Perspectives in Urology: Point-Counterpoint Archives

Point-Counterpoint: Next Generation Sequencing vs. Standard Culture – Next Generation Sequencing

Posted by Seth K. Bechis, MD | Sep 2023

Seth K. Bechis, MD, expresses concerns with standard urine cultures and discusses the efficacy and efficiency of next generation sequencing. Dr. Bechis first examines standard urine cultures, noting their 30%-50% diagnostic error rate. He outlines other shortcomings of standard urine cultures, including their expensive and relatively slow process, inaccurate contamination results, unclear threshold for positive tests, and additional error rates.

Dr. Bechis cites two studies in which researchers discovered inaccuracies in urine culture results for clinically suspected UTI patients and women with dysuria. He then discusses polymerase chain reaction-based (PCR-based) assays and next generation sequencing (NGS). He highlights an advantage of this combination, explaining that it can detect every organism in a sample. Dr. Bechis evaluates PCR-based assays and NGS further and explains their ability to identify both bacteria and fungi.

He supports NGS technology by introducing three examples that compare standard urine cultures to NGS. These examples address UTI patients, cystitis patients, and renal stone patients.

Dr. Bechis highlights the increased detection capabilities of NGS compared to standard urine cultures, noting that NGS can even lead to better treatment and more appropriate antibiotic use. He also explores a pilot study that compared urine cultures to NGS and found that 80%–90% of physicians would have changed their preoperative antibiotics approach based on NGS results. Dr. Bechis completes his discussion by reviewing NGS benefits, advocating for NGS implementation in practice.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Next Generation Sequencing vs. Standard Culture–Standard Culture.”

Point-Counterpoint: Next Generation Sequencing vs. Standard Culture – Standard Culture

Posted by Karen L. Stern, MD | Sep 2023

Karen L. Stern, MD, reviews Next Generation Sequencing (NGS) concerns, places for NGS in urology, and benefits of standard urine cultures. Dr. Stern analyzes a 2017 study of 44 patients, explaining that NGS can lead to overtreatment. Using statistics from the CDC, she also illustrates the potential for NGS to contribute to antibiotic resistance.

Dr. Stern notes that NGS is generally expensive since it is labor intensive, and the technology may not be cost-effective in high-risk patients. She also reviews the potential for increased false positives with NGS, comparing the sensitivity and specificity rates of NGS and standard urine cultures. She highlights the lack of research on NGS and calls for additional analysis into its capabilities.

However, Dr. Stern reviews data from the World Congress and concedes that NGS may have some specific uses in urology. Dr. Stern continues by comparing stone cultures and renal pelvis urine cultures to preoperative midstream urine cultures, highlighting the utility of these cultures while acknowledging the lack of research comparing them to NGS.

She transitions to a 2018 study and evaluates the listed NGS successes, expressing doubts about the usefulness and nature of these successes. Dr. Stern completes her discussion by emphasizing the need to research NGS further and reserve NGS for specific areas in urology, urging urologists to turn to standard cultures for detection.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Next Generation Sequencing vs. Standard Culture–NGS.”

Germline Screening and Polygenic Risk Scores

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

Christopher J. Kane, MD, FACS, provides a comprehensive overview of genetic testing in prostate cancer. He emphasizes the importance of distinguishing somatic mutations from germline mutations, and explains the concept of high-penetrance genomic syndromes.

Dr. Kane highlights that genetic testing can be done on various tissues, with cheek swabs and blood tests being the most common methods. He identifies common genetic changes, such as BRCA2, and mentions testing companies like Invitae, Color, and Foundation.

The discussion also covers the significance of single nucleotide polymorphisms (SNP) in non-coding regions of DNA and their role in inherited mutations. Dr. Kane discusses the criteria for testing, including personal or family history suggestive of an inherited syndrome, test validity, and its impact on patient care.

He underscores the relevance of genomic testing for advanced prostate cancer patients, as actionable therapeutics are available for those with DNA repair gene abnormalities. Dr. Kane refers to the Pritchard article, which revealed a higher frequency of genomic syndromes in men with metastatic prostate cancer than previously estimated. Dr. Kane concludes by acknowledging the limitations of family history and the superiority of SNP testing as a predictor of prostate cancer risk.

Point-Counterpoint: 24-Hour Urine Tests vs. Empiric Therapy – Empiric Therapy

Posted by Manoj J. Monga, MD, FACS | Sep 2023

Manoj J. Monga, MD, FACS, presents his argument for empiric therapy over 24-hour urine testing in kidney stone evaluation. Dr. Monga begins by explaining empiric therapy, including empiric dietary therapy, and describes it as a conservative treatment plan. He displays data on the effects of drinking fluids on reducing recurrence of kidney stones, as well as the positive effect of fruit and vegetable intake in terms of reducing kidney stone recurrence.

Dr. Monga then shifts gears to empiric medical therapy, displaying encouraging study data on the use of thiazides to reduce stone recurrence. He also displays data on citrates and stone recurrence, pointing out that this data is weaker, and asserting that citrates should not always be used with patients with kidney stones.

Dr. Monga acknowledges that not many stone patients—even high-risk stone patients—get a 24-hour urine test and that number is actually dropping. He also displays data showing that the use of a 24-hour urine test has no bearing on three-year recurrence across patient populations. Dr. Monga concludes by citing this lack of supporting data for the 24-hour urine test, and re-emphasizes the ease, speed, and efficacy of empiric therapy for patients suffering with kidney stones.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: 24-Hour Urines vs. Empiric Therapy–24-Hour Urine Tests.

Point-Counterpoint: 24-Hour Urine Tests vs. Empiric Therapy – 24-Hour Urine Tests

Posted by Karen L. Stern, MD | Sep 2023

Karen L. Stern, MD, discusses the benefits of 24-Hour urine tests over Empiric Therapy alone in the diagnosis and treatment of kidney stones. Dr. Stern cites American Urological Association (AUA) guidelines urging “additional metabolic testing in high-risk or interested first-time stone formers and recurrent stone formers.” Dr. Stern explains that metabolic urine testing, such as the 24-Hour test, is effective in screening for other relevant health issues, in addition to providing treatment guidance.

She cites data that show that kidney stones lead to renal dysfunction, and emphasizes that kidney stones often need more than dietary recommendations to treat. Medical therapy can help reduce stone recurrence.

Dr. Stern points out that 24-hour urine tests track patient compliance. She then discusses adverse effects of medication and asserts that 24-hour urine testing helps focus the therapy to the patient’s individual needs rather than taking a one-size-fits-all approach. Dr. Stern summarizes her points that 24-hour urine testing for kidney stones is guideline-supported, provides a workup of a chronic disease, provides effective screening, tracks compliance, and avoids unnecessary side effects and costs for patients.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: 24-Hour Urines vs. Empiric Therapy–Empiric Therapy.”