2022

Innovations in Urologic Residency Education

Posted by | Mar 2022

Wesley A. Mayer, MD, Associate Professor of Medicine, Assistant Dean of Graduate Education, and Vice Chair of Education in the Scott Department of Urology at Baylor College of Medicine in Houston, Texas, discusses innovations in urologic residency education in the face of changing technology and COVID-19. He begins with a brief history of medical training, explaining that the apprenticeship model was standard until around the start of the 20th century, when William Halstead began to develop the traditional surgical education experience featuring intense and repetitive experiences with surgical patients. Dr. Mayer then lists new challenges in modern surgical training, including work-hour restrictions, influence from other high-stakes fields, an increasingly litigious environment, rising expectations from the public, a progressive physician shortfall, and generational changes in learning style and needs. He argues that to meet these challenges, modern surgical training should: leverage simulators as well as inanimate and animate models; deconstruct complex surgeries into component skills; incorporate structured objective assessment tools; utilize concise, constructive, real-time feedback; address broader stressors impacting trainees, such as wellness and burnout; develop non-surgical skills; and innovate through servant leadership. Dr. Mayer then discusses recent innovations in open surgical training, highlighting the benefits of using cost-effective models based on cheaper materials and 3D printing rather than expensive traditional benchtop models and cadaveric simulations. He moves on to look at innovations in endoscopic surgical training and innovations in laparoscopic/robotic surgical training, emphasizing the benefits of virtual reality training models and video-based coaching. Dr. Mayer summarizes the recent experience of resident education in the Scott Department, particularly focusing on the department’s participation in a trial of SIMPL, a smartphone-based surgical skills assessment tool. He then briefly expands upon innovative feedback models and ways to manage trainee wellness and burnout. Dr. Mayer also considers the effect of COVID-19 on surgical training, observing that while the pandemic led to reduced resident work hours and increased concern that residents would not be able to meet minimum case requirements, the rise of videoconferencing allowed for the positive development of nationwide urology didactics. He closes the presentation by discussing innovative educational uses of social media and the importance of non-technical skills training.

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Mini PCNL versus Standard PCNL

Posted by | Mar 2022

Manoj J. Monga, MD, FACS, Professor and Chair of Urology at the University of California, San Diego, compares mini percutaneous nephrolithotomy (mini PCNL) for renal stone removal to standard percutaneous nephrolithotomy (PCNL). He begins by looking at who needs a PCNL, explaining that he typically performs them on patients with a stone larger than 15mm, but that he also sometimes performs PCNL on stones when there are anatomical considerations that would make it difficult to get to the stone ureteroscopically. Dr. Monga notes that PCNL has the best outcomes and results in the best quality of life of any stone removal technique. He then poses the question: Why not treat every stone with PCNL? The answer, of course, he says, is because 4/1000 patients die from PCNL due to sepsis. Dr. Monga then moves on to discuss mini PCNL, noting that it was originally assumed to potentially be safer than PCNL, but that a 2001 study showed there was no advantage. He also observes that the smaller sheath used in mini PCNL actually increases the risk of infectious complications, and that outcomes are worse and operating room time is longer with mini PCNL compared to standard. However, Dr. Monga notes, there does appear to be a lower risk for bleeding and fewer transfusions, which might result in less kidney volume loss.

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Bladder-Sparing Trimodality Therapy

Posted by | Mar 2022

Daniel A. Hamstra, MD, PhD, Chairman and Professor of Radiation Oncology at Baylor College of Medicine in Houston, Texas, discusses bladder-sparing trimodality therapy for patients with bladder cancer, explaining the role of each aspect of care, outcomes in terms of quality of life, and the potential future role of checkpoint inhibitors. He begins by noting that successful organ preservation approaches in oncology are common (e.g., in breast cancer, head and neck cancer, and extremity sarcoma) and can reasonably be applied to bladder cancer as well. Dr. Hamstra then introduces the standard care pathway for trimodality bladder preservation, from transurethral resection of bladder tumor (TURBT), to neoadjuvant chemotherapy, to radiotherapy with radiosensitizing agent, to follow-up with repeat cystoscopy. He goes into detail about the role of each portion of treatment, arguing that surgical management, concurrent chemotherapy, and radiation therapy are all critical to treatment success. Dr. Hamstra also discusses how radiation should be delivered in terms of effectiveness and toxicity and considers the question of whether to treat the bladder only or the pelvis and bladder with radiation. He then looks at patient-reported quality of life after bladder preservation, highlighting that while many patients report declines in bladder-related quality of life immediately following chemoradiotherapy, they generally improve to baseline after 6 months, and ⅔ of patients report stable or improved quality of life on long-term follow-up. Finally, Dr. Hamstra touches on future additions to bladder-sparing treatment such as checkpoint inhibitors, highlighting the ongoing INTACT trial of concurrent chemoradiation with or without atezolizumab for localized muscle invasive bladder cancer. He concludes that trimodality bladder preservation represents a viable but underutilized option for T2-T4 bladder cancer that requires coordinated care between urology, medical oncology, and radiation oncology. Dr. Hamstra reiterates that each component of treatment is critical, quality of life outcomes are excellent, and newer agents may also improve outcomes.

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Management of Men With PI-RADS 4-5 Lesions and Negative Biopsy

Posted by | Mar 2022

Samir S. Taneja, MD, Professor of Urologic Oncology at NYU Grossman School of Medicine, discusses how to approach a negative MRI-targeted prostate biopsy in men with PI-RADS 4 or 5 lesions, explaining both why an MRI-targeted biopsy for a high suspicion MRI might be benign and what steps to take to determine the biopsy’s accuracy. Citing the PROMIS study, he notes that MRI is not entirely accurate and has neither a perfect positive predictive value (PPV) nor a perfect negative predictive value (NPV), though PPV is better at Gleason Grade greater than or equal to 3+4. Dr. Taneja then lists factors influencing PPV of MRI/template biopsy, including the given definition of clinically significant prostate cancer (csPCa), indication for biopsy, the prevalence of disease in the sampled cohort, and biopsy technique/operator skill. He goes into depth on how the MRI-targeted biopsy technique might influence the likelihood of a false negative, noting how the PROFUS study showed that csPCa was more often found with fusion biopsy compared to visual targeting. Dr. Taneja also considers the significance of the number of cores taken, observing that while most men are diagnosed with csPCa in the first core, there is a subset that requires core 3 and 4. He synthesizes the data into a set of suggestions for a clinical approach to a negative MRI-targeted biopsy in the setting of PI-RADS 4-5 abnormality, stating that clinicians should assess how confident they should be in the biopsy, assess the accuracy of imaging, repeat imaging in 6-12 months to rule out a false positive and, if the abnormality persists, they should perform a repeat biopsy.

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