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Advocating for Your Patient

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses how to and why one should advocate for patients following a denial of coverage by an insurance company. He explains why insurers deny coverage for mediations, services, durable medical goods, and treatments, noting that even if a rejection is successfully appealed, the process adds weeks or months to the reimbursement. Dr. Baum shares a success story of going the extra mile for a patient and the lessons he learned from that experience. He highlights the value of pursuing these cases, particularly the most egregious rejections. While appealing a rejection will not always be successful, he contends that nothing provides as much satisfaction as advocating for one’s patient.

New Prescribing Information on Survival Benefit for Nubeqa® (Darolutamide) Approved

E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, interviews Neal D. Shore, MD, Medical Director for the Carolina Urologic Research Center in Myrtle Beach, about the recent FDA amendment to the package insert for NUBEQA®, or darolutamide. The amendment includes new information for patients with non-metastatic castration-resistant prostate cancer (nmCRPC) from the ARAMIS trial on overall survival and other endpoint data, including time to pain progression and time to the requirement for cytotoxic chemotherapy. Drs. Crawford and Shore discuss how the recent data demonstrating darolutamide’s overall survival benefit validates the previous use of metastasis-free survival as a surrogate for value. They also talk about the value of darolutamide for patients with nmCRPC who may not see much benefit to taking another medication. Drs. Crawford and Shore conclude by considering darolutamide’s future, mentioning the ARASENS trial looking at darolutamide’s benefits for patients with metastatic hormone-sensitive prostate cancer and discussing potential new research into darolutamide in the mCRPC space.

Use of Social Media in Men’s Health Urologic Practice

Brian S. Christine, MD, a urologist and Fellowship Director and Director of Prosthetic Urology and Men’s Sexual Health at the Urology Centers of Alabama in Birmingham, discusses the use of social media in men’s health urologic practices. He begins by discussing older mediums and why they are no longer effective at getting the word out, as well as the limitations of word of mouth. He goes on to talk about why leveraging social media platforms is important for reaching the widest possible audience and attracting new patients. Dr. Christine then explains what has worked for him and his practice and what has not. He emphasizes the importance of creating a personal website that is separate from the practice that can be linked to all of one’s social media accounts. He also highlights the social media platform that has been the most effective for him: Youtube. Youtube is particularly helpful because it allows users to upload high-quality educational videos; the majority of Dr. Christine’s new patients that seek him out on their own do so after watching one of his surgical videos. Dr. Christine then gives advice about how to be successful on Youtube and pitfalls to avoid when making videos. He offers specific tips about how to make the same kind of high-quality videos that appear on his Youtube channel. Finally, he observes that the biggest roadblock is not making the commitment to begin.

COVID-19 Vaccine Roundtable Discussion

E. David Crawford, MD, Professor of Urology at UC San Diego and Editor-in-Chief of Grand Rounds in Urology, interviews Alan H. Bryce, MD, Medical Director of the Genomic Oncology Clinic at Mayo Clinic Arizona in Scottsdale, and Neil H. Baum, MD, Professor of Urology at Tulane Medical School, about the COVID-19 vaccine—how it works, its safety, and possible side effects. Currently, Pfizer and Moderna have each created a vaccine for the novel coronavirus, both of which are mRNA vaccines containing code for the protein found within the virus. Dr. Bryce describes how this portion of RNA causes cells to synthesize what is known as a “spike protein,” which then stimulates an immune response. He observes that side effects are typically mild and similar to what one could expect with a standard flu vaccine, notwithstanding rare, severe reactions. Dr. Baum then addresses the psychological manifestations associated with COVID-19, such as anxiety, fear of contracting or spreading the disease, PTSD, depression, and even suicide. It is important to note that these symptoms are also associated with burnout which, within the medical community, impacts urologists to a greater degree. Dr. Baum warns that the stress of being a frontline worker, decreases in income, and the shift from in-person to telehealth appointments and related “Zoom fatigue” may further increase burnout among urologists.

Finding a New Perspective with Locum Tenens

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, presents the benefits of locum tenens, a contractual arrangement in which a physician works temporarily in another practice. These work assignments vary in duration and serve several purposes, including to fill vacancies in communities without urologists or to offer a break for a full-time urologist and/or those working in rural communities, who are often on-call 24/7. For doctors, locum tenens can decrease stress and lower the risk of burnout, as well as allowing them to gain experience by working with a new patient population in a different hospital or clinical setting. Semi-retiring urologists may use locum tenens as they transition, and newly-minted practitioners may use such assignments to determine the best practice fit for a permanent position. Dr. Baum touts the financial benefits: such as paid living expenses and travel costs, and possible stipends while on assignment. Additional perks include focusing on clinical work sans office politics, business responsibilities, or paperwork. He concludes with a review of the contract details, drawing attention to key areas such as compensation and malpractice coverage, as well as exclusions like health insurance and retirement.

Active Surveillance Criteria and Follow-up Protocol

Michael A. Brooks, MD, Assistant Professor of Urology and Oncology at Baylor College of Medicine in Houston, Texas, discusses active surveillance and follow-up protocol best practices. In 2020 BCM started integrating MRI Fusion Biopsy into active surveillance protocol using best evidence. Dr. Brooks starts off by discussing the evidence for this new protocol from two different North American cohorts. He looks at MRI fusion biopsy in biopsy naive men, and discusses using MRI fusion biopsy for confirmation. He considers whether we can get rid of diagnostic and confirmation systematic biopsies as they can be replaced by the more accurate MRI fusion biopsy. He continues to discuss how often the biopsy needs to be repeated and special considerations that may need to be made when using this technology. He emphasizes that this is still very new and there are some special scenarios that are under studied. Some of the special scenarios include patients with high volume GG1, patients with GG2, and African American patients. Dr. Brooks also goes over the specific protocols that Baylor College of Medicine follows before discussing some pitfalls of the MRI fusion biopsy using a few case reviews as examples.

High Intensity Focused Ultrasound (HIFU) Ablation in a Salvage Setting

John H. Jurige, Jr., MD, HIFU Program Director for the HIFU Center of Excellence in Louisville, Kentucky, discusses high intensity focused ultrasound (HIFU) ablation therapy for patients with radiorecurrent prostate cancer. He explains that this is a difficult subset of patients to treat, since they have very aggressive prostate cancer. Treatment will often fail, so one of the main objectives of treatment in this group must be quality of life preservation through avoidance of treatment morbidity and use of ADT. Focal HIFU is exceptional in this regard, even if its 5-year biochemical failure-free survival rates have historically been comparable to other forms of treatment. Dr. Jurige notes that these outcomes may be improved through better patient selection, and by starting patients on therapy at earlier stages of recurrence. Better patient selection, which can be more readily achieved with the recent improvements to prostate imaging, can also help prevent adverse effects like urethral stricture and rectal fistula. Dr. Jurige concludes by recommending that urologists give patients a full assessment and get all the studies they can before starting them on salvage HIFU after radiation.

Next Generation DNA Sequencing for Genitourinary Implants

Paul H. Chung, MD, Assistant Professor and Director of the Division of Reconstructive Urology at the Sidney Kimmel Medical College of Thomas Jefferson University, discusses infection of genitourinary implants and how next-generation sequencing can be used to manage device infection. Presenting his results from a recently published article with the Canadian Journal of Urology, he outlines the methods, outcomes, and recommendations for clinicians, specifically those removing malfunctioning or infected penile prostheses and artificial sphincters. Dr. Chung highlights the benefits of polymerase chain reaction (PCR) and next-generation sequencing (NGS) including faster processing time, greater sensitivity, and the ability to run both fungal and bacterial analysis in the same setting. Additionally, NGS is useful in the selection of perioperative antibiotics and irrigation solutions, as well as determining how to coat devices during implant surgery. Following the presentation, Grand Rounds in Urology editor J. Curtis Nickel, MD, FRCSC interviews Dr. Chung to further discuss the clinical implications of his research. In the conversation, they compare biofilm collection techniques, noting that PCR and NGS are most helpful in a clinical setting, whereas extended culture is useful in a research setting.

PCa Commentary | Volume 148 – December 2020

This Commentary discusses how olaparib and rucaparib offer a needed additional treatment option for men with mCRPC.

A Better Mousetrap: Minimally-Invasive Management of Symptomatic Caliceal Diverticular Stones in the Era of Robotic Surgery

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine, discusses the pros and cons of different techniques for managing caliceal diverticular stones, a simple problem requiring a complex solution. The presentation aims to provide a framework for the identification and management of this condition since there are not enough high-quality studies to have a definitive strategy. Dr. Link discusses caliceal diverticulum incidence, etiology, and presentation, as well as the specific qualities of stones in caliceal diverticula, noting that stone formation is not caused by the presence of a caliceal diverticulum, but rather by the same metabolic anomalies experienced by other stone formers. He then dissects the different surgical options for treatment, including: extracorporeal shockwave lithotripsy (ESWL), which results in stone-free rates of ≤25% and should only be used in patients who cannot tolerate more effective therapy; ureteroscopic management, which is superior to ESWL but still has low success rates; and percutaneous management, which was the gold standard treatment before the era of robotic surgery, and results in a stone-free rate between 70 and 100%, although it can be a challenging surgery. Dr. Link also discusses laparoscopic diverticulectomy and robotic true partial nephrectomy, more aggressive approaches that may be needed if percutaneous management fails. He concludes with several case studies, emphasizing that treatments should be tailored to individual patients.

Overall Survival with Sipuleucel-T in Patients Treated for Advanced Prostate Cancer

Rana R. McKay, MD, Associate Professor of Medicine at the University of California, San Diego, and Co-Leader of the Genitourinary Oncology Disease Team at the Moores Cancer Center, discusses the results of a study that compared the efficacy of first-line and any-line sipuleucel-T to that of novel hormonal agents in Medicare beneficiaries with metastatic castration-resistant prostate cancer (mCRPC). The intent of the study was to see how the use of sipuleucel-T, which has been available for just over a decade and was the first autologous vaccine approved for a solid tumor, might be impacted by the introduction of so many new therapies for mCRPC in the last 10 years. Dr. McKay explains that the results show that, for the population studied, use of sipuleucel-T, both as first-line and any-line therapy, results in a statistically significant improvement in overall survival compared to patients who never received sipuleucel-T and were instead treated with other novel hormonal agents. Following her presentation, E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology, conducts a Q&A session with Dr. McKay in which they discuss the increasing acceptance of sipuleucel-T among medical oncologists, combination therapies with sipuleucel-T, and the future of sipuleucel-T, among other subjects.