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LUTS: Latest in Prevention, Clinical Trials, and Approved Treatments

Posted by | Mar 2022

Michael E. Albo, MD, Vice Chair of the Department of Urology at the University of California, San Diego, gives an overview of how to assess and treat lower urinary tract symptoms (LUTS) in men. He presents a case of a 65-year-old patient referred to a urologist due to benign prostatic hyperplasia (BPH). Dr. Albo explains that in the old treatment algorithm, the question of how to treat this patient would have been simple: urinary symptoms would be treated with a non-specific Alpha blocker, and then if symptoms persisted, the urologist would offer transurethral prostatectomy (TURP) or a simple prostatectomy. However, Dr. Albo notes, the updated treatment algorithm currently in use is far more complex and features many options. This is due in part, he observes, to the realization that LUTS is not just related to the prostate, but rather has a complicated etiology related to other parts of the body including the bladder and urinary tract. Dr. Albo returns to the example of the 65-year-old referred for BPH, and explains that based on the new algorithm, initial evaluation of this patient will likely feature taking his medical history, giving him a physical examination, getting his International Prostate Symptom Score (IPSS), performing urinalysis, having him keep a 3-day voiding diary, and counseling him on options for intervention. Dr. Albo explains that determining prostate size is important as well since volume predicts symptom progression and risk of complications, and can inform treatment selection. He also observes that when selecting a treatment, a treatment’s effect on sexual function is an important factor for most men, regardless of age. Dr. Albo then lists additional suggested evaluation techniques for patients with LUTS, including assessment of prostate size and shape, checking post-void residual (PVR) volume, and performing uroflowmetry and urodynamic testing. He notes that none of these has enough data to prove they should be used in everybody. Dr. Albo moves on to how to treat LUTS, explaining that the goals of treatment include alleviation of bothersome symptoms, prevention of complications, prevention of progression, and minimization of complications of treatment. He discusses watchful waiting for LUTS, highlighting that 85% of men with mild LUTS are stable at one year, but 36% of men with moderate LUTS cross over to surgery within 5 years. Dr. Albo concludes that the complicated new guidelines are helpful, but far from where they need to be.

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Long-Term Outcomes with Monotherapy for LR and fIR Prostate Cancer

Posted by | Mar 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society (ABS) and Grand Rounds in Urology, Timothy N. Showalter, MD, MPH, Associate Professor of Radiation Oncology at the University of Virginia in Charlottesville, discusses long-term outcomes of and recent advances in brachytherapy monotherapy for low-risk (LR), favorable intermediate-risk (fIR), and selected unfavorable intermediate-risk (uIR) prostate cancer. He begins by listing potential advantages of brachytherapy monotherapy, highlighting that it features a single episode of care, is cost-effective, is multidisciplinary, has excellent long-term outcomes, features established technology to support tailored dosimetry and quality, and has been the subject of recent advances that enhance implant quality and reduce toxicity. Dr. Showalter then considers patient selection for brachytherapy monotherapy, noting that MRI may be useful in selecting patients with LR, fIR, and selected uIR disease. He emphasizes the importance of assessing whether a patient’s anatomy is suitable for implant based on gland size and arch interference, as well as the need to determine whether a patient has adequate baseline urinary function. Dr. Showalter also lists contraindications to brachytherapy monotherapy, including relative contraindications such as a large TURP defect, a large gland, and a large median lobe, as well as absolute contraindications such as inability to tolerate anesthesia, unacceptable operative risk, and the absence of a rectum. He then moves on to consider long-term outcomes of brachytherapy monotherapy, noting that for LR, fIR and selected uIR, follow-up data indicates biochemical progression-free survival of greater than 90%. Dr. Showalter also observes that outcomes are favorable in terms of toxicity, although there are some declines in urinary and sexual function. Finally, Dr. Showalter briefly summarizes recent advances in brachytherapy, emphasizing the role of advanced imaging such as MRI in helping to tailor brachytherapy dose and increase the personalization of care.

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Emerging Treatments for BCG Unresponsive Non-muscle Invasive Bladder Cancer

Posted by | Mar 2022

Amirali Salmasi, MD, Assistant Professor of Urology at the University of California, San Diego, discusses available and emerging treatments for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle invasive bladder cancer (NMIBC). He begins by giving a brief history of intravesical BCG and explaining how BCG works, before moving on to discuss treatments for BCG-unresponsive NMIBC. Dr. Salmasi observes that valrubicin was the best available treatment for a long time, but suggests that some of the many emerging treatments may prove superior. He then summarizes recent and ongoing research into various potential therapies for BCG-unresponsive NMIBC, including: sequential gemcitabine and docetaxel; intravesical cabazitaxel, gemcitabine, and cisplatin; chemohyperthermia treatment; CG0070, an oncolytic adenovirus; superagonist N-803; intravesical nadofaragene firadenovec gene therapy; and pembrolizumab. Dr. Salmasi concludes that, for the moment, the gold standard treatment for a patient with BCG-unresponsive bladder cancer remains radical cystectomy, but he argues that if someone is not eligible for or turns down cystectomy, pembrolizumab is now the go-to rather than valrubicin, although this may change depending on the results of some of these ongoing trials.

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Representative Murphy’s Vision for Medical Reform

Posted by | Mar 2022

Congressman Gregory F. Murphy, MD, a practicing urologist and the Representative from North Carolina’s 3rd District, shares his vision for medical reform to help cut costs, ensure appropriate physician reimbursement, and improve care with E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego. Dr. Crawford congratulates Rep. Murphy on his recent assignment to the House Ways and Means Committee, where his position on the Subcommittee on Health will allow him to help set the agenda on medical reform. Dr. Murphy lists the top issues he feels need to be addressed to move medicine forward, including cutting regulation, increasing predictability in what doctors are going to get paid, and improving the accessibility of healthcare to the average American. Dr. Crawford and Rep. Murphy elaborate on these topics, first commenting on the rise of middlemen in healthcare, and discussing how this can limit doctors’ ability to make the correct choices for their patients. They then consider causes and potential solutions to high prices, from getting rid of direct-to-consumer advertising of pharmaceuticals to having doctors take the lead on cutting costs by choosing more inexpensive treatments and reducing waste. Rep. Murphy also comments on the current status of the No Surprises Act, which is intended to end high out-of-network medical bills. Dr. Crawford and Rep. Murphy conclude with a brief discussion of the VA.

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‘Hand Size’ and Healthcare

Posted by | Mar 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, considers how common healthcare metrics can be faulty, much like the idea that larger hand size signifies a better quarterback. He explains that many in the football industry have long assumed that small hands result in fumbles and bad throws, and have therefore used hand size as a metric when drafting quarterbacks. However, as a recent article about successful, small-handed quarterbacks Patrick Mahomes and Joe Burrow demonstrates, this metric is inherently flawed. Dr. Baum suggests that this is a useful story to keep in mind when considering certain common healthcare metrics and concepts that are not as infallible or relevant as they seem. For instance, he notes that urologists commonly measure erectile dysfunction post-retropubic radical prostatectomy or external radiation therapy, but patients are actually far more interested in continence than sexual function. Dr. Baum also argues that common metrics like resting heart rate and body-mass index actually provide less useful health information than heart rate variability and waist circumference, respectively. He then observes that even one of the most widely-held beliefs in healthcare—that doctors have to see and touch a patient in order to properly treat them—has proven inaccurate with the rise of efficient, affordable telemedicine. Dr. Baum concludes that healthcare professionals should challenge conventional wisdom, and that doing so may help with finding new metrics and new methods for treating patients.

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