Latest Videos Archives

Conducting Patient Surveys

Posted by Neil H. Baum, MD | Feb 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, gives recommendations on how urologists can improve their practices by conducting patient surveys. He notes that one of the key needs and wants of urologists is to monitor the urologist-patient encounter, and he highlights two pathways to success in this area: (1) find out what the patient wants and give him/her more of it; and (2) find out what the patient does not want and avoid it. Dr. Baum explains that the best way to identify what patients do and do not want is to conduct patient surveys. He recommends using a suggestion box and notes that in his own practice, he gives patients a card with six yes-or-no questions on the front and space on the reverse side for patients to write out the three questions they would like to have answered during their visit. Dr. Baum also suggests creating online surveys with questions such as “How likely are you to recommend this practice to others?” and “How responsive were the staff and the doctors to your questions?” He concludes that urologists need to listen to their patients and need to ask them how they can serve them better.

Nephron-Sparing Renal Surgery: A Deeper Dive Into How Local Recurrence Issues Alter Preoperative and Postoperative Decision-Making

Posted by Richard E. Link, MD, PhD | Feb 2022

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine in Houston, Texas, discusses the evolving standard of care for renal tumors, and how to determine whether someone should have nephron-sparing surgery. He provides some history, explaining that radical nephrectomy used to be standard for all patients with renal tumors, but that due to improvements in technology and technique, partial nephrectomy is now used in a large percentage of cases. Dr. Link argues that with this great power to perform partial nephrectomies on almost all renal tumors comes a great responsibility to make sure that patients receive appropriate care for their individual cases. He observes that this can be complicated for multiple reasons, including that: decision-making about suitability for nephron sparing is not solely an oncologic decision; resecting more complex tumors may be associated with higher perioperative complication risks and likely results in more renal function loss; older or sicker patients tolerate complex or more lengthy surgery less well and may be less ideal candidates; and older patients likely have less to gain from nephron-sparing due to life expectancy. Beyond those concerns, Dr. Link lists and discusses several fundamental oncologic questions to consider in determining whether a patient is a good candidate for partial nephrectomy or not. These include assessing the risk of pathologic upstaging of “resectable appearing” tumors, the impact of tumor complexity on positive margins and how positive margins after partial nephrectomy alter outcome, the risk of de novo ipsilateral second primary tumors in the future and whether pathology and stage alter this risk in some fashion, and whether the patient would benefit more from a radical nephrectomy. Dr. Link concludes that: upstaging of cT1 tumors to pT3a at partial nephrectomy is relatively rare and portends a statistically significant if rather modest negative impact on recurrence free survival; risk of upstaging appears to be higher for larger tumors, higher RENAL scores, higher grade tumors, and those with irregular morphology; renal sinus fat invasion does not appear to be higher risk for poor oncologic outcomes than perinephric fat invasion; there is little data supporting better oncologic outcomes for radical nephrectomy as compared to partial nephrectomy for completely resected pT3 renal cell carcinoma; true positive surgical margins after partial nephrectomy have a significant negative impact on oncologic outcomes; larger tumors with higher RENAL scores raise the risk of positive margins at partial nephrectomy; and since little data exists about risk of second ipsilateral primary tumor development this should not drive decision making today outside of a genetic “diagnosis.”

Brachytherapy for Prostate Cancer

Posted by Mira Keyes, MD, FRCPC, FABS | Feb 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society and Grand Rounds in Urology, Mira Keyes, MD, FRCPC, FABS, Clinical Professor at the University of British Columbia (UBC) and a radiation oncologist at the Vancouver Centre of the British Columbia Cancer Agency (BCCA), gives an overview of brachytherapy for prostate cancer (PCa), making a case against its declining use based on its efficacy. She begins by introducing the American Brachytherapy society, which was founded in 1978 to provide insight, rationale, and research into the use of brachytherapy in the treatment of both malignant and benign conditions. Dr. Keyes then describes how brachytherapy was performed with radium tubes when it was invented in 1901, and was then subsequently done with needles beginning in 1915. She concludes her short history by marking 1983 as the beginning of the modern era of prostate brachytherapy, thanks to advances in imaging capabilities. Dr. Keyes discusses data showing that brachytherapy is associated with better survival in patients with local to advanced cervical cancer. She then goes over the processes for high dose rate and low dose rate brachytherapy for PCa, focusing on the quick recovery, high cure rates, and minimal to no incontinence or sexual dysfunction as benefits for both treatments. Dr. Keyes shows data on brachytherapy utilization for PCa depicting its decline since 2003 due to robotic prostatectomy use, PSA screening changes, active surveillance low-risk treatment recommendation changes, and higher reimbursement for IMRT and robotic surgery. She also discusses data showing that 10% of US cancer care spending is on prostate cancer, with the highest procedure cost per patient going to robotic surgery. Dr. Keyes compares the use of brachytherapy in the US to that of Canada, stating that Canada’s increasing use is due to a reimbursement system that incentivizes brachytherapy, and the education of the public, residents, general practitioners, and urologists. She concludes that the benefits of brachytherapy support its use for localized PCa in the US.

Urologic Perspective on the Current and Emerging Role of Multi-Modality Imaging and Radiogenomics

Posted by Mohummad Minhaj Siddiqui, MD | Feb 2022

Mohummad Minhaj Siddiqui, MD, Associate Professor of Surgery at the University of Maryland School of Medicine and Chief of Urology at the Baltimore VA Medical Center in Redwood, Maryland, discusses the role of precision imaging and genomics in managing localized prostate cancer. He first considers how treatment strategies will vary based on cancer aggressiveness, ranging from active surveillance in low-risk cancer to multimodal treatment in advanced and metastatic cancer. Dr. Siddiqui cites the PROMIS study which stratified risk of significant cancer based on MRI suspicion score of lesions. He points out that even at that high end of the scale, MRI identified cancers in some patients that either had insignificant or no cancer, demonstrating that imaging cannot replace biopsy. Equally important, at the low end of the scale, half of patients have cancer not shown in the scan. Dr. Siddiqui adds that while a scan may not suggest high-risk cancer, this is not the same as not having cancer. He then discusses the growth of genomic profiling in understanding genomic characteristics of prostate cancer. Genomic profiling is available for different stages of prostate cancer workup from susceptibility characterization to disease risk stratification and prediction of treatment response. The GC score in genomic characterization has similar limitations as imaging, leading to the question of whether these two modalities are capturing the same underlying issue or complementing each other. Dr. Siddiqui then describes how he uses imaging in a surgical setting for margin size and extracapsular extension at radical prostatectomy. He concludes that while it is not perfect, advanced imaging can improve risk stratification and assist with cancer staging and treatment planning. Similarly, genomics can also improve risk stratification and can reduce interventions like adjuvant radiation.

Testosterone, Weight Loss / Weight Gain, and Testosterone Replacement Therapy (TRT)

Posted by Mark A. Moyad, MD, MPH | Feb 2022

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, and Martin M. Miner, MD, Co-Director of the Men’s Health Center and Chief of Family and Community Medicine for Miriam Hospital, and Clinical Professor of Family Medicine and Urology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, investigate the ways in which body mass index (BMI) correlates with testosterone levels and how this knowledge can be used in a medical setting. Dr. Moyad begins the discussion with Dr. Miner’s presentation on the possibility of testosterone needs increasing as BMI increases, wherein Dr. Miner found that obese men required higher doses of testosterone to reach eugonadal levels than men who were not obese. Dr. Miner states that he expects the results of a long-term safety study of testosterone will soon show that testosterone therapy is safe over the long term, allowing physicians and researchers to focus on the symptomatic benefit of testosterone in areas such as mood and cardiovascular risk. Dr. Moyad asks if weight loss and increased fitness could possibly reduce the need for testosterone therapy, to which Dr. Miner responds that it may be possible if both weight loss and a reduction in comorbidities occur but it is unlikely in patients over 60. They conclude that weight loss can help make testosterone therapy more effective but it is unclear if it would be enough to reduce testosterone therapy altogether because of a multitude of genetic variables.