Topic: Patient Care

Approach to Pyeloplasty Failure

by Kirk D. Redger, MD | Sep 2024

Kirk D. Redger, MD, provides a comprehensive discussion on recurrent ureteropelvic junction (UPJ) obstruction, emphasizing diagnostic approaches, treatment strategies, and the importance of tailored patient care.

In this 13-minute presentation, Redger highlights the importance of knowing a patient’s prior interventions when determining the next steps for treatment. Treatment plans are individualized, taking into account patient goals, age, comorbidities, and previous surgeries. Frail patients, those with active malignancies, or those with poor renal function may benefit from non-surgical management like stent placement. For surgical candidates, options range from endoscopic procedures and balloon dilation to complex reconstructive surgeries, such as robotic or open pyeloplasties.

Pediatric to Adult Transition in Urology

by Daniel Wood, MBBS, PhD, FRCS | Sep 2024

Daniel Wood, MBBS, PhD, FRCS, provides an overview of the transition from pediatric to adult care for patients with complex urological conditions. This 6-minute talk highlights the challenges patients face as they move from a trusted pediatric care team to adult providers, emphasizing the need for continuity of care. Dr. Wood explains that transition is not merely the transfer of care but involves preparing young adults to manage their health, develop long-term care plans, and ensure they are connected with adult healthcare providers.

Wood touches on the significance of managing neuropathic bladder conditions in patients transitioning from pediatric to adult care. He underscores the necessity of addressing sexual health and fertility, topics often overlooked. The speaker also stresses the role of multidisciplinary care, involving nephrologists and urologists, to optimize patient outcomes.

Optilume for BPH – Considerations for Use

by Ryan P. Terlecki, MD, FACS | Jun 2024

Ryan P. Terlecki, MD, FACS, examines the use of Optilume, a novel drug-coated balloon technology, in treating benign prostatic hyperplasia (BPH), focusing on its efficacy, safety, and clinical considerations.

He begins by explaining the mechanism of action of Optilume and reviews clinical trial data demonstrating its effectiveness in improving urinary flow rates and reducing symptom severity in patients with BPH. He highlights key findings, such as significant improvements in International Prostate Symptom Score (IPSS) and quality of life metrics, underscoring the potential of Optilume as an alternative to traditional BPH treatments like pharmacotherapy and surgical interventions.
He discusses patient selection criteria, potential contraindications, and the need for thorough patient evaluation before opting for this treatment. Dr. Terlecki delves into the procedural aspects of Optilume use, including technical considerations for optimal deployment and strategies to minimize complications.
Furthermore, Dr. Terlecki explores the comparative advantages of Optilume over existing BPH treatments and considers the economic implications.

Doublets and Triplets: Patient Selection

by David S. Morris, MD, FACS | Jun 2024

David S. Morris, MD, FACS, explores the nuances of patient selection for doublet and triplet therapies in prostate cancer, providing an in-depth analysis of current strategies and emerging evidence. He begins by outlining the principles behind using doublet and triplet therapies, focusing on the rationale for combining multiple agents to enhance therapeutic efficacy and overcome resistance mechanisms.
Dr. Morris discusses the critical factors influencing patient selection. He examines the role of clinical and molecular biomarkers in guiding therapy choices, highlighting how these markers can predict response to treatment and help identify patients who are most likely to benefit from more intensive therapeutic regimens. By leveraging biomarkers, clinicians can tailor treatments to achieve the best possible outcomes while minimizing adverse effects.
He reviews key clinical trials that have investigated doublet and triplet therapies, providing a detailed analysis of their design, results, and implications for clinical practice. His analysis includes a discussion on how to balance the potential advantages of aggressive treatment with the need to manage toxicity and maintain patient quality of life.
Dr. Morris also addresses the practical aspects of implementing doublet and triplet therapies, including considerations related to dosing, administration, and monitoring. He emphasizes the importance of a multidisciplinary approach in managing patients receiving these complex regimens, involving collaboration among oncologists, urologists, and other healthcare professionals to optimize care.

Cognitive Bias in Training and Practice

by Justin J. Badal, MD | Dec 2023

Justin J. Badal, MD, examines the impact of cognitive bias in medical training and practice on clinical decision-making, diagnostic accuracy, and patient outcomes. He begins by defining cognitive bias, and analyzing common biases, including:

Representativeness Bias
Misconception of Regression Bias
Availability Bias
Adjustment and Anchoring Bias

Dr. Badal demonstrates examples of the impact of each bias in diagnostic testing, clinical decision-making, and patient outcomes. He concludes by making recommendations for counteracting cognitive bias in practice with evidence that bias training improves overall clinician performance.

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.

Adjuvant-Salvage Radiotherapy Following Prostatectomy

by Richard G. Stock, MD | Oct 2023

Richard G. Stock, MD analyzes adjuvant and salvage radiotherapy following prostatectomy in prostate cancer patients with high-risk features or biochemical recurrence post-surgery. Adjuvant radiotherapy is administered shortly after prostatectomy in patients with adverse pathological features, such as positive surgical margins or seminal vesicle invasion, aiming to eradicate microscopic residual disease. Salvage radiotherapy is employed in response to a rising prostate-specific antigen (PSA) level indicating biochemical recurrence after an initial period of undetectable PSA post-surgery.
Dr. Stock reviews pivotal clinical trials and studies, including the SWOG 8794, EORTC 22911, and ARO 96-02 trials, which have demonstrated the efficacy of adjuvant radiotherapy in improving biochemical progression-free survival and overall survival in patients with high-risk features. He highlights the long-term benefits of early intervention with radiotherapy, emphasizing its potential to prevent metastatic progression.

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.

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