Latest Videos Archives

Pitfalls in Perineal Surgery

Posted by Ryan P. Terlecki, MD, FACS | May 2022

Ryan P. Terlecki, MD, FACS, Vice Chair and Associate Professor of Urology, Director of the Men’s Health Clinic, Director of Medical Student Education, and Fellowship Director for Reconstructive Urology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, discusses perineal surgery and key elements of preoperative planning to optimize the surgeon and patient experience while highlighting some intraoperative technical considerations to facilitate efficiency. He advises practitioners to choose patients commensurate with their own experience, to prioritize risk reduction, to under-promise and over-deliver, and to maintain technical poise. Dr. Terlecki addresses helping patients set expectations, which is dependent upon the patient’s preoperative level of suffering and upon the definition of success. He discusses patient preparation and the importance of doctors investing time to understand their patients as well as his own requirements, such as patients undergoing urine testing and suspending blood thinners preoperatively. He underlines the importance of clearly laying out the process—from start to finish—for the patient. He also warns of the “CURSED” patient—one who is compulsive-obsessive, unrealistic, revision-seeking, surgeon-shopping, entitled, and in denial. Dr. Terlecki then turns to optimizing the operating room through organization and aiming for what he calls “SWEET”; doing things the same way each and every time. He suggests video primers for support staff and an instrument and equipment checklist as well as pre-gaming with anesthesiologists and paying special attention to patient preparation. He addresses antibiotic stewardship before shifting to some technical items, highlighting the challenge of working in tight spaces during perineal surgery and the importance of surgeons freeing their hands and not struggling. Dr. Terlecki discusses the importance of illumination and magnification but advises surgeons to be mindful of ergonomics and equipment weight. Dr. Terlecki discusses considerations when doing artificial urinary sphincter (AUS) surgery, such as challenges when a patient has had a prior sling, before turning to combination cases (sling or AUS with inflatable penile prosthesis [IPP]). Here, he advises surgeons to accomplish the sling part of the operation first, noting that single-incision approaches are problematic and there are implications for the patient, the surgeon, and the hospital. Dr. Terlecki offers several items that allow for more efficient use of the surgeon’s time during urethroplasty. For example, surgeons should know whether the repair is an anastomotic repair or a substitution repair. He prefers scoping before and during the procedure to avoid a suboptimal incision site and addresses instruments that can be helpful throughout surgery. Dr. Terlecki then turns to the principles for urethral surgery, and poses a question for practitioners’ consideration: “If this was going perfectly, what would it look like?” He closes by citing Sir William Osler who advocated for equanimity, meaning the ability to calmly assess a situation, determine the best course of action and correction, and then to move forward. Dr. Terlecki discusses the importance of asking for help when needed, emphasizing that reaching out also helps build relationships and is a sign of excellence, not weakness.

Treating BPH: Comparing Treatment Modalities

Posted by Michael E. Albo, MD | May 2022

Michael E. Albo, MD, Vice Chair of the Department of Urology at the University of California, San Diego, compares the efficacy, safety, and considerations for a variety of treatment options—both traditional surgical and newer, minimally-invasive therapies—for patients with benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS). He begins by outlining the surgical management of LUTS attributed to BPH before discussing the goals and selection of treatment. He explains the patient and urologist perspectives in terms of evaluating minimally invasive therapies before summarizing the various treatment options as a whole. The first are resection treatments, including transurethral resection of the prostate (TURP) (which Dr. Albo calls “the gold standard”) and transurethral incision of the prostate (TUIP). Next he describes enucleation technologies, including simple prostatectomy, laser enucleation of the prostate (using holmium [HoLEP] or thulium [ThuLEP] lasers), and bipolar enucleation. Dr. Albo explains that while simple prostatectomy should be considered only for patients with large to very large prostates, laser enucleation options are size-independent options for the treatment of LUTs/BPH; additionally, the HoLEP and ThuLEP options have more favorable perioperative safety and he advises these be considered as treatment options in patients at higher risk of bleeding. Dr. Albo then addresses vaporization procedures, including bipolar transurethral vaporization of the prostate (TUVP) and photoselective laser vaporization of the prostate (PVP), explaining that PVP is likely safe for patients on anticoagulants. At this juncture he turns to the minimally-invasive prostatic urethral lift (PUL), citing studies showing this is less effective than TURP but with similar quality of life improvements. Dr. Albo makes the point that trials need to better evaluate minimally invasive interventions in terms of whether patients are able to discontinue medication and therefore whether that intervention can be considered successful. He discusses water vapor thermal therapy (WVTT), citing data supporting the preservation of erectile and ejaculatory function and five-year data showing sustained changes in International Prostate Symptom Score (IPSS) and Qmax. Robotic waterjet treatment (RWT) has been shown to be effective and safe, with the main drawback being bleeding; Dr. Albo predicts that, while more needs to be learned as far as RWT for larger prostates, this procedure could be game-changing. He mentions two additional procedures, transurethral microwave therapy (TUMT) and prostate artery embolization (PAE) (which currently is not recommended outside the context of clinical trials) as well as an investigational treatment with nitinol struts to remodel the bladder neck. He concludes by asserting that the field has come a long way in terms of the sophistication of the surgical treatment algorithm, emphasizing the importance of a discussion with the patient in terms of side effects, the availability of technology at the institution, and the surgeon’s skill level in the decision-making process.

Non-Muscle Invasive Bladder Cancer: Guidelines-Based Approach

Posted by Raj S. Pruthi, MD, MHA, FACS | May 2022

Raj S. Pruthi, MD, MHA, FACS, Professor in the Department of Urology at the University of California, San Francisco, reviews the American Urological Association (AUA)-Society of Urologic Oncology (SUO) guidelines on diagnosing and treating non-muscle invasive bladder cancer (NMIBC). He begins with some statistics, relating that in 2017, there were approximately 79,000 new cases of bladder cancer, 16,800 deaths, and greater than 500,000 survivors. Dr. Pruthi observes that bladder cancer is a disease of older individuals, and he predicts that the population of bladder cancer patients will increase as the population ages. He then highlights key facts about NMIBC, explaining that most patients recur, some progress, and the ability to predict recurrence and progression is based on patient-specific disease characteristics. Dr. Pruthi introduces the 2016 AUA/SUO guidelines, noting that the panel featured a patient advocate. He goes over the guidelines point by point, starting with diagnosis. Dr. Pruthi underscores the importance of performing a complete visual transurethral resection of bladder tumor (TURBT) at initial diagnosis, explaining that incomplete TURBT is a contributing factor to early recurrences. He notes that risk calculators for NMIBC are limited by lack of applicability to current populations, and also that no study has evaluated the effectiveness of urinary biomarkers to decrease mortality or improve outcomes compared with standard diagnostic methods. When discussing guidelines around treatment, Dr. Pruthi emphasizes the importance of re-resecting T1 disease since understaging occurs in about 30% of cases and patients with residual T1 (after presumed complete resection) have up to an 80% chance of progression. He also discusses guidelines around BCG administration and BCG relapse. Dr. Pruthi then looks at cystectomy, arguing that waiting until progression to muscle invasion may prove fatal. He concludes by discussing guidelines around follow up.

Patients Come Second

Posted by Neil H. Baum, MD | May 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, argues that the best way to make a medical practice more successful is to focus on improving the experience of the employees, putting their needs ahead of patients and finances. He explains that while the “knee-jerk reaction” to the erosion of a practice’s bottom line is to cut staff, equipment, resources, and investments, putting employees first actually leads to greater financial success, since happier employees will take better care of patients. In turn, these satisfied patients will leave positive reviews, driving new patients to the practice and increasing productivity and profitability. Dr. Baum gives several suggestions on how to put employees first, recommending that practice owners start by measuring employee engagement and employee satisfaction with surveys. He concludes by saying that practice owners should “forget employee of the month” and instead try to praise and compliment their employees every day.

Industry Perspective: AR-V7 Testing for Men with Advanced Stage Prostate Cancer

Posted by Daniel Shoskes, MD, FRCSC | May 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, discusses AR-V7 testing for men with metastatic castrate-resistant prostate cancer (mCRPC). He begins by noting that mCRPC cannot be cured, but patients with mCRPC often benefit from multiple lines of sequential therapy. Dr. Shoskes explains that when one therapy fails, choosing the next therapy can often be difficult, in part because patients often prefer AR-targeted therapy over taxanes due to the less burdensome side effect profile of AR-targeted therapies. As a result, even though secondary AR-targeted therapy is only effective 22-46% of the time, AR-targeted therapies are administered back-to-back up to 60% of the time. Dr. Shoskes observes that AR variants are a common cause of AR-targeted therapy resistance, and of those variants, AR-V7 is one of the most common and best understood. He defines AR-V7 as a splice variant of the androgen receptor protein which is active without the ligand binding domain, making it resistant to abiraterone, enzalutamide, and apalutamide. Dr. Shoskes then introduces the Oncotype DX AR-V7 Nucleus Detect assay, which he argues can help clinicians quickly direct their mCRPC patients toward the right treatment. He explains that the Nucleus Detect assay detects the AR-V7 protein in the nucleus of circulating tumor cells, is predictive of resistance to AR-targeted therapies, provides easy-to-interpret and actionable results, and only requires a simple blood draw. Dr. Shoskes highlights that the Nucleus Detect assay has been validated in three independent studies, all of which found that it to be predictive of non-response to AR-targeted therapy. He concludes by discussing outcomes, noting that in the validation studies, AR-V7+ patients experienced a 76% survival benefit from being placed on taxane therapy versus AR-targeted therapy.