Mohit Khera, MD, MBA, MPH, Professor and F. Brantley Scott Chair in Urology at Baylor College of Medicine, discusses strategies for optimizing erectile function following radical prostatectomy in men with prostate cancer.
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Michael A. Gorin, MD, discusses biomarkers for diagnosing prostate cancer, including PSA, mpMRI, and serum and urine tests. He gives an overview of the history of prostate specific antigen (PSA), emphasizing that PSA screening is beneficial even as he acknowledges that PSA’s high sensitivity and low specificity result in many unnecessary biopsies. There are now many serum and urine biomarker tests that can help provide more specificity, including 4KScore, Prostate Health Index, SelectMDx, and ExoDx Prostate IntelliScore (EPI), all of which are endorsed by the NCCN Guidelines. Dr. Gorin notes that, when price is considered, SelectMDx and EPI outperform the other tests. Dr. Gorin concludes the presentation by discussing how multiparametric MRI should be used in prostate cancer diagnosis, noting that while there is little official guidance on this yet, he uses it in his own practice if a patient has a PSA ≥3 and receives an abnormal result from a serum or urine biomarker test.
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In this nine-minute commentary, Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses a problem-solving solution that he uses in his practice called “the 5 whys” as an alternative to stopgap solutions. He suggests identifying the root cause of the problem, which can easily prevent future occurrences, especially if the solution is inexpensive to implement. Dr. Baum then looks at the implementation of the 5 whys in a urologic setting, using the common issue of scheduling as an example, emphasizing that the purpose of drilling down on causes to a problem is to find the root cause and therefore a solution, rather than placing blame. Dr. Baum then discusses how to implement this approach to solving problem in a urologic practice, emphasizing the need to include all staff in the solution and to focus on long-term success rather than short-term, quick-fix solutions. Finally, he goes over the steps involved in effective problem solving, in particular the need to evaluate the improvements to see if the solution was effective or not.
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E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, compares transperineal prostate biopsy to transrectal ultrasound (TRUS)-guided prostate biopsy, listing the pros and cons of each. He establishes that the transperineal approach is superior to the transrectal one in minimizing risk of sepsis and urinary tract infection, although transperineal biopsy is more associated with urinary retention. Dr. Crawford goes on to discuss the comparative cost and convenience of the techniques, observing that TRUS-guided biopsy is typically far less expensive and that more doctors have the requisite experience and equipment to perform such a biopsy as opposed to a transperineal one. Dr. Crawford suggests that the transrectal approach is currently easier than the transperineal one for most urologists and patients, but notes that urologists may want to consider tailoring their technique to an individual patient’s particular needs and risk factors. However, Dr. Crawford concludes by introducing a demonstration of a transperineal 3D mapping biopsy, suggesting that this may be disruptive technology capable of transforming prostate cancer care.
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Behfar Ehdaie, MD, MPH, a urologic surgeon at Memorial Sloan Kettering Cancer Center, discusses how MR-targeted prostate biopsy in active surveillance improves detection of higher grade prostate cancer and reduces misclassification of patients with low-risk disease. He summarizes the findings of studies that demonstrate MR-targeted biopsy’s superiority over systematic biopsy in detecting cancer, the particular benefits of MR-ultrasound software fusion prostate biopsy as compared to visually targeted biopsy, and the importance of combining MR-targeted biopsy with systematic biopsy since some tumors are not visible on MRI. Dr. Ehdaie also notes that patients on active surveillance particularly benefit from scheduled MR-targeted biopsies since only using changes in surveillance MRI and clinical stage to trigger biopsy can cause many higher grade cancers to be missed. Dr. Ehdaie concludes by emphasizing the importance of using a transperineal biopsy technique as opposed to a transrectal one in order to reduce complications and improve cancer detection.
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