2021 Archives

Fear and Frustration Among Women with Recurrent UTIs

Posted by Victoria C. Scott, MD | Jan 2022

In conversation with A. Lenore Ackerman, MD, PhD, Assistant Professor of Urology and Director of Research in the Division of Female Pelvic Medicine and Reconstructive Surgery at the University of California, Los Angeles, Ja-Hong H. Kim, MD, Associate Professor in the Division of Pelvic Medicine and Reconstructive Surgery at the University of California, Los Angeles, and Victoria C. Scott, MD, Associate Program Director of the FPMRS Fellowship at Cedars-Sinai Medical Center, discuss a recent study of the experience of women with recurrent urinary tract infections (rUTIs). Dr. Scott explains that 29 women were recruited to participate in 1 of 6 focus group discussions to investigate the perspective of women suffering from rUTIs. She then lists some preliminary themes from the discussions with the women, including fear of development of antibiotic resistance, widespread knowledge of the collateral damage from antibiotics, concern about taking unnecessary antibiotics, anger at physicians for “throwing” antibiotics at them, a feeling that the medical profession underestimates the impact of rUTIs, a need for research on nonantibiotic options for prevention and treatment, and resentment towards the medical system for not dedicating more research efforts to providing more timely diagnosis. Dr. Scott synthesizes these themes into two emergent concepts: fear about the overuse of antibiotics and frustration at the medical system for not providing alternative treatments or taking rUTI symptoms seriously. Dr. Kim then notes that this initial study has produced two additional studies on the current management of rUTIs that take expert and personal care provider experiences into account. Dr. Ackerman highlights the importance of data capturing that patients are not seeking antibiotics necessarily in the way doctors assume they are, though Dr. Kim does add the caveat that the women in the study were a relatively homogeneous group of college-educated white women. Dr. Ackerman also muses that the attitudes expressed in this study suggest that this population may be interested in a vaccine for rUTIs. Drs. Ackerman, Scott, and Kim conclude by noting that the study made evident the importance to patients with rUTIs of focusing on their experience rather than merely the clearance of bacteria.

Local Therapy – Managing Locoregional (LR) Complications in Metastatic Prostate Cancer

Posted by A. Edward Yen, MD | Jan 2022

A. Edward Yen, MD, Assistant Professor of Medicine in the Hematology and Oncology Section at Baylor College of Medicine in Houston, Texas, explains the use of local therapy, meaning treatment to the primary prostate, in patients with metastatic prostate cancer. He outlines locoregional complications in these patients, calling it a significant problem and pointing out that these complications may threaten further therapy and survival. He predicts this problem may worsen due to the increasing incidence of metastatic prostate cancer and the fact that more patients are living longer with metastatic disease. Dr. Yen poses the question, “Is there a role for local therapy beyond palliation?” He describes and cites outcomes from a selection of retrospective studies that support a survival benefit associated with local therapy in metastatic prostate cancer patients. Dr. Yen then turns to the HORRAD study, whereby patients with metastatic castration-sensitive prostate cancer (mCSPC) were given androgen deprivation therapy (ADT) with or without prostate radiation. Dr. Yen analyzes the data on the study’s endpoints, overall survival (OS) and time to prostate-specific antigen (PSA) progression, which conclude there was no difference in OS but a potential benefit in those with fewer than five bone metastases and that there was a significant prolonging of the median time to PSA progression with the addition of radiation therapy (RT). Dr. Yen then describes the multi-arm, multi-stage STAMPEDE trial that looked at systemic therapy with or without RT in patients with mCSPC. The trial concluded there was no difference in OS but there was improvement in failure-free survival (FFS) for patients receiving RT. Dr. Yen points out that in the prespecified subgroup analysis, local therapy was associated with OS benefit in patients with low disease burden. He then lists ongoing studies before turning to future questions regarding local therapy in patients with metastatic prostate cancer, such as those involving patient benefit and risk factors, staging and stratification, and the effects of concurrent treatment. Dr. Yen concludes that patients receiving local therapy should be included within the context of one of the many clinical trials taking place.

Updates in mpMRI

Posted by Kirsten L. Greene, MD, MAS, FACS | Jan 2022

Kirsten L. Greene, MD, MAS, FACS, the Paul Mellon Professor and Chair of Urology at the University of Virginia School of Medicine, gives an update on multiparametric (mp) MRI’s current role in prostate cancer detection, surveillance, staging, and recurrence. She defines mpMRI as featuring diffusion weighted images and being dynamic contrast enhanced (DCE), but also notes that biparametric MRI, which omits DCE, appears to be an effective option as well. Dr. Greene goes over the different MRI-targeted biopsy trials for prostate cancer detection, including PROMIS, PRECISION, MRI FIRST, 4M, TRIO, and PRECISE, and she explains that all of these show that mpMRI has superior sensitivity to transrectal ultrasound (TRUS) for high-grade disease, but that mpMRI alone does miss anywhere from 5 to 10% of clinically significant cancer. For this reason, Dr. Greene says, the recommendation is to use MRI prior to biopsy and use image-guided techniques, but also keep systemic biopsy. She then briefly discusses the NCCN 2021 guidelines for use of mpMRI for initial biopsy, confirmatory biopsy, prior to second biopsy, and for recurrence. Dr. Greene also looks at mpMRI for serial imaging during active surveillance, explaining that it is useful for identifying missed or anterior lesions and for delaying the next biopsy after confirmatory biopsy, but also that when to stop active surveillance based on MRI alone is controversial. She also considers the future of mpMRI in combination with PSMA PET. Dr. Greene concludes that there is a clear role for MRI (multi and biparametric) in detection, active surveillance, pre-treatment staging, and recurrence, and she reminds viewers that MRI accuracy depends upon the equipment and the experience of the radiologist.

Improving Productivity, Reducing No-Shows

Posted by Neil H. Baum, MD | Jan 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, gives advice on how urologists can identify the causes behind and reduce the number of no-shows in their practices. He defines no-shows as patients who miss their appointments without calling ahead of time, leaving expensive holes in a practice’s schedule. Dr. Baum recommends that urologists identify the cause of no-shows in their practice by reviewing the electronic medical record, calling patients to ask why they did not keep their appointment, calculating the number of no-shows on a quarterly basis, and monitoring the trend. He explains that no-shows tend to be self-pay and Medicaid patients, patients with urgencies or emergencies, new patients, and patients given appointments for dates more than 4 or 5 weeks after they call. Dr. Baum then gives several suggestions on how to prevent no-shows, such as creating daily “sacred” time slots in the schedule for new patients, urgencies, and emergencies so that these patients can be seen soon after they call without disrupting the schedule. He also recommends sending automated appointment reminders that give patients the option of confirming, canceling, rescheduling, or leaving a message. Dr. Baum argues that charging no-shows is not a great option, since these fees can be difficult to collect and can create ill-will. Instead, he suggests urologists should consider no longer giving appointments to repeat no-shows. He concludes that preventing no-shows is a proactive process and that urologists should identify and remove the obstacles preventing patients from keeping their appointments.

Is Open Partial Nephrectomy Still an Option for Challenging Renal Masses?

Posted by Michael A. Brooks, MD | Jan 2022

Michael A. Brooks, MD, Assistant Professor of Urology and Oncology at Baylor College of Medicine in Houston, Texas, evaluates open partial nephrectomy as an option for challenging renal masses and compares it to the robotic retroneoscopic and laparoscopic techniques. He begins by discussing three patient cases, each one using a different treatment option. The robotic retroneoscopic partial nephrectomy patient experienced minimal blood loss, an operation time of 4 hours, and was discharged on the 3rd day post-op. The laparoscopic partial nephrectomy patient also had minimal blood loss, a 3-hour operation time, and was discharged on post-op day 3. The open partial nephrectomy patient experienced greater blood loss, a 5-hour operation time, and was discharged on post-op day 2. Dr. Brooks also explained the technique for each, highlighting the importance of port placement for robotic surgery, a lack of cortical stitches to avoid compressing the kidney for open partial nephrectomy, and the use of intraoperative ultrasound for all three procedures. He then considers two papers, the first of which found that oncological outcomes for open and robotic patients were very similar but that open partial nephrectomy produced higher blood loss, longer ischemia time, and a longer post-op course in patients. The second paper focused on the impact of specific surgeons and found that surgeon skillset and experience created high variability in outcomes. Dr. Brooks concludes that open partial nephrectomy remains a good option for complex renal masses, that the approach can vary from patient to patient based on tumor characteristics, and that the approach is likely less important than surgeon training, experience, and case volume.