Topic: Posts

Expectations for Mentorship Among APPs: What Urologists Should Know

by Mikel L. Gray, PhD, FNP, PNP, CUNP, CCN-AP, FAANP, FAAN | May 2024

Mikel L. Gray, PhD, PNP, FNP, CUNP, CCCN, FAANP, FAAN, provides guidance on how Urologists and APPs can get the most out of mentorships. Dr. Gray begins by reviewing the critical importance of APPs in Urology, and highlighting the AUA’s history of explicit support of APPs in urologic practice.

Dr. Gray then outlines the general experiences of APPs regarding training and fellowship in urology practices, and the lack of available structure for advancement. He outlines the various paths for APPs to enter into practice, and the challenges they represent.

Dr. Gray then turns to the role of the Urologist in mentoring urologic APPs. He explicitly highlights the “4 Cs” that the Mentor Urologist must actively facilitate for a successful mentorship: Connection, Conversation, Community, and Culture.

Dr. Gray concludes by providing guidance on what an APP should actively seek out in a mentor. He underscores the importance of finding the right mix of subspecialty and general urology in a practice, and seeking both Urologist and APP mentors.

Lasers in Stone Surgery: Principles and Tips/Tricks for Lasers in URS and PCNL

by Seth K. Bechis, MD | May 2024

Seth K. Bechis, MD, discusses applications, principles, and tips for using lasers in ureteroscopy and percutaneous nephrolithotomy. He begins by providing an overview of currently available laser technology, including short vs. long pulse and pulse modulation lasers, and their underlying mechanics.

Dr. Bechis then delves into how to match the appropriate laser with the desired treatment result based on the pros and cons of each device. Dr. Bechis provides real-world examples and use cases for laser devices, including:

Low Power Holmium Lasers
High Power Holmium Lasers
Pulse Modulation Lasers
Thulium Fiber Lasers
Thulium:YAG Lasers

Dr. Bechis concludes by summarizing laser-based approaches to stone treatment, explaining that important considerations include the desired treatment result and the laser’s pulse energy, frequency, and pulse width/modulation. He notes the importance of accounting for unique patient factors, such as anatomy and comorbidities, in addition to the technology’s capabilities when selecting laser treatment.

Restriction Spectrum Imaging Guided Biopsy

by Michael A. Liss, MD, PhD, MAS, FACS | May 2024

Michael A. Liss, MD, PhD, MAS, FACS, discusses how Restriction Spectrum Imaging (RSI) Guided Biopsy can aid in processing and interpreting MRIs by reducing false positives and improving MRI distortion. Dr. Liss begins by describing the top current issues with MRI sequencing: varied positive predictive values and Apparent Diffusion Coefficient (ADC) distorting MRI results.

Dr. Liss then discusses the role of RSI-guided biopsy in mitigating the weaknesses of conventional MRI. He illustrates what an MRI sequence with RSI using compartmental, nuclear volume, and geometric filtering looks like.

Dr. Liss concludes with examples of RSI-MRI results in patients with different Gleason scores and inflammation. He compares the efficacy of RSI-MRI in differentiating between inflammatory and regular lesions and presents data that supports the use of RSI-MRI in lowering the frequency of false positive biopsies due to the misclassification of inflammatory lesions.

Clinical Impact of PSMA PET Prior to Prostatectomy

by Robert E. Reiter, MD, MBA | May 2024

Robert E. Reiter, MD, MBA, illustrates the diagnostic and predictive value of PSMA PET imaging and the role of PSMA as a biomarker. He begins by examining the sensitivity of PSMA PET against that of MRI and the benefits of using combined PSMA PET/MRI for intermediate-risk tumors.

Dr. Reiter then turns to the functionality of PSMA PET/CT as a predictor of clinical outcome. He presents data comparing pre- and post-prostatectomy PSMA and CAPRA-(S) scores in association with biochemical recurrence, noting that PSMA outperformed CAPRA-(S) scores in some situations.

Dr. Reiter concludes by examining the utility of PSMA as a biomarker for tumor biology and how that can inform treatment. He presents data comparing tumors with high PSMA expression against those with low PSMA expression. He notes that PSMA-high tumors are responsive to primary treatment, while low-PSMA tumors are likely to require secondary treatment.

APP-Directed Management of Female Sexual Health and GU Syndrome of Menopause

by Aleece R. Fosnight, MSPAS, PA-C, CSCS, CSE, IF, NCMP, HAES | May 2024

Aleece R. Fosnight, MSPAS, PA-C, CSCS, CSE, IF, NCMP, HAES, discusses APP-lead treatment of female sexual health and genitourinary syndrome of menopause (GSM). Ms. Fosnight begins by describing symptoms of GSM, including hormonal, sexual, and GI symptoms. She notes that, while up to 84% of menopausal women face GSM symptoms, half have never been treated.

Ms. Fosnight then turns to GSM diagnosis and treatment options, including hormonal treatments, non-hormonal treatments, and physical therapy. For each treatment, she addresses safety, side effects, and contraindications.

Ms. Fosnight concludes by emphasizing the importance of clear communication and preventative action. As many menopausal patients are likely to experience GSM, she emphasizes the importance of a frank, supportive dialogue between practitioner and patient, noting that there are many safe treatment options available.

Bladder Cancer: Optimizing Detection and Minimally-Invasive Management

by Alejandro R. Rodriguez, MD | May 2024

Alejandro R. Rodriguez, MD, discusses detection and minimally invasive management of bladder cancer. Dr. Rodriguez begins by noting that bladder cancer is the 10th most-commonly diagnosed cancer worldwide, and presents the American Urological Association (AUA) risk stratification that provides the basis for non-muscle-invasive bladder cancer (NMIBC) management.

Dr. Rodriguez notes that the most frequent treatment for NMIBC is Transurethral Resection of Bladder Tumor (TURBT.) While he contends that conventional TURBT is the best tool for clinical staging of NMIBC, he enumerates the risks and drawbacks of the procedure.

Dr. Rodriguez then describes narrow-band imaging (NBI) as an additional modality, and presents data showing that TURBT performed in NBI modality reduces NMIBC recurrence risk. Further, NBI with white light cystoscopy TURBT may lower recurrence risk with little-to-no effect on risks of adverse events.

Finally, Dr. Rodriguez turns to the role of TUR in muscle-invasive bladder cancer (MIBC), with a focus on clinical staging, histology and grade, and bladder preservation options. He notes that trimodality therapy is the primary option for patients with MIBC that seek bladder preservation as an alternative to radical cystectomy.

Molecular Targeted Imaging

by Phillip J. Koo, MD | May 2024

Phillip J. Koo, MD, gives a high-level overview of the current state of molecular targeted imaging in identifying prostate cancer. Dr. Koo begins by establishing the sensitivity and accuracy of PSMA PET molecular targeted imaging at various PSA levels. He compares the efficacy of the four most commonly used commercially available agents in PSMA PET, noting that there is no data available that indicates one agent is superior to another.

Dr. Koo then delves into the sensitivity of different PSMA PET agents, including Gallium-68-PSMA-11 and Fluorine-18-DCFPyl. He highlights that imaging is not yet a reliable replacement for prostatectomy, using a few case studies as supporting evidence.

Dr. Koo concludes by reviewing the issue of biochemical recurrence and how it impacts disease management. He notes that molecular targeted imaging can detect recurrences in different sites in the body, and how current data may support a more aggressive treatment approach in the future.

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.

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