Latest Videos

The Medical Assessment and Surgical Management of Adrenal Masses for the Practicing Urologist

Posted by | Feb 2022

Wesley A. Mayer, MD, Associate Professor of Medicine at Baylor College of Medicine in Houston, Texas, discusses how urologists should medically assess and surgically manage adrenal masses. He begins by briefly going over his sources, including the 2016 European Society of Endocrinology Clinical Practice Guideline, the 2011 Canadian Urology Association Guidelines, the 2009 American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Guidelines, material from UpToDate, and the work of Alexander Kutikov, MD, FACS. He highlights the fact that there is no AUA guideline on adrenal masses, as well as very little new guidance in this space. Dr. Mayer suggests that urologists should be more involved in managing adrenal masses since they are surgical experts of the retroperitoneum, familiar with the anatomy and pathophysiology of the kidneys and adrenal gland, and experts at minimally invasive surgery. He then defines the adrenal mass as a >1 cm lesion that can arise from the medulla or cortex. He explains that the majority are discovered incidentally and are called “adrenal incidentaloma,” and advances in modern imaging technology have significantly increased their prevalence. Most adrenal masses are benign lesions but some are not, and Dr. Mayer lists three important questions a urologist should ask to determine risk when confronted with a mass, including whether there are characteristics suggestive of a malignancy, whether the mass is hormonally active, and whether the patient has a history of malignancy. He then summarizes key points in how to evaluate adrenal masses radiologically and metabolically, and discusses when biopsy is necessary. Dr. Mayer follows this with an overview of surgical management, noting that laparoscopic adrenalectomy is standard of care for most masses and open adrenalectomy should be performed if adrenal cortical carcinoma is suspected. He also shows a video of an adrenalectomy for pheochromocytoma. Dr. Mayer concludes by explaining that follow-up is important since some masses will convert to being hormonally active and/or will have concerning growth characteristics.

Read More

Saw Palmetto and BPH – Past, Present, and Future

Posted by | Feb 2022

After an introduction from E. David Crawford, MD, Professor of Urology at the University of California, San Diego, and Editor-in Chief of Grand Rounds in Urology, 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, interviews J. Curtis Nickel, MD, FRCSC, the Canada Research Chair in Urologic Pain and Inflammation and Professor of Urology at Queen’s University in Kingston, Ontario, on the history of the herbal medicine saw palmetto and its efficacy as alternative medicine for benign prostatic hyperplasia (BPH). Dr. Moyad observes that in the early 2000s, saw palmetto was widely discussed in North America, but seems to have disappeared from the conversation in recent years. Dr. Nickel explains that while this is true, saw palmetto continues to be developed as a treatment option in Europe. He then notes that the STEP and CAMUS trials were some of the main contributors to North American loss of interest. The 2006 STEP trial failed to prove that saw palmetto had greater efficacy than placebo in BPH by North American medical standards, which Dr. Nickel believes was due to there being different forms and sources of saw palmetto extract and it being difficult to control for which would be used in a study at the time in North America. Dr. Moyad highlights that while this trial may not have found a benefit to saw palmetto, it also found it to be as safe as placebo. Dr. Nickel then goes into further detail about the CAMUS trial, which he worked on, and which was initially based heavily on European studies. However, due to the negative results of the STEP trial, CAMUS was redesigned, and ultimately it too found little difference between saw palmetto and placebo. Dr. Nickel notes that he feels that he and his fellow researchers may have missed something critical in that trial, and ponders why the two North American studies had negative results while so many other trials had positive ones. He also notes that he continues to recommend saw palmetto as an adjunct therapy to many of his patients based on the international literature. Drs. Moyad and Nickel then discuss some of the sourcing difficulties related to saw palmetto, as well as different extraction methods. Dr. Moyad then references Permixon, a European medicinal product derived from saw palmetto, and Dr. Nickel discusses how the way that it is regulated and processed differs from how saw palmetto is handled in North America. Dr. Nickel clarifies that he thinks that saw palmetto is a good alternative treatment for BPH patients looking for less invasive disease management options as long as a USP (US Pharmacopeial Convention)-approved product that is analyzed thoroughly is used.

Read More

Active Surveillance – When Can You Continue Watching and When Do You Intervene?

Posted by | Feb 2022

Guilherme Godoy, MD, MPH, Assistant Professor of Urology and Urology Oncology, Dov Kadmon, MD, Professor of Urology, and Michael A. Brooks, MD, Assistant Professor of Urology and Oncology, all at Baylor College of Medicine in Houston, Texas, discuss active surveillance (AS) for prostate cancer by using numerous case studies outlining patient characteristics, evaluation methods and diagnosis, the discussion and decision-making process, treatment, and outcome data to illustrate best practices. Their panel discussion covers magnetic resonance imaging (MRI)-fusion biopsy and systematic biopsy and highlights the need to use both as they are complementary. The doctors also discuss risk-benefit analysis; the role of urine, blood, and genomic testing; treatment algorithms, and important considerations such as those surrounding the patient’s overall health and life expectancy. Dr. Kadmon highlights the importance of integrating experience, common sense, and research. He emphasizes that integrating prostate MRI in AS protocol is imperative and MRI is important both when starting AS and in follow up. The doctors caution that MRI is not infallible; if the follow-up MRI is negative but there is strong suspicion for progression, a regular follow-up biopsy is justified. They advise that these follow-up biopsies be done for a reason and not just not based on an arbitrary time interval. Dr. Kadmon reiterates the point that a fusion biopsy and a systematic biopsy are complementary and should be carried out simultaneously and concludes by reviewing success elements involved in prostate MRI, including the equipment and protocols used, the experience of the radiologist, and whether the radiology program includes a quality improvement feedback loop, emphasizing that all these factors are important.

Read More

Transperineal Biopsy & Classification of Risk Using Novel Gleason Pattern Quantification

Posted by | Jan 2022

Behfar Ehdaie, MD, MPH, a urologic surgeon at Memorial Sloan Kettering Cancer Center in New York City, outlines the role of Gleason pattern quantification on prostate cancer outcomes. He explains data indicating biopsy pathology primary Gleason grade (GG) is prognostic of disease recurrence after treatment. Research showed an association between the total length of Gleason pattern 4 across all biopsy scores and worse pathologic outcomes among men with GG2 prostate cancer. Dr. Ehdaie explains the total length of Gleason pattern 4 across all biopsy cores best predicts risk of adverse pathology post radical prostatectomy (RP) compared to overall percentage or maximum percentage pattern 4 in a single core. Dr. Ehdaie then asserts that multi-parametric magnetic resonance imaging (mpMRI) and image-based tracking software has improved detection of higher grade prostate cancer. He displays data that show MR-targeted prostate biopsy improves detection of higher grade disease for men on active surveillance. Dr. Ehdaie explains 22 percent of patients on active surveillance experienced an increase in Prostate Imaging Reporting and Data System (PI-RADS) score on surveillance MRI, emphasizing that patients do experience changes in imaging that can be correlated with outcomes. He then explains the shift to transperineal biopsy and points out it enables systematic cores to be taken in a gridlike fashion that offers opportunity for standardization. He displays data comparing transperineal and transrectal biopsy that indicate transperineal prostate biopsy improves detection of higher-grade prostate cancer for men under active surveillance. Dr. Ehdaie concludes that transperineal biopsy may provide a standardized technique for better sampling and, consequently, better classification of risk, emphasizing that technology capable of transitioning from transrectal to transperineal prostate biopsy is key. Dr. Ehdaie concludes his talk by emphasizing that the incorporation of total biopsy length Gleason pattern 4 improves risk classification for men with GG2 and GG3 prostate cancer. This can help select patients for active surveillance and can develop triggers to recommend subsequent treatment. Additionally, Dr. Ehdaie reiterates that adding systematic biopsy cores to MR-targeted biopsy improves overall detection of higher-grade cancer, and seamless transition from transrectal to transperineal biopsy enables a template-based biopsy technique to standardize sampling for risk stratification.

Read More

Join the GRU Community

- Why Join? -