Topic: Posts

Care Considerations for the Man on ADT

by Alejandro R. Rodriguez, MD | May 2024

Alejandro R. Rodriguez, MD, discusses the management of metabolic, cardiovascular, and other side effects of Androgen Deprivation Therapy (ADT). In this lecture, Dr. Rodriguez highlights common side effects of ADT as a treatment, including:

Bone-Density Loss
Cardiovascular Disease
Diabetes and Other Metabolism Changes
Sexual Dysfunction

For each of these conditions, Dr. Rodriguez presents management strategies that can be used by physicians, patients, and members of the patients’ care team.

Interviews with Icons: Alan Wein, MD, PhD, FACS

by Neil H. Baum, MD | May 2024

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, interviews Alan Wein, MD, PhD, FACS, on the past, present, and future of overactive bladder treatment in Urology. Among his many achievements, Dr. Wein has co-written or co-edited +30 books on Urology, including several editions of the textbook, Campbell Walsh Wein Urology, and holds editorial board positions on 14 journals. Additionally, Dr. Wein is largely credited as the researcher who lead the charge to rename “unstable bladder” to overactive bladder.

In this interview, they discuss Dr. Wein’s perspective on:
The History of Overactive Bladder
The Role of Pharmacology in Lower Urinary Tract Dysfunction
The Evolution of Incontinence and Overactive Bladder Treatments
The Role of AI and Telemedicine in Treatment
The Future of Urinary Incontinence and Overactive Bladder Management

Effective Strategies for Priapism

by R. Caleb Kovell, MD | May 2024

R. Caleb Kovell, MD, discusses management strategies for acute refractory ischemic priapism, including shunting, tunneling, and prosthesis. Dr. Kovell begins his lecture by reviewing the erectile recovery windows and imaging techniques for establishing acute ischemic priapism.

Dr. Kovell 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. Kovell concludes by discussing outpatient management of acute ischemic priapism. He highlights the importance of establishing the patient’s Sickle Cell Disease status, and cautioning against immediately prescribing PDE5is to outpatients.

Bone Health and Non-Cardiovascular Side Effects of ADT

by Scott B. Sellinger, MD | May 2024

Scott B. Sellinger, MD, FACS, addresses ADT’s impact on bone health and other non-cardiovascular side effects of the therapy. He begins by noting that men on ADT are at significant risk of bone fracture, and reviewing the mechanisms behind the increased bone loss and fracture risk in these patients.

Dr. Sellinger presents best practices for assessing and treating patients with increased risk of fracture. He discusses lifestyle interventions, vitamin supplements, and other therapies to prevent bone loss.

Dr. Sellinger concludes by touching on non-cardiovascular side effects of ADT. He discusses best practices for combatting declines in mental, physical, and sexual health that result from ADT.

TRAVERSE Trial Update

by Mohit Khera, MD, MBA, MPH | Apr 2024

Mohit Khera, MD, MBA, MPH, presents the latest updates from the TRAVERSE Trial, examining the cardiovascular effects of testosterone therapy. This presentation is an update to Dr. Khera’s “Results from the TRAVERSE Trial” lecture, which was presented to the Grand Rounds in Urology audience in August 2023.

Dr. Khera begins by reviewing the history of the TRAVERSE Trial and its initial results regarding the impact of testosterone therapy on cardiovascular health. He outlines the design of the TRAVERSE Trial, which concluded in January 2024 with a final enrollment count of 5,246 men.

In addition to the original secondary and tertiary endpoints regarding cardiovascular safety and prostate safety, Dr. Khera discusses other secondary endpoints in the trial. These endpoints were sexual function, depression, bone fractures, diabetes, and anemia.

Dr. Khera concludes by delving into the final results of testosterone therapy on all endpoints in the trial. He notes that the results indicate that testosterone therapy does not significantly worsen BPH symptoms and may protect against the development of anemia. However, he notes that testosterone therapy may raise the risk of bone fractures and pulmonary embolisms.

Pros and Cons of the ReIMAGINE Trial

by Matthew R. Cooperberg, MD, MPH | Apr 2024

Matthew R. Cooperberg, MD, MPH, discusses the strengths and weaknesses of the Risk and Screening arms of the ongoing ReIMAGINE trial. He begins by describing the two arms of the study, ReIMAGINE Screening and ReIMAGINE Risk, and then focuses on the Screening arm, digging into the participant data.

Dr. Cooperberg addresses the sequence of screening tests in the ReIMAGINE trial, and reasserts the value of PSA as an initial screening marker, using supporting evidence from the ongoing STHLM3-MRI trial.

Dr. Cooperberg concludes by explaining that ReIMAGINE Risk will be useful as a biorepository in the future. While ReIMAGINE Screening shows PSA with magnetic resonance imaging (MRI) is better than PSA alone, he reiterates that as a first screen, PSA <1 (or 1.5) is tough to beat. Dr. Cooperberg explains that MRI is useful for helping to guide biopsy and is acceptable as a second screening tool. However, other markers are more effective and less expensive in the United States.

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

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