Your Premier Urology Education Resource

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

LEARNING CENTERS

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

Disaster Planning for Urology Practices

GRU Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses his personal experience with disasters, and the lessons he has learned from them. While most urology practices do not have a written disaster plan, disruptive disasters are far more frequent than most urologists realize. Dr. Baum shares what happened to his practice when Hurricane Katrina hit New Orleans in 2005. Emphasizing that there are many different types of disasters that can hit anywhere at any time, he suggests writing a contingency plan that includes instructions for both the emergency operation mode and the recovery, discusses the process of notifying patients, staff, and vendors, and covers the importance of transferring expensive medical equipment and medications to safer locations. Dr. Baum also details a basic disaster supply kit and a recovery box.

When All Else Fails: Holmium Laser Enucleation of the Prostate as Retreatment for BPH

Nicole L. Miller, MD, FACS, Associate Professor of Urology at Vanderbilt University Medical Center, discusses Holmium laser enucleation of the prostate (HoLEP), particularly focusing on the retreatment setting. AUA guidelines have recently been updated and now mirror EAU guidelines which suggest sizing a prostate before determining treatment options. Dr. Miller examines case studies that underscore the effectiveness of HoLEP in removing large prostates after the patients had previously undergone unsuccessful treatments, including transurethral resection of the prostate (TURP) and prostatic urethral lift. She then analyzes outcomes of a study that compared primary HoLEP (pHoLEP) to retreatment (rHoLEP) observing that the retreatment setting patients experienced shorter operative times, shorter length of stay, had less tissue resected, and had a higher rate of urethral stricture and clot retention. In spite of its utility, HoLEP has not been widely adopted and represents 4% of procedures, which Dr. Miller attributes to the steep learning curve associated with HoLEP. Lastly, she enumerates the barriers within the US medical system to physicians undertaking the HoLEP learning process and concludes that while Europe has numerous options for physicians to learn the technique, the American focus on robotic surgery means that fewer students learn open orifices surgical procedures.

Updates in Muscle Invasive Bladder Cancer

Sia Daneshmand, MD, Associate Professor of Urology and Director of Clinical Research at the University of Southern California, describes the current landscape of muscle invasive bladder cancer treatment, highlighting developments in radical cystectomy and chemotherapy. He observes that while radical cystectomy has long been the gold standard, efforts are being made to preserve reproductive organs in female patients who have low-stage disease. Dr. Daneshmand also notes the significant number of neoadjuvant chemotherapy phase II trials currently underway. While studies examining adjuvant chemotherapy have shown promise, the limitations of these trials necessitate further research. Similarly, research comparing super-extended lymph node dissection (LND) with extended LND have yielded insignificant p-values, but absolute numbers demonstrate a positive upward survival trend over 5 years. Dr. Daneshmand concludes that additional clinical trials will reveal the optimal combination and sequencing of treatment options.

Kaiser Permanente Prostate Cancer Risk Calculator 1.0

Joseph C. Presti, Jr., MD, FACS, Regional Leader of Urologic Oncology Surgery at Kaiser Permanente Northern California, discusses the development of Kaiser Permanente’s new prostate cancer risk calculator and its merits. Dr. Presti explains that older risk calculators tend to oversimplify variables like race, are based on outdated systematic biopsy schemes, and are often poorly calibrated due to the sampling frame used. Using TRIPOD guidelines (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) and the LASSO (least absolute shrinkage and selection operator) system of selection, Kaiser Permanente researchers determined that the variables that ought to be included in a prostate cancer prediction model are age, race, PSA, body-mass index, family history, number of prior negative biopsies, digital rectal exam (DRE), and prostate volume. They created 3 different models based on this, with the simplest but least accurate including clinical core variables but no DRE and no prostate volume, the second-most accurate including DRE but no prostate volume, and the most accurate including DRE and prostate volume. Dr. Presti notes that all of these models compare favorably to other risk calculators.

Seven Heavenly Virtues in the Urologic Practice

GRU Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses seven best practices for successful urologists to ensure business success, as well as how to cultivate them. Dr. Baum highlights areas such as phone etiquette, response times for phone calls and email, and cleanliness of facilities. He also suggests good habits for improving communication between urologists and patients as well as urologists and referring physicians. Dr. Baum further discusses ways to increase visibility in the community and how to exceed patient expectations.

Updates in Screening: Prostate Cancer Guidelines

Gerald L. Andriole, Jr., MD, a 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, reviews guidelines for prostate cancer screening, including the unchanged 2018 AUA guidelines and the 2020 updates to the NCCN and EAU guidelines. Following this, he explains why he disagrees with a 2020 article that suggests physicians use a PSA level of 10 ng/mL as the threshold when referring PCa patients to urology and thus biopsy. Lastly, he outlines five ways physicians can improve the early detection of prostate cancer.

An Introduction to the Urinary Microbiome: Part 3 – Manipulating the Microbiome for Urologic Health

In the third lecture of a three-part foundational series for Grand Rounds in Urology’s Next Generation Microbiome and Urologic Infections Learning Center, J. Curtis Nickel, MD, FRCSC, Professor of Urology at Queen’s University in Ontario, Canada, discusses possible ways to manipulate the microbiome to promote urologic health. He explains that, at present, there are four basic ways to positively influence the microbiome: eating a good diet, exercising, avoiding environmental pollution, and avoiding unnecessary antibiotics. Dr. Nickel also discusses various potential treatments currently being explored that involve manipulating the microbiome for managing disease, such as: gastrointestinal recolonization with Oxalobacter formigenes to treat urinary stone disease; targeting particular microbiota for cancer management; using Lactobacillus probiotics, fecal transplants, urine transplants, and a whole-cell inactivated bacteria vaccine to protect against urinary tract infections; and phage therapy. Dr. Nickel concludes that urologists do not have to always kill off bacteria, including seemingly pathogenic bacteria, but rather they need to understand how the bacteria changes in various disease states.

Seven Deadly Sins in the Urologic Practice

GRU Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses seven deadly “sins” that can occur in a urologic practice. Dr. Baum covers bad habits, including being unavailable to patients or making them wait an unreasonable amount of time, failing to manage your online reputation, and lack of search engine optimization on a practice’s website. For each of these “sins,” Dr. Baum offers some innovative solutions for conquering them.

PCa Patients on ADT- Improving Bone Health Monitoring Through Specialty Clinic Collaboration

Megan E. Milne, MD, a rheumatology fellow at Duke University in Durham, North Carolina, discusses efforts to encourage the referral of patients with prostate cancer treated with androgen deprivation therapy (ADT) to the High Risk Osteoporosis Clinic (HIROC) at her former institution, the University of Texas Southwestern. ADT decreases bone mineral density and increases patients’ risk of iatrogenic osteoporosis and minimal trauma fractures, but this risk is often under-discussed and referral rates to HIROC of patients treated with ADT were initially very low. By creating a best practice advisory (BPA) and conducting provider education meetings, doctors at HIROC were able to increase the referral rate from 4% to 59%, thus increasing the number of post-intervention patients receiving DXA and vitamin D monitoring. Dr. Milne notes that many patients with HIROC referral still did not receive anti-resorptive therapy, largely because of logistical delays, but concludes that they achieved sustained improvement in addressing bone health through both the development of a medical record BPA, and interdepartmental collaboration and education.

An Introduction to the Urinary Microbiome: Part 2 – Impact on Urinary Disease

In the second lecture of a three-part foundational series for Grand Rounds in Urology’s Next Generation Microbiome and Urologic Infections Learning Center, J. Curtis Nickel, MD, FRCSC, Professor of Urology at Queen’s University in Ontario, Canada, discusses how changes to the urinary microbiome, which he previously described as helping maintain urinary health, can contribute to the development of urinary disease. Dr. Nickel summarizes the findings of several studies that evaluate the impact of the microbiome on urologic chronic pelvic pain, observing that dysbiosis appears to be more important than any particular bacterium in the development of chronic prostatitis/chronic pelvic pain syndrome, female bladder pain, and female lower urinary tract symptoms (LUTS), although researchers have identified some candidate organisms. Dr. Nickel notes that the development of struvite stones and calcium oxalate stones are also associated with dysbiosis. He concludes by discussing the role of bacteria in urinary cancers, explaining that distinct microbiome patterns appear to be related to certain responses to bladder cancer, and that prostate cancer is often associated with prostate inflammation caused by bacterial infection, although the role of the microbiome in prostate cancer development has yet to be determined.

Ureterocutaneostomy: A Valuable Option for Urinary Diversion in the Elderly Patient?

Margit Fisch, MD, FEAPU, FEBU, Director and Chair of the Department of Urology and Pediatric Urology at University Medical Center Hamburg-Eppendorf in Hamburg, Germany, discusses the value of ureterocutaneostomy as a urinary diversion technique for the increasing number of older, sicker patients with urothelial carcinoma of the bladder. Dr. Fisch explains that, compared with other urinary diversions, ureterocutaneostomy is a simpler, shorter procedure with no significant quality of life differences. She then summarizes the findings of a cystectomy series, which showed that even though patients who had undergone ureterocutaneostomy were older, more likely to have comorbidities, and more likely to have had prior pelvic/abdominal surgeries and irradiation compared with patients who had received ilial/colonic conduit or continent diversion, they had the shortest surgeries and hospital stays during cystectomy, as well as no difference in 30-day complication rate. The benefits of ureterocutaneostomy are further corroborated by a study which compared ureterocutaneostomy to urinary diversion with use of bowel, and found that ureterocutaneostomy patients had shorter operating room time, shorter time in the ICU, and fewer serious complications, although they did experience higher long-term morbidity, probably because of comorbidities. Dr. Fisch notes that ureterocutaneostomy has late complications such as abscess formation, ureteral necrosis, stoma stenosis, and pyelonephritis, but concludes that conduits are no better in this area, and that the benefits of ureterocutaneostomy make it a valuable and useful diversion in elderly patients.