Video Archives

Beyond Antibiotics: Introducing Vaccine-Based Approaches to Recurrent UTIs in Women

Posted by J. Curtis Nickel, MD, FRCSC | Mar 2021

J. Curtis Nickel, MD, FRCSC, the Canada Research Chair in Urologic Pain and Inflammation and Professor of Urology at Queen’s University in Kingston, Ontario, gives an overview of current and prospective treatment for recurrent urinary tract infections (UTIs), focusing on alternatives to antibiotics. He begins by summarizing the history of antibiotics for UTIs, noting that new antibiotics were discovered very quickly from the 1940s through the 1970s and that doctors believed at the time that infectious diseases would soon be a problem of the past. However, antibiotic-resistant microbes are now so prevalent that Dr. Nickel suggests that humanity is entering the “post-antibiotic era.” He then considers the available non-antibiotic treatments for recurrent UTI prevention in pre- and postmenopausal women. For premenopausal women, traditionally-recommended alternative prophylactic treatments include changes in hygiene practices, pre- and post-coital voiding, and avoidance of hot tubs, tampon use, and douching, but guidelines say that case-control studies demonstrate that these suggestions do not significantly impact recurrent UTI risk and can reinforce shame and self-blame. Dr. Nickel lists several alternative therapies with varying levels of evidence for this cohort, including increased water intake, cranberry extract, probiotics such as D-mannose, and methenamine hippurate. Dr. Nickel also recommends probiotics, D-mannose, and cranberry for postmenopausal women, though he also notes that the evidence-based approach for this cohort is vaginal estrogen therapy. According to Dr. Nickel, the future of recurrent UTI prevention for both cohorts is a vaccine. In the final part of his presentation, Dr. Nickel looks at treatment options for symptomatic UTI. Guidelines suggest antibiotics in these cases, but evidence indicates that UTI is typically self-limited and rarely progresses to more severe disease, and that there is little benefit to antibiotics for UTI beyond modestly faster symptomatic improvement. Dr. Nickel suggests treating symptomatic UTI with phenazopyridine, NSAIDS, urine alkalization, methenamine hippurate, and even herbal and dietary therapies. After summarizing his key points, Dr. Klotz goes into greater depth regarding vaccines for UTI prevention in a conversation with E. David Crawford, MD.

Biomarkers and Clinical Decisions – Integrating with Clinical Parameters, Imaging & Prognostic Instruments

Posted by Matthew R. Cooperberg, MD, MPH | Mar 2021

Matthew R. Cooperberg, MD, MPH, Professor of Urology and Epidemiology & Biostatistics and Helen Diller Family Chair in Urology at the University of California, San Francisco (UCSF), outlines the current role of biomarkers in clinical decision-making for prostate cancer. In the first part of the presentation, he discusses markers for pre-diagnosis evaluation, noting that candidate markers have to improve on an existing multivariable gold standard, have to identify potentially lethal prostate cancer, and should be held to the same standard as other biomarkers. Dr. Cooperberg goes over the tests that are currently available, and considers where markers belong in the testing sequence. He observes that liquid markers have better negative predictive value for high-grade cancer than MRI does, and also emphasizes the continued importance of systematic biopsy. He then explains the emerging UCSF diagnostic sequencing approach, in which patients with an elevated marker receive a biopsy regardless of MRI results. In the next part of the presentation, Dr. Cooperberg looks at the relatively stagnant state of post-diagnosis markers. According to him, risk groups are outdated and need to be replaced. He then summarizes the 2nd San Francisco Consensus Statement on this matter, which says that a putative biomarker must be shown to improve on an existing, validated, multivariable model reflecting all available clinical information, and explains that while some biomarkers meet this criteria, they are not yet standard of care. Dr. Cooperberg concludes that the liberal use of secondary tests to aid decision-making before and after biopsy helps drive balance of risks and harms in favor of early baseline PSA screening with low initial threshold, that MRI can help target biopsy and stage cancer but does not replace need for initial systematic biopsy, and that no test is binary.

Cardiovascular & Metabolic Risk Profiles of Hormonal Agents for Managing Advanced Prostate Cancer

Posted by Celestia S. Higano, MD | Mar 2021

Celestia S. Higano, MD, FACP, Adjunct Professor in the Department of Urologic Sciences at the University of British Columbia and Medical Director of the Prostate Cancer Supportive Care Program at the Vancouver Prostate Centre, reviews her 2020 paper outlining the cardiovascular risks associated with ADT and new treatments for prostate cancer, highlighting its increasing relevance in the wake of recent approvals for drugs like relugolix. She explains that there is controversy in the literature regarding whether ADT increases cardiovascular risks, but suggests that patients who are already at risk of cardiovascular disease may see more adverse cardiovascular effects on ADT. Phase 3 trials combining ADT with drugs like enzalutamide, apalutamide, and abiraterone, as well as other second-generation antiandrogens, demonstrate greater cardiovascular risk to patients on a combination as opposed to on ADT alone. Dr. Higano emphasizes that urologists must discuss risk factors for cardiovascular disease with their patients before prescribing these treatments, and she recommends following the Vanderbilt Cardiooncology Group’s ABCDE checklist with them.

Managing Inappropriate Patient Requests

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 how to manage inappropriate patient requests. He provides examples of common requests, reasons for saying ‘no,’ and how to maintain a positive doctor/patient relationship while doing so. Example scenarios include requests to add on extra days to a work exemption, inappropriate prescription medication, unnecessary procedures, requests for the medical records of an aging parent, and asking to remain in the office after an appointment has ended. Dr. Baum recommends proposing alternative solutions to the request and offering to reassess later if necessary. He advises doctors to gain their patients’ buy-in by involving them in the solution and asking them to agree to the plan. Additionally, reminding patients of a doctor’s ethical obligation against lying, violating HIPAA, or providing unsuitable care can help them understand the decision. It is important to document such requests in the patient’s file along with an explanation of the steps taken to address the reasons for the request.

Active Surveillance 2021 – Patient Selection, Monitoring, and Innocuous Interventions

Posted by Laurence Klotz, MD, FRCSC | Mar 2021

In the third part of a Platinum Lecture trilogy on active surveillance, Laurence Klotz, MD, FRCSC, Professor of Surgery and holder of the Sunnybrook Chair of Prostate Cancer Research at the University of Toronto, discusses patient selection, monitoring, and innocuous interventions for active surveillance of prostate cancer. He argues that active surveillance is safe for appropriately-selected younger men, as well as for Black patients. Dr. Klotz also explains that placing men with intermediate-risk cancer can be safe, again with appropriate selection and careful follow-up. He then gives an overview of innocuous interventions for patients on active surveillance, including diet, exercise, smoking cessation, vitamin D, low-dose statins, and metformin.