Video Archives

Image-Guided Minimally-Invasive Whole Gland Treatment

Posted by Steven S. Raman, MD | Mar 2021

Steven S. Raman, MD, Clinical Professor of Radiology and Director of Prostate MR Imaging and Interventions at the David Geffen School of Medicine of the University of California, Los Angeles, explains how magnetic resonance imaging (MRI) aids in prostate cancer staging, diagnosis, follow-up, treatment planning, and image-guided treatment. After reviewing relevant FDA guidelines, Dr. Raman outlines the MRI-guided transurethral ultrasound ablation (TULSA)-PRO® treatment planning and delivery process, noting the potential for real-time MR thermometry and feedback control. To further display benefits of the treatment, he reviews outcomes from the TACT trial. He then addresses potential next steps in prostate tissue ablation.

The Case for Standard Imaging

Posted by David Utz | Mar 2021

L. Michael Glodé, MD, FACP, Professor Emeritus of Medical Oncology and the former Robert Rifkin Chair for Prostate Cancer Research at the University of Colorado Cancer Center in Aurora, Colorado, presents the case for standard imaging over second-generation technology in urologic oncology. One compelling reason to consider standard imaging like bone scans is the extensive data that have culminated in criteria on when to order routine scans such as these. Advanced imaging currently lacks both the wealth of data and scanning criteria, leading to questions about the frequency of false positives and false negatives and whether radiologist training is consistent. Dr. Glodé observes that we understand the limitations of conventional imaging, adding that there is insufficient data to make any such determination about the accuracy of second-generation scans. Since trials studying second-generation anti-androgens over the last few years have employed conventional imaging, Dr. Glodé suggests the more sensitive second-generation imaging could potentially deny patients with now-visible metastases access to some drugs based on eligibility criteria. The cost of newer imaging techniques is also prohibitive, especially if they do not replace current scans or change approaches to treatment. He concludes that the level 1 evidence on treatment of non-metastatic castration-resistant prostate cancer using conventional scans weighed against the cost of second-generation scans and the potential for inconsistent application of newer technology suggest that doctors should better utilize current standard imaging.

Immunotherapy for NMIBC: Emerging and Expanding Indications

Posted by Jennifer M. Taylor, MD, MPH | Mar 2021

Jennifer M. Taylor, MD, MPH, Assistant Professor of Urology at Baylor College of Medicine in Houston, Texas, reviews new indications for immunotherapy for non-muscle invasive bladder cancer (NMIBC). She discusses the most common immunotherapy option, presents active clinical trials, and evaluates new treatment options. AUA guidance has previously stated that immunotherapy should be reserved for highest-risk NMIBC, and that for lower-risk cancer, patients and clinicians should weigh the benefit ratio when considering whether immunotherapy is an appropriate treatment choice given the possibility of adverse events. However, a shortage of the most common intravesical immunotherapy, bacillus Calmette-Guerin (BCG), in combination with increased numbers of BCG-unresponsive patients, have altered the treatment landscape. Dr. Taylor reviews the 2018 definition of BCG-unresponsive NMIBC and identifies several ways to determine whether a patient is BCG-unresponsive. Finally, she discusses the approval of pembrolizumab as a newly-available treatment for BCG-unresponsive NMIBC. In the study that led to the approval, 41% of patients had a complete response and no patients progressed to muscle invasive bladder cancer or metastasis. These favorable results are notable given that the gold-standard alternative is radical cystectomy. Additionally, pembrolizumab is well-tolerated and while adverse immune-related events are serious, they are rare and can be managed. Other treatments are also currently under investigation.

Rationale for Focal Therapy for Prostate Cancer

Posted by Abhinav Sidana, MD, MPH | Mar 2021

Abhinav Sidana, MD, Urologic Surgeon at the University of Cincinnati Medical Center, makes a case for the adoption of focal therapy for patients with prostate cancer as an alternative to radical treatment or active surveillance. To show how incorporating focal therapy into the treatment paradigm could help personalize care, Dr. Sidana highlights three points: the shortcomings of a treatment strategy that involves only dichotomous options; the increasing need for treatment tailored to the biology of prostate cancer; and how the advent of visible prostate cancer due to next-generation imaging has altered treatment approaches. Following this, Dr. Sidana takes questions from E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology, about related topics, including the role of micro-ultrasound in the disease space and the patient followup process.

Outcomes Measurements: The Road from Volume to Value

Posted by Neil H. Baum, MD | Mar 2021

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses the shifting paradigm in healthcare from the volume of services provided to the value of services. He describes outcome management, how to get started, and challenges to this approach. This client-centric approach to healthcare delivery redefines value to equal health outcomes that matter to the patient divided by cost. To implement this approach, Dr. Baum advises starting with conditions that have quantifiable measures such as radical prostatectomy, BPH, or ureteral stones. Outcomes have historically been measured by mortality, morbidity, readmission rate, and length of stay, but the new standard will consider patient satisfaction, which can be measured by looking at the length of time it took to for the patient to make an appointment, time spent waiting in the exam room, whether their questions were answered, and if they received a follow-up on test results. He notes that AUA guidelines can also provide a rubric for outcomes that are important to both the physician and the patient. Dr. Baum underscores that patients who have a positive experience have better clinical outcomes and improved quality of life. Similarly, outcome management is proactive and promotes innovation with the goal of improving care.