BackTable Urology

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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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/oiF3pD

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SHOW NOTES

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.

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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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EARN CME

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

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SHOW NOTES

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.

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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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Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/7YanKm

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SHOW NOTES

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.

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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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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Em4or1

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SHOW NOTES

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.

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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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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/a1DEz5

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SHOW NOTES

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.

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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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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/xK1fKn

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SHOW NOTES

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.