Perspectives in Urology: Point-Counterpoint Archives

Updates in Advanced Prostate Cancer

Posted by Alan H. Bryce, MD | Oct 2023

Alan H. Bryce, MD, reviews the current landscape of advanced prostate cancer treatment. Dr. Bryce begins by addressing the dwindling access to second-line treatment options as patients progress through therapy lines.

He then reviews findings from the STAMPEDE study, which explored the use of combination therapy involving ADT and abiraterone for high-risk prostate cancer patients. Dr. Bryce endorses this kind of combination therapy, highlighting its effect on overall survival rates.

Finally, Dr. Bryce touches on treatment intensification for patients with MHSC-9 positivity. Using a data-driven approach, he recommends combination therapy and the potential role of triplet regimens.

Improving Outcomes and Revenue with Patient Navigation

Posted by Shirley H. Lee, CRNP-FNP, MPH | Oct 2023

Shirley H. Lee, CRNP-FNP, MPH, explains how patient navigators positively impact patient visits, prostate cancer identification, and revenue. She begins by highlighting the patient navigator’s aim to support patients throughout all aspects of their healthcare journey. She turns to the American Cancer Society to pinpoint the need for patient navigators.

She then focuses on 2022 patient navigator outcomes from Genesis Healthcare Partners. Notable outcomes included more emergency room visits averted, better identification of cancer and cancer progression, and increased patient satisfaction. She reviews a prostate cancer case study, and finds that patient navigators can collaborate with office staff and providers to coordinate care, thereby helping patients and generating $270,000 in chronic care model (CCM) revenue. She notes that patient navigators can align with CCM, as in the case of clinical staff who perform billable non-face-to-face care coordination.

She then analyzes urology group participation and eligible diagnoses. She introduces a CCM case study, examining a practice with 500 Medicare patients, and explaining how practices can financially support the work of patient navigators. Lee discusses how patient navigators can impact ancillary services. She also utilizes a prostate cancer case study to illustrate how patient navigators can guide patients through appointments and treatments. She closes with a three-step patient navigator guide tailored to prostate cancer, encouraging practitioners to implement a patient navigator system and improve patient care.

Point-Counterpoint: Holmium vs. Thulium Laser – Holmium

Posted by Seth K. Bechis, MD | Oct 2023

Seth K. Bechis, MD, discusses concerns with thulium fiber lasers (TFLs) and highlights holmium laser capabilities and their benefits. He opens by reviewing laser procedure terminology and noting the holmium laser’s increased reliability in comparison to TFL. Dr. Bechis analyzes misconceptions of TFL frequency capabilities and examines the pulse features of holmium lasers. He highlights pulse modulation in holmium lasers, a feature that allows urologists to reduce retropulsion.

He continues by examining the short and long pulse settings of holmium lasers, emphasizing that issues associated with short pulse fire, such as retropulsion and fiber degradation, can be solved with long pulse. Dr. Bechis discusses the variety offered by holmium lasers and eases concerns associated with the holmium laser’s special circuit requirements. He reviews MOSES pulsed laser modulation and similar technology.

He also explores different stone treatment methods, including fragmenting, dusting, and popcorning. Dr. Bechis stresses the significance of popcorning, noting that the holmium laser surpasses TFL in this technique and provides the retropulsion level necessary for effective fragmentation. He then reviews advantages and disadvantages of dusting, fragmenting, and popcorning, leading to a discussion on whether dusting or fragmenting is preferable in stone treatment.

After reviewing multiple studies, including a study from the EDGE Research Consortium, Dr. Bechis notes that there is no clear winner between dusting and fragmenting and pinpoints caveats to the literature on the subject. He then analyzes thermal injury concerns with TFL. Dr. Bechis concludes with a focus on the holmium laser’s ability to maximize efficient power and minimize heat, explaining TFL’s relative inefficiency and additional heat concerns.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Holmium vs. Thulium Laser–Thulium.”

Point-Counterpoint: Holmium vs. Thulium Laser – Thulium

Posted by Karen L. Stern, MD | Oct 2023

Karen L. Stern, MD, discusses the advantages of the thulium fiber laser (TFL) compared to the holmium laser. She highlights the increased irrigation, visibility, and flexibility of the technology, emphasizing its ablation capabilities and citing studies from the American Urological Association and the European Association of Urology.

Dr. Stern addresses TFL concerns and notes the increased convenience, hearing safety, and cost-effectiveness of TFL. She also encourages utilizing thulium fiber laser enucleation of the prostate (ThuFLEP) rather than holmium laser enucleation of the prostate (HoLEP), noting ThuFLEP’s increased water absorption ability and hemostatic approach.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Holmium vs. Thulium Laser – Holmium.”

Managing the Side Effects of ADT

Posted by Tyler F. Stewart, MD | Oct 2023

Tyler F. Stewart, MD, discusses the management of the side effects of androgen deprivation therapy (ADT) in prostate cancer patients. Dr. Stewart begins by focusing on four common side effects of ADT: Fatigue, weight gain, osteoporosis, and hot flashes.
He first focuses on fatigue, a clinically relevant or severe side effect in 57 percent of patients, and weight gain. For patients who are obese at baseline, 70 percent will gain 10 or more pounds after six months of ADT.

Dr. Stewart explains that for both the fatigue and weight gain, exercise is the most important treatment, describing a randomized trial that examined resistance training and resistance and cardiovascular exercise vs. usual care. Results showed that fatigue was reduced and vitality increased with both exercise regimens.

He then turns to the risk of osteoporosis and explains that osteoporotic fractures occur in 20 percent of men by five years after starting ADT. He recommends calcium and vitamin D, bone mineral density evaluations, exercise with resistance, and consideration of osteoclast inhibitors or denosumab for patients with osteoporosis or osteopenia with a high fracture risk assessment tool (FRAX) score.

Finally, Dr. Stewart addresses hot flashes which, if they are affecting patient quality-of-life, can be treated with venlafaxine, gabapentin, oxybutynin, or medroxyprogesterone acetate. However, Dr. Stewart cautions against the use of medroxyprogesterone acetate because of the risk of cancer progression as a side effect.