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Next Generation Microbiome and Urologic Infections

Editor: J. Curtis Nickel, MD, FRCSC

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

LATEST CONTENT

Telephone Techniques to Generate New Patients

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, offers advice on improving clinic telephone protocols, which in turn can help generate new patients for a practice. He discusses the importance of telephone etiquette, as well as specific techniques that are important to do correctly. Dr. Baum urges consistency when answering the phone, and stresses the importance of giving top priority to new patients. He covers different ways to improve the new patient telephone experience, and emphasizes the importance of avoiding gaps in phone coverage during office hours. Overall, he urges practices to get rid of phone trees and highlights the importance of talking to a human. Dr Baum also offers some advice on how to handle after hours telephone calls that will help maintain a good patient experience.

Clinical Case Discussion: Metastatic Prostate Cancer and Evidence for More Precision Therapy

A. Edward Yen, MD, Assistant Professor of Medicine in the Hematology and Oncology Section at Baylor College of Medicine, introduces a metastatic prostate cancer case, and through it explores and reviews treatment options. He discusses homologous recombination and the role that it plays in DNA repair pathways, noting that 25% of patients with advanced prostate cancer have deleterious mutations in DNA damage repair genes which lead to an increased risk of prostate cancer and chance of having nodal and/or distant metastases. Dr. Yen then reviews the TRITON2 study on rucaparib in mCRPC patients with homologous recombination deficiency and the PROfound study on olaparib in mCRPC patients with homologous recombination repair alterations, both of which found a far greater response to treatment in the cohorts with the target mutations. Next, Dr. Yen discusses PARP inhibitors and their side effects, such as fatigue, nausea, pulmonary embolism, anemia, and others. Through his exploration of treatment options, Dr. Yen concludes that next-line chemotherapy is the best option for the patient given the visceral progression of their disease.

PSMA PET Gallium Scan Approved by FDA

E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology, interviews 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 UCLA, on yesterday’s FDA approval of PSMA PET gallium scans for use in prostate cancer patients at the University of California, Los Angeles, and the University of California, San Francisco. Dr. Reiter, one of the investigators on the study that led to this, discusses how the approval, which was a joint effort between teams at UCLA and UCSF, is the first approval of a PSMA targeting agent in the United States, and will give new, potentially more effective options for urologists to stage prostate cancer for both newly-diagnosed and recurrent disease, leading to earlier detection of both metastatic disease and sites of recurrence, as well as improved overall management of the disease. They also discuss costs and potential insurance coverage at the currently-approved UCLA/UCSF sites and beyond, next steps for broader approval, and the implications of using PSMA PET in a theranostics approach to diagnosis and treatment of mCRPC and oligometastatic prostate cancer, as well as other disease states.

Updates in Upper Tract Urothelial Cancer: Challenges in Diagnosis and Treatment

Surena F. Matin, MD, the Monteleone Family Foundation Distinguished Professor in the Department of Urology at MD Anderson Cancer Center, gives an overview of upper tract urothelial carcinoma (UTUC), comparing it to bladder UC and outlining risk factors, imaging options, and possible treatment paths. He posits that the lack of research on UTUC is a major reason for the challenges in diagnosing and treating the illness. When compared to bladder UC, UTUC has more imprecise staging options, more anatomical barriers for therapy, and unclear lymphadenectomy templates. Dr. Matin identifies UTUC risk factors such as tobacco, exposure to aromatic amines and arsenic, and also discusses classification issues related to patients with hereditary UTUCs. He then discusses how imaging is the backbone of staging and grading, but has limitations, recommending a CT chest scan or chest X-ray to rule out metastases, a cystoscopy to assess bladder capacity, and a ureteroscopy to assess tumor size. Dr. Matin concludes with a discussion of radical nephroureterectomy as a treatment option, stating that it is highly curative but at the cost of kidney function. He believes that adjuvant topical therapy could help solve the problem of treatment options but notes that there is not enough data to be certain of this yet.

Priapism: A Management Enigma

Michael Coburn, MD, FACS, Professor and Russell and Mary Hugh Scott Chair of the Department of Urology at Baylor College of Medicine, discusses priapism and the American Urological Association’s (AUA) guidelines on managing the illness. He gives an overview of priapism, outlining differences between ischemic, non-ischemic, recurrent, primary, and secondary priapism, and discusses a range of contributing risk factors. Next, Dr. Coburn reviews study data on the different qualities of ischemic and non-ischemic priapism, explaining that the latter often is chronic and characterized by less rigidity in the penis, while ischemic priapism tends to be characterized by a fully rigid, very painful erection which contains abnormal cavernous gases. He then discusses treatment recommendations for various forms of the disease, ranging from oral medication for intracavernosal-caused priapism to complex specialty treatment for priapism related to underlying medical conditions. Dr. Coburn concludes by recommending that physicians use the AUA guidelines to create a treatment algorithm for priapism, making sure that if a deviation is made that it is well documented and explained.

The Unique Experience of Upper Tract Urothelial Carcinoma in Taiwan

Hsiang Ying Lee, MD, Assistant Professor of Urology at Kaohsiung Medical University Hospital, discusses upper tract urothelial carcinoma’s (UTUC) unusual prevalence in the Taiwanese population, along with the national effort to gather more information on the disease. She explains that while there are 1-2 cases of UTUC per 100,000 people in Western countries, there are 4.09-4.37 cases per 100,000 people in Taiwan, as well as a much higher ratio of UTUC to all urothelial carcinomas and a higher proportion of men with the disease compared to the West. Dr. Lee notes several possible reasons for this, including the high rates of exposure to aristolochic acid and arsenic in Taiwan. She then discusses the efforts of a whole Taiwan collaborative clinical study designed to identify high-risk patients in the country, explore new treatments, and develop a UTUC guideline for Taiwan. The presentation concludes with a Q&A session in which Dr. Lee emphasizes the need to find better biomarkers for UTUC.

Urologic Debate Part 2: MRI vs. Molecular Markers: Which One Should I Use? Markers Perspective

In the second part of this urologic debate, E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, argues that while MRI has a role in prostate cancer detection, PSA and other molecular marker tests should be used earlier in sequence. He notes that while many healthcare providers are unhappy with the current state of early detection for prostate cancer, this has less to do with PSA’s merits as a test for determining the relative risk of prostate cancer, and more with a lack of good guidance on how to interpret it. Dr. Crawford argues that all men with a PSA greater than 1.5 should receive further evaluation, first for evidence of benign prostatic hyperplasia, and then for prostate cancer. Other molecular markers can help determine increased risk and help doctors decide whether or not to biopsy, and marker tests like ConfirmMDx can also help if a biopsy is inconclusive. Dr. Crawford concludes by noting that MRI is best used after patients have been biopsied.

Urologic Debate Part 1: MRI vs. Molecular Markers – Which One Should I Use? MRI Perspective

In the first part of this urologic debate, Guilherme Godoy, MD, MPH, Assistant Professor of Urology and Urology Oncology at Baylor College of Medicine in Houston, Texas, argues for multiparametric MRI (mpMRI) as the better diagnostic tool for finding prostate cancer as compared to molecular markers. He observes that while there are many different commercial markers available to aid decision-making before diagnosis, at initial diagnosis, and after treatment, mpMRI can help in all three of these prostate cancer management spaces. Dr. Godoy also argues that while molecular tests may inform risk, a biopsy preceded by MRI will still be necessary, and that biopsy can be improved and optimized by mpMRI. He then discusses different techniques and equipment that can be used with mpMRI, how to interpret and report the results from mpMRI, and the trial evidence for mpMRI’s effectiveness. Dr. Godoy concludes that mpMRI functions as “the ideal biomarker,” as it increases accuracy and decreases the number of biopsies and helps to optimize care after cancer diagnosis.

Time Saving Tips #1: Getting a Handle on Prior Authorizations

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses how getting a handle on prior authorizations can help doctors deal with loss of income. At present, many doctors are facing lost revenue due to decreasing reimbursements and rising overhead costs, and one of the best ways to deal with this problem is to increase efficiency and productivity by learning how to make the most of prior authorizations. Dr. Baum explains why prior authorization is important, as well as how the process has changed in the last five years. He then advises that it is a good idea to have one person on staff who is a prior authorization expert as this will make the process more efficient and decrease the number of denials. He emphasizes the importance of the expert having deep knowledge of various red flag features of prior authorizations, which can result in huge delays and even denials. The bottom line according to Dr. Baum is that these specialists can do a great deal to improve productivity, efficiency, and even staff morale.

Immunotherapy For Muscle Invasive Bladder Cancer

A. Edward Yen, MD, Assistant Professor of Medicine in the Hematology and Oncology Section at Baylor College of Medicine in Houston, Texas, discusses the findings of recent immunotherapy trials for muscle invasive bladder cancer (MIBC). He explains that cisplatin-based neoadjuvant chemotherapy combinations are the current standard of care for MIBC and can provide a significant overall survival benefit, but 40 to 50% of patients are not eligible for cisplatin to begin with, and only 20% of those eligible patients actually receive cisplatin, which suggests that there are major therapeutic gaps that immunotherapies could potentially fill. Dr. Yen goes into depth on the findings of the phase II PURE-01 study of pembrolizumab, the phase II ABACUS study of atezolizumab, and the phase I NABUCCO study of nivolumab/ipilimumab, observing that all three therapies produced good responses and appeared to be correlated to different biomarkers from one another. He concludes by predicting that neoadjuvant immunotherapy will become standard of care for cisplatin-ineligible patients, but he also stresses that future studies should include higher-risk patients and should focus on predictive biomarkers.

Current Diagnosis and Management of Female Stress Incontinence

Alexander Gomelsky, MD, FACS, B.E. Trichel Professor and Chair in the Department of Urology at LSU Health Shreveport, discusses current guidance regarding the diagnosis and surgical management of female stress incontinence (SUI). He frames his presentation around the 2017 AUA/SUFU Guidelines which, while based on more high-level evidence than prior guidelines, still use an index patient who does not match the majority of women urologists are likely to see for SUI. Dr. Gomelsky particularly focuses on this limitation, noting for instance that doing urodynamic testing, which does not appear to be useful for index patients, can help urologists meet the particular needs of non-index patients (e.g., women of advanced age, women with high BMIs, women suffering from recurrent/persistent SUI, women who have had prior surgery for SUI, etc.). He further discusses both the benefits and adverse events associated with different available surgical therapies for treating SUI, emphasizing that while mesh for transvaginal repair of pelvic organ prolapse has been banned, evidence still supports mesh placed abdominally for pelvic organ prolapse, as well as midurethral slings for SUI.