BackTable Urology

This week on BackTable Urology, urologists Dr. Aditya Bagrodia (UC San Diego) and Dr. Giovanni Cacciamani, assistant professor of urology at the University of Southern California, discuss how artificial intelligence can improve urology practice and research.---SHOW NOTESFirst, Dr. Cacciamani explains the origin of artificial intelligence (AI) and machine learning, which started with Alan Turing. AI learns from a large amount of data and adds on layers of knowledge as it increases the quantity of data it collects. For this reason, Dr. Cacciamani explains the principles behind algorithmic learning and the concept of generative AI. Large language models are examples of generative AI that can generate original videos, images, and text. Next, Dr. Cacciamani explains how his interest in AI started at USC. During the pandemic, he had free time and wanted to find a solution to the repetitive tasks that caused burnout in fellows, residents, attendings. He learned more about AI principles and established the first AI center of urology in the world at USC in order to integrate AI into academia.Then, he and Dr. Bagrodia discuss the potential areas of AI applications, such as scribing, billing, constructing nomograms for early detection and prognosis, and imaging interpretations. Additionally, Dr. Cacciamani shares research about how AI is helping radiologists to improve the accuracy of diagnostic imaging. He encourages academic institutions to be involved in AI product development in biotech companies as well. Then, the doctors discuss the use of AI in surgery, which can serve as a co-pilot minimally invasive surgery. Dr. Cacciamani shares about the USC ICAROS lab, which explores ways to use AI to detect intraoperative complications and near miss events.The episode ends with a discussion about the ethics of using AI in medicine. The doctors discuss concepts of data privacy, accountability, and explainability. Dr. Cacciamani emphasizes the importance of establishing multiple regulatory agencies to monitor AI use and create guidelines for generative AI in academia. Dr. Bagrodia agrees that AI should never take away from the physician-patient relationship, but in contrast, enhance the time the physician spends with the patient.---RESOURCES“Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again” by Eric TopolWorld Health Organization: Ethics and Governance of Artificial Intelligence for Healthhttps://www.who.int/publications/i/item/9789240029200Cacciamani GE, Anvar A, Chen A, Gill I, Hung AJ. How the use of the artificial intelligence could improve surgical skills in urology: state of the art and future perspectives. Curr Opin Urol. 2021 Jul 1;31(4):378-384.https://pubmed.ncbi.nlm.nih.gov/33965984/

This week on BackTable Urology, urologists Dr. Suzette Sutherland (University of Washington) and Dr. Kristin Chrouser (University of Michigan) discuss the importance of ergonomics for surgeons in the OR and in the clinic to prevent physical ailments that can lead to early retirement and burnout.---SHOW NOTESFirst, Suzette and Kristin explain the risks of various procedures and the positions that can put urologists in vulnerable positions. They discuss how the angle, length of time, stillness, and head weight play a role in the potential for injury. They also explore how technology like adjustable loupes and the placement of surgical monitors can help reduce the strain. Next, they highlight the importance of educating staff on proper ergonomics and encouraging urologists to incorporate ergonomic checks into the World Health Organization's universal time out process. They also recommend taking micro breaks, which are short 60 second stretching breaks every 45 minutes. They encourage surgeons to involve the entire team when stretching as well.The importance of physical fitness is indisputable in reducing musculoskeletal problems for surgeons. Suzette and Kristin discuss the culture of surgery and the generational differences between surgeons, which influence the way doctors think about and talk about pain. According to them, making ergonomic initiatives part of the core residency education is crucial.

This week on BackTable Urology, Dr. Aditya Bagrodia (UCSD), medical oncologist Dr. Rana McKay (UCSD) and radiation oncologist Dr. Shankar Siva (University of Melbourne) discuss the growing role of radiation therapy in kidney cancer treatment.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---SHOW NOTESShankar first explains the original historical studies that provided evidence of the limited efficacy of low dose conventional radiation therapy (RT) in treating kidney cancer. However, he and Rana discuss how stereotactic body radiation therapy (SBRT), a newer technology which delivers a higher dose per fraction more accurately, has shown better outcomes in clinical trials than conventional RT. They also explain the associated risks with SBRT and how neoadjuvant therapies can be combined with radiation. They also consider the use of SBRT in bulky tumors and those with IVC thrombus. All three doctors agree that radiation therapy needs to be incorporated into a multimodal approach to kidney cancer. They also discuss the potential of radiation therapy in the cytoreductive setting and its role in delaying systemic therapy in patients with oligometastases.Finally, they explore the possibility of using PET imaging to detect oligometastatic disease. Although prostate-specific membrane antigen positron emission tomography (PSMA PET/CT) imaging is mostly used to stage prostate cancer, other solid tumors like renal cell carcinoma (RCC) may also express PSMA. For this reason, they agree that a next generation PSMA PET/CT equivalent for RCC could be revolutionary. Lastly, they predict what the future of RCC could hold by examining newer therapies, such as radioligand therapy and cyberknife.---RESOURCESKidney Cancer Association: 2023 International Kidney Cancer Symposium (Nov. 9-11)https://www.kidneycancer.org/ikcs/2023-ikcs-north-america/Decipher by Veracytehttps://decipherbio.com/WellPrepthttps://wellprept.com/

In this episode of BackTable Urology, Dr. Jose Silva interviews Dr. Andrew Sun, director of the Center for Men's Health at Urology Partners of North Texas, about various men's health issues, such as sexual dysfunction, low testosterone, and infertility.---CHECK OUT OUR SPONSORKYZATREX™www.kyzatrex.com---SHOW NOTESFirst, the doctors discuss testosterone replacement therapy. They explain the tests and treatments available and the role of lifestyle factors and estradiol in testosterone production. They delve into the various protocols for administering testosterone injections, including the popular IM and subcutaneous methods and the pros and cons of weekly injections. Next, they cover alternative treatments, such as oral testosterone and testosterone gels. They look into the different types of first-line oral testosterone treatments available, such as KYZATREX, and examine the benefits of each. Additionally, they discuss the distribution model for oral testosterone treatments and the role of cash payments in increasing accessibility.Finally, they explore how a dedicated men's health center can offer quicker conversations with patients and how doctors can use specialty networks to purchase and dispense medications. Both doctors emphasize that having a passionate champion in men's health matters when it comes to successfully executing a men’s health program.---RESOURCESKYZATREX™ by Marius Pharmaceuticalshttps://www.kyzatrex.com/

Dr. Mohit Khera, a Baylor professor and andrology researcher specializing in male reproductive medicine and testosterone therapy. He walks through diagnosing low testosterone and the key labs to check. He explores lifestyle drivers, fertility-preserving options versus replacement, new oral formulations, dosing strategies to avoid peaks, and safety monitoring including hematocrit and cardiovascular data.

This week on BackTable Urology, Dr. Juan Javier-Desloges, a urologic oncologist at UC San Diego, interviews Dr. Neil Taunk, a radiation oncologist leading the Brachytherapy and Procedural Radiation program at the University of Pennsylvania, about his experience with using SpaceOAR rectal spacer for prostate cancer radiotherapy.---CHECK OUT OUR SPONSORBoston Scientific SpaceOAR Hydrogelhttps://www.bostonscientific.com/spaceoar---SHOW NOTESFirst, the doctors explore the nuances of rectal spacing and the best candidates for this procedure. They discuss various large-scale trials from different research institutions about the efficacy of rectal spacing in different types of radiation, like proton beam, external beam, and brachytherapy. He also notes the time crunch that comes with using a spacer and highlights the importance of understanding a patient's anatomy before performing the procedure. Additionally, he shares his insight on how extracapsular extension of the tumor can affect the rectal spacing procedure, as well as the potential benefits of rectal spacing for certain patient populations. Dr. Taunk also considers the differences between the two gels (Barrigel and SpaceOAR) available on the market and delves into specific differences between the two products.Lastly, they emphasize the importance of pre-operative counseling for the imperfect management of patients because suboptimal gel placements and complications, such as intravascular injection and pulmonary embolism, are possible.---RESOURCESSpaceOAR Hydrogel by Boston Scientifichttps://www.bostonscientific.com/spaceoar

This week on BackTable Urology, Dr. Jill Buckley speaks with internationally-renowned urologic reconstructive surgeon, Dr. Sanjay Kulkarni, about his upbringing, training, and insights on urethroplasty.---SHOW NOTESFirst, Dr. Kulkarni discusses his upbringing and the importance of education in his family. Then he outlines the challenges he faced in the 1980s when he began to introduce urethroplasty in his hometown in India. He established a small hospital with two operating theaters and 20 beds in 1995 that transformed into a 100-bed urology center in 2021. Additionally, he started the Kulkarni School of Urethral Surgery, which has since been an international training site for surgeons from around the world.Next, Dr. Kulkarni elaborates about the mentors and experiences that have shaped his career. He introduced the buccal mucosa technique in 1997, applied it to penile urethra in 2000, and innovated the one-side dissection technique in 2009. The doctors then discuss the potential advances in urethral surgery, including stem cells and tissue engineering, and Dr. Kulkarni’s interest in robotics and reconstructive urology. Finally, Dr. Kulkarni shared his admiration for his various peers and mentors in the field.Finally, he shares his last surgical pearls and emphasizes the importance of attending workshops and observing in the theater to develop one's technique and passion for surgery. He ends the episode by highlighting the importance of out-of-the-box thinking and how it can lead to innovation.

In this episode of BackTable Urology, Dr. Silva and Dr. Zamip Patel, a urologist specializing in male infertility and andrology at Southeast Male Infertility and Urology/Andrology, discuss infertility trends and causes, as well as artificial intelligence in surgical robotics and fertility.---SHOW NOTESFirst, the doctors discuss the rising rate of infertility in the US and around the world, and the potential causes behind it. They consider the impact of obesity and environmental cues, like endocrine disruptors, on fertility rates. Then, they transition to reflecting on the rapidly changing landscape of infertility treatments and how insurance coverage and third party providers are playing a role in treatment selection. They also examine the impact of government mandates on fertility coverage, and the implications for employers who want to provide fertility benefits to their employees. Next, they explore the challenges of diagnosing infertility, such as lack of awareness and the importance of optimizing the male side to improve IVF outcomes.Zamip then explains artificial intelligence (AI) can augment male fertility diagnostics and therapeutics. Advanced neural networks have enabled us to identify candidate genes in large sets of data that weren't available before, leading to a more accurate diagnosis. AI can also help the fertilization process, as it can aid in selecting the most viable sperm and egg, and identify the best embryos for implantation. Zamip also adds that AI can assist in the genetic analysis of blastocysts and how it may help avoid discarding embryos unnecessarily. We consider the potential benefits of AI alongside the ethical implications of using AI in such delicate procedures.Although AI can dramatically improve the healthcare industry and revolutionize treatments for men's health, both doctors agree that there is a need for a humanistic touch in the medical field, even as AI becomes more advanced.---RESOURCESWellPrepthttps://wellprept.com/

In this episode of BackTable Urology, Dr. Bagrodia interviews Dr. Peter Scardino, world-renowned urologist and professor emeritus of urology at Memorial Sloan Kettering Cancer Center (MSK), about his journey to becoming a urologist and life lessons he has learned along the way.Dr. Scardino was born in Portsmouth Naval Hospital at the end of World War II and grew up in Savannah, Georgia. The fact that his father was a urologist and his attendance at a National Science Foundation special summer science program started his interest in medicine. He had an early interest in science and worked harder than anyone else. This work ethic led him to pursue an undergraduate degree at Yale and a medical degree at Duke. Then, he trained in general surgery at Massachusetts General and pursued urology training at UCLA. Dr. Scardino also speaks about his experience in hospital administration and business management. We discuss how he was inspired to gain knowledge in the field, and how a group of faculty members got together to learn from a retired businessman and the University of Houston. He shares personal stories about his mentors and insights on how mentors can help guide people to their best interests. He also emphasizes the importance of engaging in leadership and administration early on in a career.Additionally, he shares about the challenges he faced when making the decision to move from being chair of urology at Baylor College of Medicine to Memorial Sloan Kettering. They also discuss the division of attitudes towards making urology a department, and how it affected Dr Scardino's personal life. Finally, Dr Scardino reflects on the lessons he has learned throughout his career and the importance of striking a balance between work and personal life.

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.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/f2sdAy---SHOW NOTESFirst, 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.---RESOURCESChang 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/