BackTable Urology

In this episode of BackTable Urology, Dr. Jose Silva and Dr. Bilal Chughtai discuss their workup for benign prostate hyperplasia (BPH) and how they use Greenlight Laser therapy and pharmacologic interventions to treat this common condition.---CHECK OUT OUR SPONSORBoston Scientific GreenLight Laser Therapyhttps://www.bostonscientific.com/greenlight---SHOW NOTESFirst, the doctors discuss workup of BPH. Questionnaires, like the International Prostate Symptom Score (IPSS) are helpful when in the first clinic evaluation. They also discuss differential diagnoses of urinary obstructive symptoms.Then, they discuss who is and isn’t a candidate for a GreenLight laser therapy. They also touch on the topic of pre-operative antibiotics. Dr. Chughtai then describes in detail the steps of the procedure to ensure an open channel and removal of the correct prostate lobes. Next, he discusses the possible risks and benefits of doing an ejaculatory hood sparing procedure. Additionally, they explore the hood technique and how it's used to preserve mucosa at the apex of the prostate.They also consider the importance of having a discussion about ejaculation with patients before the GreenLight procedure. Additional technology or adjunctive medications, such as alpha blockers and PDE5 inhibitors may be necessary as well. Finally, Dr. Chughtai explains his post-operative medications and the decision to discharge or admit for overnight observation.---RESOURCESGreenLight Laser Therapy:https://www.bostonscientific.com/en-EU/health-conditions/enlarged-prostate/our-treatments/greenLight-laser-therapy.html

In this episode, host Dr. Jose Silva speaks with Dr. Duke Herrell, CEO and CMO of Virtuoso Surgical, a robotic surgery tool known for its exceptional dexterity and precision.---SHOW NOTESDr. Duke Herrell is a minimally invasive urologic surgeon and professor at Vanderbilt University. Dr. Herrell came to Vanderbilt for his surgical fellowship, where he met Bob Webster, a mechanical engineer who had developed concentric tube robots made out of an elastic metal. Together, they worked to form the metal into curves that could create a tentacle-like motion for clinical applications. Over the next 15 years, Dr. Herrell and three co-founders started their company, Virtuoso Surgical, and received grant funding to move forward with their startup.The surgical device features two 1-millimeter dextrous tools inserted through a rigid scope that is capable of carrying a versatile array of instruments. The device is currently intended for the urologic procedures including removal and enucleation of prostate tissue, bladder lesion removal and sampling, and transurethral resection of bladder tumors (TURBT). Notably, the device addresses a critical issue in tumor staging by improving the accuracy of margin determination, which is a game-changer for the 50% of TURBT procedures that yield specimens lacking muscle or clear margin information. Beyond urology, the device has the potential to improve other surgical procedures that utilize a rigid scope in a constrained environment including pulmonology, neurosurgery, and ENT interventions.Dr. Herrell and his team are also developing EndoTheia, a micromachine instrument that functions as a steerable catheter, specifically designed for flexible ureteroscopy. This device is currently in the verification and validation phase.---RESOURCESVirtuoso Surgical:https://virtuososurgical.net/

This week on BackTable Urology, Dr. Kristen Scarpato (Vanderbilt University), Dr. Todd Morgan (University of Michigan), and Dr. Philip Kim (Kaiser Permanente) discuss their urologic oncology fellowship experiences, the importance of mentorship, and work-life balance as urologists.---SHOW NOTESFirst the doctors discuss the changing landscape of urologic oncology fellowships and the favorable job market for those graduating from residency. They also share how their experiences in residency and mentorship from esteemed urology professionals shaped their paths towards urologic oncology. Additionally, they discuss the Society of Urologic Oncology (SUO) Clinical Trials Consortium and its role in providing education and resources to fellows. Benefits of joining an SUO fellowship program include the ability to participate in clinical trials and gain mentorship opportunities.Finally, the doctors examine the reality of balancing early career work and family responsibilities. They analyze the effect of burnout on our work-life balance and the different stages of career and family life. They conclude the episode by emphasizing the importance of intentionality in both aspects of their lives.---RESOURCESSUO Clinical Trials Consortiumhttps://suoctc.org/home.aspx

This week on BackTable Urology, Dr. Aditya Bagrodia (UC San Diego), Dr. Clint Cary (Indiana University), and Dr. Gagan Prakash (Tata Memorial Hospital) discuss the diagnosis and management of metastatic testicular cancer.---SHOW NOTESFirst, the doctors discuss when orchiectomy and retroperitoneal lymph node dissection (RPLND) are necessary. They also summarize the relevant tumor markers and laboratory values to obtain and discuss the possibility of teratomas. Then, they examine the role of chemotherapy in the treatment of metastatic testicular cancer.The doctors then transition to explaining how to manage patient expectations before orchiectomy and RPLND. They discuss the various complications of the procedure as well as the potential benefits of using 3D models and animations to explain the surgery to patients. They also cover the complications of chemotherapy as well and emphasize the importance of preparing the patient for the side effects of all treatment combinations. Then, they delve into specific surgical techniques that can prevent surgical complications when resecting testicular cancers.Finally, the doctors discuss the importance of gaining experience with observing RPLND and training at a high volume urology center to gain more insight into the complexities of the operation. Finally, they emphasize the importance of having an experienced team to handle the operation.

In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Christopher Anderson (Columbia University) discuss the diagnosis and workup of kidney cancer, including renal biopsy techniques.---SHOW NOTESFirst, the doctors explore the importance of cross-sectional imaging and IV contrast to identify and manage small renal masses. Many factors are important, such as patient age and comorbidities, hereditary cancer predisposition syndromes, and size cut-off criterias. They also emphasize the importance of time in helping patients understand their diagnosis and the individualized approach to each case.Then, they move on to discuss the role of biopsies in identifying and managing small renal masses. Biopsies can determine whether a tumor is malignant and help with treatment decisions. They also discuss the AUA guidelines for when to consider a real biopsy as well as the risks and benefits of biopsy procedures. Then, they give a short summary of a few biopsy techniques.After the renal biopsy, a decision has to be made about whether or not to operate on a small renal mass. Aditya and Christopher emphasize the importance of understanding patient goals and the risks of accidentally removing a benign tumor. They also explore factors in deciding on which patients would benefit from treatment of indolent tumors. Biopsies can help avoid over-treatment if they can be used to reduce unnecessary operations. The doctors end by discussing the follow-up and the importance of close monitoring for any signs of recurrence.

This week on BackTable Urology, Dr. Suzette Sutherland (University of Washington) and Dr. Priyanka Gupta (University of Michigan) discuss the multifactorial components that can contribute to pelvic pain and how urologists can approach treatment for this condition.---SHOW NOTESPelvic pain can originate from bladder-centric symptoms, pelvic floor dysfunction, GI-centric symptoms, gynecologic symptoms, musculoskeletal and psychosocial issues, and systemic problems. First, the doctors summarize how to perform a thorough pelvic physical exam. They explain how to identify the obturator muscles and levator complex with a digital exam. They differentiate between bladder-centric pain and pelvic floor-centric pain and emphasize not beginning with a speculum exam, which can cause pain in some patients. They also suggest using a speculum to check for masses or lesions and prescribing vaginal estrogen supplementation.Then, Suzette and Priyanka examine the role of pelvic floor physical therapy in treating pelvic pain and how to communicate with patients about what to anticipate in physical therapy. In addition, Priyanka explains the approach to transvaginal injections for pelvic floor dysfunction, including the injection of a mix of long-acting anesthetics at 1, 3, 5, 7, 9, and 11 o'clock behind the pubic bone and deeper at the level of the ischial spine. Finally, she discusses the role of insurance coverage for these injections.

This week on BackTable Urology, Dr. Jose Silva and Dr. David Sas, a pediatric nephrologist at the Mayo Clinic-Rochester, discuss clinical presentation and prevention of kidney stones in children as well as workup of metabolic diseases.---SHOW NOTESFirst, David explains how laboratory and genetic tests can be useful when determining the cause of kidney stones. Obtaining a 24-hour urine sample and analyzing stone composition are important for understanding the causes of stone formation in teenagers. Environmental and genetic factors can also contribute to the formation of stones. For example, CYP24A1 mutation a gene can cause a hypersensitivity to vitamin D and calcium in the diet.Next, David and Jose discuss lifestyle modifications for preventing stones in teenagers. They talk about how to limit sodium intake, the use of thiazide diuretics, and supplementing potassium citrate for calcium oxalate stones. Furthermore, they delve into the causes of hyperoxaluria, which are genetic primary hyperoxaluria and enteric hyperoxaluria. Additionally, they discuss the rare monosodium urate stones, which are usually associated with metabolic acidosis but can be caused by chronic diarrhea or eating a lot of protein.The doctors end by discussing the challenges of transitioning pediatric management to adult management. Lastly, they discuss the potential causes of why more kids are forming stones, such as increasing sweet juices and fast food in the diet.

This week on BackTable Urology, Dr. Manoj Monga (UC San Diego) invites Dr. Margaret Pearle (UT Southwestern) to discuss kidney stone prevention with lifestyle changes and medical therapy.---SHOW NOTESFirst, the doctors reflect on Dr. Pearle and Dr. Yair Lotan’s paper from 2008 that predicted the impact of climate change on kidney stones. Dr Pearle then shares her recommendations for lifestyle changes to prevent kidney stones, such as increasing fluid intake and reducing sodium and animal protein intake. She also advises on reducing oxalate intake in diets and maintaining adequate calcium intake to ensure bone health.Next, the doctors discuss strategies for treating and preventing stones with medical therapy. They explore the use of thiazides and potassium citrate for both calcium oxalate and calcium phosphate stones, as well as the importance of evaluating PTH levels and serum uric acid levels in these patients. They also discuss the role of dietary oxalate and bowel disease in determining when to order genetic testing. Additionally, they explore the nuances of treating hypercalciuria with thiazide holidays and the use of potassium citrate as a second line therapy. Potassium citrate is beneficial for alkalinization and citrate supplementation. There are different benefits when comparing the liquid formulation to the tablets.Finally, they discuss the use of urinary pH and xanthine oxidase inhibitors, the importance of genetic testing, and the importance of fluid intake and potassium citrate for cystine stones.---RESOURCESBrikowski TH, Lotan Y, Pearle MS. Climate-related increase in the prevalence of urolithiasis in the United States. Proc Natl Acad Sci U S A. 2008 Jul 15;105(28):9841-6. doi: 10.1073/pnas.0709652105. Epub 2008 Jul 14. PMID: 18626008; PMCID: PMC2474527.

This week on BackTable Urology, Dr. Jose Silva invites Mark Goldberg, a certified sex therapist, to discuss psychogenic erectile dysfunction and his role as a sex therapist for patients and couples.---SHOW NOTESFirst, Mark shares his expertise on how to address performance anxiety in patients. He explains that performance anxiety can present in different ways for different people and that it is important to understand the unique thoughts and feelings associated with each individual's manifestation. He recommends what is best for patients who are insistent on immediate relief and emphasizes the importance of finding a balance between a challenging lifestyle and having enough mental bandwidth to have the desired sexual function.Next, they speak about the causes of premature ejaculation, which can be lifelong or acquired and across the board or situational. He outlines the two general areas of focus to address premature ejaculation, which are over-excitation and performance anxiety. He then discusses the different methods to treat the different causes, such asl medications, and cognitive and behavioral interventions.Then, Mark speaks about the difference between men and women's expectations of sexual performance. Men tend to have higher expectations of themselves, while women oftentimes feel like they are not living up to the bar. Mark also discusses the role of telehealth, as it is easier for therapists to work with people outside of the United States than across state lines. Mark also shares his experience of starting his radio podcast during the COVID-19 pandemic.---RESOURCESCenter for Intimacy, Change, and Connectionhttps://centericc.com/team/Erectile Dysfunction Radio Podcasthttps://podcasts.apple.com/us/podcast/erectile-dysfunction-radio-podcast/id1529816999

This week on BackTable Urology, Dr. Hooman Djaladat (USC Keck School of Medicine), ​​Dr. Sanam Ladi Seyedian (Vanderbilt University Medical Center), and Dr. Alireza Ghoreifi (USC Keck School of Medicine) explore the different pathways to higher education in urology in the US for foreign medical graduates.---SHOW NOTESFirst, the doctors discuss the challenges that international medical graduates (IMGs) face when transitioning to the US for higher education in urology. Knowing oneself and having a purpose are important, as well as preparing for the financial and cultural challenges that come with the transition. They also examine the role of age, mentorship, team work, and preparation in pursuing a training program in the United States. Mentors and advisors can help applicants be aware of the requirements for a full license needed to do research and practice medicine abroad. Additionally, they stress the importance of being open to new experiences, gaining cultural competency, and developing professional skills.Finally, they wrap up by highlighting the importance of asking for and receiving feedback. They share their personal strategies that they have found helpful in their own journeys, as well as the importance of self-reflection and growth.