Latest Videos Archives

How to Utilize MRI for Focal Therapy Planning

Posted by Samir S. Taneja, MD | May 2022

Samir S. Taneja, MD, the James M. Neissa and Janet Riha Neissa Professor of Urologic Oncology, Co-Director of the Smilow Comprehensive Prostate Cancer Center, and Vice Chair of the Department of Urology at NYU Grossman School of Medicine, discusses how to use MRI in planning and doing follow-up on focal therapy for prostate cancer. He begins by introducing the critical decisions in focal therapy implementation, including candidate selection, method of disease mapping/identification, choice of energy, and manner of follow-up/verification of efficacy. Dr. Taneja then lists imaging-related factors influencing oncologic efficacy including tumor size/extent, tumor location, focality, energy source, and gland size. He considers biopsy vs. MRI in treatment planning, explaining that systematic biopsy is inadequate for mapping disease, transperineal template biopsy is the gold standard, and MRI/MRI-targeted biopsy is not perfect, but very good. Dr. Taneja notes that MRI misses some clinically significant cancer, but observes that a 9 to 10 millimeter MRI/MRI-targeted biopsy guided focal ablation seems to identify all the index tumors. He also goes over imaging factors such as disease location and volume affect the choice of energy selection for focal therapy. Dr. Taneja then considers the benefits of imaging post partial gland ablation, explaining that very early imaging evaluates the anatomy of ablation but not its efficacy, intermediate interval imaging guides biopsy and identifies need for retreatment, delayed imaging identifies recurrence. He also briefly discusses the use of PET in cases where MRI does not detect recurrence. Dr. Taneja concludes that MRI has the ability to localize the index tumor, that margin considerations should take into account the known limitations of MRI in disease mapping, and that MRI remains the essential mainstay for monitoring following focal ablation.

Lessons from LEGO Blocks

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, considers five lessons medical practices can learn from the successes of the LEGO toy company. He begins with a brief history of the LEGO company, explaining that it started declining in 1992, but was able to reverse this decline in 2014 and is now the largest toy company in the world. Dr. Baum then goes through lessons for medical practices modeled on the success of LEGO, beginning with the idea of connectivity. He observes that each LEGO piece connects to every other piece, with no piece dominating, and he argues that practices must similarly connect with patients, hospitals, other providers, insurance companies, and the community. Dr. Baum’s second lesson is to build the right team, just as LEGO did a decade ago when it looked like the company was on its way to bankruptcy. He suggests that those running a medical practice ask themselves whether they would rehire each employee in their practice, and whether their doctors and staff are practicing at the top of their licenses. Dr. Baum’s third lesson is to create a clear path, much as LEGO did when they reconnected with their signature block and pivoted away from other products like video games. Medical practices, Dr. Baum argues, should be similarly focused on ensuring every patient has a positive experience. The fourth lesson is to create value based on the customer. Just as LEGO works to maintain customer satisfaction by replacing missing pieces from kits for free and using focus groups to develop new products, Dr. Baum suggests medical practitioners should observe how their patients interact with their practice and ensure they are not making assumptions based on outdated or inaccurate information by conducting regular patient surveys. Finally, Dr. Baum recommends that medical practices follow LEGO’s lead in developing strategic partnerships. He explains that LEGO’s partnerships with Star Wars, Harry Potter, and Disney lead to increased visibility, sales, and profits, and argues that medical practices can do much the same by nurturing partnerships with hospitals, payers, and the community.

Focal Prostate Cryotherapy

Posted by Thomas J. Polascik, MD, FACS | May 2022

Thomas J. Polascik, MD, FACS, Professor of Surgery at Duke University and Director of Surgical Technology at the Duke Prostate and Urological Cancer Center, discusses focal prostate cryotherapy and recent data on the treatment’s outcomes. He begins by describing the ideal patient for focal cryotherapy as someone with a greater than ten-year life expectancy and single or multiple mpMRI-visible, biopsy-proven Gleason Grade 2 prostate cancer (PCa) in locations amenable to ablation. Dr. Polascik outlines the procedure and states that the goals of the treatment are eradication of PCa, avoiding urinary and sexual dysfunction, and being a fast and simple outpatient procedure. He then begins discussing data on focal cryotherapy that shows that vitamin D3 functions as a sensitizer to cryoablation and that it is reasonable to re-treat about 20% of PCa patients with focal therapy. Dr. Polascik reviews the latest cryotherapy outcomes that all show focal cryotherapy to be approaching 100% rates of metastasis-free survival, cancer-specific survival, and urinary continence. He summarizes several studies that also show continence to be at about 95-100%, while potency was shown to be between 40-80%. Dr. Polascik then considers a study of long-term outcomes of focal therapy for low-intermediate risk cancer that found focal cryotherapy capable of increasing the time until radical or systemic therapy. He summarizes another study on anterior gland focal cryoablation showing that it can be effective based on erectile function and International Prostate Symptom Score (IPSS) not changing post-treatment. Dr. Polascik discusses expert consensus on how to surveil focal cryotherapy patients post-op, focusing on how in-field failure is a sign of poor treatment while out-of-field failure signals poor patient selection. He concludes by giving an overview of the Focal Therapy Society and by considering the future of focal cryotherapy.

Overactive Bladder vs. Interstitial Cystitis: Overlapping Conditions?

Posted by John Thomas Stoffel, MD | May 2022

John Thomas Stoffel, MD, Associate Professor of Urology and Chief of the Division of Neurourology and Pelvic Reconstruction within the University of Michigan Department of Urology in Ann Arbor, Michigan, discusses how to differentiate overactive bladder (OAB) from interstitial cystitis (IC), as well as how to appropriately treat both conditions. He begins with some background, explaining that OAB is common and affects 30 to 50 million women worldwide. IC is also common, and may affect between 2 and 17% of US adults. Dr. Stoffel argues that despite this prevalence, clinicians do not understand the depth of these conditions nor how to differentiate them. He then defines OAB as “[urinary] urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia,” whereas IC is an unpleasant sensation (pain, pressure, discomfort) perceived to be related in the urinary bladder, associated with LUTS, of greater than 6 weeks duration in the absence of infection. Dr. Stoffel posits that IC is more associated with sensory symptoms while OAB more associated with motor symptoms. He then discusses the work-up for OAB and IC, explaining that the work-up for the former should include a physical exam, urine analysis, and a voiding diary, while the work-up for the latter should feature a physical exam, a history of symptoms, urinalysis, urine culture, and urine cytology. Dr. Stoffel moves on to treatment strategies, describing the treatment of OAB as like a ladder, moving sequentially from behavioral therapy to medications to neuromodulation/onabotulinum toxin. He recommends tracking outcomes for OAB with patient reported outcome measures (PROMS), and highlights the effectiveness of behavioral therapies such as timed voiding/fluid management, weight loss, and biofeedback. Dr. Stoffel also notes that there are no clear winners among OAB medications, and he emphasizes the need to define patients’ expectations. He describes the treatment strategy for IC as less like a ladder than a grab bag, explaining that “initial treatment type and level should depend on symptom severity, clinician judgment, and patient preferences.” Dr. Stoffel briefly considers the evidence for neuromodulation and onabotulinum toxin, concluding that they are effective for OAB, but there is little extended data in IC.

PSMA Targeted Therapies and the Role of the Urologist

Posted by Phillip J. Koo, MD | May 2022

Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses PSMA targeted therapies for prostate cancer and the urologist’s role in using radiotherapy. He begins by looking at the results of the VISION trial of lutetium-177 PSMA-617 for metastatic castration-resistant prostate cancer (mCRPC), explaining that radioligand therapy significantly increased overall survival and radiographic progression-free survival. Dr. Koo then considers the TheraP trial of lutetium-177 PSMA-617 versus cabazitaxel which saw far better PSA response in PSMA arm than in the cabazitaxel one. He notes that the amount of imaging used in patient selection for TheraP would be impractical in a real-world setting. Dr. Koo also looks at the slate of upcoming clinical trials of PSMA, highlighting the number of combination therapy trials in the CRPC setting, as well as the number of trials looking at PSMA’s potential role in earlier phases of the disease. Finally, Dr. Koo discusses the role of the urologist in the new PSMA era, arguing that urologists need to understand and be comfortable with PSMA since it is an increasingly important tool for treating advanced prostate cancer. He recommends that urologists create advanced prostate cancer clinics featuring targeted radiotherapy clinics.