Video Archives

Deciphering Options for Testosterone Replacement Therapy and Managing Withdrawal

Posted by Jesse N. Mills, MD | Apr 2024

Jesse N. Mills, MD, discusses the importance of testosterone replacement therapy and presents an algorithm for determining treatment and managing withdrawal. He begins with an overview of the history of the study of testosterone, from the first recorded effects of castration to the warning against the over-prescription of testosterone therapy issued in 2015 by the FDA.

Dr. Mills discusses the AUA guidelines for testosterone replacement therapy and the lack of on-label options for treatment. He presents options for on-and-off-label testosterone replacement therapy.

Dr. Mills then presents an algorithm for determining the best treatment option for the patient, beginning by addressing male fertility concerns. He addresses questions of lab work, transference, insurance, administration, and other patient and physician concerns.

Dr. Mills concludes with the discontinuation of testosterone replacement therapy and when it is indicated. He discusses the available options for weaning patients off of testosterone, cautioning strongly against abrupt discontinuation.

LuPSMA: Imaging-Based Patient Eligibility Role of Tumor Heterogeneity & FDG

Posted by Hossein Jadvar, MD, PhD, MPH, MBA | Apr 2024

Hossein Jadvar, MD, PhD, MPH, MBA, MSL, FACNM, FSNMMI, discusses imaging-based patient eligibility for Lutetium-177 Prostate-Specific Membrane Antigen (177Lu-PSMA) and the role of tumor heterogeneity and 18F-fluorodeoxyglucose (FDG) in treatment failure. He begins by reviewing a study on the prediction of time to hormonal-treatment failure in metastatic castration-sensitive prostate cancer with FDG positron emission tomography/computed tomography (PET/CT) and another study assessing the association of FDG PET/CT with overall survival in men with metastatic castration-resistant prostate cancer (mCRPC).

Dr. Jadvar addresses mCRPC tumor heterogeneity within and across tumors and prediction of discordance between Gallium-68-PSMA-11 therapy and FDG, citing the LuPSMA trial, the TheraP trial, and the VISION trial. He then shares data on PSMA heterogeneity in mCRPC related to circulating tumor cells (CTC), metastatic tumor burden, and response to targeted RLT.

Dr. Jadvar shares the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM) consensus statements that PSMA PET demonstration of PSMA expression should be mandatory before treating with 177Lu-PSMA RLT. He then shares patient case studies illustrating the pros and cons of FDG PET/CT in PSMA radiopharmaceutical therapy (RPT).

Dr. Jadvar concludes by emphasizing that PSMA PET should be mandatory before PSMA RPT. He reminds practitioners to carefully consider what is optimal vs. what is required vs. what is practical.

Transperineal Biopsy: Rationale, Outcomes, and Techniques

Posted by Arvin George, MD | Apr 2024

Arvin K. George, MD, discusses the rationale behind performing transperineal biopsies over transrectal biopsies, supporting outcome data, and actionable techniques to combat the perceived shortcomings of the procedure. Dr. George begins by providing data on the fluoroquinolone-resistant infection risks of transrectal biopsies, and that, by avoiding the issue of antibiotic-resistant rectal flora, transperineal biopsies circumvent the rising rate of infections and strengthen antibiotic stewardship during procedures.

Dr. George then addresses the issue of patient pain in transperineal biopsies. He offers techniques on ideal administration of local anesthetic for decreasing patient pain.

Dr. George concludes by providing information on patient set-up, procedure equipment, and transperineal guides, presenting multiple options and encouraging urologists to choose according to their needs. He offers several resources for urologists and their patients from the Michigan Urologic Surgery Improvement Collaborative.

Interviews with Icons: Mickey Karram, MD

Posted by Neil H. Baum, MD | Apr 2024

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, interviews revolutionary urogynecologist, Mickey Karram, MD, on topics ranging from urogynecological cosmetic surgeries to robotic pelvic reconstruction. Dr. Karram is an internationally renowned urogynecologist and pelvic surgeon, widely considered to be a pioneer in the field. He has co-authored several of the leading textbooks and reference books in the study of Urogynecology, in addition to publishing over 200 peer-reviewed articles in medical journals.

In this interview, Dr. Karram shares his insights on:

Fostering Collaboration Between Urology and Gynecology Specialists
Urogynecological Cosmetic Procedures
Female Sexual Dysfunction
The Use of Robotics in Pelvic Reconstruction
The Future of Pelvic Reconstruction

Pain Management Advice for Urologists in the Wake of the Opioid Crisis

Posted by Brian J. Flynn, MD | Apr 2024

Brian J. Flynn, MD, discusses the opioid crisis in the United States, and the role of urologists in taking action against this growing problem. Dr. Flynn begins by highlighting factors that contribute to the opioid epidemic’s growth, with a specific focus on Colorado. He drives home the urgency behind addressing this epidemic by emphasizing the ubiquity of opioid related deaths across all ages, genders and socio-economic strata.

Dr. Flynn argues that the problem lies specifically in prescribing opioids in far excess post-surgery, as most patients take only a fraction of what is prescribed, with extra pills then being distributed to, and consumed by, non-patients. He underlines the correlation between the number of opioids prescribed and the number of opioid related deaths.

Dr. Flynn examines the role of Urology in prescribing opioids relative to other fields of medicine in prescribing opioids, finding that urologists land somewhere in the middle in terms of prescribing opioids to patients. He looks at different urology surgeries and recommends alternatives to opioids to address patients post-op pain.

Dr. Flynn concludes with a review of the ALTO project from Colorado that aims to offer alternatives to fentanyl whenever possible. He provides practical solutions to address the opioid epidemic at the physician level, but recognizes that changes at multiple levels of practice and legislature are needed to address it effectively on a national scale.