2024 Archives

Molecular Imaging: PSMA PET/CT

Michael Hofman MBBS, FRACP, FAANMS, FICIS, GAICD | Feb 2024

Michael Hofman, MBBS, FRACP, FAANMS, FICIS, GAICD, compares the effectiveness of PSMA PET with CT against the standard CT and bone scan. He begins by briefly reviewing findings from the ProPSMA study, which indicated that PSMA PET/CT had greater accuracy in identifying prostate cancer than a standard CT plus bone scan, or “conventional imaging.”

Dr. Hofman discusses the adoption of PSMA PET/CT as a standard of care in different international medical guidelines. He notes that some medical communities have embraced PSMA PET/CT as a replacement for conventional imaging in patients who meet the appropriate criteria for PSMA PET/CT, while others have only adopted it as a supplement to conventional imaging.

Dr. Hofman argues against a common argument for keeping conventional imaging scans as part of standard care, the issue of stage migration. Dr. Hofman argues that, while PSMA PET/CT is a more sensitive test, it also has greater specificity and yields fewer false-positives than conventional imaging. He supports this point by evaluating several equivocal studies comparing PSMA PET/CT and CT/bone scans in patients with various metastatic burdens.

Dr. Hofman concludes with a brief discussion on the lower financial burden of PSMA PET/CT, and on the future directions of PSMA PET/CT in detecting quantitative total tumor volume. He acknowledges the lack of standardization in PSMA PET/CT reporting and encourages fellow clinicians and academics to participate in the creation of standard reporting practices for PSMA PET/CT.

Expanding the Surgical Options for Primary and Recurrent Male Stress Incontinence

Brian J. Flynn, MD | Feb 2024

Brian J. Flynn, MD, evaluates current and upcoming surgical options for treating primary and recurrent male stress incontinence. He begins by reviewing the medical, social, and urethral characteristics of male stress urinary incontinence (SUI) surgical candidates.

Dr. Flynn then evaluates the risks and benefits of male perineal slings (MPS), artificial urinary sphincters (AUS), and adjustable continence therapy (ACT) devices. He notes that, presently, the least effective surgical option also has the least risk of complications for the patient.

Dr. Flynn concludes by presenting examples of patients with various levels of male SUI and how MPS, AUS, and ACT apply to each case. He reiterates that focusing on patient quality of life is paramount in the successful treatment of male SUI.

Prostate MRI for Dummies

Sadhna M. Verma, MD, MBA, FSAR | Feb 2024

Sadhna Verma, MD, FSAR, presents an overview of the use of multiparametric MRI in evaluating the prostate. Dr. Verma begins by reviewing the three elements of a multiparametric MRI in prostate cancer treatment: T2 Weighted Imaging (T2W), Diffusion Weighted Imaging (DWI), and Dynamic Contrast Enhanced (DCE) Imaging.

Dr. Verma presents examples of T1 and T2 Weighted (T2W) MRI images, which are used to illustrate the zonal anatomy of the prostate. She notes that T1 and T2 MRI is weak when it comes to identifying problems in the transition zone.

Dr. Verma then moves to Diffusion Weighted Imaging (DWI) to measure cell diffusion as a means of locating tumors. However, she notes that DWI is not very accurate for recently-biopsied patients.

Dr. Verma concludes by briefly touching on Dynamic Contrast Enhanced (DCE) Imaging to measure tumor vascularity, and how DCE combines with T2W and DWI to give each identified lesion a PI-RADS (Prostate Imaging Reporting and Data System) score. She emphasizes that a PI-RADS score should only be used in detection of clinically significant prostate cancer, and presents examples of how prostate cancer can be identified in peripheral zones, transition zones, and extra-prostatic locations through the use of multiparametric MRI.

An Algorithm to Pacify the Male Patient with Chronic Genital Pain

Ryan P. Terlecki, MD, FACS | Feb 2024

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.

Optimizing In-Office Management for BPH, by the Numbers

Ricardo R. Gonzalez, MD | Feb 2024

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.