Topic: Patient Care

Focal Brachytherapy for Prostate Cancer

by Juanita M. Crook, MD, FRCPC | Oct 2023

Juanita M. Crook, MD, FRCPC, discusses the use of focal brachytherapy for prostate cancer treatment. She highlights the importance of patient selection, technical considerations, efficacy, and post-focal therapy monitoring. Dr. Crook demonstrates the significance of accurate localization through mpMRI and template mapping biopsies for precise treatment planning for patients with favorable-risk disease and a low disease burden.

Dr. Crook discusses the evolution of active surveillance in managing low-risk patients. She also emphasizes the need for careful candidate selection, considering factors like unilateral disease, lower intermediate risk, PSA levels, and life expectancy.

Dr. Crook touches upon various focal therapy scenarios which should be tailored to the patient’s specific case. She discusses options which fall under the umbrella of focal therapy such as low dose rate (LDR) or high dose rate (HDR) brachytherapy, cryotherapy, and HIFU.

Future Prospects of AI Technology in the Lower Urinary Tract

by Arnulf Stenzl, MD | Aug 2023

Arnulf Stenzl, MD, discusses the future prospects of artificial intelligence (AI) combined with precision surgery and robotics in the diagnosis and treatment of the lower urinary tract. He outlines an intraoperative multisensory approach for tissue differentiation involving sensor development with mechanical, optical, and electric properties. Combined with AI modeling, the result is a scoring system for intraoperative identification of tissue characteristics based on multimodal/multiscale data with tissue differentiation by optical emission spectroscopy.

Dr. Stenzl displays data on the discrimination of tissue based on electrical impedance. He points out the value of discrimination of deeper tissue layers using model-based optical sensors to see and avoid, for example, vessels and nerves. Dr. Stenzl then describes a device for intraoperative real-time elastography, even at the cellular level.

He emphasizes the importance of consistent AI tissue modeling, covering multiple physical domains to combine different sensors and inform the best actions. Dr. Stenzl explains that AI can extract and reproduce features for navigation during surgery. Dr. Stenzl re-emphasizes the importance of precision surgery moving toward intraoperative diagnostics that builds on the traditional standard of frozen section and predicts the further development of precision surgery and AI technologies in the coming years.

Adjuvant Treatment for Recurrent Urethral Strictures: Optilume Drug-Coated Balloon (DCB)

by Salvatore Micali, MD | Jul 2023

Salvatore Micali, MD, discusses the treatment of recurrent anterior urethral strictures using the Optilume drug-coated balloon. Dr. Micali provides a brief overview of urethral strictures, emphasizing anterior urethral strictures, their causes and recurrence, and their impact on patient QoL.

Dr. Micali touches on the two best-known treatments for urethral strictures, endoscopic urethrectomy by the Sachse method and urethroplasty. He notes that recurrence of urethral strictures is less likely in patients who underwent urethroplasty, but that patients prefer the minimally-invasive endoscopic urethrectomy.

To combat recurrent anterior urethral strictures, Dr. Micali examines the Optilum drug-coated balloon (DCB) in combination with endoscopic urethrectomy. He explains the advantages of using an anti-proliferative drug-coated balloon to dilate the urethra after an endoscopic urethrectomy in order to prevent recurrent strictures.

Dr. Mical concludes by guiding the audience through a study comparing patients treated with the Optilum DCB versus patients treated with only an endoscopic urethrectomy over one year. He includes video demonstrations of the Optilume DCB operation.

Financial Toxicity: The New Driver of Healthcare Policy?

by Deepak A. Kapoor, MD, FACS | Jul 2023

Deepak A. Kapoor, MD, FACS, discusses the issue of financial toxicity in healthcare, which he believes will shape health policy. He highlights the rising healthcare costs in the United States compared to other OECD countries, emphasizing the increasing burden shifted onto patients. This shift is primarily driven by the formation of healthcare exchanges, leading to higher deductibles, co-payments, and changing insurance plans.

Kapoor reveals that urological tumors account for a significant portion of cancer spending in the United States, exceeding $200 billion annually. Cancer care, in general, poses a profound economic burden, with patients depleting their savings, reducing retirement funds, and delaying medical care due to costs. Disturbingly, one in four cancer patients lose their homes within five years of diagnosis.

Dr. Kapoor emphasizes the disproportionate impact of this economic burden on marginalized populations, including single mothers, low-income individuals, and historically marginalized groups like Blacks and Hispanics. Dr. Kapoor provides an example of how a simple referral to a hospital-based imaging facility can result in significantly higher costs compared to a radiology facility in a community setting.

PSA Screening in 2023

by Gerald L. Andriole, Jr., MD | Jun 2023

Gerald L. Andriole, Jr., reviews evidence supporting a more comprehensive family history and biomarkers in screening and treating prostate cancer. Andriole underscores the power of a well-taken family history. He suggests doctors counsel patients on their hereditary risk of prostate cancer, emphasizing the importance of one diagnosed high risk family member, to reduce the rate of mortality.

Describing the Germline Mutations in Metastatic PCa, Andriole recommends all patients with prostate cancer who have certain characteristics be encouraged to speak to their physicians about whether they may need genetic testing for an inherited mutation. When looking in detail at polygenic risk scores (GRS,) knowledge of high GRS decreased mortality rate.

Andriole highlights the Prompt Test, the direct to consumer, poly-genomic test in the US. In comparison, the UK Biobank data compares prevalence and hazard ratio to show the frequency is higher, some predict cancer aggressiveness. He expects to hear a lot about the prompt test in future.

Dr. Andriole recommends identifying patients with clinically significant PCa earlier through a lower PSA cutpoint. He suggests using image guided Micro US or MRI, or a transperineal biopsy to show potentially indicative biomarkers.

Caring for Underserved and Vulnerable Populations for Over 23 Years

by Fernando J. Kim, MD, MBA, FACS | May 2023

Fernando Kim, MD, MBA, FACS, Chief Emeritus of Urology at Denver Health Medical Center and Professor of Surgery/Urology at the University of Colorado at Denver, shares insights gathered from his more than 23 years of caring for underserved and vulnerable populations. Dr. Kim describes some of the needs and characteristics of these populations, and gives examples of the traumatic experiences to which those populations are regularly exposed. He also emphasizes the importance of physicians understanding their patients’ cultures, communication styles, and needs so that they can effectively treat those patients.

He addresses time constraints for patients who cannot afford to be out of work, and how developing a minimally-invasive practice can help support those patients. He cites disparate oncological profiles along demographic lines, as well as research that supports multiple factors influencing patient treatment selection. For example, he explains that, especially for African-American men, the less invasive nature of cryoablation appeared to influence opinions regarding surgery for the treatment of localized prostate cancer.

Dr. Kim cites another study that reaffirms the importance in health disparities research of modeling interactions between race/ethnicity and variables that reflect diverse aspects of a patient’s socioeconomic circumstances, since the research showed that doctors’ treatment recommendations were less aggressive for poor or indigent populations. He concludes by reemphasizing the importance of empathy, cultural humility, and understanding when working with vulnerable and underserved communities.

Prostate Microultrasound

by Gerald L. Andriole, Jr., MD | May 2023

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.

Culture of Patient Safety Part 2

by Fernando J. Kim, MD, MBA, FACS | Sep 2019

Fernando J. Kim, MD, MBA, FACS, discusses internal physician factors and external factors in the current medical field that can put careers and patient safety at risk. He then reviews ways in which systems thinking and professionalism can optimize outcomes in urology practices.

Culture of Patient Safety

by Fernando J. Kim, MD, MBA, FACS | Aug 2019

Fernando J. Kim, MD, MBA, FACS, reviews the historical events contributing to the emergence of patient safety as a healthcare discipline. He describes efforts in the urologic field, specifically from the American Urological Association (AUA), to advance the culture of patient safety.

Perioperative Pathways: What We Know Works

by Sanjay G. Patel, MD | Jun 2019

Sanjay G. Patel, MD, outlines the rationale behind implementing Enhanced Recovery After Surgery (ERAS) protocols in order to reduce stress, maintain postoperative physiology, and enhance mobilization for patients undergoing cystectomy. He then reviews the data evaluating different ERAS interventions in each perioperative period.

Current Topics in Urological Patient Safety

by J. Kellogg Parsons, MD, MHS, FACS | Feb 2019

J. Kellogg Parsons, MD, MHS, FACS, reviews general principles of patient safety as applied to urologic practice. He provides practical instructions about handling urologic complications, specifically rhabdomyolysis, venous thromboembolism (VTE), air embolism, laparoscopic bowel injury, and prostate biopsy infections.

Shared Decision Making for Prostate Cancer Decisions: When the Patient has a Laundry List and the Doctor has 8 Minutes

by Sigrid V. Carlsson, MD, PhD, MPH | Jan 2019

Sigrid V. Carlsson, MD, PhD, MPH discusses the psychology, history, and practical application of shared decision making. She then provides recommendations for clinicians counseling patients deciding whether or not to undergo PSA screening and if they should go on active surveillance.

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