Topic: Posts

Fusion Biopsy Technologies and Techniques

by Peter A. Pinto, MD | Apr 2024

Peter A. Pinto, MD, discusses the evolution of prostate cancer biopsy and imaging techniques in the past twenty years, from blind systematic biopsies to MRI-ultrasound fusion biopsies. He begins by noting that prostate cancer was the only solid-organ tumor diagnosed without image guidance going into the 21st century.

When MRI was introduced as an imaging modality for prostate cancer diagnosis, urologists developed several different techniques for incorporating MRI into biopsy procedures. Dr. Pinto briefly covers the history and development of in-bore biopsies, cognitive fusion biopsies, and MRI-ultrasound fusion biopsies.

He concludes with reviewing the currently available devices in this space. He evaluates each system as it relates to biopsy needle targeting route, tracking and navigation, MRI-ultrasound fusion opportunities, ultrasound image acquisition, and biopsy fixation.

Practical Steps for Clinical Efficiency Relative to Physician Burnout

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

Ryan P. Terlecki, MD, FACS, offers actionable steps to keep a clinical practice efficient in the face of the epidemic of physician burnout. In this presentation, he discusses how the first step in keeping an efficient and effective practice is to develop a familiarity with:

The Differences Between Efficiency and Effectiveness
The Role of Planning, Consistency, and Reevaluation in Quality Improvement
Management Strategies Which Prioritize Workflow and Well-Being

Dr. Terlecki frames burnout management around a few key principles for efficient and effective clinical practice. He provides real-world examples and applications of these steps to combat and compensate for physician burnout in both practice and academic settings.

Treatment of Male Stress Urinary Incontinence

by Brian S. Christine, MD | Apr 2024

Brian S. Christine, MD, provides guidance on the assessment and treatment of stress urinary incontinence (SUI) after radical prostatectomy. Dr. Christine begins by discussing the pelvic support changes that happen in men post-prostatectomy, the relationship between the loss of pelvic support and incontinence, and the different mechanisms behind moderate and severe SUI.

Dr. Christine encourages urologists to assess each post-prostatectomy patient presenting with SUI symptoms using a thorough work-up to determine SUI mechanism and severity, an awake cystoscopy to visualize the function of the external sphincter, and a Standing Cough Test. He explains that these three steps in SUI assessment allows the attending physician to ensure that the treatment will match the severity and mechanism of the patient’s incontinence.

He then explores the process of selecting the optimal treatment between the two principal surgical options for treating male SUI: the male sling and the artificial urinary sphincter. Dr. Christine reiterates the importance of tailoring the therapy based on the information gathered during the assessment, and advises urologists to visit surgeon educators on-site and develop their surgical placement skills.

Dr. Christine concludes by exploring the treatment of recurrent SUI in men who have been previously treated for SUI. He provides guidance on treating men with a prior male sling and men with a malfunctioning or affected artificial urinary sphincter.

Deciphering Options for Testosterone Replacement Therapy and Managing Withdrawal

by Jesse N. Mills, MD | Apr 2024

Jesse N. Mills, MD, discusses the importance of testosterone replacement therapy and presents an algorithm for determining treatment and managing withdrawal. He begins with an overview of the history of the study of testosterone, from the first recorded effects of castration to the warning against the over-prescription of testosterone therapy issued in 2015 by the FDA.

Dr. Mills discusses the AUA guidelines for testosterone replacement therapy and the lack of on-label options for treatment. He presents options for on-and-off-label testosterone replacement therapy.

Dr. Mills then presents an algorithm for determining the best treatment option for the patient, beginning by addressing male fertility concerns. He addresses questions of lab work, transference, insurance, administration, and other patient and physician concerns.

Dr. Mills concludes with the discontinuation of testosterone replacement therapy and when it is indicated. He discusses the available options for weaning patients off of testosterone, cautioning strongly against abrupt discontinuation.

Transperineal Biopsy: Rationale, Outcomes, and Techniques

by Arvin George, MD | Apr 2024

Arvin K. George, MD, discusses the rationale behind performing transperineal biopsies over transrectal biopsies, supporting outcome data, and actionable techniques to combat the perceived shortcomings of the procedure. Dr. George begins by providing data on the fluoroquinolone-resistant infection risks of transrectal biopsies, and that, by avoiding the issue of antibiotic-resistant rectal flora, transperineal biopsies circumvent the rising rate of infections and strengthen antibiotic stewardship during procedures.

Dr. George then addresses the issue of patient pain in transperineal biopsies. He offers techniques on ideal administration of local anesthetic for decreasing patient pain.

Dr. George concludes by providing information on patient set-up, procedure equipment, and transperineal guides, presenting multiple options and encouraging urologists to choose according to their needs. He offers several resources for urologists and their patients from the Michigan Urologic Surgery Improvement Collaborative.

Interviews with Icons: Mickey Karram, MD

by Neil H. Baum, MD | Apr 2024

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, interviews revolutionary urogynecologist, Mickey Karram, MD, on topics ranging from urogynecological cosmetic surgeries to robotic pelvic reconstruction. Dr. Karram is an internationally renowned urogynecologist and pelvic surgeon, widely considered to be a pioneer in the field. He has co-authored several of the leading textbooks and reference books in the study of Urogynecology, in addition to publishing over 200 peer-reviewed articles in medical journals.

In this interview, Dr. Karram shares his insights on:

Fostering Collaboration Between Urology and Gynecology Specialists
Urogynecological Cosmetic Procedures
Female Sexual Dysfunction
The Use of Robotics in Pelvic Reconstruction
The Future of Pelvic Reconstruction

Pain Management Advice for Urologists in the Wake of the Opioid Crisis

by Brian J. Flynn, MD | Apr 2024

Brian J. Flynn, MD, discusses the opioid crisis in the United States, and the role of urologists in taking action against this growing problem. Dr. Flynn begins by highlighting factors that contribute to the opioid epidemic’s growth, with a specific focus on Colorado. He drives home the urgency behind addressing this epidemic by emphasizing the ubiquity of opioid related deaths across all ages, genders and socio-economic strata.

Dr. Flynn argues that the problem lies specifically in prescribing opioids in far excess post-surgery, as most patients take only a fraction of what is prescribed, with extra pills then being distributed to, and consumed by, non-patients. He underlines the correlation between the number of opioids prescribed and the number of opioid related deaths.

Dr. Flynn examines the role of Urology in prescribing opioids relative to other fields of medicine in prescribing opioids, finding that urologists land somewhere in the middle in terms of prescribing opioids to patients. He looks at different urology surgeries and recommends alternatives to opioids to address patients post-op pain.

Dr. Flynn concludes with a review of the ALTO project from Colorado that aims to offer alternatives to fentanyl whenever possible. He provides practical solutions to address the opioid epidemic at the physician level, but recognizes that changes at multiple levels of practice and legislature are needed to address it effectively on a national scale.

Selecting the Optimal Energy Source

by Samir S. Taneja, MD | Mar 2024

Samir S. Taneja, MD, compares the merits and limitations of the leading energy sources used in prostate focal ablation. The sources available for use in prostate ablation today include laser, electroporation, radiofrequency, photodynamic therapy, high-intensity focused ultrasound (HIFU), cryosurgery, drugs/toxins, radiations (focal/interstitial), surgery, steam, and gold nanoparticles.

Dr. Taneja outlines the ideal criteria for an energy source based on the individual characteristics of the patient and their disease, as well as real-world considerations like ease of use and insurance coverage. He gives examples of which energy sources are best-suited for certain cases based on disease presentation and other factors.

In a full focal therapy practice, the optimal situation would be one with multiple energy sources available so that physicians can tailor treatments to each individual patient. Since this saturation of options can be daunting to physicians just starting in a focal therapy program, Dr. Taneja advises practitioners to pick one energy source to practice at first, limiting patient selection to those with disease that is best-treated with that specific modality. After becoming proficient with that energy source, more can be added to increase candidate selection.

Managing the Man with Ejaculatory Dysfunction

by Jesse N. Mills, MD | Mar 2024

Jesse N. Mills, MD, presents management strategies for men presenting with ejaculatory dysfunctions, ranging from premature ejaculation to ejaculodynia. He begins by acknowledging that there is no current FDA-approved treatment specifically for any kind of ejaculatory dysfunction.

Dr. Mills then separates men presenting with ejaculatory dysfunction into distinct categories based on the symptom they are experiencing, and follow-up questions to ask these patients. These five main groups are Premature Ejaculation, Delayed Ejaculation, Anejaculation, Ejaculodynia, and Post-Orgasmic Illness Syndrome.

Throughout the presentation, Dr. Mills discusses each category of dysfunction and available treatment options. He concludes by highlighting the need for further study of post-orgasmic illness syndrome.

The Who and Why of Focal Therapies

by Abhinav Sidana, MD, MPH | Mar 2024

Abhinav Sidana, MD, MPH, discusses the selection processes, objectives, and data supporting the use of focal therapy to treat prostate cancer. He begins with an overview of the state of focal therapy, and how it can be used to provide more personalized prostate cancer treatment to patients.

Dr. Sidana then compares the weaknesses of focal therapy to those of radical surgery and surveillance. He notes that while focal therapy has been criticized for its shortcomings in addressing “invisible” and multifocal cancers, radical surgery has permanent negative effects on patient QOL and that many patients on active surveillance drop out after a certain length of time.

Dr. Sidana then addresses recent advances in focal therapy which can partially mitigate some of the shortcomings of focal therapy. He focuses on advancements in MRI accuracy and specificity which makes treating multifocal and previously invisible clinically significant cancers using focal therapy effective.

Dr. Sidana concludes by outlining strategies for patient selection for focal therapy. He presents examples of ideal patient and disease characteristics for focal therapy treatment and lists relevant contraindications.

Active Surveillance of Renal Mass

by Frances M. Alba, MD | Mar 2024

Frances M. Alba, MD, discusses the benefits of active surveillance of small renal masses (SRM) as a treatment option. Dr. Alba begins by presenting data that most SRM have low or very low malignant potential. Despite this, SRM are removed routinely without preoperative pathologic diagnosis and Dr. Alba asserts this raises the question of significant overtreatment.

Dr. Alba then addresses metastasis, explaining that risk of metastases is exceedingly low for SRM. She describes a prediction calculator to support personalized-treatment selection and explains that regardless of treatment, the vast majority of patients will die of other causes. She emphasizes overall survival is influenced by patient risk factors.

Dr. Alba addresses quality-of-life issues for patients being treated with active surveillance, including the impact of illness uncertainty. She covers trends in active surveillance before outlining her recommendations, suggesting an initial period of six months to establish a trend. She advises asking patients about fears, concerns, and life events. She points out that active surveillance can be used to delay intervention in patients with competing medical or life issues and delayed intervention is safe.

Dr. Alba concludes by emphasizing that active surveillance is the ultimate nephron-sparing management modality and patients can be managed conservatively with serial imaging. Dr. Alba reminds practitioners that intervention for SRM imposes physical, emotional, mental, and financial burdens on patients and families, and that active surveillance can alleviate many of these concerns.

Conquering the Curve in Peyronie’s Disease

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

Ryan P. Terlecki, MD, FACS, discusses risks and benefits of Peyronie’s disease treatments, advocating for surgery as a definitive treatment. Dr. Terlecki asserts the condition is poorly understood with a “lot of garbage” in print and online. (e.g., advice not to operate early on, assumptions the injury is from tunical damage, and problematic data on intralesional injections).

From a treatment standpoint, Dr. Terlecki addresses treatment dogma he sees as problematic. He debunks claims for various treatments, like vitamin E, colchicine, Xiaflex, and pentoxifylline, and makes a case against extracorporeal shock wave therapy.

Dr. Terlecki addresses surgery and explains that, for patients with adequate rigidity, plication or grafting is effective. However, patients with inadequate function require inflatable penile prosthesis (IPP) and curvature correction. He cautions against degloving, tunical excision, and plicating for implant cases.

Dr. Terlecki concludes that Peyronie’s patients are often distressed and need clear communication and a realistic understanding of treatment risks and benefits. He calls surgery the gold standard, and says plication should be considered first for potent patients without complex defects.

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