Video Archives

Lyndon Johnson and His Kidney Stone

Posted by Neil H. Baum, MD | Apr 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, highlights the importance of imagining how the United States healthcare system could change by reflecting on how different the world would be had Lyndon Johnson’s kidney stone not been successfully removed. He explains that in 1948, Johnson was running for a US Senate seat and was deadlocked against the favorite, when he developed an obstructing kidney stone in the upper third of his ureter. He thought he would require a ureterolithotomy, but did not want to since that might require him to drop out of the race. Dr. Baum explains that Johnson met with Dr. Gershom Thompson at the Mayo Clinic for a second opinion, and Thompson agreed to try an endoscopic stone removal, even though he had never before removed a stone in the upper third of the ureter. Thompson was successful, and Johnson had a prompt recovery, allowing him to return to the campaign and win. Dr. Baum notes that Johnson’s recovery raises several “what if” questions, such as “how might the world have changed if LBJ had not had a successful endoscopic retrieval of a proximal ureteral stone and been unable to win his Senate race?” Dr. Baum considers Johnson’s legacy as President of the United States, from passing the Civil Rights Act to accelerating US military involvement in Vietnam. He then asks, “what if we did not have the two government healthcare programs, Medicare and Medicaid, that were instituted and approved during the Johnson Administration?” This leads him to ask a whole series of “what if” questions, such as “what if we had a single payer system?” and “what if we could put more enjoyment back in the practice of medicine?” He concludes that it may be time to ask some “what if” questions, and he suggests that by doing so, it may be possible to find ways to repair the current healthcare system rather than seeing it as fundamentally immutable.

Industry Perspective: The Oncotype DX Genomic Prostate Score Assay Test

Posted by Daniel Shoskes, MD, FRCSC | Mar 2022

Daniel Shoskes, MD, FRCSC, Medical Director in Medical Affairs for Urologic Oncology at Exact Sciences, and Emeritus Professor of Urology at the Cleveland Clinic, explains how Exact Science’s Oncotype DX Genomic Prostate Score (GPS) assay test works, and considers its utility in guiding treatment decisions. He begins by discussing why genomics are of interest in relation to prostate cancer, highlighting the fact that abnormal gene expression may lead to abnormal/unregulated cell growth, which in turn may lead to irregularity on direct palpation, altered appearance on MRI, elevated PSA, and disordered gland appearance on histology. The researchers at Exact Sciences, Dr. Shoskes explains, hypothesized that these clinical features might not completely capture the prognosis of the patient, and that looking at gene expression directly might give further information. He relates how the researchers selected genes for association with metastasis and then refined the list for associations with death and adverse pathology. They found 17 genes that predicted recurrence in both the primary and highest Gleason patterns, and also had consistent analytical performance and expression in samples as small as 1mm. Dr. Shoskes then discusses how predictive this 17-gene assay is, noting that the GPS assay is an independent predictor of metastasis and prostate cancer death within 10 years of radical prostatectomy and may be associated with prostate cancer outcomes for up to 20 years after diagnosis. He highlights that incorporating the GPS result with NCCN Guidelines can provide a comprehensive risk profile. Dr. Shoskes considers how the GPS assay can be used practically, explaining that for low-risk patients, it can help inform shared decision-making for active surveillance vs. immediate therapy with curative intent, while for higher-risk patients, it can help inform the decision for treatment intensification. He concludes that the Oncotype DX GPS assay provides meaningful, actionable information on the biologic potential of prostate cancer independent of clinical, pathologic, and radiographic data.

Active Surveillance or Focal Therapy as Primary Management

Posted by Laurence Klotz, MD, FRCSC | Mar 2022

Laurence Klotz, MD, Professor of Surgery at the University of Toronto and the Sunnybrook Chair of Prostate Cancer Research, addresses when it is appropriate to use focal therapy versus active surveillance (AS) for prostate cancer. He observes that focal therapy for prostate cancer is controversial, with some doubting its efficacy entirely, and gives the disclaimer that he approaches the subject as an advocate for focal therapy in certain cases. Dr. Klotz then discusses the goals of AS, explaining that for de novo Gleason grade 1 patients, the purpose is to identify higher grade cancer, and for Gleason grade 2-3, the goal is identification of clinical progression while the disease is still curable. He notes that with AS, historically the risk of ‘progression’ to higher grade cancer has been 40%, while with focal therapy, the risk of failure is 35-40%, meaning that the risk of unrecognized/persistent GG ≥ 2 is similar for both. Dr. Klotz then considers the uses and appeal of focal therapy, emphasizing the benefits of a treatment that preserves the prostate and also allows time to intervene if the cancer returns. He also mentions some of the misuses and risks of focal therapy, arguing that it can be difficult to use in cases of tumor multifocality and heterogeneity and that the significant limitations of imaging and targeting, especially for Gleason grade 2 disease, can be challenging. Additionally, Dr. Klotz highlights the lack of level 1 evidence supporting focal therapy. He goes on to discuss what makes good candidates for partial gland ablation, describing patients with a Gleason grade 2 solitary unilateral lesion as being in the ‘sweet spot’ for focal therapy, while patients with more widespread or slightly higher grade disease may be candidates, but not necessarily. Dr. Klotz would not advise partial gland ablation to young patients with high-volume Gleason grade 1 unilateral disease who have a clear target on MRI, or to patients with Gleason grade 4 disease who have a small solitary lesion on biopsy and MRI. He then discusses the current management protocols for both AS and focal therapy in detail before concluding with a look at the future of focal therapy. Dr. Klotz argues that, despite the controversies, patients will increasingly demand focal therapy and therefore the urology field has a mandate to confirm its oncologic effectiveness and safety, and to determine which of the many methods of focal therapy is best.

Bottom Line Shrinking? Check Your EOBs

Posted by Neil H. Baum, MD | Mar 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses the importance of reviewing explanations of benefits (EOBs) in a medical practice to ensure the practice is receiving appropriate compensation. He defines EOBs as feedback on the effectiveness of a practice’s billing/coding, and argues that failing to review EOBs will result in a decrease in cash flow. Dr. Baum claims that reviewing EOBs strengthens management of the billing team and helps practices know why they are or are not successful, since “what gets measured gets managed.” He gives the example of an overwhelmed biller who failed to submit 10% of claims for 12 years and rarely appealed denials. By reviewing EOBs, Dr. Baum explains, the managing partner can identify the problem and gather proof that billing needs improvement. He discusses several other benefits of reviewing EOBs, noting that EOBs show deficiencies and how to correct them, as well as provide tracker data on a practice’s payor mix and frequency of highly paid procedures. Dr. Baum recommends that practices review EOBs approximately every three months, using an exception report to track any deviation in compensation. He says that doing so will take little more than an hour per month and help practices ensure they are paid what they deserve in an era of decreasing reimbursements and increasing overhead expenses.

New Advances in Penile Implant Infections Detection in 2022

Posted by A. Lenore Ackerman, MD, PhD | Mar 2022

In conversation with A. Lenore Ackerman, MD, PhD, Assistant Professor of Urology and Director of Research in the Division of Female Pelvic Medicine and Reconstructive Surgery at the University of California, Los Angeles, Gerard D. Henry, MD, a urologist with WK Advanced Urology in Shreveport, Louisiana, and President of the Louisiana Urological Society, provides an update on his research into the detection of penile implant infections. Dr. Henry explains that bacterial infection is more common than urologists realized, noting how, 20 years ago, he and his colleagues found a biofilm on the penile implants of patients who appeared to just be experiencing mechanical failure. He then describes a study comparing next generation sequencing (NGS) versus traditional culture in penile implants and suggests that NGS might be the new gold standard for assessing penile implant infections since it can identify not only what bacteria are present, but also the abundance of bacteria. Dr. Henry highlights that NGS has demonstrated that the main form of bacteria affecting penile implants is not Staphylococcus epidermidis, as long believed, and that Escherichia coli and Pseudomonas are more common. He argues that by more specifically identifying these bacteria, urologists may be able to better treat patients and avoid having to remove implants. Dr. Henry then introduces a new, currently-recruiting, prospective, randomized study of next generation sequencing versus traditional cultures for clinically infected penile implants and the impact of culture identification on outcomes. The discussion concludes with a question-and-answer session in which Dr. Ackerman asks about outcomes in the upcoming trial, other potential applications of NGS in urology, and the potential source of the bacteria identified by NGS.