BackTable Urology

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.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---SHOW NOTESFirst, 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.---RESOURCESDecipher Prostate Genomic Classifier by Veracytehttps://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.---SHOW NOTESFirst, 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.---RESOURCESAmerican Urologic Association (AUA) Position Statement on the Supreme Court’s Decision to Overturn Roe v. Wadehttps://www.auanet.org/about-us/aua-statement-on-overturning-roe-v-wadeAmerican College of Obstetricians and Gynecologist (ACOG) Abortion Policyhttps://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/abortion-policyRyan Residency Training Programhttps://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 NOTESDr. 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.---RESOURCESThe Servant: A Simple Story About the True Essence of Leadership by James C. Hunterhttps://www.amazon.com/Servant-Simple-Story-Essence-Leadership/dp/0761513698Grit: The Power of Passion and Perseverance by Angela Duckworthhttps://www.amazon.com/Grit-Passion-Perseverance-Angela-Duckworth/dp/1501111108The Road to Character by David Brookshttps://www.amazon.com/Road-Character-David-Brooks/dp/0812983416The War of Art by Steven Pressfieldhttps://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 NOTESFirst, 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.

In this episode of BackTable Urology, Dr. Aditya Bagrodia invites Dr. Yair Lotan, professor of urologic oncology at UT Southwestern, and oncologist Dr. Suzanne Cole to discuss types of adjuvant treatment for high risk bladder cancer, including chemotherapy, radiation therapy, and immunotherapy.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---SHOW NOTESFirst, they discuss the benefits of neoadjuvant chemotherapy for bladder cancer, which includes a 5-10% absolute advantage and a 20% reduction in likelihood of dying. They also discuss potential barriers to neoadjuvant chemotherapy and the importance of having a discussion with a medical oncologist to determine eligibility for cisplatin-based treatment, such as MVAC chemotherapy. Next, they explore the differences between adjuvant and salvage therapy, as well as how to approach post-operative complications and counseling; it is important to discuss the risk of disease recurrence and initiate conversations about future chemotherapy early in treatment.Then, the doctors explore when to consider immunotherapy instead of cisplatin-based chemotherapy, the success rates of chemotherapy treatments, and the potential of cell-free DNA testing to predict outcomes. They consider the implications of false negatives and false positives and agree that clinical trials are important to gain a better understanding of the technology and how it could be used in personalized medicine. They also discuss when radiation therapy is appropriate for recurrence in the retroperitoneum and the use of metallic clips to create a target zone for radiation oncologists.Finally, they consider the difficulty of convincing patients to accept additional therapy and the lack of level 1 evidence for adjuvant therapy. However, they remain optimistic about the progress being made with upper tract studies, innovative new treatments, and the potential of biomarkers to predict response.

In this episode of BackTable Urology, Dr. Silva invites Dr. Ronald Cadillo to speak about the realities of reconstructive surgery and bladder neck reconstruction and explore the challenges of transitioning from performing oncologic surgeries to reconstructive surgeries.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/plWnX7---SHOW NOTESFirst, Dr. Cadillo shares his journey from being a urologist in Peru to coming to the United States in search of a better opportunity to help his family. Then, he discusses his experience of transitioning from open to robotic surgery. He discusses his experience with interviewing at programs and how he felt in the moment of being accepted into the robotic program at the University of Pennsylvania. Next, he describes the experience of completing a robotic boot camp.Dr. Cadillo faced challenges when returning to Puerto Rico, where there was a greater need for oncology and reconstructive surgeries. He learned that having a healthy obsession when learning new techniques is important, as well as having adequate resources, such as videos and mentors. In his opinion, practice and experience are the most important components of successful reconstructive surgeries. He then shares how he used mentorship and collaboration to deal with complex cases. Finally, he explains how the field of reconstructive urology in Puerto Rico has changed in the past four years with the arrival of a new generation of young urologists.

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.---CHECK OUT OUR SPONSORBoston Scientific Rezum Water Vapor Therapyhttps://www.bostonscientific.com/rezum---SHOW NOTESFirst, 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.

On this episode of BackTable Urology, Dr. Jose Silva and Dr. Jay Simhan, director of reconstructive urology at Fox Chase Cancer Center, discuss how urologists can demonstrate their value to hospital systems.---SHOW NOTESFirst, Dr. Simhan explains the changing nature of urology practice. He opts for the term “health systems urologist” over “private practice urologist” because many urologists are managed by smaller medical groups that are owned by larger hospital groups. He notes that this multi-tiered system of management can cause tension around decision making and increase senior leadership turnover when hospital finances change.Then, Dr. Simhan explains the four ways that doctors can generate value, which is clinical productivity, departmental service, academics or research, and teaching. Clinical productivity is often measured by the RVU system, which assigns a certain number of value units to a procedure. Hospital systems may encourage urologists to choose surgical procedures over office-based procedures to increase RVUs. Although RVUs are arbitrarily set by the Centers for Medicare & Medicaid Services (CMS), each hospital or medical group can increase the number of RVUs per procedure to their own discretion. Dr. Simhan believes that urologists should band together to negotiate fair RVU systems.Finally, they end the episode by discussing concrete ways to demonstrate value as a urologist. Generally, minimizing complications and maximizing RVUs is helpful. Dr. Simhan advises urologists who are joining a new system to build their name and referral network to earn a long term contract. Usually, there is no RVU requirement in the first employment contract. In the later years, he recommends putting in the effort to understand productivity metrics and downstream costs and revenues in order to maximize earnings and potential.

On this episode of BackTable Urology, Dr. Jay Shah (Stanford University) and Dr. James McKiernan (Chair of Urology, Columbia University / New York Presbyterian Hospital) discuss practical tips to develop and maintain successful mentor-mentee relationships in medicine.---SHOW NOTESFirst, Dr. McKiernan explains how he started his mentorship journey, which started when he began to build a research team. He explains that the residents and medical students received advice from him while working on his team. He notes that forced mentor-mentee relationships never work because both sides need to have shared priorities and values. His decision to take on a mentee depends on whether the trainee in question could potentially benefit him and the field of urology as a whole. For a mentee to fulfill these criteria, they must show interest in projects, have willingness to put time into the relationship, and complete all tasks to the best of their ability.Next, Dr. McKiernan discusses how organizations can develop successful mentorship programs. He suggests building in structured, recurring meetings for both sides to prioritize the relationships. He also notes that hiring faculty members who want to mentor and who prioritize using their protected time for education can greatly increase the ease of establishing a mentorship program. He also discusses the importance of racial and gender diversity in leadership positions, but does not think that they should be barriers to mentorship. Finally, he emphasizes that mentorship meetings are not performance evaluations, as discussions should focus on the future goals and priorities of the mentee.

On this episode of BackTable Urology, Dr. Jose Silva invites endocrinologist Dr. Rodrigo Valderrabano onto the show to discuss the impact of testosterone replacement therapy on hypogonadic patients and prostate cancer survivors.---SHOW NOTESFirst, Dr. Valderrabano explains the role of testosterone in the body, which is to create the male phenotype and to maintain sexual function and muscular strength. There is a strong relationship between bone building and testosterone, as testosterone is converted to estrogen to maintain bone density. He then explains what constitutes low testosterone, which is difficult to define due to testing imprecision, fluctuating hormone levels throughout the day, and other comorbidities, like obesity. To be diagnosed with hypogonadism, patients will need at least 2 lab tests and display clinical symptoms as well. For all patients who are interested in starting testosterone replacement therapy (TRT), Dr. Valderrabano measures total and free testosterone, sex hormone binding globulin, and LH and FSH to determine if the patient has primary hypogonadism or secondary hypogonadism.Next, the doctors discuss different methods of testosterone delivery, such as injections, gels, patches, pellets, pills, and intranasal sprays. Dr. Valderrabano prefers to use gel, as it mimics the natural daily release of the hormone and results in less pituitary interference. However, he notes that the patient must be careful not to transfer the gel onto household contacts. Dr. Silva prefers to give testosterone injections. Then, the doctors discuss how recent literature disproves the claim that testosterone replacement therapy causes BPH/LUTS symptoms.Finally, Dr. Valderrabano speaks about his research trial focused on giving TRT to prostate cancer survivors who have hypogonadism. His patient cohort includes prostate cancer patients who have a low risk of disease recurrence are at least 2 years into remission, have normal PSA levels, and are on no other hormone therapy treatments. His main outcomes are physical and sexual health. He also explains his data collection methods and collaboration with other institutions. Lastly, he emphasizes that physicians must collaborate with their patients to balance the risk of disease recurrence and their quality of life to determine if TRT is a good option for them.