2021 Archives

Hemi-gland HIFU Ablation: Initial Outcomes From 100 Cases

Posted by Samuel Peretsman, MD | Feb 2021

Samuel J. Peretsman, MD, a urological oncologist with Urology Specialists of the Carolinas in Charlotte, North Carolina, discusses the results and the implications of two recent American studies of high-intensity focused ultrasound (HIFU) for treating prostate cancer. In the first part of the presentation, Dr. Peretsman reviews the initial outcomes of a study on HIFU of hemigland ablation for prostate cancer. He explains that reports of focal HIFU performed in the United States have been lacking, and therefore this study aimed to report the initial and largest American series of HIFU prostate gland ablation as a primary treatment for prostate cancer. Dr. Peretsman discusses the methodology, limitations, and results of the study, concluding that short-term results of focal HIFU indicate safety, excellent potency and continence preservation, and adequate short-term prostate cancer control. In the second part of the presentation, Dr. Peretsman outlines the lessons learned from a study of salvage robotic prostatectomy following whole-gland HIFU. Based on the data on patients with HIFU-persistent disease, Dr. Peretsman argues that there is room for improvement in HIFU treatment follow-up in order to optimize the results of salvage therapies. He also concludes that more assurance of successful salvage therapy may boost patient confidence in HIFU as a primary therapy choice.

Germline Genetics and Prostate Cancer Evolution and Aggressivity

Posted by Paul Boutros, PhD, MBA | Feb 2021

Paul C. Boutros, PhD, MBA, Professor of Human Genetics and Urology at the University of California, Los Angeles, explains the relationship between the germline and cancer evolution, as well as the implications this relationship has for screening and care. Dr. Boutros begins by explaining why it makes sense to study the germline, noting that while cancer is a disease of somatic mutations, there are already many known germline risk factors and evidence suggests that 20% of prostate cancer biopsies could be avoided if patients received a polygenic risk score. Dr. Boutros then looks at the results of a study from his lab at UCLA which show that the germline drives somatic epigenomics and that some single nucleotide polymorphisms (SNPs) are prognostic. Another yet-to-be-published study by the same team suggests that the germline also drives somatic mutations, with multiple quantitative trait loci (QTLs) predicting somatic driver mutations. This means that mutations that occur early in tumor evolution and can increase the likelihood of aggressive cancer are more likely to occur in certain people based on genomic factors. This also appears to be the case with multiple cancer types. Dr. Boutros concludes by noting possible future directions for research in this area, including multi-ancestric studies and studies into germline influences on the transcriptome and proteome. He also observes that it is not yet clear how this research should be integrated with diagnostic and prognostic tests nor how it could influence decision-making.

Building Your Urologic Castle: Barriers to Entry (Part 1 of 2)

Posted by Neil H. Baum, MD | Feb 2021

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses barriers to potential patients coming to a urologic practice. He suggests ensuring patients have a good initial contact with the receptionist, keeping appointment slots open for emergencies, and being transparent with finances on the practice website. Dr. Baum also suggests having between four- and five-star ratings online, obvious signage to get to the clinic, convenient parking, making the practice handicap-accessible, and having a welcoming reception area and clean bathrooms. He recommends making sure all patients’ questions have been answered at the end of an appointment, returning all calls and emails within 24 hours, and having the option of scheduling appointments online. In summary, he encourages making it easy for a patient to enter a practice.

Guideline-Based Approach to Metabolic Stone Management for the General Urologist

Posted by Wesley A. Mayer, MD | Feb 2021

Wesley A. Mayer, MD, Associate Professor of Medicine at Baylor College of Medicine in Houston, Texas, discusses the AUA guidelines for the medical management of kidney stones, also known as nephrolithiasis. There are 27 guidelines, fitting into the categories of evaluation, diet therapy, pharmacologic therapy, and follow-up. Dr. Mayer urges urologists to care for the whole patient, and to not just focus on the surgical issue. Nephrolithiasis is both a surgical and medical disease, making follow-up with these patients essential. For example, urologists can use a metabolic work-up to reduce the risk of future stone formation. Dr. Mayer concludes by reemphasizing that stone management often requires multiple modalities, including diet and medication, and by noting that for complex cases, urologists may want to consider referring patients to a dietician or other expert.

Active Surveillance 2021 – From Bench to Bedside

Posted by Laurence Klotz, MD, FRCSC | Feb 2021

In the first part of a Platinum Lecture trilogy on active surveillance, Laurence Klotz, MD, Professor of Surgery and holder of the Sunnybrook Chair of Prostate Cancer Research at the University of Toronto, discusses the history of active surveillance for prostate cancer as well as current guidance for its implementation. He first notes the major issues in early prostate cancer in the present day, including risk assessment prior to diagnosis, diagnostic evaluation of localized disease, and image-guided partial gland ablation therapy. Dr. Klotz then looks back to early papers suggesting that radical treatment may be unnecessary and ineffective in treating low-risk prostate cancers, remarking on their influence on himself and his colleagues’ 2002 feasibility study on watchful waiting. He reflects on how active surveillance has become widely accepted since that publication, and discusses what urologists have learned regarding patient selection, especially in terms of molecular genetics. Dr. Klotz then compares different studies of active surveillance, focusing on one with broad patient selection criteria and one with conservative selection criteria. The study with broader patient criteria found a raw prostate cancer-specific mortality of 1.5% and an actuarial mortality of 5% at 15 years, while the more conservative study found a prostate cancer-specific mortality of 0.5% at 15 years. Dr. Klotz notes that the 5% actuarial mortality in the first study was determined to be largely the result of the presence of pattern 4 disease at baseline. He also observes that there has been a convergence of selection criteria since those studies came out. Dr. Klotz concludes by discussing current active surveillance protocol, emphasizing the importance of doing a confirmatory biopsy.