Latest Videos Archives

PCa Commentary | Volume 161 – January 2022

Posted by Edward Weber, MD | Jan 2022

This Commentary looks at bipolar androgen therapy (BAT) as a treatment option for metastatic castration-resistant prostate cancer (mCRPC).

Is Open Partial Nephrectomy Still an Option for Challenging Renal Masses?

Posted by Michael A. Brooks, MD | Jan 2022

Michael A. Brooks, MD, Assistant Professor of Urology and Oncology at Baylor College of Medicine in Houston, Texas, evaluates open partial nephrectomy as an option for challenging renal masses and compares it to the robotic retroneoscopic and laparoscopic techniques. He begins by discussing three patient cases, each one using a different treatment option. The robotic retroneoscopic partial nephrectomy patient experienced minimal blood loss, an operation time of 4 hours, and was discharged on the 3rd day post-op. The laparoscopic partial nephrectomy patient also had minimal blood loss, a 3-hour operation time, and was discharged on post-op day 3. The open partial nephrectomy patient experienced greater blood loss, a 5-hour operation time, and was discharged on post-op day 2. Dr. Brooks also explained the technique for each, highlighting the importance of port placement for robotic surgery, a lack of cortical stitches to avoid compressing the kidney for open partial nephrectomy, and the use of intraoperative ultrasound for all three procedures. He then considers two papers, the first of which found that oncological outcomes for open and robotic patients were very similar but that open partial nephrectomy produced higher blood loss, longer ischemia time, and a longer post-op course in patients. The second paper focused on the impact of specific surgeons and found that surgeon skillset and experience created high variability in outcomes. Dr. Brooks concludes that open partial nephrectomy remains a good option for complex renal masses, that the approach can vary from patient to patient based on tumor characteristics, and that the approach is likely less important than surgeon training, experience, and case volume.

Changing Paradigm in Testosterone Therapy Treatment Options

Posted by Mohit Khera, MD, MBA, MPH | Jan 2022

Mohit Khera, MD, MBA, MPH, Professor of Urology and Director of the Laboratory for Andrology Research at the McNair Medical Institute at Baylor College of Medicine in Houston, Texas, discusses testosterone therapy, focusing on four key topics: oral testosterone, testosterone and COVID-19, testosterone and prostate cancer, and lifestyle modification. Dr. Khera provides a historical context for oral testosterone treatments, noting that the US has only recently seen expansion of this option. He describes the inTUne study which showed that 7% of patients may increase or start hypertension medication while on a testosterone oral therapy, but that overall patients experience a lower rate of erythrocytosis when compared with those receiving injectable and topical forms of testosterone. Dr. Khera then reviews several studies examining the relationship between COVID-19 and testosterone. Early studies showed men were more severely affected by COVID-19 than women. Paradoxically, low serum testosterone may be protective against acquiring COVID-19, but the same low serum testosterone can also result in a more severe outcome if that same patient acquires COVID-19. Additionally, COVID-19 also directly impacts the testicles in that serum testosterone levels significantly decrease from their pre-COVID-19 levels. Transitioning to prostate cancer, Dr. Khera describes the paradigm shift over the past 15 years, with physicians previously viewing testosterone as dangerous to now seeing it as protective. He illustrates the point with a prostate saturation model that shows the non-linear relationship between testosterone, PSA, and prostate size. Dr. Khera then considers treatment options with high levels of testosterone, such as bipolar androgen therapy, that have shown promising results. He concludes with a review of lifestyle modifications that can also improve testosterone levels, such as weight loss, sleep, and varicocele.

Use of MRI-Targeting Increases Overdiagnosis and Overtreatment

Posted by Andrew J. Vickers, PhD | Jan 2022

Andrew J. Vickers, PhD, Attending Research Methodologist at Memorial Sloan Kettering Cancer Center in New York City, asserts that the current diagnostic use of MRI-targeting leads to overdiagnosis and overtreatment. He begins by stating that methods of detection such as systematic biopsies and measuring prostate-specific antigen (PSA) don’t tend to lead to underdiagnosis and undertreatment. To illustrate the reasons MRI-targeting leads to overdiagnosis and overtreatment, he displays data showing that in MRI-targeted biopsy the method of grading the core samples leads to higher grading of overall disease. Dr. Vickers points out that Gleason grade is not an inherent property of a tumor, but is instead a surrogate outcome. He then illustrates that biochemical recurrence (BCR) risk and risk of death for high-grade cancer on surgical pathology is dramatically reduced for clinically low-risk patients. Dr. Vickers cites the PRECISION trial which indicated that the MRI-targeted biopsies found far fewer low-grade cancers and more high-grade cancers, but the overall number of cancers identified was essentially the same. Dr. Vickers asserts that these results are consistent with a scenario whereby the technique simply characterized some of the low-grade cancers as high-grade. He then cites another study during which patients had both a systematic and an MRI-targeted biopsy; the MRI targeting identified more cancers that, in turn, led to more treatment. Dr. Vickers suggests this is problematic and opines that urologists do not need to find high-grade cancer in men with low-grade cancer on systematic biopsy. He supports his assertions by citing another study that followed 2,907 men for 17 years. Of those men, there were five cases of metastasis, with just two being potentially preventable. He also cites the European Randomized Study of Screening for Prostate Cancer (ERSPC) Rotterdam study which followed over 3,000 men with a negative sextant biopsy for 11 years and recorded just seven (.02 percent) deaths during that time. Dr. Vickers concludes that the number of men whose prostate cancer would have to be identified and treated in order to save one life is very large and MRI-targeting is leading to excessive overdiagnosis and overtreatment. Dr. Vickers then states that while there should be a clear clinical indication for MRI, such as negative biopsy with rising PSA, the current National Comprehensive Cancer Network (NCCN) guidelines call for treatment irrespective of the method of detection. Dr. Vickers concludes there is an urgent need for more restrictive use of MRI-targeting, evolved treatment guidelines for MRI-detected tumors, and additional research on oncologic risk of MRI-detected tumors.

Minimally-Invasive BPH Therapies

Posted by Christopher P. Smith, MD, MBA, MSS | Dec 2021

Christopher P. Smith, MD, MBA, MSS, Associate Professor of Urology at Baylor College of Medicine in Houston, Texas, considers data on prostatic urethral lift (PUL) and water vapor therapy for benign prostatic hypertrophy (BPH), and analyzes three case studies using the treatments. He begins with an overview of his case studies of men with BPH who all have an International Prostate Symptom Score (IPSS) above 19 and are on tamsulosin but are struggling with the lack of full relief and side effects of the medication. Dr. Smith then discusses the 2021 AUA guidelines for BPH treatment supporting the use of the IPSS at each patient visit to track symptoms and engage patients in early discussions of surgical options in the case of inadequate medications. He continues by summarizing data on the use and efficacy of PUL and water vapor therapy for BPH: a study on the adoption, safety, and retreatment rates of prostatic urethral lift found an increase in the use of the treatment of 10.4% from 2014 to 2018; PUL has passed GreenLight as a preferred procedure as of 2019, accounting for 30% of all BPH procedures; the L.I.F.T. trial and REZUM II trial found that PUL produced significant improvement in symptom scores, quality of life and flow rate when compared to a control; a prospective, randomized, multinational study of PUL versus transurethral resection (TUR) of the prostate found that PUL patients had a more rapid return to baseline activities than TUR patients by 6 days; the MedLift study showed that PUL patients experienced a 75% improvement in IPSS compared to a 34% improvement in control patients; PUL has also been found to have the lowest complications compared to Rezum, TURP, and GreenLight; a study comparing durability predictors after PUL found that men with worse disease states were found to need retreatment at higher rates; PUL is capable of improving ejaculatory function following treatment, while water vapor therapy reduces it; and there has been no recorded difference in outcomes between groups with or without prior prostate surgery. Dr. Smith concludes by stating that all three of his cases were treated with PUL, leading to their IPSS dropping to below 5 and them being taken off of medication.