BackTable Urology

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.

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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.

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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 the BackTable Urology Podcast, Dr. Bagrodia talks with Dr. Daniel Spratt, professor and chairman of radiation oncology at Case Western University in Cleveland, about the workup and treatment of high risk prostate cancer.

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CHECK OUT OUR SPONSOR

Veracyte

https://www.veracyte.com/decipher

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SHOW NOTES

First, Dr. Spratt defines high risk prostate cancer and discusses how to evaluate non-specific PSMA PET findings. He notes the importance of standardized systems to avoid over-calling such findings and discusses the role of CT scans and MRI scans when necessary. Finally, the doctors emphasize the importance of synthesizing PSMA PET findings into their decision-making. Next, the doctors discuss the use of germline and genomic testing, specifically Decipher testing, to characterize the tumor. Germline testing can determine eligibility for neoadjuvant PARP inhibitor trials, and biomarkers have the potential to improve radiation therapy outcomes. Although they quickly summarize the NCCN guidelines, they also emphasize the importance of patient counseling to determine the right treatment plan.

Then, the doctors move on to discuss the different radiation treatments available for treating high-risk prostate cancer, such as conventional fractionation, brachytherapy, and ultrahypofractionated radiotherapy. They also explain the use of protons in treating high-risk prostate cancer, which is difficult because of the lack of high-level evidence and financial benefit when using protons compared to conventional radiation treatments.

Finally, they wrap up the episode by explaining the correlation between early PSA responses and the success of radiation therapy. Surgery and radiation are often used together in treating most cancers, and how combining both can cut down the chances of PSA recurrence.

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RESOURCES

Veracyte Decipher:

https://decipherbio.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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ExosomeDX

https://www.exosomedx.com/

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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.

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RESOURCES

ExoDx Prostate Test:

https://www.exosomedx.com/

In this episode of BackTable Urology, Dr. Bagrodia, program director Dr. Steve Hudak (UTSW) and resident doctor Dr. Theresa Olmstead (UC San Diego) discuss the tangible advice for having successful urology away rotations and crafting an outstanding urology residency application.

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SHOW NOTES

First, the doctors discuss advice for first and second-year medical students interested in urology. Students in the early stages of their medical journey should be honest and transparent with themselves and mentors about their interests, abilities, and goals. The removal of STEP 1 scores and other metrics has allowed students to determine if a specialty is right for them without the fear of being turned away. Connections, research, and opportunities for first and second year medical students are important, but taking the time to find a mentor who resonates with them and committing to projects that will help them move forward is also essential.

Then, the doctors discuss the process of applying for away rotations and Theresa shares her experience of doing three away rotations. Additionally, they explain the job interview-like process of away rotations and how to best prepare for the process, like taking the time to understand and orient oneself in the situation. Both Theresa and Steve agree that punctuality, being oneself, and assessing program fit are very important.

Next, the doctors share tangible advice on how to ask for stellar letters of recommendation, such as having tangible examples to share with letter writers, taking the time to talk to faculty ahead of time, and providing their curriculum vitae and personal statement. They also discuss the pros and cons of the signaling process. Finally, they give interview tips, such as having unique stories to share, and being concise and succinct when answering questions.

In this episode of BackTable Urology, Dr. Jose Silva and Dr. Suzette Sutherland, director of Female Urology at the University of Washington, discuss new therapies for overactive bladder (OAB).

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Wellprept

https://wellprept.com/

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/V7Flno

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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.

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RESOURCES

Wellprept

​​https://wellprept.com/

In this episode of BackTable Urology, Dr. Bagrodia and urologic oncologist Dr. Piyush Agarwal (University of Chicago) discuss the impact of music to keep them focused and set the mood in the OR.

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Wellprept

https://wellprept.com/

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SHOW NOTES

First, the doctors explore different types of music that can be used in the OR to help set a certain tone or rhythm for a procedure. They discuss the use of Bollywood, classic rock, show tunes, EDM, R&B, lo-fi, as well as other music genres to help create a more enjoyable OR environment. They also touch on the importance of having the right crew to enjoy music in the OR, as well as the humorous associations that some surgeons have with certain music. Dr. Agarwal then explains why Apple Music and Spotify are his preferred platforms for streaming music in the OR. Additionally, they look at the power of sharing playlists on Spotify to create a community.

Finally, they discuss the importance of engaging the team in the OR and encouraging other members to contribute to the music selection. They end the episode by exploring how nostalgic music can bring back fond memories of childhood and lift the spirits of everyone in the OR.

In this episode of BackTable Urology, Dr. Jose Silva, radiation oncologist Dr. Neil Mariados, and urologic oncologist Dr. Dan Welchons discuss techniques and benefits of rectal spacing for radiation therapy in prostate cancer patients.

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Barrigel

https://barrigel.com/

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SHOW NOTES

First, Dr. Mariados explains the need for rectal spacing in order to minimize the toxicities of prostate radiation. He then discusses the national rectal spacing trials (SpaceOAR and Barrigel) that he and Dr. Welchons participated in. The doctors also mention that most patients are interested in rectal spacing in order to minimize toxicities, but having a tumor with extracapsular extension is a contraindication of the procedure.

Then, the doctors compare two rectal spacing products, SpaceOAR and Barrigel, in the context of setup and product materials. They explain the Barrigel technique, which is performed through the transperineal approach. Preoperatively, their patients receive Valium and oxycodone. After the surgery, the spacer can be visualized through a CT scan. Dr. Welchon also reflects on his process of learning the Barrigel procedure and the satisfaction that comes with helping patients avoid toxicities.

The stability of Barrigel is 1 year. Most patients feel little to no discomfort after the procedure, and the doctors do not prescribe any postoperative antibiotics. The most serious complication of rectal wall spacing is rectal wall invasion, which occurs after incorrect product placement. However, the doctors discuss ways to avoid this complication, like using tactile feedback. They also emphasize the similarities between rectal spacing technique and transperineal prostate biopsies. Finally, they emphasize the importance of publications and education to avoid misunderstanding and myths about rectal spacing.

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RESOURCES

Barrigel Rectal Spacer

https://barrigel.com/

In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with urological oncologist Dr. Ashley Ross from Northwestern University about risk factors of prostate cancer and the importance of genome expression tests to predict tumor characteristics.

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CHECK OUT OUR SPONSOR

Veracyte

https://www.veracyte.com/decipher

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SHOW NOTES

First, the doctors summarize how to determine stage and risk of prostate cancer by assessing local and regional staging with MRI and PET-PSMA scans. They discuss the significant role of Gleason grade groups and genetic variants and genetic predisposition for prostate cancer. They underscore the importance of evaluation beyond the microscopic cellular structure of the cancer and using tools like MRI to reduce unnecessary biopsies.

Next, they explain the factors involved in the decision to treat or observe prostate cancer. Dr. Ross shares insights into the three possible lines of progression that prostate cancer can take and how to identify them in a patient. He illuminates the differences between germline and genomic testing, the impact of genomics on treatment decisions, and the crucial role of shared decision making. The doctors also consider the cost of genomics and the patient's expectation of what will happen before making a decision. Although there is a lack of standardization in the qualification and execution of prostate cancer surveillance, national trials are being done nationally that could influence guidelines around the use of genomics and active surveillance.

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RESOURCES

Decipher Prostate Genomic Classifier by Veracyte

https://www.veracyte.com/diagnostics/prostate-cancer

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.

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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.

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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.

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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.

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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