BackTable Urology: Recent Episodes
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The BackTable Urology Podcast is a resource for practicing urologists to learn tips, techniques, and practical advice from their peers in the field. Listen here or on the streaming platform of your choice.
This week on BackTable Urology, Dr. Suzette Sutherland (University of Washington) and Dr. Olivia Chang (UC Irvine) discuss reasons for uterine preservation and hysteropexy techniques for prolapse repair.
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SHOW NOTES
First, Suzette and Olivia discuss the value of keeping the uterus in place for women undergoing prolapse repairs, as well as the indications for apical suspension surgery. They also note the historical context of hysterectomy and why it has been the go-to treatment for so long. Next, the doctors discuss the advantages of hysteropexy over hysterectomy for prolapse repair, such as a shorter operative time, less bleeding, and a quicker recovery. The doctors then go into more detail about the best approaches for prolapse repair, like weighing the options of permanent sutures versus delayed absorbable sutures. They also analyze recurrence rates after prolapse surgery, specifically in the anterior compartment.
Then, they explore the data on how the choice to keep the uterus in place can stem from a woman's personal and cultural views. Olivia shares about the Value of Uterus questionnaire, a six-question survey instrument that can quantify how a woman values her uterus. It can streamline clinic visits and help to predict whether a woman would choose a uterine-preserving procedure. The doctors note that there is research demonstrating a correlation between valuing the uterus and sexual activity.
Finally, Suzette and Olivia contraindications for leaving the uterus in place. They emphasize the importance of assessing for abnormal uterine bleeding and cervical pathology before recommending uterine preservation. They suggest that listeners review the current guidelines around preoperative workup and consider transvaginal ultrasound or endometrial biopsy first. Lastly, they emphasize the importance of symptom and risk stratification and shared decision making when it comes to uterine preservation.
RESOURCES
Chang OH, Walters MD, Yao M, Lapin B. Development and validation of the Value of Uterus instrument and visual analog scale to measure patients' valuation of their uterus. Am J Obstet Gynecol. 2022 Jun 25:S0002-9378(22)00483-5. doi: 10.1016/j.ajog.2022.06.029. Epub ahead of print. PMID: 35764134. https://pubmed.ncbi.nlm.nih.gov/35764134/
This week on the BackTable Urology Podcast, Dr. Jose Silva discusses sexual health with Dr. Arthur “Bud” Burnett, professor of urology at John Hopkins University, with an emphasis on the importance of preventative medicine in improving sexual health and different treatments for erectile dysfunction.
SHOW NOTES
First, Bud and Jose explore the various treatments available for patients with erectile dysfunction (ED). They not only discuss how oral drugs can be used to treat the majority of patients, but also how to manage a young patient with a single episode of ED. Furthermore, they evaluate the safety of these oral drugs and the alternatives, such as injections, rings, and vacuum erection device therapy.
Next, they note the important role of testosterone replacement therapy (TRT) in improving sexual health for prostate cancer survivors. They also delineate various modalities of testosterone replacement therapy such as gels, injectables, and pellets, and their safety profiles. They both agree that it is important to follow guidelines and monitor patients who are on TRT. Additionally, they note the prevalence of Peyronie's Disease, and the psychological implications the condition can have on men.
The doctors then move onto the topic of priapism, a condition where a man experiences an erection for a prolonged period of time. They explore the potential causes of the disorder, the treatments available, and the potential therapies that may help prevent it from occurring. Finally, Dr. Burnett also shares his journey to writing his book, The Manhood Rx, in order to provide men with a comprehensive resource to improve their sexual health and overall wellness.
RESOURCES
The Manhood Rx: Every Man's Guide to Improving Sexual Health and Overall Wellness by Arthur Burnett https://www.amazon.com/Manhood-Rx-Improving-Overall-Wellness/dp/1538166593
WellPrept https://wellprept.com/
This week on BackTable Urology, Dr. David Albala, chief of urology at Crouse Hospital, and Dr. Jose Silva discuss the benefits and integration of biomarkers in prostate cancer diagnosis.
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SHOW NOTES
First, Dr. Albala explains the history of PSA testing, which was the first test to screen patients for prostate cancer. He explains that in the past, positive PSA testing (>4 ng/mL) and digital rectal exams (DRE) could lead urologists to the decision to biopsy the prostate. He notes the importance of taking into account clinical risk factors, like age, family history, race, genetic markers like BRCA1/2. PSA cutoffs should also follow age-specific considerations, and PSA is not a specific test for cancer as some patients with biopsy proven prostate cancer can have normal PSA levels. Current USPSTF guidelines recommend PSA screening at age 45 in patients with risk factors (African American, positive family history, etc.) and at age 55 in patients without risk factors, but this should be subject to shared decision making.
Then, the urologists discuss the use of urine and blood biomarkers to determine whether a biopsy is necessary, as bleeding and infection are possible complications. Dr. Albala’s prostate cancer workup involves the following: a PSA level first, a repeat PSA level if the first one was between 2-10 ng/mL in a patient older than 50, and then the ExoDx exosome test. If the exosome test returns with a value greater than 15.6, he will perform an MRI fusion prostate biopsy. If the exosome test is less than 15.6, he will repeat the test in 6 months. He notes that benefits of the urine exosome test include affordability and reduction in the need for DREs and biopsies in patients without cancer.
Finally, Dr. Albala discusses future possibilities of layering biomarker tests and encourages early screening for prostate cancer. He ends the episode by emphasizing prostate cancer treatment should be personalized because many cases of prostate cancer are indolent and may be overtreated.
RESOURCES
ExoDx Prostate Test: https://www.exosomedx.com/
In this episode of BackTable Urology, Dr. Jose Silva and Dr. Suzette Sutherland, director of Female Urology at Northwestern university, discuss new therapies for overactive bladder (OAB).
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SHOW NOTES
First, they describe the symptoms of OAB which include an increased frequency and urgency of urination, sometimes leading to urinary incontinence. Conservative measures include pelvic floor exercises, diet, and lifestyle changes. If patients fail conservative measures, urologists can prescribe anticholinergics. However,beta agonists are preferable because they do not cross the blood-brain barrier. Then. the doctors briefly chat about the use of these agents in Alzheimer disease patients as well, which may be dependent on insurance approval.
Next, Dr. Sutherland summarizes surgical devices to treat OAB and the clinical trials supporting each of them. Sacral nerve neuromodulation is a device that has been on the market for years, but newer models that include fixed and rechargeable batteries are starting to become more available. Additionally, the Neuspera is a sacral nerve neuromodulation that operates wirelessly through Bluetooth. The doctors also compare the two existing models of sacral neuromodulation (Medtronic vs. Axonics).
One newer surgical treatment is tibial nerve stimulation, and Dr. Sutherland summarizes her placement technique, voltage settings, intraoperative testing, and the importance of a healthy ankle evaluation prior to placing the device. promising results, in-office, sedation, healthy ankle evaluation. She also notes that repositioning the leads in sacral and tibial neuromodulation in a followup visit may be necessary. Finally, she shares about Fempulse, vaginal stimulator mimicking a pessary, that is still being tested in research trials.
RESOURCES
Wellprept https://wellprept.com/
In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with PGY4 urologist Dr. Chloe Peters (University of Washington) and OB/GYN Dr. Beverly Gray (Duke University) about their work in women's health and advocacy, and how the Dobbs ruling has impacted their respective medical fields.
SHOW NOTES
First, the doctors explore the implications of state abortion laws on the OB/GYN and urology workforces and how they may directly impact where people choose to live and work. Dr. Peters and Dr. Gray explain the complexities of state abortion policies, as well as the differences between restrictive and nonrestrictive states. The Dobbs ruling in June 2022 gave individual states the power to regulate any aspect of abortion not protected by federal law, thus overturning Roe v. Wade. Both doctors emphasize that this ruling affects all urologists and OB/GYNs in private and academic settings, because they provide unsafe environments for patients who need them.
Recent studies and surveys show how restrictive abortion laws are impacting the urology rank lists and applications. One in five applicants to the urology match took programs off their list because they are located in states with illegal abortion laws, and almost 60% said they would worry about their health and safety if they matched in a state with restrictive laws. In summary, all three doctors agreed that restrictive laws can have a direct impact on residency and urology recruitment efforts.
Finally, they observe that the increasing diversity in the field of urology has encouraged younger, female members to advocate for better access to healthcare. They remain optimistic that the current generation can use their voices to create change and provide better access to care for all.
RESOURCES
American Urologic Association (AUA) Position Statement on the Supreme Court’s Decision to Overturn Roe v. Wade https://www.auanet.org/about-us/aua-statement-on-overturning-roe-v-wade
American College of Obstetricians and Gynecologist (ACOG) Abortion Policy https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/abortion-policy
Ryan Residency Training Program https://ryanprogram.org/
In this episode of BackTable Urology, urologists Dr. Jay Shah (Stanford University) and Dr. Brantley Thrasher (University of Kansas) discuss the importance of self-improvement and listening in leadership, a skill that has to be learned and honed over time.
SHOW NOTES
Dr. Brantley Thrasher reflects on a piece of advice he received several years ago when considering a leadership role he wasn't ready for. He emphasizes the importance of mentors, the power of honest conversation, and listening to show your team that they can trust you and be willing to follow your lead. He notes that when looking for a leadership role, it's important to know your skillset and to be honest with yourself and those around you. It is also important to recognize when someone is not the right fit for a particular leadership role and to be willing to be open and honest with them about it. He shares his experience of having to tell a friend that they don't have the skill set for the job, and how he has seen people treating their team in a disrespectful way.
Finally, he also discusses his past experience as the chair of Urology at Kansas and president of the AUA and Society of Urological Oncology, as well as his current role as the chair of the Society of Academic Urology and the executive director of the American Board of Urology. Finally, he offers advice to those looking for a leadership role on how to assess if they have the skills for the job. He recommends books such as The Servant, Grit, The Road to Character, and The War of Art.
RESOURCES
The Servant: A Simple Story About the True Essence of Leadership by James C. Hunter https://www.amazon.com/Servant-Simple-Story-Essence-Leadership/dp/0761513698
Grit: The Power of Passion and Perseverance by Angela Duckworth https://www.amazon.com/Grit-Passion-Perseverance-Angela-Duckworth/dp/1501111108
The Road to Character by David Brooks https://www.amazon.com/Road-Character-David-Brooks/dp/0812983416
The War of Art by Steven Pressfield https://www.amazon.com/War-Art-Winning-Creative-Battle-audio-cd/dp/1501260626
In this episode of BackTable Urology, urologist Dr. Manoj Monga (UC San Diego) and clinical nutritionist Dr. Kristina Penniston (UW Madison) discuss the role of diet in kidney stone prevention and how urologists can partner with dietitians to create integrated stone clinics.
SHOW NOTES
First, the doctors explore how to adjust fluid intake based on the patient's body size and consistency of bowel movements. They also cover ways to be creative with fluids, including incorporating low sugar, low calorie, and low alcohol beverages into the diet, as well as scheduling and flavoring options. They review the importance of mineral content in hard and soft water, and the potential benefits of alkaline water. Finally, they discuss the recommended sodium intake per day.
Next, Dr. Penniston explains that oxalate, a common component of kidney stones, is found in many plant foods, such as spinach, potatoes, sweet potatoes, beans, rhubarb, beets, nuts, and grains. She discusses how oxalate bioavailability can be reduced by the simultaneous consumption of foods and beverages containing calcium. Finally, she outlines the many non-dairy alternatives for calcium that are available.
Lastly, the doctors discuss how certain diets can increase and decrease the acidity of the urine. They debate the effects of intermittent fasting on stone risk, as well as the healthiest diet to lose weight without increasing stone risk. They end by emphasizing the importance of lifestyle changes and how a balanced and varied diet is key to successful weight loss.
This week on the BackTable Urology Podcast, Dr. Jose Silva invites Dr. Seth Bechis onto the show to discuss the diagnosis and treatment of BPH with Rezum, a minimally invasive surgical that uses water vapor to dissolve prostate tissue.
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SHOW NOTES
First, the doctors emphasize the importance of establishing a relationship between primary physicians and urologists to improve the referral times of patients with BPH. They also discuss how involving patients in the cystoscopy process can help them with the decision-making process and maintaining better bladder health in the long run.
Then, Dr. Bechis summarizes current BPH treatments, and how to effectively manage post-treatment patient expectations. He emphasizes the importance of over preparing patients for the potential side effects of BPH treatments, and strategies for adjusting their expectations. They also discuss the ideal candidates and prostate sizes for Rezum therapy. Additionally, Dr. Bechis discusses the technical aspects of the procedure, including his anesthesia regimen, needle placement, antibiotic prophylaxis, and postoperative care.
Finally, they explain the importance of following up on a PSA test annually after a prostate procedure and how to manage anxious patients who may be checking their PSA too frequently. As urologists, they have to counsel patients upfront about all of their options, so having flexibility to take different paths is helpful if their priorities change. Lastly, they touch on the idea of performing prophylactic procedures as a preventative measure.
In this episode of BackTable Urology, Dr. Bagrodia and Dr. Jay Raman, the chair of urology at Penn State Health, discuss advancements and future directions of medical education for trainees.
SHOW NOTES
First, the doctors discuss the need for medical education to incorporate multimedia and active learning into residency curriculums and CME courses. Dr. Raman notes that although the copious amounts of articles and videos online may be overwhelming, integrating quality videos, textbook chapters, and journal articles into a standardized curriculum for urology residents can teach them the fundamentals of urology. Additionally, he notes that this approach takes into consideration different learning styles.
Dr. Bagrodia emphasizes how the AUA core curriculum has leveled the playing field for trainees, as it has standardized education across all training programs. He suggests a model of having residents do pre-work by learning from the AUA curriculum on their own time and then using valuable in-person time with attendings to review case examples. Dr. Raman agrees that meeting in person for resident lectures or conference courses should be interactive and incorporate active learning exercises. They then reflect on the social value of getting together in order to network and discuss cases casually, but concede that virtual meetings can be more convenient for family life and comfort.
Next, the doctors discuss the role of simulation in education. Dr. Bagrodia notes that simulation increases practice opportunities for residents, which makes them safer and more competent surgeons. Dr. Raman is excited about virtual reality technology, which makes simulation more feasible and realistic for many training programs. The doctors then discuss the possibility of incorporating simulation into board exam certifications. Dr. Raman explains the traditional arc of residency training and proposes changes to this arc to help align resident education better with their future practice types and meet the current need for more general urologists. Finally, they end the episode by addressing the need to expand resident and CME education beyond clinical education to include topics like social determinants of health, time management, wellness, and environmental stewardship.
In this episode of BackTable Urology, Dr. Bagrodia and Dr. Jay Simhan, director of reconstructive urology at Fox Chase Cancer Center, discuss how to demonstrate value at a private or academic physician job.
SHOW NOTES
The doctors first briefly discuss the process of obtaining a physician job. Dr. Simhan believes that physicians should negotiate their contracts only out of necessity. He encourages new attendings to demonstrate their own value to the administrators who create their contracts. Next, the doctors move onto advice for the first 3 months in a new job. Both doctors agree that the goal should be to learn who people are and earn their respect, whether they are residents, trainees, other attendings, nurses, MAs, or administrators. Dr. Simhan also emphasizes the importance of building your own cultural philosophy and deciding what you care about. Then, the doctors discuss the traditional 3 A’s: available, affable, and able. Dr. Simhan notes that for a new physician, availability and affability are probably more heavily weighted for new hires. Dr. Bagrodia believes that accountability should be the 4th A because physicians should know when to accept their mistakes and move forward. Finally, Dr. Simhan explains how he had to learn the landscape of his new department at Fox Chase Cancer Center in order to figure out how he could build and fit in his reconstructive urology program.
Finally, the doctors discuss how to engage in tactful self-promotion to demonstrate your value. Dr. Simhan explains that recognition is not a negative result to seek, as it can fuel your passion (e.g. bigger patient base, support for funding, etc.). He encourages doctors to have a personal website, to always update referring doctors after clinical visits and surgeries, and to be available to trainees and nurses. Additionally, Dr. Bagrodia advises physicians to meet with their department chairs and mentors to discuss progress and ask for help. He discourages physicians from giving unsolicited advice to their colleagues.
Finally, the doctors share some of their miscellaneous tips for demonstrating value within a hospital system. Dr. Bagrodia notes that it is helpful to be prepared with talking points, ideas, and solutions when meeting with hospital administrators. Dr. Simhan adds that it is important to fully commit to the responsibilities that you agree to take on.
In this cross-specialty episode of BackTable OBGYN, Dr. Amy Park chats with Dr. Jose Silva, a board certified urologist and co-host of BackTable Urology, about the workup, counseling, and management of urinary incontinence and pelvic organ prolapse.
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In this episode, guest host Dr. David Canes interviews Dr. Matthew Allaway about PrecisionPoint, his medical device for transperineal prostate biopsy, and his journey towards changing the paradigms of prostate cancer diagnosis.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with two fellow urologic oncologists, Dr. Timothy Clinton (Brigham and Women’s Hospital) and Dr. Eugene Pietzak (Memorial Sloan Kettering), about the management of BCG-refractory non muscle-invasive bladder cancer.
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In this special episode, Dr. Phil Pierorazio (University of Pennsylvania) invites Dr. Rana McKay (UC San Diego) and Dr. Raquibul Hannan (UT Southwestern) about treatment options for renal cell carcinoma (RCC) patients in preparation for the 2022 International Kidney Cancer Symposium in Austin, Texas.
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SHOW NOTES
First, the doctors discuss their excitement for the 2022 IKCS. They have benefited greatly from participating in collaboration and networking, improving their wellness strategies, learning about new clinical trials, and debating difficult cases at academic conferences like IKCS.
Next, Dr. Pierorazio presents four different difficult RCC classes to the doctors and asks for an outline of their treatment plans. He starts with localized disease and works towards more aggressive and nodally invasive cancer. For each case, Dr. McKay and Dr. Hannan explain recent developments in clinical trial data, side effect considerations, and the importance of assessing patient comorbidities. All three doctors draw conclusions based on their previous patients as well. Additionally, Dr. McKay explains why it is important to understand what the patient understands about their cancer diagnosis before presenting these treatment options to patients. Dr. Pierorazio has learned to ask patients about their greatest cancer-related fear in order to guide his treatment decisions. Dr. Hannan advises doctors to look at the failure rates of clinical trials along with the success rates.
Cases presented: Localized clear cell RCC patient with 1 kidney Adjuvant chemotherapy for a post-nephrectomy patient with T3a clear cell RCC Papillary RCC patient with a 10 cm mass and a 10 cm para aortic lymph node Chromophobe RCC patient with an 8 cm renal mass and spinal metastasis
In this episode, Dr. Aditya Bagrodia speaks with Dr. Manoj Monga, chair of the urology department at UC San Diego, about his unique journey to becoming a urologist as well as extra-academic passions that have led him to understand the importance of advocacy.
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SHOW NOTES
First, Dr. Monga shares the story of his childhood. As an Indian born and raised in Belfast, Ireland, he had to adapt to living among a different culture and religion. In his childhood, he was surrounded by bomb scares and bomb drills because of the religious and political conflict in Ireland. His parents ultimately made the decision to move to Ontario, Canada for family safety. He finished his schooling in Ontario, Canada and noted that his decision to pursue medicine was more based on a path of least resistance rather than initial passion. He chose medicine out of practicality, but was interested in a musical career because he played the french horn, trumpet, and saxophone. He still plays musical instruments and has realized that many musical skills, such as practice and challenging himself, have translated into medical skills.
He then speaks about his early career. Dr. Monga did not start out with an ultra-focused goal of becoming a urologist. He started as a categorical general surgery intern at Tulane because of his interest in trauma and reconstructive surgery. In his second year in Louisiana, he gained his first exposure to urology and decided to fill an empty spot in the urology residency program. However, he took a 1 year research gap at Tulane to study endourology, pyelonephritis, and andrology. He noted that this year helped him with aligning his career with his wife’s career and prompted him to think about an academic career. He finished residency and trained at a variety of institutions, such as UC San Diego and the Cleveland Clinic.
Then, Dr. Monga reflects about his transition to UC San Diego as the chair of urology during the pandemic. It was difficult to leave his family at first, but he was impressed by the teamwork and selflessness of his department. Shortly afterwards, he became the secretary of AUA, a position that was fulfilling, but also one that challenged his time management skills.
Finally, Dr. Monga explains why taking action and being an advocate is so important in his professional and personal life. Inspired by recent events, he has taken multiple trips to provide medical relief in Ukraine. He found that the refugee history he encountered abroad resonated with him and motivated him to create a better world for his kids by developing meaningful passions. He encourages using urology for social responsibility by advocacy and raising funds for important causes instead of stopping at social media to raise awareness.
Finally, Dr. Monga sums up three big lessons he has learned. First, he is fortunate for the open paths and family/mentor support. Second, he has learned to temper his enthusiasm for simple answers to complex issues. Finally, he realizes the importance of sharing experiences to let people who are suffering know that they are not alone.
In this episode, Dr. Jose Silva interviews private practice urologist Dr. Jordan Luskin, a community urologist practicing in West Palm Beach, about special considerations for rural / community medicine urologists.
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SHOW NOTES
Rural / community medicine urologists often do not have many urologist colleagues around to consult while in the OR, and some practices have minimal or no robotic surgery systems. Dr. Luskin and Dr. Silva emphasize that when the decision between whether to perform a procedure themselves or refer the patient to a bigger hospital system needs to be made, they must always think about factors other than surgery too. For example, the OR staff may not be adequately trained to assist in a certain procedure, and patients may need additional resources for supportive care after surgery that are not possible to obtain at a smaller practice. Additionally, having minimal to no RNs or advanced practice providers means that community urologists need to deal with every small issue that patients have. Dr. Luskin sees these responsibilities as an opportunity to learn about the road to post-operative recovery for his patients.
Next, Dr. Luskin emphasizes the importance of always being up to date and learning new surgical techniques. When he transitioned to doing robotic prostatectomies, he kept in touch with his Georgetown residency attendings. He also uses Twitter to find recent scientific literature about different urologic fields.
The doctors speak about OR mentality next. Dr. Luskin recommends avoiding doing more than one long case everyday, because it is mentally challenging to approach the second case with a good mindset if the first case was not ideal. He is self-aware of his mindset and has even canceled surgeries because he felt like he was not going to operate at his best. Dr. Silva also speaks about how to deal with frustration with OR staff, as turnover rates are high in community medicine. They both agree reframing can help overcome negative mindset. Dr. Luskin adds that teaching staff who are unfamiliar with a procedure can lead to more comfort and enjoyment for both parties next time the same procedure is done. Finally, Dr. Luskin encourages community urologists to pick and choose their procedures carefully by always balancing the costs and rewards.
In this episode, Dr. Aditya Bagrodia interviews pelvic floor therapist Vanita Gaglani from Vanita’s Rehab about the role of pelvic floor physical therapy for early continence recovery after prostatectomy.
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SHOW NOTES
She starts the discussion by explaining her schedule for seeing prostatectomy patients. She usually has the patient come in for a preoperative visit to counsel him on proper nutrition, hydration, and shows him how to do Kegel exercises correctly. She advises her patients against drinking tea, coffee, or soda because these liquids can irritate the surgical sites. She recommends doing complete Kegels involving the pelvic floor muscles around the rectum first because she believes these muscles are stronger. When the patient is ready to progress, she then advises them to practice Kegels with the pelvic floor muscles around the urethra. Her regimen consists of 6-8 sets of 10 quick repetitions, each held for 1-2 seconds. She also mentions that “hold” is often a vague term; male patients usually squeeze too hard and cause muscle fatigue, which causes the prostatic sphincter to lose control and leak more urine. Therefore, she emphasizes that Kegels must be done gently at first. Additionally, she encourages her patients to start Kegels at least 3 weeks before surgery.
Then, she schedules the first postoperative visit 4-5 days after the catheter removal. During the first postoperative visit, she often hears the complaint that patients are continent while sitting but incontinent when standing up and walking. To teach her patients how to get up without leaking, she shows them how to sustain pelvic floor contraction while standing. She notes that this skill is more a result of endurance, not strength; overfatigue of the pelvic floor during the daytime is very common. She also evaluates lumbar and hip muscle strength too, as they both contribute to pelvic floor strength. Additionally, she discourages patients from getting up to use the bathroom frequently because this behavior may cause bladder capacity to decrease. To prevent this behavior, engaging in breathing exercises while in butterfly position and using thinner pads can help. By 10 weeks, 98% of patients should be completely dry. For the 2% of patients who are incontinent for more than 10 weeks, another factor (such as scar tissue, bladder spasms, and constipation) may be at play.
Finally, Vanita discusses resources for patients seeking more information about pelvic floor physical therapy. She has her own website with information and journals as well as her own book, “Life after Prostatectomy and Other Urological Surgeries: 10 Weeks from Incontinence to Continence."
RESOURCES
Vanita’s Rehab http://vanitasrehab.com/resources/
“Life after Prostatectomy and Other Urological Surgeries: 10 Weeks from Incontinence to Continence” (Vanita’s book available on Amazon)
In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses benefits and advice for effective mentorship with Dr. Andrew Winer, Chief of Urology at Kings County Hospital Center and assistant professor at SUNY Downstate.
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SHOW NOTES
First, the doctors define the purpose of mentorship as a relationship that serves to connect a mentor, with a certain skill set and knowledge, with a mentee, who wants to obtain the same skill set and knowledge. Dr. Winer considers mentorship a two-way street, since he has been able to learn a lot from his past mentees. He draws a distinction between coaching and mentorship; coaches give small pieces of advice sometimes, while a true mentor invests lots of time in the relationship. Additionally, he encourages mentees, especially medical students, to get rid of the fear factor of reaching out, as all mentors have been in their shoes before. He also emphasizes the importance of mentees showing up prepared for meetings out of respect for the mentor’s time
Next, the doctors discuss the requirements of being a mentor. Although both of them agree that there is no formal training requirement to be a mentor, mentors should possess certain qualities, like selflessness. They should not follow their own agenda–instead, they should focus on what their mentee’s interests are. Additionally, taking credit for mentee’s work is unacceptable. Next, mentors should be accessible to their mentees and let them know that they can remind their mentors about deadlines. Finally, honesty is very important. Mentors should be able to give their mentees constructive criticism.
Then, they give practical advice for mentors who want to guide medical students and residents. Establishing a goal first and compartmentalizing their mentees’ journeys is always helpful. Mentors should serve as advocates, but have to be honest when writing recommendation letters for students and residents. Additionally, they explain that residents become organic leaders early on, as many of them take on the responsibility of teaching medical students. Attending leadership most commonly trickles down to resident leadership. They end the episode by discussing benefits of mentoring a mentee who is different from themselves, in terms of generation gap, gender, ethnicity, and life experiences.
In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses retroperitoneal lymph node dissection (RPLND) for early stage testicular cancer with Dr. Clint Cary and Dr. Timothy Masterson from Indiana University School of Medicine.
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SHOW NOTES
First, the doctors discuss how to approach T1 testicular cancer, which does not show elevated markers or nodal metastases. All the doctors agree that the best approach is just surveillance of the tumor without RPLND, unless there is evidence of somatic transformation. Because some patients have anxiety about just doing surveillance, they assure them that only 10-15% of T1 tumors progress. However, there are different warning signs for different tumor histologies. It is important to get medical oncologists on board quickly in order to have a balanced presentation of treatment options for the patient. The doctors agree that surgeons must counsel patients on the possible complications of RPLND, such as retrograde ejaculation, hernias, and lymphatic leaks, but the probability of these events is low.
Next, the doctors discuss whether certain tumor markers can predict the relapse of an early stage testicular cancer. They agree that LDH is not an important marker to check, as it may be falsely elevated. An elevated AFP level can be concerning, but urologists should always put the value into context by comparing to the patient’s normal baseline levels and seeing if there is an upward trend. Finally, hCG levels can falsely be elevated by marijuana and hypogonadism. Then, the doctors share their imaging protocol. Standard chest, CT, and pelvic imaging is needed, and Dr. Bagrodia favors chest CT over CXR for better visualization. The doctors also note that more pre-operative imaging immediately before an orchiectomy is not always necessary if the surgeon already has recent imaging.
Additionally, the doctors explore approaching T2 testicular cancer, in which there are positive nodes confined to peritoneal nodes. Dr. Masterson and Dr. Cary agree that axial CT imaging is superior. More preoperative factors would be considered such as the focality of the lymph nodes involved, the duration of surveillance time, primary histology of the tumor, and the size of mass. Depending on which lymph nodes are positive (i.e. paraaortic, pelvic. etc.), a surgeon can choose the best RPLND template (modified, unilateral, bilateral). The doctors then explain their intraoperative and postoperative anesthesia protocol. They do not routinely administer DVT prophylaxis before surgery because of the risk of lymphatic leakage. Additionally, they are careful not to disseminate disease by disrupting tumor, which can cause abnormal patterns of metastases
Next, the doctors share their post-operative advice for patients. With regards to diets, a lower fat diet will lead to quicker recovery. Ejaculatory function remains normal for patients with unilateral surgery, but should recover within 8-12 months in patients with bilateral surgery. Surgical pathology can determine whether the patient should start adjuvant therapy. For N1 tumors, no adjuvant chemotherapy needed. For N2 tumors, the decision depends on histology and patient factors. Additionally, the doctors explain that extranodal extension does not always mean relapse is inevitable. For this reason, it is important to consider the histology of the tumor. The doctors end the episode by discussing new research on seminoma relapse.
In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with urologist Dr. Anne Schuckman from the University of Southern California about advantages and advice for blue light cystoscopy, a procedure performed to identify bladder tumors during transurethral resection of bladder tumor (TURBT).
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SHOW NOTES
Blue light cystoscopy causes the tumor cells that pick up dye to glow pink. According to Dr. Schuckman, urologists pick up 20% more tumors using blue light than they do with only white light. If they do not pick up these tumors with white light, the cancer is bound to recur because of unresected tumors. Using blue light cystoscopy during TURBT can lead to a more complete resection of the bladder tumor, therefore reducing the need for repetitive anesthesias events and resections, a reduction in bladder scarring and dysfunction overtime, and lessen the psychological impact of recurrent disease on patients. Blue light cystoscopy is most optimal in non-muscle invasive bladder cancer and carcinomas in situ but has not yet been extensively studied in muscle invasive disease.
Next, Dr. Schuckman shares some practice building tips for using blue light cystoscopy. She always scopes the patient with white light in the clinic first in order to identify the location of the tumor before heading to the OR. At USC, every patient receives a blue light cystoscopy during TURBT because changing workflow for each patient is hard on their system. Thus, it is easier on the staff to standardize the procedure for everyone. She then discusses the necessary materials for introducing blue light cystoscopy into a urology practice. Urologists will need to obtain Cysview, the medication that is inserted into the bladder 30 minutes to 1 hour before the cystoscopy to dye the tumor cells. Additionally, a cystoscope with white and blue light, a resectoscope, a light box, and an image generator are also necessary. She estimates that a blue light cystoscopy system will cost around $80-100k, and advises urologists to have a couple sets on hand in case of malfunction.
Finally, Dr. Schuckman shares technical advice for blue light cystoscopy. She encourages urologists to spend time washing the Cysview out of the bladder and avoiding bleeding when inserting the scope, as this can obscure the visual field. She performs a full white light cystoscopy and then a blue light cystoscopy in order to make a mental map of the bladder to determine the borders of her planned biopsy. She emphasizes that experience is the most important factor in gaining confidence with blue light cystoscopy, and notes that urologists can gain better white light cystoscopy skills through training with blue light cystoscopy as well. Finally, the two doctors agree that blue light cystoscopy is very sensitive and does have a greater false positive rate than white light cystoscopy.
In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with urologist Dr. Karim Bensalah from the Universitaire de Rennes and medical oncologist Dr. Rana McKay from UC San Diego about adjuvant therapy for advanced kidney cancer.
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First, the doctors discuss when to bring up adjuvant therapy. All three doctors agree that having the discussion early with patients is helpful to the patient and other specialties involved if the cancer is expected to be aggressive after reviewing initial imaging. Dr. Bensalah usually waits until the final pathology results arrive in order to determine the specifics of the adjuvant therapy treatment and refer his kidney cancer patients to medical oncology. He does not use nomograms if the patient does not ask for specific rates of recurrence. However, Dr. McKay uses nomograms often.
Next, the doctors discuss different oncological factors that may convince them to start their patients on adjuvant therapy, such as a large tumor size, advanced tumor stage/grade, an IVC thrombus, extrarenal metastases, and nodal involvement. Additionally, patients with multiple comorbidities and elderly patients may benefit from adjuvant therapy. Both Dr. Bagrodia and Dr. McKay agree that genomic sequencing of tumors is not helpful in making the decision to start adjuvant therapy, as there needs to be more research around this topic. Dr. Bensalah then explains the difference between approval and billing of tyrosine kinase inhibitors (TKI) in Europe.
Finally, the doctors discuss different clinical trials centered around the TKI Pembrolizumab (Keytruda). Dr. McKay notes that there have been very few positive trials and that she is reluctant to put her patients under a year of toxicity if there is a chance of overtreatment. Although many people have few mild side effects, severe side effects, such as diabetes, colitis, and fingernail necrosis, can be observed. Finally, the doctors discuss the importance of generating more research on the response of non clear cell renal carcinomas to adjuvant therapy. Currently, all these cancers are classified as one category but have different histology and response to therapies.
RESOURCES
Register for the 2022 International Kidney Cancer Society Symposium: https://www.kcameetings.org/2022-ikcs-north-america/
In this episode of BackTable Urology, Dr. Aaron Fritts talks with Dr. David Canes, a urologist and founder of WellPrept, a curated patient database that aims to improve and streamline patient education before their clinic visits.
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SHOW NOTES
First, Dr. Canes explains his motivation for starting WellPrept. Because he was always interested in entrepreneurship, he primed himself to look for problems in healthcare. One big problem he noticed that he and his colleagues were experiencing was burnout from explaining the same procedures over and over again to his urology patients. He found himself going through the motions, feeling disconnected from his patients, and not being able to have deeper conversations about their care. This realization motivated him to start sending basic information about procedures and conditions to his patients before their clinic visits. After initial success within his own practice, he decided to create WellPrept, a central hub for patient information from resources curated by individual physicians. Individual physicians or whole departments can pay for a subscription and share information with their own patients. Since its inception, WellPrept has encouraged physicians at a variety of institutions to create their own web pages with trusted content for their patients; some doctors have even created their own videos to explain procedures to patients.
Next, Dr. Canes speaks about the future direction of WellPrept. Although it is growing in popularity within the urologic community, he wants to expand WellPrept to other fields of medicine as well. He is also working on developing a shared library, or packages of crowdfunded patient education that every physician can share with their patients. Additionally, he is working with special societies and other databases to share more already published content through WellPrept, which he views as an effective delivery system.
He also discusses the adversities he has faced, such as reluctance from some colleagues. However, he has found a great start up community via social media platforms like Twitter and mentorship from venture capitalists and other entrepreneurs. Finally, Dr. Canes shares tips for work-life as a physician-entrepreneur.
In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses methods and benefits of smoking cessation in urologic oncology patients with Dr. Christian Fankhauser from Luzerner Kantonsspital and Dr. Richard Matulewicz from Memorial Sloan Kettering.
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First, the doctors discuss the role of urologists in taking charge of smoking cessation. Because smoking cessation directly minimizes surgical complication and increases longevity in urologic oncology patients. It is beneficial to have other medical professionals, such as physicians in other specialties (e.g. cardiology) and PAs, working to encourage smoking cessation as well.
Next, they discuss the initial intake of a smoking patient. Screening patients for smoking is not happening as commonly as it should. Additionally, it is important to use non-judgmental phrasing and tone in order to make the patient feel comfortable with sharing information. When screening for smoking, the 5A Model can be used: ask, advise, assess, assist, and arrange smoking cessation therapy. However, this method can take up a lot of time during the clinic visit. Thus, pre-visit questionnaires are efficient. When counseling a patient to quit smoking, it is best to set a quit date within 2-3 weeks before surgery. Some evidence-based benefits to smoking cessation include: inhibition of bladder cancer progression, increases in longevity, minimizing perioperative complications, prevention of erectile dysfunction and infertility, and the promotion of wound healing. Dr. Bagrodia also mentions that bladder treatment outcomes from adjuvant chemotherapy and intravesical therapy will improve with cessation. Some common cessation techniques are nicotine replacement therapy and stress reduction techniques.
The urologist can take the lead on smoking cessation or refer the patient to a counselor. In Europe, Dr. Fankhauser sends the patient to their general practitioner to initiate cessation therapy, while Dr. Matulewicz encourages urologists to learn how to document cessation encouragement as a separate billable service. Finally, the doctors share resources for urologists wanting to help their patients quit smoking. All three urologists agree that there should be more formal education initiatives about cessation for medical students and residents and that society guidelines should emphasize the importance of smoking cessation more strongly. Dr. Matulewicz encourages his patients to call the number 1-800-QUIT-NOW- to connect to state health departments, which provide nicotine replacement medications and trained counselors. Finally, Dr. Fankhauser discusses his smoking cessation research and emphasizes that it’s never too late for patients to stop smoking.
In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses radiation therapy for favorable intermediate-risk prostate cancer with radiation oncologist Dr. Amar Kishan, Chief of the Genitourinary Oncology Service for the Department of Radiation Oncology at UCLA.
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First, the doctors discuss important patient factors to consider when designing a radiation therapy regime. Dr. Kishan emphasizes the importance of considering the patient’s baseline characteristics and preferences. Because favorable intermediate-risk prostate cancer is curable, his top priority is optimizing post-operative quality of life in areas such as urinary function, bowel function, and sexual function. In order to measure baseline characteristics, he uses various questionnaires, such as the IPSS questionnaire and the SHIM score. Additionally, he takes a thorough patient history in order to screen for any contraindications for radiation, such as a history of pelvic radiation, active inflammatory bowel disease, radiosensitivity syndromes, and lower urinary tract symptoms (LUTS). He mentions that TURP and HoLEP procedures are not contraindications for radiation therapy, but recommends waiting 12 weeks after the operation to start radiation because of the risk of hematuria. He also recommends MRI for imaging.
Additionally, he discusses the option of combining radiation therapy with adjuvant androgen deprivation therapy (ADT). Because the likelihood of curing favorable intermediate-risk prostate cancer with radiation monotherapy is high (90% over 7-10 years), ADT is often not required. However, he considers ADT if the Gleason score and volume of disease point to a more aggressive prostate cancer. He also uses the Decipher test, a molecular test that helps him decide whether or not to include ADT in a patient’s treatment regime. Dr. Kishan notes that de-intensifying conventional therapy must be based on evidence and towards a goal of reducing the absolute risk of the patient.
Dr. Kishan also explains the different radiation therapy options. There are two main categories: external beam radiation and brachytherapy (internal radiation). External beam radiation delivers an X-ray dose daily. The conventional timeline is 9 weeks of therapy but a shorter 5-day SBRT course can be used. Brachytherapy is a surgical procedure in which the surgeon places radioactive pellets inside the prostate. The pellets are left inside the patient in low-dose brachytherapy, while they are removed after 15-20 minutes in high-dose brachytherapy. Dr. Kishan believes that an extra boost of brachytherapy is not required and can in fact introduce more toxicities. Contraindications to brachytherapy include bleeding risks, anesthesia risks, larger prostates (large median lobe), and pubic arch interference. For external beam radiation, spacers for patients with rectal problems and fiducial markers may help with narrowing margins needed for treatment, since the prostate is a mobile organ.
Finally, Dr. Bagrodia and Dr. Kishan delve into a discussion about recent radiation therapy trials and briefly discuss the field of radiogenomics, an area that is developing DNA screening tests to predict idiosyncratic reactions to radiation therapy.
In this episode of BackTable Urology, Dr. Jill Buckley, professor of urology at UC San Diego, interviews Dr. Jack McAninch, professor emeritus of urology at San Francisco General Hospital and an international leader in the field of genitourinary trauma and reconstructive surgery.
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First, Dr. McAninch delineates his path to becoming a doctor. He grew up in Merkel, a small Texan town, and worked on an oil rig after high school to save money for college tuition. He attended Texas Tech University and majored in animal husbandry. After college, he received a master’s degree in animal science from the University of Idaho. However, during his time in graduate school, he was required to take various pre-medical classes and discovered a passion for medicine. He applied to and received an acceptance to the University of Texas Medical Branch in Galveston. During his time in medical school, he worked as a research assistant in the plastic surgery department and discovered his interest in surgery and reconstruction. However, he chose urology as his specialty as the hours and training were less demanding than plastic surgery. He decided to enlist in the army and was sent to Letterman Army Hospital in San Francisco to complete his urology residency. During his time there, he operated on many Vietnam war soldiers and gained valuable insight in acute care and reconstructive surgery. After being stationed in Germany for 3 years, he returned to San Francisco and was recruited to San Francisco General Hospital to start a reconstructive urology program. As the only reconstructive urologist, he worked closely with the general and trauma surgeons to manage a high-volume caseload. He then went on to start the first fellowship in reconstructive urology at UCSF.
Next, Dr. McAninch explains his different leadership roles throughout his career, including being an original board member of the Society of Genitourinary Reconstructive Surgeons (GURS), the president of the American Board of Urology, the president of the American Urological Association, and an important leader representing the urologic field in the American College of Surgeons. Finally, Dr. Buckley and Dr. McAninch end the discussion by reflecting on the phenomenally rapid technological advancements that have been made in the field of urology.
RESOURCES
Society of Genitourinary Reconstructive Surgeons https://societygurs.org/
In this episode of BackTable Urology, Dr. Silva interviews Dr. Katie Murray, a urologic oncologist from the University of Missouri, about management of high and low-grade upper tract urothelial cancer.
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Dr. Murray prefaces the discussion by explaining that historically, upper tract urothelial cancer (UTUC) has been treated similarly to bladder cancer, but the two malignancies are actually very different. For this reason, there are no set guidelines for the management of UTUC in the United States. Then, she describes her typical workup of a UTUC patient. ALthough most of her referrals are from general urologists who already diagnosed UTUC in patients, she sometimes gets referrals for patients with gross/microscopic hematuria that leads to a de novo diagnosis of UTUC. Dr. Murray will perform a routine cystoscopy and a ureteroscopy on her patients; she prefers the Olympus scope with narrow band imaging and a flexible ureteroscope without a ureteral access sheath, respectively. She does not always perform a retrograde pyelogram because her decision depends on the patient’s comorbidities and cytology results.
Then, Dr. Murray explains her surgical techniques for managing UTUC. For low-grade and small tumors, she will perform an endoscopic ablation during the biopsy if the tumor is easy to remove. For larger tumors, she will only perform a biopsy and further evaluate the patient for the next steps. She notes that all biopsies have a risk of spreading the cancer along the ureter, as urothelial cancer can implant anywhere in the tract during the procedure. Additionally, although she does not use balloon dilation during biopsies, she places a stent instead. For visualization, she uses the single action pump system (SAPS). Finally, she explains the importance of intravesical therapy after ablation.
Next, Dr. Murray explains the difference in managing low versus high-grade UTUC. Low grade UTUC has a high recurrence rate (over 50%). For low grade tumors, endoscopic ablation is her first-line treatment. She also recommends a six-week course of JELMYTO, a mitomycin gel as a non-surgical option. She uses a cystoscope or nephrostomy tube to deliver the JELMYTO medication. For patients with a high-grade tumor, Dr. Murray only performs an ablation if the patient has contraindication to every other surgical procedure. For distal high-grade UTUC, she performs a distal ureterectomy with a node dissection and follows with a ureteral implant. For proximal high-grade UTUC in the renal pelvis, she will perform a nephroureterectomy. In all high-grade tumors, she emphasizes the importance of thorough assessment of pelvic nodes and chest/abdomen/pelvis imaging to accurately stage the cancer. When deciding whether to start neoadjuvant chemotherapy before surgery, Dr. Murray recommends collaborating with the oncologist.
Lastly, Dr. Murray explains her approach treating a patient with bilateral UTUC, which is to prioritize surgical management of the worst side first.
In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Sam Chang, chief of urologic oncology at Vanderbilt University, about surgical tips and tricks for intermediate and high risk bladder cancer.
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SHOW NOTES
First, the doctors discuss important considerations during the initial patient visit. Dr. Chang emphasizes that reviewing previous evaluations and treatments is important for patients with recurrent disease. Also, if the patient is a current smoker, smoking cessation should be encouraged. Dr. Chang will not perform a cystoscopy if the lesion is obvious. However, he acknowledges that this procedure may be necessary if the imaging is ambiguous. Some tips and tricks he shares for blue light cystoscopy include: using lidocaine, applying pressure when passing the scope, and training effective procedure nurses. He notes that residents will greatly improve their cystoscopy skills as they gain more experience.
Next, Dr. Chang shares his tips for a transurethral resection of bladder tumor (TURBT). He usually employs a bipolar TURBT and starts resecting in a normal-appearing bladder, being sure to balance speed with judiciousness when resecting. Additionally, he tries to obtain pathologic specimens from various tissue sites and the appropriate tissue layer orientation in order to facilitate pathological analysis of the tumor. Further, he notes that thorough OR dictation matters greatly, especially if the patient transfers to the care of a different provider or if a revision surgery is needed. He encourages urologists to give as many details as possible about the appearance, location, size, and nature of the tumor. For bladder carcinoma in situ, Dr. Chang cauterizes the tumor instead of resecting it in order to spare the specimen from destruction. For tumors involving the diverticulum, he obtains his sample with extra caution, as this location increases the possibility of tumor spillage. Then, the doctors compare and contrast different types of intravesical therapy.
Finally, the doctors discuss postoperative TURBT care. Dr. Chang usually does not place a postoperative stent because most of his patients do not develop stenosis. However, in cases of CT-proven hydronephrosis, a stent is necessary. He will also leave a catheter in all his patients for 3-4 days to prevent clot retention during recovery. Finally, he prescribes post-operative maintenance gemcitabine. Revision resection procedures if there was lots of tumor left behind after the first surgery or if the tumor was present in a difficult anatomic location. Dr. Chang repeats the resection before administering intravesical therapy. Lastly, he emphasizes that in cases of muscle-invasive bladder tumors, he would rather get rid of all the tumor than worry about preserving muscle.
In this episode of BackTable Urology, Dr. Jose Silva interviews Dr. Amy Pearlman, director of the Men’s Health Program at the University of Iowa, about building a men’s health program, managing her digital footprint, and her role as a female physician in men’s health.
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SHOW NOTES
First, Dr. Pearlman outlines her journey to becoming a urologist specializing in men’s health. She completed her medical degree at Baylor College of Medicine, urology residency at the University of Pennsylvania, and a fellowship in urologic reconstruction at Wake Forest. She recounts the people she met and the skills she acquired during training that prepared her to build her own men’s health program at the University of Iowa. Next, she explains the purpose of her men’s health program, which is to build a referral network made of multidisciplinary physicians. She sees herself as a “matchmaker” for male patients and different providers who can treat the right conditions at the right time. Two strategies that helped her build her network quickly were: emailing department chairmen for referral recommendations and directly asking physicians which patient cohorts they most prefer to see. Additionally, she encourages doctors to connect patients to providers outside of academic institutions. For example, she has extensive connections with pharmacists, rehab specialists, and medical device representatives who also specialize in men’s health.
Then, Dr. Silva and Dr. Pearlman discuss the role of social media in medicine. Dr. Pearlman notes that social media has helped her immensely with growing her practice and networking outside of her own institution. Although she mainly uses Twitter to manage her professional network, she has had great success in educating patients via her Youtube videos about sexual dysfunction and treatments. Besides providing patient education, these videos allow patients to assess whether Dr. Pearlman would be the right fit as their urologist. Furthermore, each of her patients recieve an informational packet about sexual health before they see her in clinic. She feels that these packets normalize the conversation around sex and primes patients to ask relevant questions during the visit.
Lastly, Dr. Pearlman shares her helpful tips for urologists to have conversations about sex with their patients. She usually starts by explaining basic anatomy to her patients, not making any assumptions about previous knowledge and bringing in model diagrams. Also, she has found it helpful to compare genitalia and sexual dysfunction to other body parts and common injuries in order to emphasize the medical nature of erectile dysfunction and importance of rehab. Also, as a female urologist, she has an important role in educating men about female anatomy. Finally, she acknowledges the important correlation between partner relationships and sexual dysfunction, and prioritizes the mental health of her patients.
In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses tips and tricks for radical and partial prostatectomies with Dr. Rafael Coelho, Chief of Urology Oncology at the University of Sao Paulo School of Medicine.
SHOW NOTES
First, the doctors discuss which preoperative information is most important to obtain. Dr. Coelho orders an MRI for every patient scheduled to undergo a prostatectomy because it is specific for extraprostatic extension of the tumor and indicates whether patients are viable candidates for the nerve-sparing technique. However, because negative MRIs are inconclusive, microscopic extraprostatic extension is still possible in patients with clear imaging. He also notes that nomograms for intermediate-risk patients with local disease.
Next, he delves into his surgical tips for a successful prostatectomy. To avoid incontinence, he uses a partial bladder neck sparing technique but also notes that a good bladder neck reconstruction at the end of the prostatectomy case can resolve postoperative incontinence as well. He generally avoids interfering with the dorsal venous complex as well. As far as lymph node dissections go, he follows evidence-based research and only performs an extended lymph node dissection on patients with a Gleason score of 8, 9, or 10. However, infected lymphoceles are serious complications of lymph node dissections. The doctors then discuss their individual initial approaches to radical prostatectomy and weigh the pros and cons of each one.
Additionally, Dr. Coelho strongly prefers to use a nerve-sparing technique, a decision that balances the oncological outcome and functional outcome of a patient. This technique requires a retrograde release of the neurovascular bundle and helps the surgeon define the border between the pedicle prostate and bundle more clearly. Dr. Coelho notes that this approach is also optimal for preservation of the dorsal venous complex. Dr. Bagrodia recommends using non-thermal energy sources if the nerve-sparing technique is used. A partial nerve-sparing is also an option if the surgeon determines that a small pathological margin may not affect long-term oncological outcome of a patient. Once again, Dr. Coelho emphasizes that the nerve-sparing technique of a prostatectomy is complicated, and surgeon experience matters most when optimizing outcomes.
Lastly, the doctors talk about the preservation of postoperative complications–mainly continence and sexual potency. Although some patients may experience incontinence, long-term incontinence is rare. However, long-term potency is much harder to predict because potency is multifactorial; factors such as sexual partner, anxiety, age, baseline sexual function prior to surgery all affect postoperative potency. Dr. Coelho adds that, based on his research, age and baseline sexual function are most important in predicting postoperative potency.
RESOURCES
Lestingi, J., Guglielmetti, G. B., Trinh, Q. D., Coelho, R. F., Pontes, J., Jr, Bastos, D. A., Cordeiro, M. D., Sarkis, A. S., Faraj, S. F., Mitre, A. I., Srougi, M., & Nahas, W. C. (2021). Extended Versus Limited Pelvic Lymph Node Dissection During Radical Prostatectomy for Intermediate- and High-risk Prostate Cancer: Early Oncological Outcomes from a Randomized Phase 3 Trial. European urology, 79(5), 595–604. https://doi.org/10.1016/j.eururo.2020.11.040 PubMed link: https://pubmed.ncbi.nlm.nih.gov/33293077/
de Carvalho, P. A., Barbosa, J., Guglielmetti, G. B., Cordeiro, M. D., Rocco, B., Nahas, W. C., Patel, V., & Coelho, R. F. (2020). Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes. European urology, 77(5), 628–635. https://doi.org/10.1016/j.eururo.2018.07.003 PubMed link: https://pubmed.ncbi.nlm.nih.gov/30041833/
Dr. Aditya Bagrodia talks with Dr. Lee Zhao, director of the Male Reconstructive Surgery program at NYU Urology, about indications, surgical techniques, and post-operative management for patients requiring upper tract ureteral reconstruction.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia talks with Dr. Lee Zhao, director of the Male Reconstructive Surgery program at NYU Urology, about indications, surgical techniques, and post-operative management for patients requiring upper tract ureteral reconstruction.
First, Dr. Zhao outlines his indications for upper tract reconstruction in patients with ureteral strictures. Most of his patients come from subspecialized urologists, while the other half come from self-referral. Before surgery, Dr. Zhao assesses three areas: kidney function via a renal scan, the anatomy and location of the stricture via antegrade and retrograde pyelograms, and assessment of bladder function via a cystogram. Additionally, he takes pre-existing stents out to allow the ureter to rest.
If a patient has a stricture less than 2 cm long, endoscopic management may be possible. However, if the stricture is longer than 2 cm, Dr. Zhao utilizes robotic surgery. Although he and Dr. Bagrodia discuss both single port and multiport approaches, he prefers the single port approach. He usually tries to avoid interfering with adhesions from previous surgeries and performs a concurrent ureteroscopy while gaining access. Only in cases involving obliterative strictures does he consider nephropexy.
For simple cases involving virginal abdomens, Dr. Zhao usually performs a primary ureteroureterostomy (UU). For longer strictures, he will choose to place a graft. He uses two types of grafts depending on which ureter is affected. For left sided strictures, he will perform a buccal mucosa ureteroplasty. For right sided strictures, he will use an appendiceal graft. Both grafts are able to fix strictures up to 10 cm in length. For longer strictures, he will create an ileal ureter, in which he makes an anastomosis between the ureter and the bowel. A trans UU is unusual to perform because complications are possible that will cause both tracts to fail. Dr. Zhao treats mid and proximal ureteral strictures the same but adds that Boari flaps may also be an option in mid-ureteral strictures. For distal ureteral strictures, boari flaps, psoas hitch, and other procedures can be considered instead. For distal ureteral strictures, Dr. Zhao prefers to do a non-transecting reimplant, which consists of making a longitudinal incision of ureter at stricture and dropping the bladder down to the level of stricture. This technique is best to preserve inferior blood vessels, which can be useful in patients who have fragile vascular supply from radiation therapy.
Finally, the doctors discuss post-operative management of reconstruction patients. Dr. Zhao does not routinely place a stent in all his patients and instead saves them for his buccal mucosal graft patients. Similarly, because he assesses the integrity of his anastomoses in the OR through retrograde filling or with the ureteroscope, he rarely places a drain after surgery. Finally, he prescribes post-operative antibiotics conservatively depending on the surgical technique chosen.
Dr. David Canes and host Dr. Aditya Bagrodia talk about attitudes, practices, and anecdotes to help resident and attending surgeons avoid complications.
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SHOW NOTES
In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. David Canes from Lahey Medical Center about attitudes, practices, and anecdotes to help resident and attending surgeons to avoid surgical complications.
First, the doctors discuss pre-operative rituals. Both doctors agree that reviewing relevant films and picturing the operation step-by-step is very important. Additionally, they emphasize the importance of putting the patient at ease before the surgery. Dr. Canes leaves sticky notes on patient charts that remind him of small personal details about the patient. He usually mentions these details to the patient the morning before their surgery in order to put them at ease. Dr. Bagrodia prefers to call his patients and reassure them the night before the operation. In the OR, Dr. Canes always takes his time-out meetings seriously and makes sure that everyone is able to introduce themselves. Dr. Bagrodia usually takes a moment of silence to personally reflect on the patient before starting the operation.
Next, they discuss the qualities of successful surgeons who encounter minimal complications. Although Dr. Canes concedes that technical skills are important, he thinks that the surgeon mindset is just as important. He emphasizes the importance of approaching surgical procedures systematically, breaking every big step down into smaller microsteps for precision. For difficult cases, he encourages surgeons to engage the opinion of trainees, PAs, and nurses in the OR. In these situations, he believes that patient outcomes should take precedence over pride and ego. Additionally, he highlights the importance of controlling emotions, heart rate, and respiratory rate during complications in order to think rationally.
Finally, the doctors discuss the benefits of collaboration and co-operating. Dr. Canes encourages surgeons to stop by different ORs in order to learn new techniques.
Dr. Neil Desai, a radiation oncologist with UT Southwestern, shares his perspectives on radiation therapy indications, algorithms, side effects, and prognoses for unfavorable intermediate risk prostate cancer patients.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Neil Desai, a radiation oncologist from UT Southwestern, about radiation therapy indications, algorithms, side effects, and prognoses for unfavorable intermediate risk prostate cancer patients.
Intermediate risk prostate cancer is defined by a Gleason grading score of 7 or more and a PSA level above 10 ng/mL but below 20 ng/mL. Radiation therapy is a common unimodal or multimodal therapy in these prostate cancer patients. Dr. Desi recommends additional imaging via MRI to stage the cancer before starting treatment. Additionally, bone scans and colonoscopies may be beneficial in order to find metastases and colon cancer, respectively, that can also be treated with radiation therapy (RT).
A thorough patient history is important to obtain before choosing a radiation therapy option. Dr. Desai divides his history into 2 different categories-–patient-specific factors and disease-specific factors. For patient-specific factors, baseline urinary symptoms, metabolic disorders, hormonal disorders, patient preferences, and baseline sexual potency are important. Contraindications under this category include connective tissue disorders, ulcerative colitis, and Crohn’s disease. Prostate anatomy, such as large median lobes, also need to be assessed. Dr. Desai emphasizes that many of these contraindications do not totally rule out the possibility of radiation therapy, but just warrant careful consideration of the intensity of radiation used on the patient. Next, he discusses disease-specific factors, such as the efficacy of androgen deprivation therapy (ADT). The majority of prostate cancer patients are started on ADT for 4-6 months first, and then begin RT.
Next, Dr. Desai summarizes his explanation of RT to his patients. He starts by delineating the differences between internal and external RT, which exist on a continuum. Based on which RT option the patient chooses, the acuity and duration of lower urinary tract symptoms (LUTS) will vary. The RT option he most commonly recommends to patients without contraindications is brachytherapy with an external beam, which results in less cancer recurrence but more LUTS. However, he acknowledges that brachytherapy may not be offered in all centers, may have reduced efficacy in big prostates, and may be an unfavorable choice in patients with severe LUTS. In these cases, conventional fractionation, hypofractionation, or ultra hypofractionation are better options. Furthermore, Dr. Desai dives into more technical aspects of RT, such as the importance of a full bladder as a form of protection from external beam RT and the superiority of photon-based RT over proton-based RT. Additionally, he recommends measuring PSA levels after 3 months post-RT to minimize the chance of picking up noise. He mentions that physicians should address the “PSA bounce”, a fluctuation of PSA level post-RT followed by a transient resolve, with their RT patients because it may be a source of patient anxiety.
Finally, Dr. Desai highlights the importance of the collaboration between urologists and radiation oncologists. The patient should be made aware that both specialties are in communication and feel comfortable discussing treatment options with both sides. Dr. Desai will usually advise his patients to meet with their urologists before making a final decision on their radiation therapy. Also, it is important for both sides to coordinate any new tests and check in periodically with patients.
Dr. Davies shares his valuable insights about post-operative opioid studies, disproves some myths about NSAIDs, and explains his pre-operative and post-operative pain management regimen.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Ben Davies, Director of Urologic Oncology at the University of Pittsburgh Medical Center, discuss non-opioid approaches for post-operative patients.
First, Dr. Davies discusses diversion as an indirect problem with prescribing too many opioids because many urologists forget that patients with opioid prescriptions can have family members and close contacts who have access to these pills as well. According to Dr. Davies, data shows that post-operative urologic surgery patients have a rate of addiction of 1-2% when prescribed opioids. In his opinion, most patients who undergo urologic procedures, such as cystectomies, TURPs, and partial nephrectomies, do not need narcotics for post-operative pain management. Prospective studies done in the general surgery and urological surgery field prove that there is no difference in satisfaction between patients who manage their pain via non-opioid and opioid approaches. Furthermore, opioids may cause idiosyncratic results in post-operative patients, such as anxiety and GI problems.
Next, Dr. Davies disproves some myths about NSAIDs. He does not agree with the practice of holding off NSAIDs for a week post-operatively, Also, he sees no problem with giving oral Tylenol to NPO patients. He strongly believes that bleeding risk and kidney damage as a result of toradol is minimal, and explains that creatinine levels always rise a bit post-operatively. He encourages urologists to walk their patients through the post-op pain regimen before surgery and to have pamphlets ready for distribution. Dr. Davies explains that for the most part, patients understand that opioid-related mortality deaths are rising and that 90% fentanyl and heroin users start with opioids. He also discourages doctors from prescribing extra opioid pills to patients.
Then, Dr. Davies explains his pre-operative and post-operative pain management regimen. Pre-operatively, he uses Tylenol, gabapentin, and celebrex. Intraoperatively, he uses IV ketamine, propofol, and precedex. As patients are waking up from surgery, he will give toradol. Post-operatively, he will prescribe Tylenol and Motrin. Finally, he emphasizes the need for buy-in from the hospital administration for a non-opioid approach. He discusses the importance of meeting with hospital administration and nurses to change the pain management culture of an institution. In his personal experience, he made a quality improvement project out of his non-opioid approach and figured out his personal strategy towards pain management before presenting it to his department.
RESOURCES
Pekala KR, Jacobs BL, Davies BJ. The Shrinking Grey Zone of Postoperative Narcotics in the Midst of the Opioid Crisis: The No-opioid Urologist. Eur Urol Focus. 2020 Nov 15;6(6):1168-1169. doi: 10.1016/j.euf.2019.08.014. Epub 2019 Sep 26. PMID: 31563546.
Yu M, Davies BJ. Opium Wars to the Opioid Epidemic: The Same Narcotics Cause Addiction and Kill. Eur Urol. 2020 Jan;77(1):76-77. doi: 10.1016/j.eururo.2019.10.006. Epub 2019 Nov 8. PMID: 31711720.
“Dreamland” by Sam Quinones https://samquinones.com/dreamland
“The Least of Us” by Sam Quinones https://samquinones.com/theleastofus
Aditya Bagrodia (UCSD Urology), Dr. Casey Seideman MD (OHSU Urology), and Dr. Jeff Cadeddu (UTSW Urology) share their experiences and advice for dealing with complications as surgeons.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia (UCSD Urology), Dr. Casey Seideman (OHSU Urology), and Dr. Jeff Cadeddu (UTSW Urology) discuss their experiences and advice for dealing complications as surgeons.
First, the doctors talk through dealing with complications in the operating room. The doctors emphasize the importance of maintaining a composed appearance in a state of urgent need and preparation for adverse events. For expected complications like blood loss, the surgeon can set up tools to deal with an adverse scenario, such as suction and communication with anesthesia. Furthermore, it is important to teach trainees to go through all the possible post-operative complications and develop a strategy to detect and manage them. For unanticipated issues, Dr. Cadeddu believes surgeons should think about why they did not think of and prepare for the outcomes, which is often a problem of infrequent exposure to a type of complication.
Next, the doctors discuss how to deal with feelings of self-doubt and guilt after a complication has occurred. Dr. Seideman has learned to allow herself to acknowledge these negative emotions, as they are normal feelings; similarly, Dr. Cadeddu urges surgeons to keep their sense of empathy. Both doctors agree that having someone to talk to after adverse outcomes is important, whether it be an attending, a colleague, the department chair, or even a family member. They agree that morbidity and mortality boards are important, but do not have therapeutic value.
Finally, the doctors talk about the importance of using institutional resources for support, such as other colleagues, support groups, and mental health hotlines.
In this episode of BackTable Urology, Dr Jose Silva and Dr. Esther Han discuss diagnosis and management of interstitial cystitis in women.
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In this episode of BackTable Urology, Dr. Jose Silva and Dr. Esther Han, a FPMRS physician specializing in bladder and pelvic floor health, discuss diagnosis and management of interstitial cystitis in women.
Firstly, Dr. Han explains her workup of patients with suspected interstitial cystitis (IC). Because an accurate diagnosis of IC is so rare, she sends out multiple questionnaires to her patients before their appointments and performs thorough physical exams. Upon physical examination, other conditions may appear to be more likely than IC, such as genitourinary syndrome of menopause (GSM), lichen sclerosus, vaginal atrophy, or vulvodynia. She always assesses the pelvic floor to look for hypertonicity and knots. Another common cause of bladder pain is overactive bladder (OAB) and recurrent urinary tract infections (UTI), for which she can prove with a positive bacterial culture. Aside from the physical exam, she also gets a post-void residual urine test and a urinalysis. IC falls into two subtypes–IC with Hunner’s lesions and IC without Hunner’s lesions. The latter subtype is more common and is rarely seen in younger patients and patients with frequency symptoms. For this reason, Dr. Han does not regularly perform cystoscopies on young patients. Additionally, many patients with bladder pain will not be able to tolerate a cystoscopy procedure, so she relies on the physical exam and a health history to make a diagnosis.
Treatment for bladder and pelvic pain is multimodal–many of her patients will work with physical therapists and pain management physicians for their chronic pain. Her first-line therapy for bladder pain is pelvic floor physical therapy, although the pain may get worse before it improves with therapy. She also recommends suppository vaginal Valium if needed, but thinks that more research should be done on suppository CBD. She does not prescribe opioids for pain management. If the patient has vulvodynia, hormone therapy with estrogen/testosterone creams is her chosen treatment. She notes that it is important to explain to patients that local application of estrogen does not increase their chance of developing breast cancer.
Her second-line therapy includes amitriptyline, for anxiety-driven IC, and IC cocktails, which should only be continued if the patient’s symptoms are improving. Her third-line therapy is repetitive hydrodistention, but she only performs this procedure in patients with Hunner’s lesions. Additionally, Cyclosporin A should only be used exclusively in patients with Hunner’s lesions. If the patient is experiencing concurrent pudendal pain, Stimwave pudendal neuromodulation is a possibility. Dr. Han uses clues, such as pain while sitting down, excessive standing, and pain relief when laying down to diagnose patients with pudendal pain. Her last resort to bladder pain is a cystectomy, or complete removal of the bladder. She notes that this method is not very effective, as patients may experience phantom pain. For this reason, she makes sure to explore all other options and thoroughly counsel her patients before performing this procedure.
Finally, Dr. Silva and Dr. Han discuss the evidence-based correlation between bladder pain and sexual abuse. Dr. Han encourages urologists to create a safe space for their patients to share their experiences and get quality referrals to counselors.
We talk with Dr. Scott Eggener about the importance of practical PSA screenings and shared decision making with patients. Dr. Eggener advocates for the prevention of overdiagnosis and overtreatment in prostate cancer.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Scott Eggener, director of the High Risk and Advanced Prostate Cancer Clinic at UChicago Medicine, discuss the importance of practical PSA screenings and shared decision making with patients. Dr. Eggener advocates for the prevention of overdiagnosis and overtreatment in prostate cancer.
First, the doctors shared their approaches to prostate screening in a high risk patient. Dr. Eggener considers patients to be at high risk for prostate cancer if they have a positive family history of prostate, breast, ovarian, or pancreatic cancer. Also, the risk of developing prostate cancer is higher in patients with African and Ashkenazi Jewish ancestries. For high risk patients, he recommends annual PSA screenings but rejects the notion of a concrete threshold number. Instead, Dr. Eggener recommends comparing PSA screening values to the patient’s original baseline PSA value. He emphasizes that because the majority of prostate cancers are slow growing, a rapidly rising PSA can mostly be attributed to infection, inflammation, or another inciting event. For this reason, he always performs a repeat PSA screening a couple months after the initial abnormal test is obtained.
In healthy patients with no family history of cancer, Dr. Eggener recommends initial PSA screening between 45-55 years old. Additionally, a “normal” PSA value is age-dependent. He estimates that a value of 0.6 ng/ml is normal for patients in their 40s, while 0.9 ng/ml is normal for patients in their 50s. For any value above 1.5 ng/ml, he will perform a digital rectal exam (DRE) to gain more information about prostate size.
In patients with an elevated PSA as well as an abnormal DRE, Dr. Eggener will obtain MRI imaging to look for prostatic lesions. If the MRI is clear and the patient has no other risk factors besides an elevated PSA, he will recommend PSA screening every 1-2 years. If the MRI shows prostatic lesions, he will continue with a biopsy. However, Dr. Eggener acknowledges that cancer may be a possibility in patients with clear MRI scans, as imaging can sometimes be inaccurate. Thus, he sometimes chooses to biopsy high-risk patients with normal MRI scans as well.
Finally, the doctors discuss the advantages and disadvantages of new screening tools, such as Next-Generation biomarkers and polygenic risk scores, in diagnosing prostate cancer.
Dr. Jose Silva y Dr. Fernando Cabrera, urologista de Cleveland Clinic en Florida, hablan sobre el diagnóstico y tratamiento de cálculos renales y ureterales. Los doctores discuten cuáles pacientes necesitan la intervención, los métodos quirúrgicos para romper los cálculos, y consejos sobre cada tipo de terapia.
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En este episodio de BackTable Urology, Dr. Jose Silva y Dr. Fernando Cabrera, urólogo de Cleveland Clinic en Florida, hablan sobre el diagnóstico y manejo de cálculos renales y ureterales.
Primero, los doctores discuten cuáles pacientes necesitan la intervención. Dr. Cabrera nota que la mayoría de pacientes pueden pasar un cálculo simple. Usualmente, cálculos pequeños y distales pueden ser manejados con medicamentos e hidratación, como una prueba de paso. Pero en casos más complicados–como en el caso de un cálculo obstructivo y proximal, un cálculo infectado, o una cálculo ubicado en un área difícil. Adicionalmente, Dr. Cabrera enfatiza que la sepsis es una emergencia y los urologistas deben observar por los síntomas de fiebre, altos recuentos de glóbulos blancos, e hipotensión. Dr. Cabrera prefiere usar el tomografia (CT scan) para visualizar los cálculos. Para un cálculo distal, es importante visualizar la pelvis también.
Próximo, Dr. Cabrera comparte sus consejos sobre cada tipo de terapia. Para empezar, discute su método de una prueba de paso. Prescribe a su paciente Flomax y un NSAID y se reúne con el paciente periódicamente. Si el paciente no puede pasar el cálculo en cuatro a seis semanas o sufre de dolor nuevo, Dr. Cabrera hace un segundo estudio tomográfico de baja radiación y explora la intervención quirúrgica.
Entonces, Dr. Cabrera discute los métodos quirúrgicos para romper los cálculos. No hace mucho la litotripsia por onda de choque, porque no es más eficiente que la ureteroscopia o PCNL en muchos de sus pacientes. Sin embargo, explica las tres opciones a cada paciente antes de escoger una terapia. Próximo, Dr. Cabrera describe los medicamentos preoperatorios y postoperatorios y sus herramientas (visores, fundas, láseres, etc.) y procedimientos para la ureteroscopia y PCNL. Curiosamente, nota que aunque usa el láser holmium y el láser thulium para litotripsia, prefiere el láser thulium porque es más bien organizado y provee buen enfoque. También, durante la ureteroscopia, usa el cable de seguridad en casos de cálculos complicados. En resumen, Dr. Cabrera y sus colegas tratan de evitar las nefrectomías cuando pueden.
We talk with urologist Dr. Jay Shah, leader of urologic oncology at the Stanford Cancer Center, about seizing leadership opportunities in the world of academic medicine.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews urologist Dr. Jay Shah, leader of urologic oncology at the Stanford Cancer Center, about seizing leadership opportunities in the world of academic medicine.
First, the doctors discuss the importance of finding a niche for their medical practice and research. Dr. Shah encourages young faculty members to identify a specific interest within their field and start research related to that topic. Although it was hard for him to prioritize his niche at first, he realized that gaining knowledge in quality improvement, his chosen niche, was much easier when he merged both his clinical and academic work.
Then, Dr. Shah and Dr. Bagrodia discuss the challenges of a mid-career change. Dr. Shah moved from MD Anderson to Stanford, while Dr. Bagrodia moved from UT Southwestern to UC San Diego. Both doctors agreed that changing institutional cultures and practices can be daunting; however, they noted that it was important to build credibility and to keep an open mind about listening to the ideas of their new colleagues. Dr. Shah believes that new faculty may take up to four years at their new institution before they start to feel comfortable in their new position. Dr. Bagrodia then warns against having unrealistic nostalgia for old institutions.
Finally, the doctors suggest ways to build leadership skills and gain leadership experience within the field of urology. Both doctors found leadership courses and having an executive leadership coach helpful. They also encourage young urologists to get involved in committees of urological societies, including the American Urological Association.
We talk with Dr. Shahrokh Shariat, chairman of Urology at the Medical University of Vienna, about diagnosis and management of upper tract urothelial carcinoma (UTUC) as well as differing AUA and EAU approaches to these malignancies.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Shahrokh Shariat, chairman of Urology at the Medical University of Vienna, about diagnosis and management of upper tract urothelial carcinoma (UTUC) as well as differing AUA and EAU approaches to these malignancies.
First, the doctors discuss common history and physical examination findings of patients with UTUC. Hematuria is the the most common sign, followed by flank pain and hydronephrosis. 10-15% of UTUC patients will also have Lynch syndrome, which is a condition that indicates a genetic predisposition to UTUC as well as other cancers. After initial hematuria workup, imaging of the upper tract and kidney must be obtained. Dr. Shariat obtains a CT urogram and an ultrasound for patients with suspected UTUC but waits until a tumor is identified to get a chest X-ray. Indirect signs of UTUC are: filling defects, thickening of the ureter wall, and hydronephrosis.
Performing a ureteroscopy is the next step in UTUC patients. A ureteroscopy obtains adequate specimen for grading and reveals tumor behavior and location. A ureteroscopy can also be used as a therapeutic approach if kidney preservation is possible. Dr. Shariat uses a “no touch technique” in which he uses an access sheath to prevent tumor seeding. He prefers to use a flexible ureteroscope, a holmium laser, and a basket for collection. After ureteroscopy, he places a double J stent in his patients and waits for 6 weeks before taking a second look and starting alternating imaging, if needed.
Surgical intervention may be required to treat non-metastatic UTUC. Dr. Shariat usually administers four rounds of neoadjuvant chemotherapy to his patient before operating. He recommends checking the patient’s renal function to see if cisplatin-based therapy can be tolerated. Dr. Bagrodia and Dr. Shariat then compare the outcomes of cisplatin and carboplatin-based therapy.
Next, Dr. Shariat shares his tips for segmented ureterectomy. Although this procedure is relatively uncommon, he advocates for careful closure, intraoperative chemotherapy, and clipping the ureter above and below the tumor to prevent seeding.
To end the episode, the doctors discuss new UTUC therapeutic options, such as JELMYTO, a gel-based chemotherapy administered through a catheter. Finally, Dr. Shariat emphasizes once more that UTUC is a heterogenous cancer that requires multimodal therapy.
Special guest The White Coat Investor James M. Dahle talks with Christopher Beck about where physicians can start when it comes to financial literacy, including common financial mistakes docs make when start practicing, a primer on mortgage rates, and tips on insurance.
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In this episode, White Coat Investor founder Dr. James Dahle and our host Dr. Chris Beck discuss strategies for physicians seeking to manage their personal finances and gain financial freedom.
First, Dr. Dahle explains the reasoning behind the famous quote, “live like a resident.” He explains that for an early career physician, their greatest wealth-building tool is their income. The income jump from residency to attending years can be extremely useful for quickly paying off student loans. Then, he moves on to discuss another way to resolve student debt, the Public Service Loan Forgiveness (PSLF) program. This option is ideal for physicians who have spent a significant amount of time working for a nonprofit institution (for example, during training and in academic medicine).
Dr. Dahle advises all physicians to reflect on their priorities when deciding where to allocate their assets. Possible categories could include retirement funds, 529 college savings funds, payment of high-interest debt, and emergency funds. We talk about the power of having a written plan to stay on track with financial goals and prevent ourselves from making rash decisions.
Next, we discuss different financial vehicles that can provide benefits for physicians. The “back door Roth IRA” strategy allows for yearly contributions to a tax-free retirement fund, even when a physician’s income exceeds the maximum limit for the conventional Roth IRA. Additionally, the funds in a Health Savings Account (HSA) can be used for investment, and then withdrawn at a later date, penalty-free. Dr. Dahle explains the difference between fixed rate and variable rate mortgages, noting that the latter is better for short-term loans because interest rates are unlikely to dramatically increase from year to year. Finally, Dr. Dahle covers the advantages of buying disability insurance as a way to protect physician income, especially for those working in procedural specialties.
RESOURCES
White Coat Investor: https://www.whitecoatinvestor.com/
White Coat Investor Podcast: https://www.whitecoatinvestor.com/wci-podcast/
White Coat Investor Email: editor@whitecoatinvestor.com
Passive Income MD: https://passiveincomemd.com/
Physician on FIRE: https://www.physicianonfire.com/
In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Jennifer Anger from UCSD Urology talk about care for transgender patients and gender-affirming surgery. They discuss the importance of using correct terminology, how to work up patients seeking gender-affirming care, and the multidisciplinary nature of transgender healthcare.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Jen Anger from UCSD Urology about care for transgender patients and gender-affirming surgery.
Firstly, Dr. Bagrodia and Dr. Anger discuss the importance of gender-affirming terminology and using the correct pronouns for transgender and gender-fluid patients. Dr. Anger encourages healthcare providers to always ask patients how they would like to be addressed before making assumptions based on anatomy and past history.
Next, Dr. Anger describes her workup for patients initially seeking gender-affirming pelvic reconstructive (“bottom”) surgery. Most patients seeking bottom surgery will have already started hormonal therapy and puberty blockade. In concordance with national regulations, Dr. Anger only performs gender-affirming pelvic reconstruction surgery if a patient has already lived as their preferred gender and undergone hormonal therapy for at least a year and has secured 2 letters from mental health providers stating support for their transition. For adolescents, there is an additional requirement involving the consent of two parents.
Dr. Anger emphasizes that transgender care is a multidisciplinary field. She works closely with many other physicians, such as the patient’s primary care provider, endocrinologists, mental health providers, other urologists, plastic surgeons, dermatologists, and fertility specialists. She notes that, although more attention, research, and resources have been directed towards transgender healthcare, it is still not widely available to the entire population. Thus, many patients are still seeking gender-affirming surgery in other countries, potentially exposing them to higher complication rates. Thus, she advocates for more research and advocacy in the United States for transgender patients and their medical/surgical needs.
In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Chad Ellimoottil, a Michigan Medicine urologist and Director of the U-M Telehealth Research Incubator, discuss advice and future projections for telehealth.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Chad Ellimoottil, a University of Michigan urologist and the Director of U-M Telehealth Research Incubator, discuss his advice and future projections for telehealth.
Across all specialties, 15-20% of monthly medical visits are currently being conducted via telehealth. When deciding whether a consultation is appropriate for a virtual platform, Dr. Ellimoottill recommends assessing a patient’s unique situation instead of relying on their diagnosis. He emphasizes the importance of in-person visits if AUA guidelines require the physician to perform a physical exam.
Next, Dr. Ellimoottil shares his tips for having a successful telehealth appointment. First, he notes that punctuality is even more important over a virtual platform, as many patients may assume they are using the virtual platform incorrectly if they do not see a provider at the scheduled time. Additionally, he encourages physicians to keep their eyes focused on the camera and dress as professionally as possible, whether it be through wearing a white coat or displaying their certifications in the background. Finally, he places great importance on asking the patient directly about their telehealth experience for suggestions on improving it. He notes that this action can greatly reduce the number of dissatisfied patients who do not show up to their scheduled visits.
Furthermore, the doctors discuss the future direction of telehealth. Although he notes that interstate consultations were beneficial at the start of the pandemic, Dr. Ellimoottil acknowledges that these consultations have become very complex because of recent regulatory changes. He also commends the availability of virtual interpreters in telehealth consultations, but addresses the inaccessibility of setting up a telehealth appointment to non-English speaking patients, which has contributed to healthcare inequity during the pandemic. Both doctors agree that there remains much research and many initiatives to be carried out in order to make telehealth a possibility for indigent and elderly populations as well.
Finally, the doctors discuss the impact of telehealth on physicians. Dr. Ellimoottil believes that physician satisfaction with telehealth is directly associated with their personal mindset about telehealth. Thus, telehealth may cause burnout for one provider but enhance the quality of life for another. Nevertheless, he believes that telehealth will benefit both patients and providers if it is proposed as an option to both parties.
In this episode Dr. Kumar and Dr. Bennett discuss various levels of racism found in healthcare, and share allegories of racism as outlined by Dr. Camara P. Jones, including the gardeners tale.
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In this episode, guest host Dr. Vishal Kumar interviews Dr. Ayanna Bennett about how to train ourselves to recognize perpetuated health disparities within the medical system and how we can actively work to dismantle them.
The doctors first talk about understanding racism on an institutional level, which results in a “machine” that selectively delivers better and worse aspects of healthcare to different populations. Dr. Bennett emphasizes that every disease process shows race disparities not because of inherent biological differences in racial groups, but because of unequal frequencies and quality of contact with healthcare systems.
Throughout the episode, they reference the allegories of Dr. Camara Jones, a physician-epidemiologist and civil rights activist. These allegories provide a framework for discussing nature vs. nurture for health outcomes and also privilege defined as the lack of barriers to entry.
In terms of actionable steps that providers can take toward reducing health inequity, Dr. Bennett encourages us to learn and engage with the communities that they serve. She advises us to be “counter-stereotypical” and show interest in patients’ lives outside of the healthcare setting. Finally, she calls us to analyze the impact that our institutions have on maintaining the health of the community as a whole, rather than solely focusing on individual patients.
RESOURCES
The Gardener’s Tale Allegory by Dr. Camara Jones: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446334/
Tedx Talk by Dr. Camara Jones: https://www.youtube.com/watch?v=GNhcY6fTyBM
We talk with Dr. Ashley Winter about the importance of educating physicians and patients on female sexual health, including common presenting symptoms and newer treatments.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Ashley Winter discuss women’s sexual health.
First, Dr. Winter explains her role as a urologist in providing hybrid sexual health consulting for men and women. Then, the doctors discuss basic sexual history intake questions for women. Although there are many screening questionnaires, Dr. Winter prefers to use the Female Sexual Function Index because it evaluates sexual desire, arousal, pain and orgasm ability. She also makes sure to ask about issues indirectly related to sex, such as lower urinary tract symptoms, recurrent UTIs, and pelvic pain.
Performing a complete physical exam is important in patients presenting with sexual dysfunction. Dr. Winter explains her usual genital exam, paying close attention to any abnormalities regarding the clitoris, labia majora/minora, and vestibule. She also performs a pelvic floor exam. She does not usually order a hormone panel, but may check TSH and HbA1c to rule out diabetic neuropathy.
Next, Dr. Bagrodia and Dr. Winter delve into the evaluation and management of specific sexual dysfunctions. Low libido, or hypoactive sexual desire, is a common issue for women. It can be a result of menopause, oral contraceptive use, cystectomy, postpartum concerns, vulvar disorders, selective serotonin inhibitors, history of breast/cervical cancer, or history of abuse/trauma. For patients in the last category, Dr. Winter encourages collaboration with social workers and therapists. She mentions that the American Association of Sexual Educators, Counselors, and Therapists (AASECT) is a great resource for finding these professionals. For peri/post-menopausal women, she recommends prescribing a testosterone gel. Additionally, non-hormonal treatments for low libido include flibanserin and bremelanotide.
For issues regarding sexual arousal, Dr. Winter emphasizes proper education and screening for diabetes first. If arousal is inhibited because of a lack of lubrication, then correction of estrogen levels may be necessary. Estrogen supplementation, or topical/vaginal estrogen, can be used to treat problems with arousal, as well as recurrent UTIs and genitourinary syndrome of menopause (GSM). Dr. Winter notes that these low doses of estrogen preparations are unlikely to actually raise blood estrogen levels and cause systemic side effects.
Finally, in patients who complain of pain with sex, Dr. Winter recommends education about lubricants and pelvic floor physical therapy.
RESOURCES
AASECT: https://www.aasect.org/
Dr. Amit Patel, Dr. Ranko Miocinovic, and Dr. Jose Silva discuss focal therapy for prostate cancer and share their experiences with the the NanoKnife System from AngioDynamics. Listen to the full episode to hear more about prostate biopsy techniques, benefits of the the NanoKnife System, surgical tips for a successful NanoKnife focal ablation, and future directions for incorporating focal ablation into prostate cancer guidelines.
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In this episode of BackTable Urology, Dr. Jose Silva discusses focal ablation for prostate cancer. He invites Dr. Amit Patel and Dr. Ranko Miocinovic to share their experiences with focal ablation using the Nanoknife System from AngioDynamics.
If prostate cancer is suspected due to an elevated PSA and a suspicious MRI scan, a prostate biopsy is necessary to confirm the diagnosis. Both doctors prefer to perform their biopsies through a transperitoneal approach in an office setting with local anesthesia or ProNox. If a positive biopsy for prostate cancer is obtained, additional imaging to stage the lesion and radiation oncology is helpful in prognosing and treating the cancer, respectively.
Focal ablation is a new minimally invasive surgical technique that allows destruction of the cancerous part of the prostate gland without having to destroy or remove the entire gland. Intermediate risk prostate tumors yield the best results with focal ablation, specifically in the context of preventing post-operative sexual and voiding dysfunction. Once the focal ablation sensors localize the tumor in the gland, a variety of ablation techniques can be utilized. Both Dr. Patel and Dr. Miocinovic use the NanoKnife System, an irreversible electroporation system that uses an electric current to break up cell membranes.
Proponents of the NanoKnife System believe that it causes less peripheral destruction because it preserves connective tissue and minimizes destruction of nerves. Evidence also suggests that focal ablation using the NanoKnife system lowers the rate of scar tissue formation thereby lowering the rate of erectile dysfunction, improves protection of the urethra, causes less swelling of the prostate, lowers the risk of post-operative retention, and requires shorter operating time. Finally, this method of ablation allows for consequent follow up surgeries if necessary.
Next, the doctors discuss NanoKnife procedural techniques, such as surgical approaches, and using ultrasound-guided probe placement. When using this type of ablation, it is important to monitor the wattage of the NanoKnife carefully in order to prevent the ablation from causing thermal destruction. Finally, both doctors discuss the future possibility of adding focal ablation procedures as a first line therapy to the AUA guidelines on treating prostate cancer.
Dr. Philippe Spiess from Moffitt Cancer Center discusses surgical and medical management of penile cancer. Listen now to hear more about punch biopsy techniques, surgical resection and lymph node dissection techniques, growing role of topical chemotherapy, importance of multidisciplinary tumor boards.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Phillipe Spiess from Moffitt Cancer Center discuss surgical and medical management of penile cancer.
When examining a patient for potential penile cancer, it is important to obtain a thorough history to classify the disease and perform a complete physical exam to describe the characteristics of the lesions. Frequently, a biopsy will be performed to confirm the malignancy of the lesion. Dr. Spiess prefers to use topical anesthesia over general anesthesia in his punch biopsies and sends the sample to specialized genitourinary pathologists. Imaging also reveals the presence and extent of metastatic spread of penile cancer. MRI scans are the best way to visualize the inguinal lymph nodes, but PET scans may also be used in multimodal imaging.
Surgical intervention for penile cancer depends on the tumor stage. For T0 tumors, or carcinoma in situ, topical chemotherapy is preferred. However, excision surgery, Mohs surgery, or laser ablation can also be performed for very small lesions. In general, for excision surgeries, urologists should achieve a tumor margin greater than 1 mm and send skin, deep, and urethral margin samples to GU pathology for analysis. For more aggressive and advanced T2/3 tumors, the inguinal lymph nodes should be excised at same time as penile resection in healthy patients. However, if an infected, fungating primary tumor is observed, it should be resected first before lymph node excision. Dr. Spiess recommends that urologists choose the surgical approach that they are most comfortable with performing, whether it be open or robotic. Additionally, the preoperative state of a patient is crucial. Diabetes, nutrition, smoking cessation, and other factors should be optimized to ensure favorable outcomes. Post operatively, surgical staples should stay in until the patient is completely healed, and patients should be encouraged to wear compression stockings.
The effectiveness of radiation therapy depends on the characteristics of individual tumors. Penile cancer tumors are usually radioresistant but radiation has been shown to limit retroperitoneal masses and are effective in shrinking HIV-positive tumors. Generally, radiation therapy provides symptomatic management but is not curative.
The final treatment option discussed was a total or partial penectomy. Total penectomy should only be reserved as the last resort after exhausting other options. Instead, a partial penectomy is preferred, as maximal tissue sparing can maintain feelings of masculinity and gender association and preserve mental health.
RESOURCES
InPACT Trial: https://clinicaltrials.gov/ct2/show/NCT02305654
GSRGT: https://www.gsrgt.com/
Dr. Aditya Bagrodia and Dr. Geo Espinosa discuss holistic and integrative approaches to prostate cancer.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Geo Espinosa discuss a holistic and integrative approach to preventing and treating prostate cancer. They delve into four areas of well-being: diet, sleep, exercise, and nutraceuticals/supplements.
In a low-risk patient on active surveillance, Dr. Espinosa recommends a Mediterranean diet that includes fish, plants, and whole grains. He notes that intermittent fasting may be helpful but warns against a ketogenic diet, as prostate cancer relies on lipid metabolism. Additionally, because sleep strengthens the immune system and reduces chronic inflammation, he notes that patients should limit their screen time before bed and get at least six to eight hours of quality sleep every night. In terms of exercise, committing to four to six hours of High-Intensity Interval Training (HIIT) and strength resistance a week has been proven to cause regression of prostate cancer cells. Finally, some anti-cancer supplements he recommends are: curcumin, Vitamin D, Vitamin E, fish oil, zinc, selenium, and green tea extract (EGCG).
In patients with advanced prostate cancer, he notes that all his prior recommendations should be followed even more closely. Patients with prostate cancer must adhere to stricter diets and prioritize weight training even more, especially if they are on hormone replacement therapy. Additionally in hormone replacement therapy patients, acupuncture or black cohosh can alleviate hot flashes, and magnesium can be prescribed for sleep optimization.
Emergency medicine physician and podcast founder Dr. Gita Pensa and our co-hosts Dr. Chris Beck and Dr. Aaron Fritts discuss methods of navigating malpractice lawsuits, maintaining professional identity, and prioritizing mental health.
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In this episode, emergency medicine physician and podcast founder Dr. Gita Pensa and our co-hosts Dr. Chris Beck and Dr. Aaron Fritts discuss methods of navigating malpractice lawsuits, maintaining professional identity, and prioritizing mental health.
Dr. Pensa starts by outlining her personal experience with a twelve year-long malpractice suit, which inspired her to start her own podcast, “Doctors and Litigation: The L Word.” She says that despite the fact that most physicians will face lawsuits in their career, there is a current lack of physician-centered educational resources over malpractice litigation. To combat this, she encourages physicians to share their experiences and learn from one another.
The doctors walk through major steps of a lawsuit, starting with the process of getting served with papers. Dr. Pensa emphasizes that it is important to recognize that this step could be used as the first tactical move in a lawsuit and designed to make physicians feel uneasy. The next step after getting served should always be to call the insurance carrier and have them start the process of initiating a claim. Dr. Pensa strongly advises against accessing or editing patient charts after getting served, as these actions are recorded in the EMR and can be used against the physician. Finally, Dr. Pensa discusses the process of deposition and how it serves as both a fact-finding mission and a strategic way to distort a physician’s words. She recommends practicing with lawyers to answer deposition questions clearly and concisely.
Throughout the episode, the doctors highlight the importance of maintaining one’s mental health during the litigation process. They advise listeners to seek support from friends, family, colleagues, and professionals, as long as the specific details of the case are not discussed. To close, Dr. Pensa reminds the audience that malpractice lawsuits usually have financial motivations, and they may not be an accurate representation of a physician’s competence or compassion for patients.
RESOURCES
Doctors and Litigation: The L Word: https://doctorsandlitigation.com/
“The Defendant” by Sarah Charles: https://www.amazon.com/Defendant-Sarah-Charles/dp/0394746635
“Adverse Events, Stress, and Litigation” by Sarah Charles: https://www.amazon.com/Adverse-Events-Stress-Litigation-Physicians/dp/0195171489
“How to Survive a Medical Malpractice Lawsuit” by Ilene Brenner: https://www.amazon.com/How-Survive-Medical-Malpractice-Lawsuit-ebook/dp/B005C65X2M
“When Good Doctors Get Sued” by Angela Dodge and Steven Fitzer: https://www.amazon.com/When-Good-Doctors-Get-Sued/dp/0977751104
Dr. Phillip Pierorazio from Penn Urology discusses the management of small renal masses. Listen to the full episode to hear about imaging modalities for small renal masses, distinguishing between cysts and solid tumors, ablation, enucleation, partial nephrectomy, and special considerations for von Hippel-Landau (VHL) patients.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Phil Pierorazio discuss the management of small renal masses.
Most small renal masses found incidentally through imaging from another cancer workup or an injury, and most small renal masses are not cancer. It is important to take into account the patient’s family and social history, especially if there is a family history of renal cell carcinoma and renal disorders. Dr. Pierorazio looks specifically for flank pain, hematuria, and a history of smoking because these are all risk factors for cancerous small renal masses. In every patient, he orders a basic metabolic panel and a urodynamic analysis in order to observe renal function. Because CT scans are easily reproducible and interpreted, it is his first choice imaging modality. He also orders a chest x-ray, as pulmonary metastasis is common in renal cancer.
Active surveillance is a reasonable option once a small renal mass under 3 centimeters is discovered. Before deciding to put a patient on active surveillance as opposed to surgical intervention, Dr. Pierorazio assesses patient age, life expectancy and related comorbidities, and tumor size. However, tumors smaller than 3 centimeters should be removed if there is a possibility that the masses are caused by hereditary, aggressive cancers. High suspicion for these cancers should be raised in young women with a history of hysterectomies for fibroids. Another distinction that must be made is the difference between benign cysts and solid masses. Renal tumors are often not always completely solid, so they may masquerade as cysts. In order to improve the accuracy of the diagnosis, it is important to confirm the mass characteristics with multiple modalities.
A biopsy may be needed if the renal mass grows above 3 centimeters or if the patient is wanting more information. Additionally, a biopsy can help a surgeon decide whether a partial or radical nephrectomy is a better option. There are many different surgical options following the kidney biopsy: enucleation, nephrectomy, and ablation are three of the most common options. Surgical treatments can be sorted into two different types: partial nephrectomy and nephron-sparing options that maximize preservation of renal parenchyma. If a tumor is larger than 3 centimeters and well-encapsulated, Dr. Pierorazio favors enucleation. On the other hand, surgery may be contraindicated in older patients with multiple comorbidities because they are unlikely to progress to end-stage renal disease. For this reason, Dr. Pierorazio emphasizes the importance of listening to patients’ fears and desires, as both nephrectomy and dialysis can result in different risks and complications.
RESOURCES
AUA Guidelines for Renal Masses and Localized Renal Cancer: https://www.auanet.org/guidelines/guidelines/renal-cancer-renal-mass-and-localized-renal-cancer-guideline
We talk with Dr. Siamak Daneshmand, Director of Urologic Oncology at USC Institute Of Urology, about the management of muscle-invasive bladder cancer. Listen to the full episode to learn tips for successful transurethral resections of bladder tumor (TURBT) and cystectomies, using imaging to stage bladder cancers, deciding between a cystectomy vs. trimodality therapy (TMT), and comparisons between neobladder procedures and urinary diversions.
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First, the doctors discuss the initial workup of a referred bladder tumor patient. Because almost all bladder cancers are malignant, a transurethral resection of the bladder tumor (TURBT) is the first step. Dr. Daneshmand notes that imaging may be helpful in patients with complex anatomy. He prefers to perform a CT over an MRI scan due to patient discomfort and costs.
Next, Dr. Daneshmand shares his tips for a TURBT procedure. His main goal is to perform a complete resection of the tumor. He often uses blue light enhancement to visualize the edges of tumors better, improve the educational experiences of his residents, and stage smaller tumors more easily. He notes that doing an extensive TURBT does not lead to a higher likelihood of bladder cancer metastasis. Although uncommon, bladder perforation during TURBT is a possible and serious complication. To prevent seeding in the scenario of a perforation, he advises urologists to stop high-pressure irrigation immediately. Furthermore, he trains his residents to be vigilant of the amount of fluid going in and out of the abdomen.
Another important aspect of bladder cancer care is accurately staging the bladder cancer after the TURBT. Dr. Daneshmand usually orders a CT scan of the abdomen, chest, and pelvis in order to check for metastases. He prefers not to order a PET scan, as it results in too many false positives and false negatives. In the case of the discovery of suspicious pelvic lymph nodes, he will move on with neoadjuvant therapy and keep assessing the lymph nodes via imaging. He does not usually biopsy these lymph nodes due to their precarious location between the external and internal iliac arteries.
After staging the bladder cancer, a treatment modality must be chosen. Two common options are a cystectomy or trimodal therapy (TMT). Both Dr. Bagrodia and Dr. Daneshmand agree that variant histology results do not immediately indicate one treatment over the other—a patient’s tumor must be evaluated holistically. TMT is very effective in patients with T2-T3 unilateral, muscle-invasive bladder cancer. For patients who do not meet this narrow criteria, cystectomy remains a valid option.
Next, Dr. Daneshmand gives advice for performing a successful cystectomy. He notes that the surgeon should always handle the urethra with great care, as meticulousness can lead to a lower risk of post-surgical incontinence. Also, he notes that nerve-sparing techniques for male bladder cancer patients can help with post-surgical incontinence and erectile dysfunction. However, he warns urologists to be careful not to accidentally leave tumor tissue behind during female cystectomies involving gynecologic organ preservation.
After a cystectomy, patients can either choose to undergo a urinary diversion procedure, in which the surgeon creates a different way for urine to leave the bladder, or a neobladder (ileal conduit) procedure, in which the surgeon creates a new bladder from the small intestine. Dr. Daneshmand emphasizes that having a standardized and specific approach to the patient conversation about these treatment options is very important. He encourages urologists to be clear about the consequences of each of these options on incontinence and catheter usage.
En el primer episodio en español de BackTable Urology, yo y Dr. Francisco Gelpi discutimos los tratamientos mínimamente invasivos para HPB, específicamente Urolift, Rezum, y GreenLight. Escucha el episodio completo para aprender más sobre la transición de Dr. Gelpi desde práctica oncológica académica a práctica privada enfocada en HPB, evaluación inicial de los HPB pacientes, factores importantes en la toma de decisión de un tratamiento de HPB, y beneficios y complicaciones de cada tratamiento.
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En el primer episodio español de BackTable Urology, Dr. Jose Silva y Dr. Francisco Gelpi discuten los tratamientos mínimamente invasivos para la hiperplasia prostática benigna (HPB), específicamente Urolift, Rezum, y GreenLight.
Primero, los doctores hablan sobre la transición de Dr. Gelpi desde práctica oncológica académica a práctica privada enfocada en HPB. Tomó la decisión para tener mas autonomía y libertad. Dr. Gelpi cuenta que mucho de su aprendizaje de los procedimientos de HPB ocurrió durante su trabajo después de la residencia debido al hecho de que no existía tanto tecnología para HPB hasta los años recientes.
Seguido, Dr. Gelpi habla sobre la evaluación primaria de un paciente con HPB. Es importante tomar en consideración las expectativas del paciente, la edad del paciente, y la anatomía única de cada próstata antes de escoger un tipo de intervención. Resume los métodos de imagen y análisis diferentes, como la ecografía pélvica y el examen urodinámico. También, Dr. Gelpi menciona que la situación económica de un paciente podría ser un factor importante en la selección de un procedimiento.
Entonces, Dr. Gelpi resume sus consejos para los procédures de Urolift, GreenLight, y Rezum. Además, los doctores charlan sobre la embolización de la próstata como otra opción. Usualmente Dr. Gelpi opera en un centro ambulatorio, pero para los casos de GreenLight, prefiere operar en un hospital debido al riesgo alto de infección y con los pacientes con catéteres crónicos.
Finalmente, los doctores hacen una comparación de los beneficios y complicaciones de cada opción quirúrgica. Ambos están de acuerdo de que solamente son generalizaciones porque cada paciente responde a tratamientos diferentes y puede presentar síntomas diferentes después de la cirugía. Dr. Gelpi termina el episodio animando a los urólogos hispanos a explorar, leer, aprender sobre otras cosas nuevas cada día para mejorar su conocimiento y práctica medical.
Dr. Aditya Bagrodia and Dr. Aaron Fritts talk with Dr. Phillip Pierorazio from Penn Urology about his Operate with Zen podcast and tips for surgeon wellness. They cover Dr. Pierorazio's motivation for starting a wellness podcast, preventing physician burnout, achieving work-life balance, and managing healthy competitiveness.
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In this crossover episode of BackTable Urology and BackTable VI, Dr. Aaron Fritts and Dr. Aditya Bagrodia speak with Dr. Phil Pierorazio about surgeon wellness and his mindfulness podcast, Operate with Zen.
First, Dr. Pierorazio discusses his motivation for starting the Operate with Zen podcast. During the pandemic, he crafted a new goal for himself: to be happier in surgery. He defines mindfulness as taking a moment to enjoy his livelihood and being more present at work and at home. Next, the doctors tackle the topic of physician burnout. All three doctors agree that burnout is not a badge of honor and are glad that the culture of medicine is progressing towards one that reprimands toxic attitudes early in training.
As for managing work-life balance, Dr. Pierorazio explains that once he started creating boundaries for his work schedule, he expanded what he could do. He encourages other surgeons to trust that their colleagues can handle emergencies, even if the patients are not their own patients. Collaboration with colleagues also leads to healthy competitiveness, a concept in which physicians stop comparing themselves to each other and instead celebrate their fellow colleagues. Dr. Pierorazio recommends channeling toxic competitive energy towards a drive to better a broader institution and patient care.
Finally, Dr. Pierorazio shares two of his personal tips for wellness. He avidly journals each day in order to exercise gratitude, reflect on his day, and set priorities for the next day. Finally, he emphasizes the importance of finding a wellness mentor or counselor in order to expand surgeon wellness and talent.
Dr. Jose Silva brings Dr. Jonathan Clavell back onto the show to discuss complex penile implant cases. They cover how to deal with mechanical complications of AMS700 and Coloplast Titan, penile implants in Peyronie's disease, penile implants in priapism, tips for successful revision surgery, and how to manage post-operative infections.
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First, the doctors discussed mechanical complications with three-piece inflatable penile implant devices. Dr. Clavell always directs post-operative patients to his Youtube videos where he explains how to cycle penile implants. Because older patients may have trouble finding and operating the pump, Dr. Clavell prefers to place an AMS 700, as it is easier to deflate. Additionally, he tries to place the pump as anteriorly as possible for ease of patient usage. If he notices that the tubing of the implant is too long at the time of surgery, he cuts the tubing and reconnects it again at the appropriate length. Finally, to avoid autoinflation, he takes great care in making sure that the lock-out valve of the Coloplast Titan does not hit the pubic bone.
Next, Dr. Clavell discusses different approaches to placing penile implants in complex patients. First, he tackles patients with chronic priapism, a common consequence of sickle cell disease. With priapism patients, he emphasizes the importance of severity and timing; waiting a longer time period since the patient’s last priapism episode means that there will be more scar tissue in the corpora. For these complex patients, Dr. Clavell encourages surgeons to set proper expectations with their patients, try to operate as soon as possible, and encourage their patients to use a vacuum erection device to keep corporal space open and maximize the size of implant. Additionally, he recommends coming into the operation with adequate tools that are able to drill through the fibrosis and being ready to use a counter incision or to extend the incision distally.
In patients with Peyronie’s disease, Dr. Clavell always assesses the degree of curvature first. For patients with mild curvature (under 45 degrees), he places the penile implant and uses manual remodeling techniques intraoperatively to straighten the penis. For patients with more severe curvature (more than 60 degrees), he performs a plaque incision with grafting (PIG) through a ventral non-degloving incision to avoid the risk of glans ischemia. In these severe Peyronie’s patients, he will do the PIG first and then place the implant in order to minimize implant exposure time and infection risk.
In the event where a revision surgery is necessary, Dr. Clavell orders a CT scan if the problem cannot be found upon physical examination or if he was not the surgeon who placed the original implant. He usually takes some fibrous tissue out around the pump and then places the pump in a different pocket to make sure there is no contact between the capsule and the new pump. Although he tries to take the reservoir out, he simply drains and retains reservoirs that have migrated too deep in order to avoid damaging major structures.
In patients who develop post-operative penile implant infections, Dr. Clavell usually completely removes and replaces the implant if pus is present. He notes that it is important to swab the biofilm at the time of implant removal in order to culture and identify the type of bacterial infection. He prefers to administer culture-specific antibiotics and antifungal for 2-3 weeks. Also at the time of removal, he will irrigate the patient’s corporas with Irrisept and an antibiotic solution. Research has shown that patients who develop a post-operative infection will have a 50% chance of success with another 3-piece implant.
Dr. Clavell also discusses other post-operative complications, including impending erosions and glans ischemia.
Urologist Dr. Claus Roehrborn and Interventional Radiologist Dr. Sandeep Bagla discuss the pros and cons of Prostate Artery Embolization (PAE) compared to other Minimally Invasive Surgical Treatments (MISTS) for Benign Prostate Hyperplasia (BPH). They also discuss the importance of a collaborative, multidisciplinary approach when offering these treatment options, including agreeing on the best treatment for the patient.
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In this episode, urologist Dr. Claus Roehrborn and interventional radiologist Dr. Sandeep Bagla discuss benign prostatic hyperplasia (BPH) and prostate artery embolization (PAE) in the context of counseling patients and cross-specialty collaboration.
Dr. Roehrborn starts by reviewing the history of BPH treatment, from medications like alpha-blockers and anticholinergics, to minimally invasive options like UroLift, Rezum, and PAE. He emphasizes that the latter options are growing in popularity, since they provide treatment alternatives for patients who are concerned about side effects from medications, or have not experienced symptom relief from medications.
Dr. Sandeep Bagla describes Prostate Cancer USA’s philosophy on IR/Urology partnership and how it can ultimately benefit patients. This model provides the patient with both an IR suite for the PAE procedure and a urology clinic for diagnostic assessment, determination of PAE candidacy, and follow-up assessment.
Both doctors describe ideal patients for PAE. These are usually patients with a gland size above 60 g, confirmed bladder function, and a desire to preserve ejaculation function. Contraindications include urinary retention, chronic prostatitis, and heavily calcified glands.
Finally, they describe how they manage minor short-term complications such as frequency and dysuria with medication. They track symptom relief using the International Prostate Symptom Score (IPSS), Dr. Bagla notes that the largest drop in IPSS usually occurs about 4-5 weeks post-procedure.
RESOURCES
Prostate Centers USA: https://www.prostatecentersusa.com/
“The Role of Novel Minimally Invasive Treatments for Lower Urinary Tract Symptoms Associated with Benign Prostatic Hyperplasia”: https://bjui-journals.onlinelibrary.wiley.com/doi/abs/10.1111/bju.15154
We speak with Dr. Zamip Patel about the different causes and treatments of male infertility. Listen to hear more about genetic vs. environmental causes of infertility, hormone tests, hormone replacement therapy, and varicoselectomies.
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In this episode of BackTable Urology, Dr. Zamip Patel discusses the assessment and treatment of male infertility with Dr. Silva.
Initial fertility consultations are usually made for couples who have not had success in conceiving for over a year. Dr. Patel will start with an initial semen analysis. He notes that cell differentiation depends on the quality of the lab performing the analysis. The presence of round cells and leukocytes may be indicative of a bacterial infection, and prednisone and antibiotics may be administered. Besides bacterial infections, Dr. Patel notes that there are 4 main factors for male infertility: genetic, environmental, anatomical, and hormonal.
Globozoospermia and azoospermia are two consequences of genetic mutations resulting in irregular sperm morphology and inadequate sperm production, respectively. Attribution of infertility to genetic mutations can be difficult, as microchip arrays only test for 10% of genetic defects. Sex chromosome aneuploidy can also result in male infertility, but can easily be identified via karyotyping.
Environmental factors may also contribute to male infertility. Dr. Patel notes that improving diet, exercise, and sleep is the most common solution for infertility. Additionally, he observes that supplementing diet with vitamin coenzyme Q10 has been shown to improve infertility. Finally, he explains that prolonged marijuana usage and THC intake may contribute to infertility on an individual and dose-dependent basis.
Next, Dr. Patel considers anatomical reasons for male infertility. Irregularities in vas deferens morphology and small testicular size can be observed through physical examination. A varicocele, or an enlargement of veins in the scrotum, can also cause low sperm production and quality. Patients with varicoceles will usually elect to undergo a varicocelectomy, a surgical intervention with minimal downtime and complications.
Lastly, low testosterone levels can cause male infertility. To get a clearer picture of testosterone levels, Dr. Patel recommends combining a free testosterone test with SHBG and albumin tests, which calculate bioavailability of testosterone. He will also measure TSH levels, but notes that measuring prolactin levels, which can vary individually, may potentially cause more confusion and lead to unnecessary further imaging. Although clomiphene and anastrozole can both increase testosterone concentration, Dr. Patel warns listeners about osteoporosis as a side effect of anastrozole. Additionally, he has had success with increasing testosterone levels using pituitary stimulation via hCG supplementation. Testosterone levels can also be naturally increased through healthier diets, daily exercise, and adequate sleep.
Dr. Daniel Hoffman, a urogynecologist specializing in voiding dysfunction, discuss the use of Botox, sacral neuromodulation, and bulking agents in treating overactive bladders. Listen to hear more about patient selection criteria for each treatment, botox and neuromodulation procedure techniques, and treatment side effects and complications.
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This week on the BackTable Urology Podcast, Dr. Jose Silva and Dr. Daniel Hoffman, a urologist specializing in voiding dysfunction, discuss the use of Botox, sacral neuromodulation, and bulking agents in treating overactive bladders.
First, Dr. Hoffman explains his procedure for Botox, which he suggests as a treatment option for patients with neurogenic bladders. He uses Urojet as anesthesia and injects the Botox in 0.5 cc injections following a grid template. Additionally, he saves 1 cc for the trigone of the bladder. He uses 200 units of Botox in patients with neurogenic bladders and 100 units in those with urge incontinence. Additional considerations should be made for patients with additional comorbidities, such as benign prostate hyperplasia and cystitis. For cystitis patients, increased caution around vascularized areas should be exercised. Additionally, Dr. Hoffman recommends assessing the degree of obstruction in BPH patients before treating their incontinence with Botox.
Next, Dr. Hoffman discusses his procedure for sacral neuromodulation, a procedure that he recommends for younger patients with urinary retention. Although he notes that rechargeable and battery-operated devices have equivalent functions, a patient’s ability to use and maintain the device and MRI-compatibility should be considered. He recommends allowing the patient to undergo a percutaneous nerve evaluation (PNE) before inserting a permanent device. After permanent device insertion, some patients may experience chronic pain down the leg. Dr. Hoffman recommends reprogramming the device before performing a lead revision. If a lead is fractured and lost during surgery, he advises urologists against going after the fractured lead—neurosurgery should be consulted instead. Finally, he notes that fecal incontinence may also be mitigated through sacral neuromodulation.
Lastly, Dr. Hoffman notes that bulking agents as a potential therapy for women with stress incontinence because they have little to no side effects compared to the pelvic sling. Because he has noticed that coaptite does not have the same longevity as Botox, he considers Bulkamid as a better choice. Like Botox, bulking agents can be quickly injected in the office and result in minimal patient down time.
Dr. Ranjith Ramasamy explains the known effects of the COVID-19 virus and the pandemic on testosterone levels, vasculogenic erectile dysfunction, male fertility, and sexual practice patterns. Additionally, Dr. Ramaswamy uses evidence-based medicine to debunk myths about the adverse effects of the COVID-19 vaccine on men’s health.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Ranjith Ramasamy discuss the effects of the COVID-19 pandemic and COVID vaccines on various men’s health topics, including testosterone levels, erectile dysfunction, and male fertility.
First, Dr. Ramasamy discusses the effects of COVID-19 on hypogonadism. He notes that in the initial stages of the pandemic, many providers attributed low testosterone levels as result of a sedentary and less active lifestyle because of the lockdown. However, it was later discovered that the SARS-CoV-2 virus binds to the ACE2 receptor, an important receptor present on the surface of testosterone-producing Leydig cells. Thus, temporary testosterone deficiency is a direct impact of COVID-19 infection. Dr. Ramasamy advises his recovered patients to naturally increase their testosterone levels by eating, exercising, and sleeping well.
COVID-19 is also linked to higher rates of erectile dysfunction. Dr. Ramasamy explains that the cause of ED may not be psychogenic, as the SARS-CoV-2 virus affects endothelial cells lining blood vessels. Studies have also shown that the virus can be present in penile tissue seven to 9 months post-infection. As a result, Dr. Ramasamy urges urologists to differentiate between psychogenic and vasculogenic erectile dysfunction.
Next, the doctors discuss the impact of COVID-19 on fertility. Research has shown that a COVID-19 infection may decrease sperm count in semen three to six months post-infection. Most patients have normal sperm counts after 6 months. Although birth rates have declined due to the uncertainty during the pandemic, Dr. Ramasamy notes that more male patients have requested fertility consultations with him as a proactive family planning measure.
Finally, Dr. Ramasamy uses evidence-based medicine to debunk myths about the mRNA COVID-19 vaccination on male sexual and gonadal function. He cites his most recently published article, “Sperm Parameters Before and After COVID-19 mRNA Vaccination” (JAMA) and emphasizes that there is no link between the vaccine and declining sperm count.
We finish our discussion with Dr. Angie Smith from University of North Carolina at Chapel Hill about peri-operative optimization of radical cystectomies. She discusses pre-operative incentive spirometry, opioid and NSAID regimens, post-operative drains and stents, and the importance of multidisciplinary collaboration.
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In this episode of BackTable Urology, Dr. Bagrodia and Dr. Angie Smith finish their discussion on optimizing radical cystectomy outcomes using peri-operative measures.
First, Dr. Smith emphasizes the importance of getting her cystectomy patients actively invested in their pre-operative and post-operative care. Pre-operatively, she recommends nutrition counseling, as carb loading and amino nutrition within 3-5 days before surgery have been shown to promote tissue healing. She also recommends engaging patients in pre-operative incentive spirometry, giving them a chance to learn to use their post-operative spirometers correctly. However, she does not have her patients undergo bowel prep before surgery.
Post-operatively, she emphasizes the importance of involving a multidisciplinary medical team in the patient’s recovery process. First, she recommends collaborating with anesthesia for pain management and to reduce post-operative nausea. She notes that although Tylenol is effective in mitigating post-operative pain, she sometimes sends patients home with a small opioid prescription for 1 week. She also continues to consult nutritionists and aims to have her patients on a regular diet two days after the surgery. Because long-term drains have a higher susceptibility to infection, she removes them after the first post-operative week. Finally, she involves physical/occupational therapists in the post-operative care of patients. One practice she has incorporated into her post-operative counseling is explaining to the patient why physical therapy is important, in addition to explaining general instructions, in order to increase patient compliance.
Patients who experience dehydration, acidosis, and nausea have a higher chance of readmission. Once her patients return home, she and a triage nurse monitor their hydration and sodium bicarbonate levels closely. Lastly, she invites cystectomy patients back for a survivorship care visit 6 weeks after surgery to look for pending obstructions with ultrasound.
We talk with Dr. Angie Smith about perioperative measures to optimize radical cystectomies.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Angie Smith from UNC School of Medicine discuss peri-operative measures to optimize radical cystectomy outcomes.
First, the doctors start by explaining their approaches to initial cystectomy discussions with bladder cancer patients. Dr. Smith usually provides a walkthrough of the surgery and discusses complication rates with her cystectomy patients. Because sexual dysfunction and infertility are possible long-term complications of the procedure, she emphasizes the importance of transparency and expectation management in patients.
Next, the doctors discuss the optimal timing for a cystectomy. Dr. Smith and Dr. Bagrodia usually wait at least 4 to 6 weeks after chemotherapy to perform a cystectomy. However, because Dr. Smith believes that timing is the most crucial factor in a cystectomy, she prefers to perform surgery sooner rather than later. For this reason, she performs both open and robotic surgery, depending on which approach can be done sooner. Furthermore, to anticipate a patient’s post-operative regimen, Dr. Smith uses the comprehensive geriatric assessment because she prioritizes the functional status of a cystectomy patient most. In addition to this assessment, she will evaluate a patient’s activities of daily living, hearing and vision deficits, and fall risk.
Finally, Dr. Smith emphasizes the importance of involving multiple interdisciplinary health professionals, such as medical and radiation oncology, nutritionists, wound/ostomy/continence nurses, geriatricians, and pelvic floor physical therapists. She notes that “prehabilitation”, or using physical therapy to improve a patient’s strength and fitness before surgery, is a new feasible pre-operative strategy, but its effects on distal post-operative outcomes have not yet been determined.
We talk with Dr. Jeff Cadeddu about workup and treatment options for patients with localized prostate cancer.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Jeff Cadeddu, professor of urology at UT Southwestern, about the management of localized prostate cancer.
First, the doctors discuss important considerations for an initial evaluation, such as lower urinary tract symptoms, a Gleason score, comorbidities, and a thorough family history. Dr. Cadeddu emphasizes that the main goal of the initial evaluation is to risk-stratify the prostate cancer patient. Although he does not consider any anterior surgeries as contraindications, he notes that abdominal perineal resection surgery may be challenging for surgeons.
For patients who have low-risk disease, he strongly advises choosing surveillance over surgery and radiation therapy, regardless of age. For him, active surveillance does not start until a second confirmatory biopsy, and his patients receive MRI at the beginning of every year as well as a PSA every month. Some triggers for ending the surveillance period and entering treatment are: a PSA over 10 or upstaging on an MRI or biopsy.
In patients with intermediate-risk disease, Dr. Cadeddu will either proceed with radiation therapy or prostatectomy. He notes that neither radiation nor surgery are risk-free. Although radiation does not involve pain, post-treatment incontinence, and or peri-operative risk, it can result in irritative symptoms as well as side effects from androgen deprivation therapy used in conjunction with radiation therapy. Radiation also presents a higher delayed risk of cancer recurrence, especially in younger patients. In contrast, surgery presents with more upfront perioperative risk and post-surgical complications but provides more long-term security, as post-surgical salvage radiation is possible. Although many patients have anxieties about post-surgical stress incontinence and sexual function, Dr. Cadeddu notes that 95% of patients will regain continence post-operatively by 6 months. Any incontinence after 6 months is correctable via a male urethral sling or an artificial sphincter. He explains that recovery of post-operative potency depends on the stage and volume of disease, pre-operative sexual performance, patient age, and the skill of the surgeon. If the patient experiences long-term sexual dysfunction, medicines and surgical intervention could possibly resolve the problem. For high risk patients, Dr. Cadeddu makes sure his patients are mentally prepared for multimodal therapy and recurrence.
Dr. Cadeddu is excited to see the future direction of the management of localized prostate cancer and advises surgeons to educate themselves about new studies and technologies associated with prostate cancer.
We talk with UTSW Program Director Dr. Steve Hudak and UTSW Urology Resident Dr. Blake Johnson about what it takes to get into Urology Residency these days, and pearls for a successful Urology rotation.
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In this BackTable Urology episode, Dr. Steve Hudak, UT Southwestern residency program director, and Dr. Blake Johnson, PGY-1 at UT Southwestern, give advice on how to successfully match into urology residency.
The doctors first discuss their personal journeys to urology, noting that many medical students may discover a passion for the field late into their medical education during their fourth elective rotations. Then, they review the necessary components of an application, such as: excellent performance on all clinical rotations, away rotations, research experience, strong letters of recommendation, and a strong STEP I score. They briefly discuss the transition to a pass-fail STEP I score and its effect on future applicants.
Then, Dr. Hudak explains the difficulties involved in the resident selection process. Because the urology match is competitive, he strongly assesses resilience, teamwork, and work ethic in each applicant. He notes that overcoming hardships should be noted in personal statements, as it is a salient demonstration of these qualities. Similarly, Dr. Johnson evaluates applicants based on their attitude and contributions in the clinic/OR.
Finally, the doctors share their advice for medical students on away rotations. Both agree that medical students should always remain professional, punctual, and helpful over the course of the rotation. Dr. Johnson also advises medical students to develop situational awareness by knowing when to ask questions and to anticipate residents’ needs.
Urologist Dr. Francisco Gelpi discusses surgical treatments for BPH with a special focus on the minimally-invasive GreenLight Laser prostatectomy. Listen to hear more about Dr. Gelpi’s transition from an oncology-focused practice to a BPH-focused practice, initial BPH patient workup , using prostate anatomy to choose a BPH surgical treatment, GreenLight Laser postoperative care, and the importance of BPH patient involvement and expectations.
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In this episode of BackTable Urology, Dr. Jose Silva interviews urologist Dr. Francisco Gelpi about GreenLight laser therapy and other BPH surgical treatments.
Although he was originally trained in urologic oncology, Dr. Gelpi decided to expand his expertise and incorporate BPH treatment into his medical practice as well. He also explains his decision to enter private practice and his role as a Boston Scientific proctor for Rezum and GreenLight.
When initially evaluating a male patient with voiding issues, Dr. Gelpi emphasizes the importance of lower urinary tract imaging. Although he goes through the basic questionnaire to assign the patient an AUA symptom score, he usually performs a pelvic ultrasound on the first visit. In subsequent visits, he will perform an in-office cystoscopy and teach the patient about his urinary tract anatomy simultaneously. His main goal in evaluating patients is to find ways to preserve bladder health and function.
Dr. Gelpi uses individual prostate anatomy to guide his decision on BPH treatment for each patient. If there is a substantial median lobe, he prefers to use GreenLight laser therapy. He notes that overtreating patients with GreenLight laser therapy may cause irritative symptoms post-operatively. He also acknowledges UroLift and Rezum as two very good options for patients without substantial median lobes and presents different surgical complications for each treatment. His post-operative medication regimen (pyridium, meloxicam, and colace) is identical for all three BPH treatments.
Finally, because some BPH treatments may result in post-operative pain and/or reduction of ejaculation ability, Dr. Gelpi prioritizes having transparent and honest conversations with his BPH patients. He always presents all relevant treatment options to his patients and allows them to share their expectations and priorities before reaching a decision about BPH treatment.
RESOURCES
Boston Scientific GreenLight Laser Therapy: https://www.bostonscientific.com/en-EU/health-conditions/enlarged-prostate/our-treatments/greenLight-laser-therapy.html
UT Southwestern endourologist Dr. Jodi Antonelli shares her tips and tricks for difficult ureteroscopy cases. Listen to learn about pre-op and post-op medication, dealing with large prostates and narrow ureters, variations in baskets, access sheaths, and ureteroscopes, dusting vs. basket retrieval, and performing ureteroscopies on pregnant women.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews UT Southwestern endourologist Dr. Jodi Antonelli about her tips and tricks for difficult ureteroscopy cases.
First, the doctors discuss the treatment of acute patients presenting with flank pain in the emergency department. In these cases, it is important to obtain a comprehensive patient history complete with vitals, temperature, bloodwork, urinalysis, and appropriate imaging. Indications for intervention include: febrile state, hemodynamic instability, severe pain, and a combination of tachycardia and hypertension. Dr. Antonelli advises urologists to avoid relying solely on urinalysis, as a patient with inflammation may present similar results to one with ureteral stones. In patients who require drainage, Dr. Antonelli prefers to use a nephrostomy tube instead of a stent if the ureteral stone exceeds 1.5 centimeters or if she encounters difficulty in the prostate or bladder anatomy.
For non-acute patients, a trial of passage is recommended if the stone has not occupied an obstructive position for more than 6 weeks. For stone passage patients, Dr. Antonelli prescribes NSAIDS, which she has found to be more effective than narcotics in pain management. If she decides that medical expulsive therapy is appropriate for a ureteral stone patient, she prescribes alpha blockers for both proximal and distal stones. Finally, she notes that relying on the disappearance of symptoms to confirm stone passage is insufficient; before declaring a patient stone-free, imaging, such as a KUB X-ray, must be performed.
If the trial of passage fails, surgical intervention is the next step. Ureteroscopy is an ideal minimally invasive method of extracting ureteral stones. Dr. Antonelli’s pre-operative regimen consists of obtaining a urinalysis and urine culture at least 2 weeks before surgery. She recommends at least 5 to 6 days of culture-specific antibiotics if the patient has a positive urine culture. In the context of the ureteroscopy procedure, Dr. Antonelli emphasizes the importance of being very thorough with ureteroscopy to find tumors in the bladder. Furthermore, Dr. Antonelli discusses her approaches to getting a wire past a difficult stone and dealing with anatomically complex cases that involve large prostates and narrow ureters. She acknowledges that in some cases, the best option is to place a stent to dilate the ureter and attempt the surgery again in the next week.
One method of surgically removing ureteral stones is through the use of a basket. Dr. Antonelli discusses the different basket shapes and manufacturers she prefers to use. However, if the stone is too big or positioned at an unfavorable angle for basket retrieval, dusting the stone is a possible alternative. Although Dr. Antonelli addresses the rapid advancement of dusting laser technology, she also discusses potential risks of dusting--the creation of small stone fragments increases the likelihood of stone recurrence and reduces intraoperative visibility.
The post-operative medications Dr. Antonelli prescribes are: NSAIDS, anticholinergics to help with LUTS, alpha blockers to relax ureter, urinary tract anesthetic, and stool softener. She recommends ordering a post-operative metabolic evaluation, an ultrasound, and a KUB six weeks after surgery.
We talk with Dr. Yahir Santiago-Lastra, director of the Women's Pelvic Medicine Center at UC San Diego Health about the management of cystitis and pelvic pain syndromes. She shares her insights on genitourinary syndrome of menopause, pain evaulation and treatment, and procedural options including botox and sacral neuromodulation.
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In this episode of BackTable Urology, Dr. Jose Silva discusses cystitis and pelvic pain syndrome with Dr. Yahir Santiago-Lastra, a urogynecologist and director of the Women’s Pelvic Medicine Center at UC San Diego Health.
The initial evaluation of a pelvic pain or cystitis patient must address the patient’s detailed symptoms and pain. On the first visit, Dr. Santiago-Lastra emphasizes the importance of discussing the frequency of symptoms, past treatments sought by the patient, and qualitative descriptions of the pain. She notes that some urologists will forget to consider genitourinary syndrome of menopause (GSM) as a cause for recurrent UTIs. Then, she outlines her 5-step pelvic examination procedure: vulvovaginal examination, urethral examination, classic pelvic examination, vaginal/cervix examination, and anal examination. If she finds something abnormal during the pelvic exam, she will use a hand mirror to show patients the anatomical location of their pain.
Next, Dr. Santiago-Lastra discusses the kinds of medical treatment for patients presenting with recurrent UTIs and consistently positive urine cultures. She prefers to prescribe vaginal estrogen over long-term antibiotics, but acknowledges that some patients, such as premenopausal breast cancer patients, may refuse vaginal estrogen. In these cases, she recommends Refresh cream, methenamine, prophylactic post-coital/nightly antibiotics, and sometimes intravesical gentamicin instillation. Aside from medical treatments, Dr. Santiago-Lastra also recommends pelvic floor therapy and sometimes additional holistic treatment, as pelvic pain may originate from sexual trauma.
Dr. Santiago-Lastra then discusses different options for treating pelvic pain and cystitis. For her, opioids play an extremely limited role for pelvic and bladder pain. She typically uses injections (nerve blocks), neuromodulation, pyridium, vaginal diazepam, vaginal lidocaine, gabapentin, and vaginal/systemic cannabis to treat pelvic and bladder pain. She does not usually prescribe NSAIDS because of their adverse effects from long-term use. For patients with confirmed localized bladder pain, she notes that IC cocktail (instillations) can provide some pain relief. In the rare case that all medical options have been exhausted, urinary diversion, an open surgery that removes the bladder completely, is a possible option.
Finally, Dr. Santiago-Lastra and Dr. Silva discuss Botox and InterStim (sacral neuromodulation), two new treatments for patients who have both pelvic pain and incontinence/urgency symptoms. Although Botox and InterStim are equivalent treatments, there are certain indications for each treatment. For instance, InterStim is recommended for patients with voiding dysfunction and severe bowel symptoms because Botox only directs its efficacy to the bladder.
To conclude, Dr. Santiago-Lastra emphasizes the importance of taking time to listen to pelvic pain and cystitis patients’ concerns and desires, as they commonly become long-term patients.
Dr. Aditya Bagrodia interviews urologist Dr. Steve Hudak from UT Southwestern Medical Center about post-prostatectomy incontinence. They cover an array of topics including, incontinence evaluation, managing patient expectations, kegel exercises and pelvic floor therapy, and slings vs. artificial urinary sphincters.
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In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses post-prostatectomy incontinence with UT Southwestern urologist Dr. Steve Hudak. Urinary leakage is very common after the post-prostatectomy catheter is removed. Although the majority of men will regain continence in the long-term, 10-20% will need further treatment for their incontinence.
First, Dr. Hudak emphasizes the importance of comprehensive incontinence evaluation in the clinic. He prefers to schedule two different appointments to make incontinent patients feel more comfortable; he will only take a good medical history in the first appointment and save the cystoscopy and more provocative maneuvers for the second appointment. Dr. Hudak's clinical evaluation consists of a variety of quality of life questions as well as specific questions about pad weight, pad quantity, and pad size.
Further incontinence treatment can be non-surgical or surgical. Among the non-surgical therapies, Dr. Hudak suggests Kegel exercises and pelvic floor physical therapy. Dr. Hudak encourages urologists to explore these non-surgical options with their patients first. When deciding to move onto surgical intervention, Dr. Hudak explains that the trajectory of improvement is more important than a generalized timeframe because surgery is most effective in the time period in which a patient’s progress plateaus.
Pelvic slings and the artificial urethral sphincter (AUS) are the two most common surgical techniques for resolving urinary incontinence. Urologists must take into account their incontinence patients’ medical status, progress, goals, severity of leakage, and age before deciding whether to place a pelvic sling or an AUS. Dr. Hudak notes that the AUS is preferable in patients with severe arthritis, patients who have received radiation therapy, and patients with gravity incontinence. Two possible complications with the AUS are infection and erosion, as the AUS is a mechanical device with a half-life of seven to ten years. The sling is preferable in patients with mild incontinence, as it is a less invasive surgical technique and has a minimal risk of infection.
In some cases, it is possible that post-prostatectomy patients will also need post-operative radiation, so it is crucial to time the incontinence surgery correctly. Dr. Hudak recommends performing sling surgery before radiation, but concedes that radiation treatment should not be delayed solely due to incontinence surgery. His rule of thumb is: perform surgery if radiation is presumed, but not planned. If he has to perform surgery after radiation therapy, he waits at least 3-6 months after radiation to do so, allowing his patients to restore to their baseline levels of health.
Dr. Aditya Bagrodia interviews Dr. Vitaly Margulis, professor of urology at UT Southwestern Medical Center, about locally advanced kidney cancer. They discuss various topics including classification of locally advanced kidney cancers, various imaging modalities for staging cancer, special considerations for tumor-thrombus formation, targeted therapy vs. checkpoint inhibitors, and robotic vs. open nephrectomies.
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In this episode of BackTable Urology, Dr. Vitaly Margulis, professor of urology at UT Southwestern Medical Center, joins Dr. Aditya Bagrodia in a thorough discussion about locally advanced kidney cancer.
First, the doctors classify locally advanced kidney cancers and discuss various imaging modalities used in staging this type of cancer. Dr. Margulis uses MRI, chest CT, and direct radiographic imaging to visualize patient anatomy. He notes that PET scans have a very limited role in staging.
Although extensive metastasis is not present in locally advanced kidney cancer, small metastases--such as pulmonary nodules and small pancreatic/liver metastases--may be present. In these cases, Dr. Margulis emphasizes the importance of collaboration with interventional radiologists to choose the optimal site to biopsy, as biopsy can trigger a hemorrhage of the primary tumor site. He notes that the easiest site to access may not be the best site to biopsy.
Next, Dr. Margulis discusses pros and cons of the two broad types of general systemic therapy: targeted therapy and checkpoint inhibitors. In his clinical practice, he uses a combination of both therapies and continues until the maximal response is reached. He notes that pseudoprogression, or the process of the tumor initially swelling and then shrinking, may be possible.
Furthermore, Dr. Margulis discusses general surgical considerations for other types of locally advanced kidney cancers, such as the necessity of performing a lymph node dissection and whether to take an open or robotic surgical approach. Dr. Margulis also shares special surgical considerations in locally advanced kidney cancers that cause the formation of a tumor-thrombus. He first categorizes these thrombi into two categories--bland thrombus vs. pulmonary emboli--and explains how they can make surgical intervention more complicated. When operating on these cases, he always has a multidisciplinary team with echocardiogram capabilities.
Finally, he shares his clinical opinions about neoadjuvant and adjuvant therapies, two new approaches to locally advanced kidney cancer. He notes that neoadjuvant therapy may be useful, as it can shrink the primary tumor pre-operatively, but he does not use post-operative adjuvant therapy because of its inability to increase survival rates. However, he notes that using checkpoint inhibitors in an adjuvant setting may improve outcomes.
Dr. Margaret Pearle, the Vice Chair of Urology at UT Southwestern Medical Center, joins us to discuss percutaneous nephrolithotomy (PCNL). Dr. Pearle shares advice on pre-operative urine culture analysis, CT scans, percutaneous access, and placing a ureteral stent vs. a nephrostomy tube
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In this episode of BackTable Urology, Dr. Margaret Pearle, an endourologist specializing in complex kidney stone cases, joins Dr. Aditya Bagrodia and Dr. Jose Silva to share her preoperative, intraoperative, and postoperative advice on the percutaneous nephrolithotomy (PCNL) procedure.
First, the doctors discuss preoperative considerations such as absolute indications for PCNL, preferred imaging modalities and urine culture analysis. Dr. Pearle notes that, although every kidney stone patient is a potential candidate for PCNL, PCNL is ideal for patients with large and complex stones and/or patients with no other access options besides percutaneous access. Her preferred imaging modality is CT imaging without contrast, and she emphasizes that a surgeon must study the patient’s collecting system anatomy extensively before operating. Dr. Pearle also adopts an aggressive preoperative antibiotic regimen in patients who present with positive urine culture analyses at least two weeks before the operation.
Then, Dr. Pearle discusses the PCNL operation in the context of achieving percutaneous access, her tools of choice, and operating red flags. She advocates for urologists to learn how to gain percutaneous access without the assistance of an interventional radiologist, but still acknowledges that working with an interventional radiologist is helpful, especially in cases where ultrasound-guided access is needed. She then delineates the type of guide wire, introducer set, sheaths, and nephroscopes she uses and explains how to distinguish the posterior calyx from the anterior calyx using balloon dilation and contrast. Some signs to abort the PCNL procedure are: a significant amount of bleeding, the presence of pus, and a significant perforation of the collecting system.
Finally, Dr. Pearle discusses postoperative decisions, such as whether to place a ureteral stent or a nephrostomy tube. She advises urologists to check the kidney with a flexible nephroscope and to get a postoperative contrast-enhanced ultrasound to confirm that patients are really stone-free. Also, she always gets a chest CT that includes lung bases to check for the presence of a hydrothorax.
RESOURCES
Jeffrey Wire Guide Exchange Set (Cook Medical): https://www.cookmedical.com/products/ir_jwge_webds/
Shockpulse Stone Eliminator (Olympus): https://medical.olympusamerica.com/products/shockpulse-se
Swiss LithoClast Trilogy (Boston Scientific): https://www.bostonscientific.com/en-US/products/lithotripsy/swiss-lithoclast-trilogy-lithotripter.html
Dr. Jose Silva interviews Dr. Jonathan Clavell, a high-volume prosthetic urology surgeon and assistant professor of urology at UT Health Science Center Houston, about erectile dysfunction counseling and penile implants. Dr. Clavell goes into detail about his journey as a men’s health specialist, ED workup and medical counseling, advantages and limitations of different penile implants, implants for complex ED patients (diabetics, cancer patients, etc.), and post-operative care for penile implant patients
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In this episode of BackTable Urology, Dr. Jonathan Clavell, a high-volume prosthetic urology surgeon and assistant professor of urology at UT Houston, joins Dr. Jose Silva to discuss his journey to becoming a men’s health specialist. He also shares advice on erectile dysfunction counseling and penile implant procedures and complications.
First, Dr. Clavell shares his approach to starting a successful urology private practice. Early on, he invested in marketing himself and his prosthetic services through a professional website, a Spanish radio show, an informational Youtube channel, and social media. His diverse marketing strategy succeeded in Houston, a large urban city with a sizable Hispanic population.
Next, Dr. Clavell and Dr. Silva talk about penile implants for patients with erectile dysfunction. Dr. Clavell emphasizes the importance of asking patients about their personal goals and having a partner in the room, if possible. Dr. Clavell then discusses the advantages and limitations of the two main penile implants, the AMS 700 and the Coloplast Titan. Special considerations may be given to patient age and penis size. Then, Dr. Clavell summarizes different approaches of complex ED patients needing penile implants, such as those with urinary incontinence, pump incompatibility, prostate obstructions, and diabetes.
Finally, Dr. Clavell shares his postoperative care regimen for penile implant patients. He always prescribes a week of antibiotics to prevent infections and, if needed, pain medication. He also instructs his patients on how to cycle their implants properly after 4-5 weeks if the incision site has healed.
RESOURCES
Dr. Clavell’s Youtube Video on Cycling the Coloplast: https://www.youtube.com/watch?v=o1t3YuJ_zz4&t=106s Dr. Clavell’s Youtube Video on Cycling the AMS 700: https://www.youtube.com/watch?v=07gyeibMieU Dr. Clavell’s Youtube Video on the Mini-Sling: https://www.youtube.com/watch?v=HpjJZuhA2uo Dr. Clavell’s Radio Show, Sí Se Puede: https://houstonmenshealth.com/posts/events/new-radio-show/
Dr. Aditya Bagrodia and Dr. Jose E Silva interview Brad Hornberger, PA-C in the UTSW Urology department, about bringing advanced practice providers (APPs) into your practice, and how to do it successfully. Brad goes into detail about his journey as a urological PA, advice for on-boarding new APP’s, and training PAs to do in-patient consults and assist in the OR.
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In this episode of BackTable Urology, Brad Hornberger, PA in UT Southwestern’s Urology department, joins Dr. Aditya Bagrodia and Dr. Jose Silva to discuss how to successfully incorporate advanced practice providers (APPs) like physicians’ assistants and nurse practitioners into your urology practice.
First, Brad shares tips for onboarding new APPs. He emphasizes that onboarding depends on the experience of the new hire, as there is a difference between training a new graduate versus an experienced APP. He suggests a time period of 6 months for onboarding, which includes 6-12+ weeks of shadowing. He also notes the need to identify a champion who can take responsibility and set expectations for the new hire. Additionally, Brad explains two models of clinical supervision for APPs--the shared visit model, where the APP presents the patient to the urologist, versus the independent provider model, where the APP sees the patient autonomously. Determining which model works best depends on the experience of the new hire, state laws, and billing logistics.
Brad also briefly explains how to train APPs to assist in the operating room. He recommends a gradual apprenticeship system, where APPs are able to scrub in one-on-one with an experienced APP or a urologist. OR onboarding often depends on whether the APP has laparoscopic or robotic operating experience. Brad emphasizes that exposure to both clinical and surgical environments may be very professionally and intellectually enriching for APPs, who in turn will be more likely to stay at a practice for longer.
In Part II, Dr. Aditya Bagrodia talks with Dr. Claus Roehrborn of UT Southwestern Medical Center about the surgical management of benign prostatic hyperplasia (BPH).
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In this episode of BackTable Urology, Dr. Claus Roehrborn, chairman and professor of UT Southwestern Urology department, joins our host Dr. Aditya Bagrodia to discuss surgical and post-operative management of benign prostate hyperplasia (BPH).
First, Dr. Roehrborn summarizes the different BPH surgical options based on invasiveness, use of ablation, implantation, energy source, and anatomical approaches. UroLift and the Rezum procedures are the most common minimally invasive options, while the monopolar/bipolar TURP, prostatectomies, the Greenlight (KTP) laser, and different enucleation techniques are the most common surgical options.
Next, Dr. Roehrborn discusses how patient characteristics and prostate size can help guide surgical options. He cites frailty and old age as push factors for minimally invasive techniques and greenlight lasers. To study prostate size, he recommends the point-of-care ultrasound (POCUS) because it is inexpensive and gives all the needed measurements before surgery. For large prostates (over 80 g), he proposes enucleation, simple prostatectomy, and minimally invasive treatments. For small or average-sized prostates (30-80 g), he considers all surgical options to be viable, but favors TURP or enucleation if the median lobe is substantially enlarged. He also assesses the risk of anejaculation for each approach: Urolift has no risk, Rezum and aquablation have minimal risks, other techniques depend on individual skill of the surgeon.
Dr. Roehrborn suggests a follow up visit at 1 month to evaluate urination and to stop all medication. However, he notes that some patients resume anticholinergics or beta-3-adrenergics because their storage symptoms persist. He also notes that 5-alpha-reductase inhibitors prevent prostate re-growth in genetically predisposed patients. In general, he encourages urologists to have a specific plan of action for every post-operative drug they prescribe to patients.
RESOURCES
Society of Benign Prostate Diseases: https://societyofbenign.godaddysites.com/ AUA Benign Surgical Hyperplasia Guidelines: https://www.auanet.org/guidelines/guidelines/benign-prostatic-hyperplasia-(bph)-guideline AUA MRI Prostate imaging Guidelines: https://www.auanet.org/guidelines/guidelines/mri-of-the-prostate-sop EAU Lower Urinary Tract Sympton Guidelines: https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/ POCUS Butterfly Device: https://www.butterflynetwork.com/ POCUS Clarius Device: https://clarius.com/l/pocus-ultrasound-machine/
In Part I, Dr. Aditya Bagrodia talks with Dr. Claus Roehrborn of UT Southwestern Medical Center about the medical management of benign prostatic hyperplasia (BPH).
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In this episode of BackTable Urology, Dr. Claus Roehrborn, chairman and professor of UT Southwestern Urology department, joins our host Dr. Aditya Bagrodia to discuss the clinical evaluation and medical management of benign prostate hyperplasia (BPH).
Dr. Roehrborn begins by categorizing lower urinary tract symptoms (LUTS), which are suggestive of BPH, into 2 groups: storage vs. voiding symptoms. He emphasizes the importance of evaluating the patients via the International Prostate Symptom Score (IPSS), asking about the patients’ quality of life, and considering absolute indications for intervention (retention, gross hematuria, recurrent UTI) before formulating a treatment plan for BPH.
Additionally, Dr. Roehrborn highlights two important pre-treatment tests: the flow rate test, which judges the stream intensity, and the post-void residual (PVR) urine test, which measures residual volume. Dr. Roehrborn encourages urologists to use the voided volume and residual volume to calculate the voiding efficiency, a powerful tool to drive treatment options. Finally, he advocates for the Prostate Screening Assessment (PSA) as an effective indirect measure of prostate size, since urologists should know the size and shape of the prostate before embarking on treatment.
In the last part of the episode, Dr. Roehrborn discusses the 5 classes of BPH medication (alpha adrenergic receptor blocker, 5-alpha-reductase inhibitor, anticholinergics, beta-3-adrenergic agonists, and phosphodiesterase 5 inhibitors), their side effects, and their efficacies based on each BPH patient category. He notes that positive results are possible when combining 2 classes of medication and that urologists should always guide patients through increasing dosage and tapering medications during follow-up visits.
RESOURCES
AUA Benign Prostate Hyperplasia Guidelines: https://www.auanet.org/guidelines/guidelines/benign-prostatic-hyperplasia-(bph)-guideline EAU Lower Urinary Tract Sympton Guidelines: https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/ AUA Microhematuria Guidelines: https://www.auanet.org/guidelines/guidelines/microhematuria AUA Prostate Screening Assessment Guidelines: https://www.auanet.org/guidelines/guidelines/prostate-cancer-early-detection-guideline
Dr. Jose Silva talks with Urologist Dr. Yahir Santiago from UC San Diego Medical Center about the diagnosis and treatment of pelvic floor dysfunction in women.
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In this episode of BackTable Urology, Dr. Yahir Santiago-Lastra, director of Women's Pelvic Medicine and associate professor of medicine at UC San Diego, joins our host Dr. Jose Silva to discuss treatment and management of pelvic floor dysfunction.
Dr. Santiago-Lastra starts by distinguishing between stress incontinence and urgency incontinence. She emphasizes the importance of getting to know a patient, understanding their priorities and expectations, and correctly diagnosing the predominant type of incontinence to offer appropriate treatment. She also talks about the utility of less invasive means of evaluation, such as detailed surveys and bladder diaries, over more invasive procedures like a cystoscopy or urodynamics study.
The discussion then shifts to treatment options for stress incontinence, and Dr. Santiago-Lastra states the importance of letting the patient determine the course of treatment after learning all their options. The hosts discuss the importance of pelvic floor physical therapy, and point out the lack of access to this therapy in certain communities. They then do a deep dive into sling surgery, discussing TVTs, TOTs, and mini-slings. Dr Santiago-Lastra states her preference for retropubic slings, and warns against the severe groin pain that can be caused by TOTs. The docs also talk about contraindications for sling placement, post-op care guidelines, and considerations for younger patients.
The episode ends with Dr. Santiago-Lastra restating the importance of listening to one’s patients, and counseling them about the wide variety of treatments available. She also points out language as a barrier to accessing care, and calls for more diversity in the field so patients can feel better understood.
RESOURCES
AUA Guidelines: https://www.auanet.org/guidelines/guidelines/stress-urinary-incontinence-(sui)-guideline EAU Guidelines: https://www.auanet.org/guidelines/guidelines/stress-urinary-incontinence-(sui)-guideline SISTEr Trial: https://repository.niddk.nih.gov/studies/sister/
Dr. Jose Silva talks with Urologist Dr. Aditya Bagrodia from UT Southwestern Medical Center about the medical and surgical management of testicular cancer.
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In this episode of BackTable Urology, urologic oncologist Dr. Aditya Bagrodia joins our host Dr. Jose Silva to discuss the diagnosis, treatment, and long-term management of testicular cancer.
The episode begins with an algorithm for initial work up of a testicular mass – scrotal ultrasound and tumor markers – and reviews the pre-orchiectomy timing of additional imaging and when more advanced imaging modalities like MRI or contrast-enhanced CT might be clinically useful. Dr. Bagrodia then walks through his surgical technique, highlighting practical tips to avoid common frustrations and complications. The pair also discuss operative technique and optimal timing for placement of testicular prostheses, as well as the role for partial orchiectomy in patients prioritizing fertility preservation and androgen production.
Dr. Bagrodia discusses indications for adjuvant chemotherapy and radiation, with a focus on avoiding over-treatment in these young patients and opting for observation when appropriate. He reviews surveillance protocols based on pathological stage, then walks through the management of recurrent and metastatic disease with an emphasis on the importance of multidisciplinary care.
The episode ends with an overview of Dr. Bagrodia’s current research, microRNAs. He reviews the sensitivity and specificity of these unique microRNAs in testicular cancer, explaining their potential to truly individualize care by correctly diagnosing equivocal tumors and identifying residual or recurrent disease.
RESOURCES
AUA Guidelines: https://www.auanet.org/guidelines/guidelines/testicular-cancer-guideline EAU Guidelines: https://uroweb.org/guideline/testicular-cancer/ NCCN Guidelines: https://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf
Dr. Jose Silva talks with Urologist Dr. Aditya Bagrodia from UT Southwestern Medical Center about the medical and surgical management of bladder cancer.
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In this episode of BackTable Urology, UT Southwestern urologic oncologist Dr. Aditya Bagrodia joins our host Dr. Jose Silva to discuss the diagnosis, surgical treatment, and post-operative management of bladder cancer.
The episode opens with a brief overview of the initial workup for a suspected bladder tumor with imaging and cystoscopy, then quickly moves into the OR for definitive treatment and establishment of a tissue diagnosis. Dr. Bagrodia walks us through his surgical approach for transurethral resection of a standard bladder tumor and explains some of his techniques for optimal visualization, resection in challenging locations, and minimizing cautery artifact in smaller tumors to provide the pathologist with enough tissue for a pathological diagnosis.
The conversation then turns to more complex or unusual cases, starting with the approach to particularly large tumors that are likely to be muscle-invasive. Dr. Bagrodia emphasizes the importance of working closely with medical oncology in these cases requiring multimodal therapy, then discusses how he balances the risks and benefits of aggressive resection versus a “less is more” philosophy based on the overall clinical picture. When aggressive resection is appropriate, blue light cystoscopy is particularly helpful in resecting not just the visible tumor but also peritumoral dysplasia and carcinoma in situ. The pair also discuss when to place a stent or even a nephrostomy tube when resecting at the ureteral orifice, how to troubleshoot significant urethral stricture disease, and approach to hemostatic control in difficult cases.
The episode ends with a discussion of bladder-sparing techniques for muscle-invasive bladder cancer, a guideline-directed option still largely regionalized in the United States. Dr. Bagrodia first reviews some of the relative contraindications to a bladder preserving approach, then emphasizes that it can be an efficacious option in appropriate, motivated patients so should be a treatment option included in the conversation with these select patients.
RESOURCES
AUA Guidelines, Non-Muscle Invasive Bladder Cancer: https://www.auanet.org/guidelines/guidelines/bladder-cancer-non-muscle-invasive-guideline AUA Guidelines, Muscle-Invasive Bladder Cancer: https://www.auanet.org/guidelines/guidelines/bladder-cancer-non-metastatic-muscle-invasive-guideline
Anish Parikh interviews Urologist Dr. Jose (Oche) Silva about his experiences building a practice from scratch after training, and then a Category V hurricane forced him to start over again.
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In this inaugural episode of Backtable Urology, Dr. Jose Silva reflects on his journey to becoming a urologist with host Anish Parikh.
Dr. Silva talks about his early years, growing up in a family of doctors and dentists, and knowing that medicine was a possible path for him. He talks about going back to Puerto Rico for medical school where he developed an interest in general surgery and orthopedic surgery before eventually finding his way to urology. He cites the duality of urology as a clinical and surgical specialty as a major factor in his decision to pursue the field.
Dr. Silva then discusses his decision to stay in Puerto Rico after medical school, and talks about navigating a complex system of hospitals and insurance companies. He recounts anecdotes of networking with other physicians and hospital staff as he worked to start a fledgling practice, and Anish compares the experience to starting a new business.
Finally, the two discuss the impact of Hurricane Maria, which led to Dr. Silva’s decision to move to the mainland. Dr. Silva recalls not being able to practice medicine due to power cuts while also worrying about his pregnant wife, and deciding to move in order to avoid repeating the experience. Today, he practices in Florida where he enjoys the support of a strong hospital system but misses his extended family in Puerto Rico.