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2024

An Algorithm to Pacify the Male Patient with Chronic Genital Pain

Ryan P. Terlecki, MD, FACS, presents a systematic approach to patients presenting with chronic genital pain, with the goal of identifying the underlying cause while avoiding common pitfalls with this type of patient. Dr. Terlecki begins by cautioning against assumptions about the patient, as they can cause anxieties in the provider which impact the quality of patient care.

Dr. Terlecki provides guidance on tailoring patient intake questionnaires to keep the focus on the patient’s issue and possible approaches. He gives examples of open and closed questions for male genital pain.

Dr. Terlecki then discusses the importance of setting patient expectations regarding diagnoses and what they should expect from the provider, particularly when the provider does not specialize in pain management. He then discusses common, uncommon, and overlooked causes of male genital pain.

Dr. Terlecki concludes by walking through this algorithm from intake to assessment to diagnosis and treatment. He emphasizes the importance of not dismissing patient input on treatment, but still strictly adhere to evidence-based treatment over unproven or alternative treatments.

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Optimizing In-Office Management for BPH, by the Numbers

Ricardo R. Gonzalez, MD, outlines an algorithm to determine optimal in-office BPH treatment options for both patient and practice. Dr. Gonzalez begins by categorizing BPH treatment options by risk and benefit, ranging from non-invasive to open surgical options.

While categorizing BPH treatment options, Dr. Gonzales gives examples of optimal treatment options based on patient presentation and priorities. He walks through the algorithm based on different patient priorities, emphasizing that a systemic approach to BPH treatment is necessary to pair the correct treatment with individual patients.

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Surgical Training for Radical Prostatectomy – Should the Open Approach Still Be Taught? Which Patients? Retropubic, Perineal, Mini-Incision, etc.?

Guilherme Godoy, MD, MS, explores the question of whether or not to teach residents open radical prostatectomy, weighing multifunctional surgical skills with robotic advancements. He then explains that the open approach to radical prostatectomy is the gold standard in the medical community; however, the robotic approach is more commonly performed.

Dr. Godoy proceeds by questioning whether a sufficient number of open-approach radical prostatectomies are being conducted to warrant training residents in this method. Referring to a 2020 study, he finds that perhaps too few open-approach procedures are occurring to allow for resident proficiency.

Dr. Godoy then asks whether the open approach offers any benefits, exploring four situations in which the open approach is preferred over the robotic method. Dr. Godoy then cites a 2007 study to evaluate the learning curves of open-approach radical prostatectomy subtypes compared to the robotic approach, finding drastic differences in the climb to proficiency.

He completes his presentation by stressing that resident skill and comfort level should be considered in the debate between the open and robotic approaches. Following the presentation, audience members offer points of consideration regarding rural populations, new robots, and current robot malfunctions during radical prostatectomies.

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Gleason Scoring Has Served Us Well for More than 50 Years, But It Is Time to Start Afresh

Andrew J. Vickers, PhD, discusses the weaknesses of Gleason scoring in diagnosing localized prostate cancer. Dr. Vickers begins by differentiating between Gleason “scoring” and Gleason “grading,” explaining that Gleason grading is robust, while scoring is not as robust. He emphasizes that Gleason Grade Groups 2 through 4 depend on the ratios of tissue with various Gleason scores, which he asserts make little sense.

Dr. Vickers offers clinical examples to support his assertion and explains that, with patients with Gleason Grade Group 2 disease, the total length of biopsied tissue with a Gleason score of 4 is strongly predictive of adverse surgical pathology risk. Dr. Vickers explains that in patients with Gleason Grade Group 2 disease, the amount of tissue with a Gleason score of 3 is not predictive. Dr. Vickers shares data out of France that indicate that the amount of Gleason score 4 or 5 tissue is more predictive of biochemical recurrence (BCR) and metastasis than total Gleason score.

Dr. Vickers asserts that there is a need for urologic oncologists to find a replacement for the Gleason score as the dominant influence on decision-making in localized prostate cancer. Dr. Vickers emphasizes the value of focusing on tumor size and tissue quality in disease assessment, as is done with other cancers.

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Year in Review: Emerging Data and Advances in Prostate Cancer Screening

Sigrid V. Carlsson, MD, PhD, MPH, presents an overview of advances and emerging trends in prostate cancer screening in 2023. Dr. Carlson begins by presenting data supporting the continued use of routine PSA tests for prostate cancer screening, while highlighting the need for more granular risk stratification based on individual PSA baselines to bridge existing mortality gaps based on individual PSA baselines.

Dr. Carlsson then examines current trends in using genetics for biopsy risk stratification. She presents evidence that the polygenic risk scores which predict prostate cancer incidence are not useful in predicting mortality. She then discusses the role of biomarkers, risk calculators, and MRI-based screening techniques that are available pre-biopsy.

Turning to emerging data, Dr. Carlsson concludes by presenting a selection of national and international ongoing efforts to develop risk-stratified algorithms for early prostate cancer detection. She touches on the European Union’s “Praise U” initiative, Germany’s “PROBASE” trial, the Stockholm 3 trial, and the ProScreen study.

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