looks to the future, suggesting that with more data and validation physicians will be able to treat patients based on their individual biology. Dr. Grivas concludes by arguing that it may be possible to use immune-checkpoint inhibition in patients who are unfit for cisplatin or to even avoid using cisplatin altogether, but notes that there is a need for more high-quality studies to inform discussions.

Active Surveillance 2021 – Imaging and Biomarkers

In the second part of a Platinum Lecture trilogy on active surveillance, Laurence Klotz, MD, FRCSC, Professor of Surgery and holder of the Sunnybrook Chair of Prostate Cancer Research at the University of Toronto, outlines recent developments in imaging and biomarkers and discusses how these are changing active surveillance for prostate cancer. He reviews the benefits and limitations of MRI targeting, considers the potential of high resolution micro-ultrasound, looks at how biomarkers that provide a continuous risk index might be more useful in active surveillance than most currently-available biomarker tests, and contemplates a future of data integration and artificial intelligence in active surveillance.

Hemi-gland HIFU Ablation: Initial Outcomes From 100 Cases

Samuel J. Peretsman, MD, a urological oncologist with Urology Specialists of the Carolinas in Charlotte, North Carolina, discusses the results and the implications of two recent American studies of high-intensity focused ultrasound (HIFU) for treating prostate cancer. In the first part of the presentation, Dr. Peretsman reviews the initial outcomes of a study on HIFU of hemigland ablation for prostate cancer. He explains that reports of focal HIFU performed in the United States have been lacking, and therefore this study aimed to report the initial and largest American series of HIFU prostate gland ablation as a primary treatment for prostate cancer. Dr. Peretsman discusses the methodology, limitations, and results of the study, concluding that short-term results of focal HIFU indicate safety, excellent potency and continence preservation, and adequate short-term prostate cancer control. In the second part of the presentation, Dr. Peretsman outlines the lessons learned from a study of salvage robotic prostatectomy following whole-gland HIFU. Based on the data on patients with HIFU-persistent disease, Dr. Peretsman argues that there is room for improvement in HIFU treatment follow-up in order to optimize the results of salvage therapies. He also concludes that more assurance of successful salvage therapy may boost patient confidence in HIFU as a primary therapy choice.

Germline Genetics and Prostate Cancer Evolution and Aggressivity

Paul C. Boutros, PhD, MBA, Professor of Human Genetics and Urology at the University of California, Los Angeles, explains the relationship between the germline and cancer evolution, as well as the implications this relationship has for screening and care. Dr. Boutros begins by explaining why it makes sense to study the germline, noting that while cancer is a disease of somatic mutations, there are already many known germline risk factors and evidence suggests that 20% of prostate cancer biopsies could be avoided if patients received a polygenic risk score. Dr. Boutros then looks at the results of a study from his lab at UCLA which show that the germline drives somatic epigenomics and that some single nucleotide polymorphisms (SNPs) are prognostic. Another yet-to-be-published study by the same team suggests that the germline also drives somatic mutations, with multiple quantitative trait loci (QTLs) predicting somatic driver mutations. This means that mutations that occur early in tumor evolution and can increase the likelihood of aggressive cancer are more likely to occur in certain people based on genomic factors. This also appears to be the case with multiple cancer types. Dr. Boutros concludes by noting possible future directions for research in this area, including multi-ancestric studies and studies into germline influences on the transcriptome and proteome. He also observes that it is not yet clear how this research should be integrated with diagnostic and prognostic tests nor how it could influence decision-making.

Building Your Urologic Castle: Barriers to Entry (Part 1 of 2)

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses barriers to potential patients coming to a urologic practice. He suggests ensuring patients have a good initial contact with the receptionist, keeping appointment slots open for emergencies, and being transparent with finances on the practice website. Dr. Baum also suggests having between four- and five-star ratings online, obvious signage to get to the clinic, convenient parking, making the practice handicap-accessible, and having a welcoming reception area and clean bathrooms. He recommends making sure all patients’ questions have been answered at the end of an appointment, returning all calls and emails within 24 hours, and having the option of scheduling appointments online. In summary, he encourages making it easy for a patient to enter a practice.

Guideline-Based Approach to Metabolic Stone Management for the General Urologist

Wesley A. Mayer, MD, Associate Professor of Medicine at Baylor College of Medicine in Houston, Texas, discusses the AUA guidelines for the medical management of kidney stones, also known as nephrolithiasis. There are 27 guidelines, fitting into the categories of evaluation, diet therapy, pharmacologic therapy, and follow-up. Dr. Mayer urges urologists to care for the whole patient, and to not just focus on the surgical issue. Nephrolithiasis is both a surgical and medical disease, making follow-up with these patients essential. For example, urologists can use a metabolic work-up to reduce the risk of future stone formation. Dr. Mayer concludes by reemphasizing that stone management often requires multiple modalities, including diet and medication, and by noting that for complex cases, urologists may want to consider referring patients to a dietician or other expert.

Active Surveillance 2021 – From Bench to Bedside

In the first part of a Platinum Lecture trilogy on active surveillance, Laurence Klotz, MD, Professor of Surgery and holder of the Sunnybrook Chair of Prostate Cancer Research at the University of Toronto, discusses the history of active surveillance for prostate cancer as well as current guidance for its implementation. He first notes the major issues in early prostate cancer in the present day, including risk assessment prior to diagnosis, diagnostic evaluation of localized disease, and image-guided partial gland ablation therapy. Dr. Klotz then looks back to early papers suggesting that radical treatment may be unnecessary and ineffective in treating low-risk prostate cancers, remarking on their influence on himself and his colleagues’ 2002 feasibility study on watchful waiting. He reflects on how active surveillance has become widely accepted since that publication, and discusses what urologists have learned regarding patient selection, especially in terms of molecular genetics. Dr. Klotz then compares different studies of active surveillance, focusing on one with broad patient selection criteria and one with conservative selection criteria. The study with broader patient criteria found a raw prostate cancer-specific mortality of 1.5% and an actuarial mortality of 5% at 15 years, while the more conservative study found a prostate cancer-specific mortality of 0.5% at 15 years. Dr. Klotz notes that the 5% actuarial mortality in the first study was determined to be largely the result of the presence of pattern 4 disease at baseline. He also observes that there has been a convergence of selection criteria since those studies came out. Dr. Klotz concludes by discussing current active surveillance protocol, emphasizing the importance of doing a confirmatory biopsy.

Non-Metastatic CRPC: Finding Advanced Disease with Next Gen Imaging Matters

Gerald L. Andriole, Jr., MD, the Robert K. Royce Distinguished Professor and Chief of Urologic Surgery at Barnes-Jewish Hospital, the Siteman Cancer Center, and Washington University School of Medicine in St. Louis, Missouri, defines non-metastatic castration-resistant prostate cancer (nmCRPC) as having rising PSA measurements on three consecutive measurements with a PSA of greater than two. He also defines next-generation imaging as PET scans. He discusses FACBC scans and PSMA-based PET scans, as well as the history and treatment of nmCRPC. Dr. Andriole reviews the SABR-COMET study, the STOMP trial, and the ORIOLE study. He concludes that next-generation imaging is necessary for patients with nmCRPC, that metastasis-directed therapy shows benefits, and that larger and longer trials are warranted.

Best Treatment for Male Incontinence: Sphincter

In the second part of this urologic debate, Alexander Gomelsky, MD, FACS, B.E. Trichel Professor and Chair of the Department of Urology at LSU Health Shreveport, argues that artificial urinary sphincter (AUS) is the best treatment for post-prostatectomy stress urinary incontinence. Dr. Gomelsky first describes possible surgical complications and how to set patient expectations, then reviews data on AUS and the male sling, and finally contrasts the benefits of AUS against the sling. In comparison with the sling, which is best used in patients with mild incontinence, AUS can handle any degree of incontinence including severe and persistent presentations. Noting that AUS can also be used in patients who have undergone radical therapy, those with prior urethral stricture or bladder neck contracture, and those who have undergone urethral bulking, Dr. Gomelsky suggests that AUS outperforms the sling in all scenarios. Additionally, data suggests that a sphincter would be placed after a sling failure, further underscoring its utility. Brian S. Christine, MD, argues in favor of using a sling in the first part of the debate here.

Best Treatment for Male Incontinence: Sling

In the first part of this urologic debate, Brian S. Christine, MD, Director of Prosthetic Urology and Men’s Sexual Health at Urology Centers of Alabama in Birmingham, argues that the sling is the best treatment for post-prostatectomy stress urinary incontinence in men. He goes over how to select the right candidates for a sling, the pre- and post-operative procedural steps, and the resulting success rate. Dr. Christine notes that slings are best used in patients with mild to moderate stress urinary incontinence as determined by a severity grading system. He considers two options for determining incontinence severity, the pad test and the standing cough test, observing that the latter is preferable given that it is done in-office versus by the patient at home. Dr. Christine then provides a detailed explanation of the surgical steps and technique using an AdVance XP male sling. He concludes that the sling, when used on the ideal candidate with a standing cough test grade of 0, 1, or 2, results in a post-operative success rate of 82-83% of patients who are dry or pad-free. Alexander Gomelsky, MD, FACS, argues in favor of using an artificial urinary sphincter in the second part of the debate here.