Video

ADT and Brachytherapy: The Good, the Bad, and the Ugly

Posted by Mira Keyes, MD, FRCPC, FABS | Jun 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society and Grand Rounds in Urology, Mira Keyes, MD, FRCPC, FABS, Clinical Professor at the University of British Columbia (UBC) and a radiation oncologist at the Vancouver Centre of the British Columbia Cancer Agency (BCCA), discusses the pros and cons of using androgen-deprivation therapy (ADT) with brachytherapy to treat prostate cancer. After briefly discussing how ADT affects the tumor microenvironment, Dr. Keyes goes over the numerous clinical trials that have investigated how to combine external beam radiation together with hormone therapy. She explains that these trials found that the combination increases overall survival ~10-13% over ADT or EBRT alone, and longer ADT has a greater impact on OS, even with high radiation therapy dose. Dr. Keyes observes that ASCO considers brachytherapy a standard of care and recommends it be combined with ADT for unfavorable intermediate-risk and high-risk disease. She then considers the findings of ASCENDE-RT, the HDR UK trial, and the TROG 0.304 RADAR trial, all of which looked at the combination of ADT and brachytherapy, and discusses several ongoing randomized controlled trials on the role of ADT with prostate brachytherapy. Dr. Keyes also discusses a systematic literature review of ADT + prostate brachytherapy which concludes that the addition of ADT to brachytherapy provides no benefit to cancer-specific survival with ADT, and no benefit to overall survival with ADT, but does provide up to a 15% benefit to biochemical progression-free survival. She also notes that some believe dose escalation (prostate brachytherapy boost) may obviate the need for ADT in some high-risk patients. Dr. Keyes looks at a different meta-analysis which found that the addition of ADT to external beam radiation therapy provided a greater oncologic benefit than a brachytherapy boost and that there was a high probability that intermediate-risk and high-risk prostate cancer treated with EBRT + ADT would have superior overall survival to high-risk patients treated with EBRT + brachytherapy boost. Dr. Keyes argues that this paper misses the fact that the benefit of brachytherapy is that if brachytherapy is used, the duration of ADT can be reduced in unfavorable intermediate-risk and high-risk patients, which has a significant positive impact on quality of life and overall survival. She notes that ADT has numerous negative effects on quality of life, including erectile dysfunction, dementia, osteoporosis, metabolic syndrome, and more. Dr. Keyes particularly focuses on the negative cardiovascular effects from ADT, noting that observational data shows excess cardiovascular morbidity and mortality in patients on ADT with pre-existing cardiovascular disease. She concludes that ADT should be avoided in low- and intermediate-risk prostate cancer patients treated with monotherapy, that ADT for only 12 months in unfavorable intermediate- and high-risk patients is supported by randomized controlled trials, that ADT can be omitted in selected unfavorable intermediate- and high-risk patients, and that shorter ADT duration will improve quality of life and may increase overall survival by decreasing cardiovascular disease morbidity.

Diversity, Equity and Inclusion in Urology

Posted by Fernando J. Kim, MD, MBA, FACS | May 2022

Fernando J. Kim, MD, MBA, FACS, Chief Emeritus of Urology at Denver Health Medical Center in Aurora, Colorado, characterizes diversity as a mosaic of differences and similarities—and dimensions—among people, including appearance, age, culture, ethnicity, race, language, gender, sexual orientation, religion, family environment, income level, and job title. Dr. Kim notes that communication is filtered through one’s cultural perspective, which includes characteristics and experiences ranging from things like age, race, learning style, military experience, and much more. All of this influences how people perceive one another. He points out that the “melting pot” theory of American society has evolved to where American culture values respect for individual groups and characteristics within society. Dr. Kim turns to equity and differentiates equity from equality, pointing out that equity speaks to fairness or justice while equality is the state of being equal. He explains that equity goes beyond fair treatment, opportunity, and access to information and resources for all, stressing the importance of intentionally and actively removing barriers, challenging discrimination and bias, and institutionalizing access and resources that address historical and contemporary social inequalities. Dr. Kim turns next to inclusion, which actively invites all to contribute and participate; it strives to create balance in the face of exclusive differential power and create a society where every person’s voice is valuable and no one person is expected to represent an entire community. He differentiates among Equal Employment Opportunity (EEO), affirmative action, and diversity and inclusion. Dr. Kim cites the fact that urologists today are usually men and explains that while this may be changing, the field of urology lags behind other specialities in the share of women practitioners. He explains that workforce diversity is good for business and discrimination and poor diversity management pose an economic cost, with the average EEO complaint costing an organization approximately $250,000. Further, 25-40 percent of the workforce attrition rate and 5-20 percent of lost productivity can be attributed to poor diversity management, and employee turnover costs 75-150 percent of the replaced employee’s salary. Dr. Kim cites NASA’s implementation of a strong diversity management program after the Report of the Columbia Accident Investigation Board found that organizational culture that squelched dissent, stifled differences of opinion, resisted external criticism and doubt, imposed a “party-line vision,” and prevented open communication had plagued NASA and contributed to the Columbia accident. Dr. Kim concludes by asking, “At what level do you value differences?,” differentiating among tolerance, acceptance, valuing, and the celebration of differences; he emphasizes the importance of celebrating individual differences and deeply understanding and respecting others’ viewpoints.

Pitfalls in Perineal Surgery

Posted by Ryan P. Terlecki, MD, FACS | May 2022

Ryan P. Terlecki, MD, FACS, Vice Chair and Associate Professor of Urology, Director of the Men’s Health Clinic, Director of Medical Student Education, and Fellowship Director for Reconstructive Urology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, discusses perineal surgery and key elements of preoperative planning to optimize the surgeon and patient experience while highlighting some intraoperative technical considerations to facilitate efficiency. He advises practitioners to choose patients commensurate with their own experience, to prioritize risk reduction, to under-promise and over-deliver, and to maintain technical poise. Dr. Terlecki addresses helping patients set expectations, which is dependent upon the patient’s preoperative level of suffering and upon the definition of success. He discusses patient preparation and the importance of doctors investing time to understand their patients as well as his own requirements, such as patients undergoing urine testing and suspending blood thinners preoperatively. He underlines the importance of clearly laying out the process—from start to finish—for the patient. He also warns of the “CURSED” patient—one who is compulsive-obsessive, unrealistic, revision-seeking, surgeon-shopping, entitled, and in denial. Dr. Terlecki then turns to optimizing the operating room through organization and aiming for what he calls “SWEET”; doing things the same way each and every time. He suggests video primers for support staff and an instrument and equipment checklist as well as pre-gaming with anesthesiologists and paying special attention to patient preparation. He addresses antibiotic stewardship before shifting to some technical items, highlighting the challenge of working in tight spaces during perineal surgery and the importance of surgeons freeing their hands and not struggling. Dr. Terlecki discusses the importance of illumination and magnification but advises surgeons to be mindful of ergonomics and equipment weight. Dr. Terlecki discusses considerations when doing artificial urinary sphincter (AUS) surgery, such as challenges when a patient has had a prior sling, before turning to combination cases (sling or AUS with inflatable penile prosthesis [IPP]). Here, he advises surgeons to accomplish the sling part of the operation first, noting that single-incision approaches are problematic and there are implications for the patient, the surgeon, and the hospital. Dr. Terlecki offers several items that allow for more efficient use of the surgeon’s time during urethroplasty. For example, surgeons should know whether the repair is an anastomotic repair or a substitution repair. He prefers scoping before and during the procedure to avoid a suboptimal incision site and addresses instruments that can be helpful throughout surgery. Dr. Terlecki then turns to the principles for urethral surgery, and poses a question for practitioners’ consideration: “If this was going perfectly, what would it look like?” He closes by citing Sir William Osler who advocated for equanimity, meaning the ability to calmly assess a situation, determine the best course of action and correction, and then to move forward. Dr. Terlecki discusses the importance of asking for help when needed, emphasizing that reaching out also helps build relationships and is a sign of excellence, not weakness.

Treating BPH: Comparing Treatment Modalities

Posted by Michael E. Albo, MD | May 2022

Michael E. Albo, MD, Vice Chair of the Department of Urology at the University of California, San Diego, compares the efficacy, safety, and considerations for a variety of treatment options—both traditional surgical and newer, minimally-invasive therapies—for patients with benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS). He begins by outlining the surgical management of LUTS attributed to BPH before discussing the goals and selection of treatment. He explains the patient and urologist perspectives in terms of evaluating minimally invasive therapies before summarizing the various treatment options as a whole. The first are resection treatments, including transurethral resection of the prostate (TURP) (which Dr. Albo calls “the gold standard”) and transurethral incision of the prostate (TUIP). Next he describes enucleation technologies, including simple prostatectomy, laser enucleation of the prostate (using holmium [HoLEP] or thulium [ThuLEP] lasers), and bipolar enucleation. Dr. Albo explains that while simple prostatectomy should be considered only for patients with large to very large prostates, laser enucleation options are size-independent options for the treatment of LUTs/BPH; additionally, the HoLEP and ThuLEP options have more favorable perioperative safety and he advises these be considered as treatment options in patients at higher risk of bleeding. Dr. Albo then addresses vaporization procedures, including bipolar transurethral vaporization of the prostate (TUVP) and photoselective laser vaporization of the prostate (PVP), explaining that PVP is likely safe for patients on anticoagulants. At this juncture he turns to the minimally-invasive prostatic urethral lift (PUL), citing studies showing this is less effective than TURP but with similar quality of life improvements. Dr. Albo makes the point that trials need to better evaluate minimally invasive interventions in terms of whether patients are able to discontinue medication and therefore whether that intervention can be considered successful. He discusses water vapor thermal therapy (WVTT), citing data supporting the preservation of erectile and ejaculatory function and five-year data showing sustained changes in International Prostate Symptom Score (IPSS) and Qmax. Robotic waterjet treatment (RWT) has been shown to be effective and safe, with the main drawback being bleeding; Dr. Albo predicts that, while more needs to be learned as far as RWT for larger prostates, this procedure could be game-changing. He mentions two additional procedures, transurethral microwave therapy (TUMT) and prostate artery embolization (PAE) (which currently is not recommended outside the context of clinical trials) as well as an investigational treatment with nitinol struts to remodel the bladder neck. He concludes by asserting that the field has come a long way in terms of the sophistication of the surgical treatment algorithm, emphasizing the importance of a discussion with the patient in terms of side effects, the availability of technology at the institution, and the surgeon’s skill level in the decision-making process.

Non-Muscle Invasive Bladder Cancer: Guidelines-Based Approach

Posted by Raj S. Pruthi, MD, MHA, FACS | May 2022

Raj S. Pruthi, MD, MHA, FACS, Professor in the Department of Urology at the University of California, San Francisco, reviews the American Urological Association (AUA)-Society of Urologic Oncology (SUO) guidelines on diagnosing and treating non-muscle invasive bladder cancer (NMIBC). He begins with some statistics, relating that in 2017, there were approximately 79,000 new cases of bladder cancer, 16,800 deaths, and greater than 500,000 survivors. Dr. Pruthi observes that bladder cancer is a disease of older individuals, and he predicts that the population of bladder cancer patients will increase as the population ages. He then highlights key facts about NMIBC, explaining that most patients recur, some progress, and the ability to predict recurrence and progression is based on patient-specific disease characteristics. Dr. Pruthi introduces the 2016 AUA/SUO guidelines, noting that the panel featured a patient advocate. He goes over the guidelines point by point, starting with diagnosis. Dr. Pruthi underscores the importance of performing a complete visual transurethral resection of bladder tumor (TURBT) at initial diagnosis, explaining that incomplete TURBT is a contributing factor to early recurrences. He notes that risk calculators for NMIBC are limited by lack of applicability to current populations, and also that no study has evaluated the effectiveness of urinary biomarkers to decrease mortality or improve outcomes compared with standard diagnostic methods. When discussing guidelines around treatment, Dr. Pruthi emphasizes the importance of re-resecting T1 disease since understaging occurs in about 30% of cases and patients with residual T1 (after presumed complete resection) have up to an 80% chance of progression. He also discusses guidelines around BCG administration and BCG relapse. Dr. Pruthi then looks at cystectomy, arguing that waiting until progression to muscle invasion may prove fatal. He concludes by discussing guidelines around follow up.