Perspectives in Urology: Point-Counterpoint Archives

Clinical Trials for BCG-Naive and BCG-Unresponsive NMIBC

Posted by Amirali Salmasi, MD | Jul 2023

Amirali Salmasi, MD, delves into a comprehensive discussion on risk stratification and treatment options for BCG-naive and BCG-unresponsive bladder cancer. In his enlightening presentation, Dr. Salmasi provides a thorough examination of the diverse risk groups, elucidating the distinctions between low risk, intermediate risk, and high risk based on tumor grade and size. Moreover, he delves into the crucial aspects of adequate BCG treatment and outlines the criteria for BCG unresponsiveness, enhancing our understanding of these critical factors.

Furthermore, Dr. Salmasi takes us on an exploratory journey through the realm of treatment approaches for bladder cancer. He shares insights on the exciting possibilities offered by sequential chemo, hyperthermia, immunotherapy, and targeted therapy, elaborating on their respective mechanisms and potential benefits. To bolster his insights, Dr. Salmasi highlights key studies and trials conducted, underscoring the promising outcomes that have been observed.

Point-Counterpoint: Surgery vs. Brachytherapy for Intermediate and High-Risk Prostate Cancer – Brachytherapy

Posted by Mira Keyes, MD, FRCPC, FABS | Jul 2023

Mira Keyes, MD, FRCPC, presents an informative discussion on the benefits of brachytherapy compared to surgery and external beam radiation for prostate cancer treatment. She highlights the elusive outcomes and challenges of current treatments, emphasizing the importance of patients’ quality of life and cost considerations.

Dr. Keyes explores how brachytherapy outperforms surgery in terms of PSA (prostate-specific antigen) and metastasis-free survival outcomes in high-risk and unfavorable intermediate-risk patients. These findings suggest that brachytherapy can effectively target and control aggressive forms of prostate cancer.

Additionally, she addresses the misconception that brachytherapy is only suitable for certain risk groups, explaining its effectiveness across all risk stratifications. This broader applicability of brachytherapy allows more patients to benefit from this targeted treatment option, potentially reducing the need for invasive surgeries.

The presentation also delves into the topic of toxicity, showcasing the manageable side effects of brachytherapy compared to surgery. By minimizing damage to surrounding tissues, brachytherapy reduces the risk of complications such as urinary incontinence and erectile dysfunction, which are more commonly associated with surgery.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Surgery vs. Brachytherapy for Intermediate and High-Risk Prostate Cancer – Surgery.”

Point-Counterpoint: Surgery vs. Brachytherapy for Intermediate and High-Risk Prostate Cancer – Surgery

Posted by Christopher J. Kane, MD, FACS | Jul 2023

Christopher J. Kane, MD, FACS, delivers an insightful presentation on the topic of surgery versus brachytherapy for intermediate and high-risk prostate cancer. He begins by highlighting the importance of accurately defining high-risk disease and its implications for treatment outcomes.

While various definitions exist, Dr. Kane focuses primarily on high-risk disease characterized by a PSA over 20, Gleason sum of eight, and clinical stage T2C. Dr. Kane presents his viewpoint that surgery is the optimal treatment for well-selected patients with high-risk prostate cancer. He supports this assertion by discussing several key advantages of surgery over radiation therapy.

He emphasizes the benefits of improved pathologic staging and risk assessment that surgery offers. Additionally, he notes the effectiveness of adjuvant and early salvage therapy in curing many adverse pathologic patients. Moreover, surgery provides better local control and reduces the likelihood of ureteral obstructions and urinary procedures at progression.

Dr. Kane then presents comparative risk-adjusted mortality data from various studies. These analyses demonstrate that surgery significantly reduces cause-specific mortality compared to all forms of radiation therapy. The magnitude of the differences increases with disease risk, further underscoring the value of surgery for patients with higher risk disease.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Surgery vs. Brachytherapy for Intermediate and High-Risk Prostate Cancer–Radiation.

Clinical Update on PSMA Diagnostics and Therapies

Posted by Phillip J. Koo, MD | Jul 2023

Philip J. Koo, MD, discusses the current status of PSMA PET and its role in the diagnosis, treatment, and management of prostate cancer. Dr. Koo highlights the uses of PSMA PET in patients with initial diagnosis, biochemical recurrence, and oligometastatic disease, and the variety of radiopharmaceuticals available for theranostic treatment of patients.

Dr. Koo emphasizes the evolving landscape of prostate cancer staging, with PSMA PET only being appropriate to use at certain stages. Dr. Koo concludes that PSMA PET, while not yet ready for “Prime Time,” is a powerful tool in prostate cancer management, poised to shape the future of diagnosis and patient care.

Common Drug-Induced Sexual Dysfunction in Men

Posted by Maria Uloko, MD | Jul 2023

Maria Uloko, MD, discusses symptoms, causes, and treatments of post-finasteride syndrome (PFS) and post-SSRI sexual dysfunction (PSSD) in men. She begins by defining PFS, noting its controversial status in urology. Dr. Uloko outlines PFS symptoms, including depression, suicidality, and anxiety. She explains that these psychiatric symptoms often worsen when medical professionals dismiss them as results of finasteride use.

Dr. Uloko then considers the incidence of PFS, emphasizing the need to study PFS in the treatment of male pattern hair loss and highlighting the NIH’s inclusion of PFS in its 2015 list of Rare and Genetic Diseases. She discusses how 5-alpha-reductase inhibitors cause PFS, later evaluating the results of androgen deprivation in animal models as well. This leads Dr. Uloko to highly recommend validating patient concerns. She completes her discussion of PFS by advocating for a biopsychosocial approach to treatment, noting the importance of medication cessation and educating patients.

Dr. Uloko proceeds by discussing PSSD in men. She first reviews PSSD and its symptoms, noting that the prevalence of persistent sexual side effects following SSRI discontinuation is unknown. She lists common SSRIs and explains their use in treating depression and premature ejaculations. Dr. Uloko then discusses how discontinuation of the drug can increase serotonin activity. She explains how serotonin negatively affects sexual factors, signaling PSSD’s mechanism of action. Dr. Uloko transitions into a discussion on the pathophysiology of PSSD and explores the debate surrounding this topic. She then focuses on PSSD treatment, proposing that urologists utilize a biopsychosocial approach and address correctable factors. She concludes her discussion by emphasizing the need for patient validation and further research on PFS and PSSD.