2022 Archives

The Present and Future of Artificial Intelligence in Medicine

Posted by Neil H. Baum, MD | Feb 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses current and future applications of artificial intelligence (AI) in medical practice. He describes AI as the game changer of the 21st century, and lists its numerous current uses in the clinical setting, such as reading mammograms, examining retinas of diabetic patients, reading pathology slides, screening for skin cancer, uncovering health disparity between whites and non-whites, and collating and summarizing millions of similar cases for doctors. Dr. Baum also highlights several nonclinical uses for AI, observing that AI’s ability to complete clinical data entry allows the doctor to focus on their interaction with patients. He then argues that AI will not replace physicians because clinical judgment will not be replaced by data and algorithms, patients do not want to be treated by a machine or algorithm, and AI cannot provide empathy and understanding. Dr. Baum moves on to consider the future of AI healthcare, suggesting that it will fill in the gap caused by the pending physician shortage and the aging Baby Boomer population. He claims that AI will automate routine processes that consume so much of a physician’s time, such as processing routine requests from the inbox, medication refills, and result notifications. He lists other future medical applications for AI, including improving drug compliance through home AIs like Alexa, identifying patients who are or are not eligible for certain treatments, and monitoring patients between visits. Dr. Baum concludes that AI will serve as an adjunct for physicians and help increase available knowledge while allowing doctors to focus on empathy and understanding.

The History of Penile Enlargement and the Advent of Penuma

Posted by James J. Elist, MD | Feb 2022

James J. Elist, MD, FACS, a urologist and surgeon in private practice in Beverly Hills, California, explains why a patient may request penile enlargement, lists available treatment options for these patients, and discusses how to screen and select patients for a penile implant. He highlights the importance of the selection and screening process, observing that patients may have unrealistic expectations about how penile enlargement will affect their penis, may need psychological counseling or psychotherapy to address certain feelings about their penis, and may have undergone plastic surgery that affects their options for penile enlargement. Dr. Elist then looks at Penuma®, the first FDA-cleared, patented, and manufactured subcutaneous silicone implant for penile cosmetic corrective surgery. He explains how to perform the quick outpatient surgical procedure, goes over recovery and follow-up details, and considers the benefits of the implant compared to other options. Dr. Elist notes that the Penuma® implant is permanent yet reversible, customizable to patient anatomy, has no effect on erectile function and does not interfere with the urethra, remains accessible across the country, and boasts a strong and long term track record of patient satisfaction and low adverse events.

Neoadjuvant vs. Adjuvant vs. None – “Perioperative Therapy”

Posted by A. Edward Yen, MD | Feb 2022

A. Edward Yen, MD, Assistant Professor of Medicine in the Hematology and Oncology Section at Baylor College of Medicine in Houston, Texas, summarizes research on perioperative therapies for bladder cancer and how they compare to each other. He begins with an overview of the current standard of care for muscle-invasive bladder cancer (MIBC), citing a Swiss study showing that after radical cystectomy there is still a problem of incurable disease relapse through overall survival rates below 63%, and another study showing that neoadjuvant cisplatin-based chemotherapy (NAC) combinations improve survival for MIBC by 5-8%. Dr. Yen then overviews NAC, highlighting the VESPER trial that compared cisplatin-gemcitabine (GC) and dose-dense MVAC (ddMVAC) in the perioperative MIBC setting and found that more patients were able to follow through with NAC than adjuvant chemotherapy (AC) by 21%. He discusses multiple immunotherapy trials that together show that patient responses seem better with chemo-immunotherapy than they do with immunotherapy alone. Dr. Yen then reviews the CheckMate-274 trial that found that adjuvant nivolumab treatment-related adverse effects were tolerable due to a 7% rate of being severe enough to end treatment vs. a 1.4% rate in the placebo arm. He also summarizes the IMvigor trial, which did not meet its primary endpoint of disease-free survival but found that positive ctDNA patients had an improvement from atezolizumab that was not seen in other patients. Dr. Yen concludes that GC and ddMVAC remain important perioperative chemotherapy regimens, that neoadjuvant and adjuvant therapies have situational uses, and more research will be key to refining these treatments further.

PSMA: Current State of the Art and Future Vision

Posted by Phillip J. Koo, MD | Feb 2022

Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses current and possible future applications for prostate-specific membrane antigen (PSMA) as both a diagnostic and a theranostic radiopharmaceutical for prostate cancer. He begins by considering PSMA in the diagnostic setting and explains that its current state-of-the art use is in the area of detection of metastatic disease. Dr. Koo particularly highlights its role in detecting oligometastatic disease in cases of biochemical recurrence. He also notes that PSMA currently has a role in initial staging, and that this role is likely to expand in the future. He predicts that other future diagnostic applications of PSMA will include restaging/treatment response, primary lesion characterization, and potentially prognosis. Dr. Koo then moves to discussing PSMA in the theranostic setting, mentioning the current role of Lu-177 PSMA on the “thera-” side and looking at PSMA, FDG, and PSMA plus FDG on the “-nostic” patient selection side. He also considers the question of whether imaging is even needed considering the large percentage of patients who are PSMA-positive, though he argues for the benefits of imaging. Dr. Koo lists some potential future therapeutic applications of PSMA, such as in earlier treatment, retreatment, combination therapy, dosimetry, and with alpha particles. He concludes that there are many unanswered questions, that conventional wisdom and anecdotes are not evidence-based, and that there is a need for more clinical trials and more disease site specialization within nuclear medicine.

Conducting Patient Surveys

Posted by Neil H. Baum, MD | Feb 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, gives recommendations on how urologists can improve their practices by conducting patient surveys. He notes that one of the key needs and wants of urologists is to monitor the urologist-patient encounter, and he highlights two pathways to success in this area: (1) find out what the patient wants and give him/her more of it; and (2) find out what the patient does not want and avoid it. Dr. Baum explains that the best way to identify what patients do and do not want is to conduct patient surveys. He recommends using a suggestion box and notes that in his own practice, he gives patients a card with six yes-or-no questions on the front and space on the reverse side for patients to write out the three questions they would like to have answered during their visit. Dr. Baum also suggests creating online surveys with questions such as “How likely are you to recommend this practice to others?” and “How responsive were the staff and the doctors to your questions?” He concludes that urologists need to listen to their patients and need to ask them how they can serve them better.