Your Education Resource for Urology | Grand Rounds in Urology

E. David Crawford, MD, Editor-in-Chief

LEARNING CENTERS

Next Generation Androgen Deprivation Therapy

Editor: Celestia S. Higano, MD

Next Generation Genomics and Biomarkers

Editor: Leonard G. Gomella, MD

Next Generation Upper Tract Urothelial Carcinoma

Editor: Seth P. Lerner, MD

The Role of Genetic Testing in Prostate Cancer

A. Karim Kader, MD, PhD, FRCSC, Professor in the Department of Urology and Director of Urologic Oncology at the University of California, San Diego, argues that genomic risk stratification plays an important role in our understanding of prostate cancer. He highlights the differences between germline and somatic genomic classifiers and the impact they can have on prostate cancer risk and outcome. Dr. Kader discusses the advantages and disadvantages of a wide range of genetic tests. Additionally, he discusses the differences between high penetrance and low penetrance genetic change and the implications they can have on screening, detection, and treatment decisions.

Patient Safety Concerns in Urologic Cancer Surgery and Treatment During the COVID-19 Outbreak

John W. Davis, MD, Professor of Urology and Director of the Urosurgical Prostate Program at the University of Texas MD Anderson Cancer Center in Houston, Texas, discusses how the Center is dealing with the COVID-19 crisis by setting up a committee to determine on a case-by-case basis which surgeries are to move forward, as well as which elective surgeries are still being performed. While trying to be cognizant of the need to conserve resources, the urology department is focusing primarily on large renal tumors and invasive bladder cancer. Overall, they have reduced the OR and ICU capacity to about 25% in order to make room for COVID-19 admissions. Dr. Davis also details the need to test all patients for COVID-19 prior to any elective surgery in order to lessen potential negative outcomes, self-quarantine for two weeks prior to surgery, and, if possible, delay surgery altogether in order to prevent an undiagnosed patient from infecting the OR team. This is particularly true in favorable, intermediate-risk cases that can be delayed anywhere from six months to a year without affecting outcomes.

Sarcopenia in the Prostate Cancer Patient

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Complementary/Alternative Medicine at the University of Michigan Medical Center in the Department of Urology, discusses the consequences of androgen-deprivation therapy-related skeletal muscle loss. He goes on to discuss the prevalence of sarcopenia in prostate cancer patients, the clinical studies demonstrating the efficacy of incorporating exercise for the prevention or mitigation of sarcopenia, as well as the benefits and limitations of diet and over the counter supplements for the prevention of sarcopenia.

Review of the Role of MRI-Targeted Biopsy vs Systematic Biopsy in Prostate Cancer

Mukesh Harisinghani, MD, Director of the Clinical Discovery Program Center for Molecular Imaging Research at the Massachusetts General Hospital, reviews recent research on the effectiveness of MRI-targeted biopsy as well as systematic biopsy on biopsy naive patients. Through the analysis of research results, he reveals that there is consistent evidence to support that combining the two techniques creates a substantial boost in detection rates. This boost has been proven to be a shift from a 21.4% detection rate in just systematic biopsy and 23.4% in just MRI-targeted biopsy to a detection rate of 27.7% when using combined techniques on biopsy naive patients.

The Effect of COVID-19 on Large Urology Groups: The LUGPA Perspective

Richard G. Harris, MD, President of LUGPA and UroPartners, discusses the changes being implemented at LUGPAs as a result of the COVID-19 pandemic. He notes how surgery and radiation centers are only treating patients with strong suspicion of high-risk disease, and how patients undergoing current radiation treatment protocols are maintaining continuation of care, with added safety protocols built in. These safety protocols include: hypervigilance for patient and staff safety, including mandatory masks and gloves for all staff; mandatory temperature readings before patients are allowed in the clinic; and evaluating patients prior to clinic admission for possible symptoms of COVID-19. Lastly, Dr. Harris discusses the use of telemedicine in the clinic, and how he hopes regulations that make it easier to see patients remotely will stay in place once the pandemic is behind us.

UPDATED – Billing and Regulations for Telehealth During COVID-19

Mark N. Painter, CPMA, managing partner of PRS Consulting, LLC, CEO of PRS Urology Service Corporation and the Vice President of Coding and Reimbursement Information for Physician Reimbursement Systems, Inc. (PRS), and CEO of Relative Value Studies, Inc., gives an in-depth guide for how to bill for telehealth visits as they increase during the COVID-19 crisis. He gives background information on current telehealth and telemedicine regulations and billing, including CMS (Medicare & Medicaid), as well as detailing temporary changes to the Stafford Act that have been enacted during the current coronavirus pandemic to accommodate the increased number of remote visits. Mr. Painter further details relevant billing codes and requirements for getting them approved, circumstances where co-pays may be waived, as well as requirements for treating new patients. He also covers the current situation and possible changes to multi-state practitioning as it relates to distance treatment.

Guidelines for Surgery in Urologic Cancer Patients Amid COVID-19 Outbreak

Robert G. Uzzo, MD, MBA, FACS, Chairman of the Department of Surgery and G. Willing “Wing” Pepper Endowed Professor of Surgery at Fox Chase Cancer Center–Temple University Health System, and Fernando J. Kim, MD, MBA, FACS, Chief Emeritus of Urology at Denver Health Medical Center, Professor of Surgery/Urology at the University of Colorado at Denver, and Associate Editor of the Patient Safety in Surgery Journal, discuss the rationale behind guidelines Dr. Uzzo helped develop for the American College of Surgeons and published in the Annals of Internal Medicine on when and whether to delay surgical treatment for urologic cancer during the COVID-19 outbreak. They discuss the inconsistent initial approach to delaying surgeries, as well as the system of disease classification Dr. Uzzo has been using to identify which patients can wait, which should wait, and which can’t wait for their surgeries. With a focus on kidney cancer, Dr. Uzzo discusses how these classifications are made by identifying clinical capacity, physiological age of the patient, competing risks and comorbidities, and how difficult cases are determined with a consensus among colleagues. He gives examples of patients with low volume metastatic disease with excellent performance status or locally advanced disease as candidates for systemic therapy and a delay in surgery, while patients with aggressive disease that may progress rapidly as requiring immediate treatment despite the risk of COVID-19 infection.