Highlights of NCCN/AUA Guidelines 2024
Siamak Daneshmand, MD, covers recent updates in bladder cancer guidelines, focusing on the 2024 NCCN and AUA recommendations.
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AUA guidelines
Metabolic Workup of Stones
Helena Chang, MD, delves into the medical management of kidney stones, highlighting current guidelines, challenges, and future directions.
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Intermediate-Risk NMIBC/BCG Naïve: Treatment of Choice
Leonard G. Gomella, MD, FACS, explores bladder cancer treatment, particularly in the context of intermediate-risk, BCG-naïve disease.
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SUI – AUA/SUFU Guidelines 2017 — Amendment 2023
Suzette E. Sutherland, MD, MS, URPS, discusses the AUA and SUFU guidelines for evaluating and treating stress urinary incontinence (SUI). In this five-minute talk, Dr. Sutherland reviews the five key components for evaluating a patient with SUI and discusses indications for advanced diagnostic tools such as cystoscopy and urodynamics.
Dr. Sutherland’s discussion continues with the Guideline’s treatment options, both non-surgical (pessaries, vaginal inserts, and pelvic floor muscle exercises), and surgical (bulking agents, midurethral slings). The recent amendment to the guidelines now allows clinicians to offer single-incision slings alongside retropubic and transobturator slings for patients, reflecting their comparable safety and effectiveness.
Recurrent T1HG Bladder cancer after BCG: More Intravesical Therapy or Radical Cystectomy
Frances M. Alba, MD, Associate Professor of Urology at the University of New Mexico, discusses the management of T1 high-grade bladder cancer, focusing on cases that recur following BCG therapy. In this 14-minute talk, Dr. Alba notes that continued BCG is seldom effective in these patients. Alba highlights the AUA guidelines, recommending cystectomy as the best chance to prevent disease progression, but shares additional treatment paths when not an option.
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Focal Therapy for Prostate Cancer
Fernando J. Kim, MD, MBA, FACS, discusses the benefits of focal therapy in prostate cancer treatment. He begins with a review of the weaknesses of non-focal options in the treatment of prostate cancer.
Dr. Kim then highlights the clinical and practical benefits of focal therapy. He emphasizes the advantages that focal therapy offers to underserved and vulnerable populations, and he presents supporting data and demonstrations.
Dr. Kim concludes with a comparison of the results from mpMRI fusion biopsies and targeted cryoablation. He outlines possible future directions for focal therapy and other technologies in the treatment of prostate cancer.
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Priapism: How Do We Manage, and How Do We Learn How to Manage in 2024?
Thomas J. Walsh, MD, MBA, MS, discusses practical strategies for evaluating, diagnosing, and managing ischemic priapism. He begins with an overview of the symptoms, diagnosis, associated risks, and standard treatment procedures for the management of ischemic priapism.
Dr. Walsh then turns to effective treatment options after intracavernosal phenylephrine and corporal aspiration fail. He outlines various types of distal shunting, corporal tunneling, penoscrotal decompression, and early prosthesis placement.
Dr. Walsh concludes by addressing the lack of standardized training for treating ischemic priapism. He outlines a simulation curriculum designed to quickly train and presents the results from the pilot study.
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The Artificial Urinary Sphincter in Complex Situations
Margit M. Fisch, MD, FEAPU, FEBU, discusses the use of artificial urinary sphincters for the management of complex male Stress Urinary Incontinence (SUI) cases. She begins with a review of the body of data supporting the success rates of artificial urinary sphincters in straightforward cases.
Dr. Fisch then addresses the complications and their impact on the success of artificial urinary sphincter implantation, including:
Comorbidities
Post-Irradiation Status
Post-Urethroplasty Status
Reimplantation
Use of Transcorporal Cuff
For each of these complications, Dr. Fisch demonstrates strategies and best practices for minimizing their impact on surgical and patient outcomes.
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Orthotopic Bladder Substitutes in Females: Why We Should Do It
Fiona C. Burkhard, MD, explores the benefits of orthoptic reconstruction and nerve-sparing cystectomies for female patients. She begins by outlining factors involved in the decline of orthoptic reconstruction as a whole, including the popularity of non-nerve-sparing cystectomies over continent diversion surgeries.
Dr. Burkhard challenges the perceived superiority of non-nerve-sparing cystectomies over continent diversion surgeries. She presents multiple studies which support that cystectomies had inferior or comparable outcomes to diversion in terms of functional outcomes and urethral involvement.
Dr. Burkhard examines the differences in optimizing results for male versus female bladder cancer patients. She examines the data supporting the importance of nerve-sparing surgeries for female patients in preserving continence.
Dr. Burkhard concludes by examining the benefits of using orthoptic bladder substitutes in preserving female sexual function and preventing pelvic organ prolapse. She notes that organ-sparing cystectomies allow for female patients to become pregnant post-surgery, and that they have a lower impact on patient body image than ileal conduits.
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Erectile Dysfunction Treatment – State of the Art Care in 2024
Thomas J. Walsh, MD, MBA, MS, reviews erectile dysfunction (ED) prevalence, risk factors, lifestyle, and treatments available for patients. He addresses the stigma and the biology of ED, emphasizing the importance of explaining both to patients as part of the treatment discussion.
Dr. Walsh explains that for approximately half of men, oral medications are insufficient to treat ED and shares the updated American Urological Association (AUA) guidelines for ED treatment including oral agents, intra-penile therapies, surgery, and lifestyle changes. He outlines advantages and disadvantages of therapies such as type-5 selective phosphodiesterase inhibitors, intraurethral and topical alprostadil, intracavernosal injection, penile implants, vacuum erection devices, and low-intensity shock wave (LISW) therapy.
Dr. Walsh concludes by outlining his approach to patients, emphasizing the importance of general health and using the opportunity to help patients understand the link between lifestyle and ED. He also emphasizes the importance of referring patients to a specialist when a practitioner is outside their comfort zone or if the patient requires treatments outside of their toolbox.
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Management of Neurogenic Lower Urinary Tract Dysfunction: Surgical Options with Reference to the Guidelines
Fiona C. Burkhard, MD, discusses the surgical management of neurogenic lower urinary tract dysfunction (NLUTD). Dr. Burkhard begins with an overview of the prevalence of NLUTD, its patterns related to spinal cord injury (SCI), and treatment goals. She summarizes guidelines from the European Association of Urology (EAU), the American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) regarding the surgical management of NLUTD.
Dr. Burkhard then describes clam ileocystoplasty, and shares data on the procedures’ success in stabilizing renal function and preventing anatomical deterioration. She cautions that lifelong follow-up is essential. Dr. Burkhard shares quality-of-life (QoL) data showing improvement after augmentation.
She addresses additional EAU, AUA, and SUFU guidelines on urinary diversion, before highlighting data on sex differences in bladder management, symptoms, and satisfaction after SCI. Dr. Burkhard addresses reflux prevention, bladder outlet, and catheterization issues.
Dr. Burkhard summarizes her lecture by emphasizing that, while variations exist in the grading of recommendations, overall recommendations for treatment are similar across guidelines. She reiterates the importance of the patient’s perspective and lifelong follow-up in highlighting the advantages of surgical management.
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Prostate Microultrasound
Gerald L. Andriole, Jr., MD, Director of Urology in the National Capital Region at the Brady Urologic Institute at Johns Hopkins University, discusses the uses of microultrasound in prostate assessment using the PRIMUS (Prostate Risk Identification using Micro-UltraSound) protocol, which allows most prostate ducts to be visualized and tissue patterns appreciated. He compares the accuracy of PRIMUS to its conventional analog, PRIMAD. Dr. Andriole cites research that suggests novice mircroultrasound practitioners can become adept at interpreting images and identifying lesions after as few as 30-40 scans.
He compares images and biopsy results from conventional ultrasound, microultrasound, and multiparametric magnetic resonance imaging (mpMRI) to illustrate the accuracy of microultrasound. Dr. Andriole also shares data that supports the use of systematic biopsy, micro-ultrasound targeted biopsy, and MRI together to identify the greatest proportion of clinically significant prostate cancer. However, Dr. Andriole concludes that while microultrasound is a promising tool for future identification of prostate risk, current studies like the OPTIMUM trial have yet to determine whether it can fully replace conventional diagnostic MRIs.
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