2022 Archives

Active Surveillance or Focal Therapy as Primary Management

Posted by Laurence Klotz, MD, FRCSC | Mar 2022

Laurence Klotz, MD, Professor of Surgery at the University of Toronto and the Sunnybrook Chair of Prostate Cancer Research, addresses when it is appropriate to use focal therapy versus active surveillance (AS) for prostate cancer. He observes that focal therapy for prostate cancer is controversial, with some doubting its efficacy entirely, and gives the disclaimer that he approaches the subject as an advocate for focal therapy in certain cases. Dr. Klotz then discusses the goals of AS, explaining that for de novo Gleason grade 1 patients, the purpose is to identify higher grade cancer, and for Gleason grade 2-3, the goal is identification of clinical progression while the disease is still curable. He notes that with AS, historically the risk of ‘progression’ to higher grade cancer has been 40%, while with focal therapy, the risk of failure is 35-40%, meaning that the risk of unrecognized/persistent GG ≥ 2 is similar for both. Dr. Klotz then considers the uses and appeal of focal therapy, emphasizing the benefits of a treatment that preserves the prostate and also allows time to intervene if the cancer returns. He also mentions some of the misuses and risks of focal therapy, arguing that it can be difficult to use in cases of tumor multifocality and heterogeneity and that the significant limitations of imaging and targeting, especially for Gleason grade 2 disease, can be challenging. Additionally, Dr. Klotz highlights the lack of level 1 evidence supporting focal therapy. He goes on to discuss what makes good candidates for partial gland ablation, describing patients with a Gleason grade 2 solitary unilateral lesion as being in the ‘sweet spot’ for focal therapy, while patients with more widespread or slightly higher grade disease may be candidates, but not necessarily. Dr. Klotz would not advise partial gland ablation to young patients with high-volume Gleason grade 1 unilateral disease who have a clear target on MRI, or to patients with Gleason grade 4 disease who have a small solitary lesion on biopsy and MRI. He then discusses the current management protocols for both AS and focal therapy in detail before concluding with a look at the future of focal therapy. Dr. Klotz argues that, despite the controversies, patients will increasingly demand focal therapy and therefore the urology field has a mandate to confirm its oncologic effectiveness and safety, and to determine which of the many methods of focal therapy is best.

Bottom Line Shrinking? Check Your EOBs

Posted by Neil H. Baum, MD | Mar 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses the importance of reviewing explanations of benefits (EOBs) in a medical practice to ensure the practice is receiving appropriate compensation. He defines EOBs as feedback on the effectiveness of a practice’s billing/coding, and argues that failing to review EOBs will result in a decrease in cash flow. Dr. Baum claims that reviewing EOBs strengthens management of the billing team and helps practices know why they are or are not successful, since “what gets measured gets managed.” He gives the example of an overwhelmed biller who failed to submit 10% of claims for 12 years and rarely appealed denials. By reviewing EOBs, Dr. Baum explains, the managing partner can identify the problem and gather proof that billing needs improvement. He discusses several other benefits of reviewing EOBs, noting that EOBs show deficiencies and how to correct them, as well as provide tracker data on a practice’s payor mix and frequency of highly paid procedures. Dr. Baum recommends that practices review EOBs approximately every three months, using an exception report to track any deviation in compensation. He says that doing so will take little more than an hour per month and help practices ensure they are paid what they deserve in an era of decreasing reimbursements and increasing overhead expenses.

New Advances in Penile Implant Infections Detection in 2022

Posted by A. Lenore Ackerman, MD, PhD | Mar 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, Gerard D. Henry, MD, a urologist with WK Advanced Urology in Shreveport, Louisiana, and President of the Louisiana Urological Society, provides an update on his research into the detection of penile implant infections. Dr. Henry explains that bacterial infection is more common than urologists realized, noting how, 20 years ago, he and his colleagues found a biofilm on the penile implants of patients who appeared to just be experiencing mechanical failure. He then describes a study comparing next generation sequencing (NGS) versus traditional culture in penile implants and suggests that NGS might be the new gold standard for assessing penile implant infections since it can identify not only what bacteria are present, but also the abundance of bacteria. Dr. Henry highlights that NGS has demonstrated that the main form of bacteria affecting penile implants is not Staphylococcus epidermidis, as long believed, and that Escherichia coli and Pseudomonas are more common. He argues that by more specifically identifying these bacteria, urologists may be able to better treat patients and avoid having to remove implants. Dr. Henry then introduces a new, currently-recruiting, prospective, randomized study of next generation sequencing versus traditional cultures for clinically infected penile implants and the impact of culture identification on outcomes. The discussion concludes with a question-and-answer session in which Dr. Ackerman asks about outcomes in the upcoming trial, other potential applications of NGS in urology, and the potential source of the bacteria identified by NGS.

When is Radical Cystectomy Indicated for NMIBC?

Posted by Guilherme Godoy, MD, MS | Mar 2022

Guilherme Godoy, MD, MPH, Assistant Professor of Urology at Baylor College of Medicine, in Houston, Texas, discusses the role of cystectomy in non-muscle invasive bladder cancer (NMIBC). He begins by describing the management options for NMIBC, including transurethral resection of the bladder tumor (TURBT), intravesical treatment, systemic therapy, and radical cystectomy. Dr. Godoy then explains the importance of re-TURBT, stating that it is one of the most critical steps in management for reducing understaging and improving intravesical therapy response in patients. He summarizes the indicators for cystectomy, including failure to resect, adverse pathology, and treatment failures. Dr. Godoy reviews data from a large single-institution retrospective study showing a significant difference in recurrence-free survival, cancer-specific survival, and overall survival in favor of the primary muscle invasion at presentation group vs. the progressive MIBC group. He then discusses data from a systematic review and meta-analysis of 14 studies on oncological outcomes of primary and secondary MIBC, finding worse outcomes overall for secondary muscle invasive cystectomy. Dr. Godoy looks at the European and AUA risk stratification tables, focusing on how both support aggressive management of high risk disease. He shows data from a study of the impact of variant histology on outcomes with intravesical immunotherapy, finding 40% progression-free survival compared to 17.5% in conventional bladder cancer. He states that all of this data supports cystectomy as an important and integral tool in the management of NMIBC due to its excellent oncological outcomes and potential benefit of abbreviated management and follow-up for aggressive NMIBC despite its morbidity, though the treatment may not be appropriate for everyone.

Prostate Imaging Elevated By Deep Learning

Posted by Mukesh Harisinghani, MD | Mar 2022

Mukesh Harisinghani, MD, Director of Abdominal MRI at Massachusetts General Hospital and Professor of Radiology at Harvard Medical School in Boston, Massachusetts, discusses how deep learning algorithms can improve the efficiency and accuracy of prostate cancer imaging. He highlights the importance of widespread prostate cancer screening, observing that every 3 minutes, a man is diagnosed with prostate cancer, and every 17 minutes, a man dies of prostate cancer. Dr. Harisinghani notes that patients want to get a multiparametric (mp)MRI if there is a clinical suspicion of prostate cancer and, if negative, avoid a biopsy in order to prevent unnecessary intervention and avoid cost. Because this is such a widespread need and mpMRIs are relatively time-consuming, he argues there is a need to figure out how to reduce scan time and not lose accuracy. Dr. Harisinghani explains that the two main time sinks in prostate mpMRI are T2-weighted imaging and diffusion-weighted imaging (DWI). He then demonstrates how deep learning reconstruction using software like AIR Recon DL in all 3 planes leads to significant time gain for T2-weighted imaging. Dr. Harisinghani says that many might be hesitant to ‘skimp’ on DWI, since higher b value (which takes a longer time to attain) leads to better image quality. However, he argues that deep learning can reduce scan time without reducing scan quality in DWI, and presents images comparing standard DWI and Air Recon DL to show the improved quality of the latter. Dr. Harisinghani concludes that a scan time of less than 10 minutes is not necessarily just a dream if you can apply Air Recon DL to both T2 and DWI.