Video Archives

The Third Dimension in Prostate Cancer Diagnosis

Posted by Francisco G. La Rosa, MD | Sep 2021

Francisco G. La Rosa, MD, Associate Professor in the Department of Pathology at the University of Colorado Anschutz in Denver, discusses in vivo 3D imaging and how it can benefit physicians in treating prostate cancer. He explains that, unfortunately, most views of the prostate are just 2D, but clinicians require a 3D view to really understand a lesion. Dr. La Rosa then introduces his own process of creating a 3D model of the pelvic area and producing a 3D model of a prostate that could be used to practice biopsies and other procedures at the Butcher Symposium on Genomics and Biotechnology Workshop in 2007. He displays an image of a transrectal ultrasound (TRUS)-guided biopsy procedure, explaining that going through the rectum is challenging because of probe inflexibility but a system that takes a biopsy through both the rectum and perineum can solve this challenge. Dr. La Rosa’s proposed system uses a template through which a biopsy can be done through the perineum and information from the biopsy cores and ultrasound are run through in vivo 3D biomapping software. He concludes with a discussion of how multifocality can be more challenging to overcome and states that in vivo 3D examination provides physicians and patients with a reliable assessment of grade and stage of disease and the opportunity to choose the most appropriate therapeutic options, while also showing a highly accurate ability to detect clinically significant prostate cancer lesions as compared with 3D reconstruction of prostatectomy specimens.

Practice Management Advice for the Urologist: Advocating for Your Patient

Posted by Neil H. Baum, MD | Sep 2021

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, considers how and why physicians should advocate for their patients in the face of insurance claim denials. He explains that denials occur because rejections lower costs for insurance companies and allow them to hold money for weeks or months as appeals take place. Dr. Baum then tells the story of Shelly (name and likeness used with permission), a patient of his with cerebral palsy. Shelly used a voice synthesizer (VS) to communicate, but the school board refused to allow her to keep the VS once she graduated high school. Dr. Baum describes how Shelly’s family requested a new VS from their insurance so that Shelly could attend college, but were denied on the grounds that the VS was a “creature comfort” and the insurance company was “not responsible for replacing something not present at birth.” Dr. Baum decided to serve as Shelly’s advocate, reaching out to the state insurance commissioner, the insurance company’s medical director, government representatives, and the media. As a result of this advocacy, the medical director approved coverage of the VS and Shelly was able to go to college. Dr. Baum summarizes what he learned from this experience, highlighting the power that physicians have to help their patients, but also noting that they cannot advocate for every patient since the process is too laborious. He concludes that insurance companies are focused on their bottom line, so physicians must be focused on the welfare of patients.

Testosterone Therapy in Men with Biochemical Recurrence and Metastatic Prostate Cancer

Posted by Abraham Morgentaler, MD, FACS | Sep 2021

Abraham Morgentaler, MD, FACS, Associate Clinical Professor of Urologic Surgery at Harvard University, summarizes results from a recent study on testosterone (T) therapy for patients with biochemical recurrence and metastatic prostate cancer. He provides some background, explaining that physicians have been taught that raising testosterone in a man with prostate cancer is like “pouring gasoline on a fire,” even though approximately 20 years of evidence suggests that T therapy is safe after radical prostatectomy, after radiation therapy, in patients with prostatic intraepithelial neoplasia, and in patients on active surveillance. Dr. Morgentaler notes that his and his colleagues’ research indicates that T therapy is also safe for patients with advanced disease. He then goes over the makeup and design of the observational study, which featured 22 symptomatic men of a median age of 70.5. The median duration of T therapy was 12 months, and all patients reported symptomatic benefit from the treatment. The overall mortality was 13.6% with only one prostate cancer-specific death, and morbidity was fairly low, with no cases of pulmonary embolism, spinal cord compression or pathological fractures, and no observed rapid or precipitous progression of disease. Dr. Morgentaler highlights one 94-year-old patient’s experience, describing how this man wanted to be on testosterone because androgen deprivation made him too tired to do the things he enjoyed. After 6 weeks of T therapy, this patient’s brain was clearer, his appetite had improved, and he was exercising daily, and even though he died at age 95 after 11 months of therapy, Dr. Morgentaler emphasizes the importance of T therapy’s benefit to his quality of life in his final months. He concludes that there are men who prioritize quality of life over duration, that data contradict the idea that T therapy is dangerous for patients with prostate cancer, and that T therapy might in fact be a reasonable option for selected men with metastatic disease who refuse androgen deprivation.

Radiation Oncology Perspective: Image-Guided Metastasis-Directed Therapy

Posted by Steven E. Finkelstein, MD, FACRO | Sep 2021

Steven E. Finkelstein, MD, FACRO, radiation oncologist with Florida Cancer Affiliates in Panama City, Florida, discusses 3 unique cases of recurrence after robotic-assisted laparoscopic radical prostatectomy and bilateral pelvic lymphadenectomy and their clinical management from a radiation oncology perspective. He introduces the first case of a patient with a PSA of 5.4 ng/mL and a Gleason score of 5+4 at the time of initial diagnosis. Dr. Finkelstein states that the recurrence became apparent once the patient’s PSA rose from .15 to .9 and a negative bone scan led to the initially planned treatment of post-prostatectomy radiotherapy (XRT). He explains that next-generation imaging (NGI) was then ordered and showed increased tracer uptake in an area of the left pelvis, leading the patient to begin a course of intensity-modulated radiation therapy and daily image-guided radiation therapy (IGRT). Dr. Finkelstein then moves on to the second patient, who had a PSA of 4.4 ng/mL and a Gleason score of 4+4 initially and whose recurrence was identified once their post-treatment PSA rose from .25 to 1. He describes how a negative bone scan led to initially planning a post-prostatectomy XRT, but when NGI found a sclerotic lesion in the middle right iliac bone, his treatment changed to stereotactic body radiation therapy (SBRT). Dr. Finkelstein then introduces the final patient, who had a PSA of 4.4 ng/mL and a Gleason score of 4+4 and whose recurrence was identified once their post-treatment PSA of .25 increased to 1. He states that, again, a negative bone scan led to planning post-prostatectomy XRT for the patient. NGI proved that XRT would have been insufficient by identifying a sclerotic lesion in the middle right iliac bone and 5 other bone metastases. Dr. Finkelstein concludes by noting that, due to NGI, the patient also received SBRT.

Improving Your Public Speaking Performance with PowerPoint’s Presenter Coach Tool

Posted by Neil H. Baum, MD | Sep 2021

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, explains how urologists can use PowerPoint’s Presenter Coach tool to improve their public speaking skills. He observes that while public speaking is important for building and maintaining a urology practice, many urologists lack training in this area and may even be terrified to speak in front of an audience. To help gain these skills and alleviate fear, Dr. Baum recommends using the Presenter Coach tool, a free feature in PowerPoint that gives users feedback to improve their presentations before they ever have to speak in front of another person. He explains that users can present to the computer, and the Presenter Coach will evaluate pacing and pitch, as well as use of filler words, informal speech, euphemisms, and culturally insensitive terms. Dr. Baum then goes over how to use Presenter Coach step-by-step, highlighting the benefits of its real-time feedback and in-depth rehearsal reports. He also recommends practicing with the coach more than once in order to see improvement.