BackTable Urology

On this episode of BackTable Urology, Dr. Aditya Bagrodia, Dr. Matt Allaway (Perineologic Biopsy), and Dr. Juan Javier-DesLoges (UC San Diego) discuss benefits and procedural tips for the transperineal prostate biopsy.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/6Pc55q---SHOW NOTESFirst, the doctors discuss why they invested in learning to perform transperineal biopsy. Dr. Allaway explains that transrectal biopsy can lead to rectal bleeding, infections, and sepsis. He also believes that the perineal approach offers the proper trajectory to sample the prostate appropriately. Next, they discuss the equipment required for transperineal biopsies, such as probes, ultrasounds, grid steppers, and needle sheaths. They weigh the pros and cons of performing the procedure in the office versus in the clinic. Additionally, they discuss different costs and features of different probes.Next, they discuss their techniques for obtaining the transperineal biopsy, including tips for patient positioning, probe maneuvers, and local anesthetic injections. Dr. Javier-DesLoges uses a local injection of lidocaine, normal saline, and sodium bicarbonate. Dr. Allaway then shares his advice on how to deal with obstacles, such as stool burden and rectal gas. They end the episode by highlighting the importance of collaboration and learning from others’ techniques. Dr. DesLoges strongly recommends the AUA course on transperineal biopsies as an educational resource.---RESOURCESPerineologichttps://perineologic.com/aboutpl-2/

On this episode of BackTable Urology, Dr. Mike Hsieh (UC San Diego) interviews Dr. Larry Lipshultz (Baylor College of Medicine) about his journey to becoming a renowned specialist in male infertility and reproductive medicine.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---SHOW NOTESFirst, Dr. Lipshultz explains how he became interested in urology through working in a basic sciences surgery laboratory with a urologist. He became passionate about doing research in male infertility as an intern after hearing a Grand Rounds lecture. Before his residency ended, he was sent to El Paso, Texas by the military, where he was able to start his own semen analysis laboratory to treat male infertility patients. He then accepted an AUA fellowship and followed a mentor to UT Houston for training in male infertility. He eventually transitioned to Baylor College of mEDICINEand stayed after fellowship to join the faculty.Next, Dr. Lipshultz reflects on major events in his life, such as the opportunity to perform trailblazing surgeries, like gender-affirming surgeries and vasovasostomies, and graduating productive male infertility fellows. He gives advice on balancing clinical duties and research, the importance of goal setting, and mentoring junior faculty.Finally, the doctors discuss the future of men’s health. Dr. Lipshultz disagrees with the concept of direct-to-consumer marketing and “low T clinics”, as he believes they do not exist to serve the patient’s best interest. He is excited about new research implicating that testosterone may have other health benefits besides treating erectile dysfunction and that male infertility may be an indirect measure of men’s health. He encourages urologists to explore running their own IVF clinics and incorporate biotechnology into their practices as well.

On this episode of BackTable Urology, Dr. Aditya Bagrodia, Dr. Daniel Costa (UT Southwestern), and Dr. Xiaosong Meng (UT Southwestern) discuss patient selection and procedure for TULSA-PRO, a new transurethral ultrasound ablation system that incorporates real-time MR imaging, as a focal treatment option for prostate cancer.---CHECK OUT OUR SPONSORProfound Medical TULSA-PROhttps://profoundmedical.com/---SHOW NOTESFirst, the doctors discuss the benefits of using MRI with transurethral ultrasound ablation (TULSA), which include direct visualization of anatomy, margins, and boundaries. They compare TULSA to other forms of focal management, such as cryoablation, brachytherapy, stereotactic body radiation therapy (SBRT). Compared to these methods, TULSA has lower risk of rectourethral fissures and preserves the posterior plane better, making salvage procedures more viable.Then, the doctors discuss ideal candidates for TULSA therapy, which include patients with intermediate risk and localized disease, patients with lesions in lateral or anterior portion of prostate, patients with medium sized prostates, low risk patients with lower urinary tract symptoms (LUTS) who do not want to undergo active surveillance. Patients with large calcifications may not be ideal candidates for TULSA, as the calcifications can be a shield for the ultrasound beam. The doctors recommend ordering a CT/MRI scan first to identify if calcifications are present to assess their sizes and locations. During imaging, it is also important to make sure the tumor is not close to key anatomical elements, such as the neurovascular bundle. When deciding between different focal therapies, it is important to balance oncological outcomes and quality of life preservation. Thus, the treatment decision should be a collaboration between patients, their families, the radiologist, and the urologist. The doctors also discuss special considerations for salvage therapy patients, brachytherapy patients, patient with urethral strictures, and patients with a prior history of TURP.Next, the doctors explain how to prepare patients for TULSA. The patient’s colon has to be emptied in order to reduce MRI noise during the procedure. Additionally, the doctors help patients understand the immediate side effects of the procedure, which can include reduced semen volume, urgency incontinence from bladder and prostate irritation, and temporary erectile dysfunction, and semen retention. After the procedure, the urinary catheter will have to be left inside for five days to two weeks, depending on the volume of the prostate removed. There is a 20-25% chance of recurrence.Finally, they discuss specifics of the TULSA procedure. Dr. Costa and Dr. Meng perform these procedures at the university hospital, as they need access to MRI and anesthesia. They discuss the optimal MRI window for the procedure, patient positioning, as well as their two sweep method. The total procedure time is dependent on the volume of ablation and number of sweeps, but the average total time is 3 hours. Patients are discharged on the same day, and no narcotics are prescribed. Finally, they discuss the progress of a new prospective multi-center randomized trial comparing focal TULSA therapy to surgery for intermediate risk prostate cancer patients.---RESOURCESTULSA Procedurehttps://tulsaprocedure.com/tulsa-procedure/about-tulsa-procedure/Profound Medicalhttps://profoundmedical.com/

On this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Rana McKay, a medical oncologist at UC San Diego, discuss guidelines and advances in prostate cancer treatment.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/B9kR7B---SHOW NOTESFirst, they define three types of prostate cancer. Metastatic castration-sensitive disease refers to patients with metastatic cancer who have low testosterone levels because of androgen deprivation therapy (ADT). Nonmetastatic castration-resistant disease is nonmetastatic cancer with testosterone levels unresponsive to ADT. This category is harder to define as the classification varies based on imaging modality. Finally, metastatic castration-resistant disease is the most lethal type of prostate cancer, as there is an unmet need in developing therapeutics for these patients. Traditionally, the castrate level is defined as a testosterone level <50 ng/dL.Then, the doctors discuss different types of ADT, which include GnRH agonists, GnRH antagonists, and anti-androgen receptor medications. When explaining ADT to her patients, Dr. McKay always identifies the class of the agent and common side effects (i.e.- bone composition changes, metabolic changes, and mood and libido changes). Dr. McKay notes that she has observed many patients who have had success with ADT and shares lifestyle tips that she recommends to mitigate the side effects of ADT.Next, the doctors summarize treatment options for different types of prostate cancer patients, including those with de novo metastatic prostate cancer, metastatic hormone sensitive disease, biochemically recurrent disease, and chemotherapy naive patients. In addition, they reflect on past landmark trials and current prospective trials about different combinations of therapies. They end the episode by discussing lutetium-177 as a new therapy for prostate cancer.---RESOURCESVeracyte Decipher Prostate Genomic Classifierhttps://www.veracyte.com/diagnostics/prostate-cancerProstate Cancer Foundationhttps://www.pcf.org/Zero Prostate Cancerhttps://zerocancer.org/

In this episode of BackTable, Dr. Bagrodia interviews Dr. Sia Daneshmand, chief of urologic oncology at the University of Southern California, about the research trials and treatment of stage II seminomas.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/oOcODJ---SHOW NOTESFIrst, Dr. Daneshmand defines stage II seminomas, which are seminomas that have spread outside of the testicles to the retroperitoneal lymph nodes. Stage II seminomas are further subclassified into IIa, b, or c depending on size and number of affected lymph nodes. This disease stage can present on Initial seminoma diagnosis or occur after a relapse of a stage I seminoma. There are 3 options for standard treatment for stage II seminomas: radiation therapy, chemotherapy, or retroperitoneal lymph node dissection (RPLND). Dr. Daneshmand recommends a monotherapy option to minimize toxicities and explains which treatment modalities are best for each subtype of stage II seminomas. Then, the doctors discuss common side effects of each modality. Radiation may cause cardiotoxicity, fatigue, enteritis, and secondary malignancy. Chemotherapy may cause neurotoxicity, nephrotoxicity, infertility, and tinnitus or hearing loss.The doctors also discuss RPLND as a therapeutic option. Dr. Daneshmand explains that some patients may be hesitant at first to choose this option, as this has been a large open surgery with lengthy hospitalizations in the past. However, his technique involves only making a small midline incision and using an extraperitoneal approach. His RPLND patients usually only stay in the hospital for one day and fully recover by 2 to 3 weeks. He also discusses prospective RPLND trials on stage II seminomas, including his own research project. Both doctors agree that patients should be involved in shared decision making in order to weigh the cure rate against the comorbidity rate of each therapy.Finally, Dr. Daneshmand speculates on the future of seminoma treatment, which he believes lies in advancements of individualized treatment based on biomarker data.

In this episode of BackTable, Dr. Bagrodia interviews Dr. William Flanary, a physician-comedian popularly known as Dr. Glaucomflecken, about lessons he has learned as a two-time testicular cancer survivor and the importance of humor in medicine.---CHECK OUT OUR SPONSORVeracytehttps://www.veracyte.com/decipher---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/VJvXZx---SHOW NOTESFirst, Dr. Glaucomflecken shares about his first diagnosis of testicular cancer. During his third year of medical school he felt a lump in his testicle, which led to a quick workup, diagnosis, and a full orchiectomy. The diagnosis was emotionally difficult, as he was in his mid-twenties and healthy. He returned to comedy, a skill he had developed in high school and college, to cope with his diagnosis. This time, however, he started to practice medical-based comedy with his new experiences as a medical student. He recounts other discussions he had about his cancer, such as fertility, the possibility of chemotherapy, and active surveillance.Four years after his first orchiectomy, he received his second diagnosis of testicular cancer during his last year of residency. He recounts feeling distraught and overwhelmed, as questions about fertility, hormone replacement, medical expenses, and postponing residency became more serious. He decided to have a full orchiectomy and testosterone replacement therapy, which solved his issues with fatigue and irritability. Additionally, his wife got him involved in testicular cancer support groups and foundations, including one called First Descents, an organization that encourages young adults with cancer to explore the outdoors. He notes that young patients are often overlooked in cancer support groups and encourages cancer patients to find their support networks outside of friends and family as well.Then, Dr. Flanary discusses his experience with suffering from cardiac arrest in 2020, which led to his wife doing ten minutes of chest compressions to keep him alive. He reflects on this event and concludes that it taught him how to be a better physician to his patients by making sure he involves patients’ families and encouraging him to address medical insurance issues directly.Finally, Dr. Flanary discusses how he uses humor to advocate and educate patients on social media. He notes that comedy can stimulate conversation and debate and encourages physicians to have social media presence.---RESOURCESKnock Knock Hi Podcasthttps://podcasts.apple.com/us/podcast/knock-knock-hi-with-the-glaucomfleckens/id1659572053First Descentshttps://firstdescents.org/

En este episodio de BackTable Urology, Dr. Jose Silva entrevista a Dr. Jose Saavedra, un especialista de salud sexual en Puerto Rico, sobre tratamientos mínimamente invasivos y cirugía para Peyronie's disease.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/BVuIxP---SHOW NOTESPrimero, Dr. Saavedra reflexiona sobre su trayectoria médica antes de establecer su práctica privada, Puerto Rico Sexual Wellness Clinic. Después de la formación en cirugía general durante 3 años, escogió la urología como su especialidad por la habilidad de mejorar la calidad de vida de pacientes.Después, él habla sobre su evaluación para curvatura del pene. Usualmente sus pacientes desarrollan la curvatura y sufren 3-6 meses de síntomas antes de buscar su ayuda. Síntomas importantes incluyen dolor general durante la penetración y dolor referido en testículos. Es importante preguntar sobre su historial sexual y la posibilidad de un trauma escondido. Para él, la habilidad de obtener y mantener una erección es la medida más importante para evaluar la función del pene. Explica también en cuáles pacientes recomienda el vacuum erection device, los NSAIDs, y gabapentin también. Adicionalmente, habla sobre la onda de choque (shockwave therapy), que solamente recomienda para el manejo de dolor porque no resuelve el plaque.Próximo, explica los detalles de cómo realiza sus inyecciones en la clínica y las ventajas del vacuum erection device. Además, la satisfacción, la ansiedad, y el “body dysmorphic syndrome” son sus indicaciones para la cirugía. Finalmente, describe sus técnicas quirúrgicas y consejos para pacientes para la recuperación.

En este episodio de BackTable Urology, Dr. Jose Silva entrevista a Dr. Ramon Virasoro sobre los tratamientos diferentes para estrecheces uretrales.---SHOW NOTESPrimero, Dr. Virasoro habla sobre su camino a ser urólogo reconstructivo en los Estados Unidos. Empezó su educación en Buenos Aires pero obtuvo un fellowship de reconstrucción urológica en Eastern Virginia Medical School debajo de la tutela de Dr. Gerald Jordan. Dr. Virasoro refleja en su decisión de escoger esta especialidad y también los obstáculos de ser un graduado médico internacional. Decidió quedarse en la medicina académica después de terminar su entrenamiento.Próximo, Dr. Virasoro habla sobre su práctica de reconstrucción, incluso sus estudios primeros y procedimientos más comunes para pacientes con estrecheces ureterales. Aunque los síntomas son importantes, cree que la información radiológica es clave. Los doctores también están de acuerdos de que la selección de pacientes es importante también; es importante comprender la causa, la locación, y el tamaño de la estrechez porque hay técnicas mejores para cada tipo del estrechez.Entonces, discuten sobre los tratamientos diferentes para esta condición. Para estrecheces cortos sin tratamiento previo, una dilatación con globo tiene un alto nivel de éxito. Sin embargo, si la paciente con un estrecho largo o uno que ya tenía muchos procedimientos, el globo tiene un bajo nivel de éxito. En estos casos, una reconstrucción con injerto puede ser mejor. Los doctores evalúan diferentes tipos de injertos, incluso desde la lengua y desde la mejilla. También hablan de complicaciones después de la cirugía, como la pérdida de sensación, neuropraxia, y rabdomiolisis. Adicionalmente, Dr. Virasoro aboga por la preservación de vasos sanguíneos en sus casos de reconstrucción. En casos difíciles, él siempre involucra al paciente en la discusión para escuchar sus goles y preferencias. Hará una lista de los pros y contras de cada tratamiento y dará al paciente la capacidad de elegir el tratamiento. Los doctores hablan sobre la reparación concurrente de las fístulas y el desarrollo del globo con paclitaxel también (Optilume).Finalmente, Dr. Virasoro habla de sus experiencias internacionales de voluntariado con las organizaciones de Physicians for Peace y Safe Surgery and Anesthesia for Everyone.---RESOURCESSafe Surgery and Anesthesia for Everyone (SAFE)https://www.safesurgery4all.org/Physicians for Peacehttps://www.physiciansforpeace.org/

In this episode of BackTable, Dr. Jose Silva interviews Dr. Aaron Schneider, a pharmacist, and Dr. Jordan Grant, a urologist, about compounding pharmacies and their uses in providing medications to treat urological conditions.---CHECK OUT OUR SPONSORReviveRXhttps://reviverx.com/urology/---SHOW NOTESFirst, the doctors define compounding, which is the process of creating special treatments for unique populations of patients. Compounding a medication can involve a multitude of actions, such as removing an allergen, eliminating a preservative, changing typical route of administration, and more. Dr. Grant and Dr. Schneider explain how in 2016, ReviveRX, their compounding pharmacy, realized the need for compounding urologic medications, especially to treat infertility, erectile dysfunction, and low testosterone. Additionally, the doctors explained how ReviveRX provides a unique type of intracavernosal injection that is freeze dried to help increase the shelf life and distribution efficiency of the product. Although insurance companies may not cover the cost of compounded medications, some patients with allergies to medications have seen great improvement in side effects with medication compounded to their unique needs.Next, Dr. Grant discusses his testosterone replacement therapy regimen for patients with low free testosterone levels. He explains how he integrates hCG and FSH into the treatment plan if patients have concerns about declining fertility. Then, Dr. Schneider provides an overview of the history of hCG use and regulations in commercial and compounding pharmacies.Finally, the doctors wrap up by explaining how other doctors can order from ReviveRX and steps they can take to ensure the quality of products from compounding pharmacies.---RESOURCESReviveRXhttps://reviverx.com/

In this episode of BackTable, Dr. Jose Silva and Dr. Justin Dubin chat about the benefits and pitfalls of using social media to network with colleagues and to educate patients about urological conditions.---CHECK OUT OUR SPONSORReviveRXhttps://reviverx.com/urology/---SHOW NOTESFirst, Dr. Dubin explains why he created his own social media presence, which was to control his own narrative online. However, he realized that he could also form valuable connections with other doctors through social media, which motivated him to develop his social media from a professional standpoint. For instance, he was able to connect with other researchers virtually and publish papers. He encourages other urologists to create professional social media accounts but to also portray themselves authentically.Next, he explains his job search after fellowship. He had to consider his own priorities, most important of which was to have a clinic focused on men’s health, not just general urology. Additionally, he only refers patients to primary care physicians he would go to himself. Next, he and Dr. Silva discuss the workup for patients with low testosterone. According to guidelines, treatment is warranted if the patient has a low testosterone level and is symptomatic. Dr. Dubin emphasizes the importance of explaining to young patients that testosterone replacement therapy can cause infertility through azoospermia or anejaculation. Dr. Silva debunks the myth that testosterone replacement causes prostate cancer. Then, the doctors discuss the benefits of the expanding field of telemedicine. Dr. Dubin explains that telemedicine mitigates the stigma of erectile dysfunction and increases the convenience and accessibility of urologic care.Finally, Dr. Silva and Dr. Dubin comment on the increasing incidence of misinformation from social media about urologic conditions. Dr. Dubin summarizes a paper he published about harmful myths propagated by non-medical personnel on TikTok and Instagram. Both of the doctors agree that podcasts, such Dr. Dubin’s Man Up Podcast, can provide accurate information to patients. Dr. Silva notes the importance of outreach to younger patients, who utilize social media more and are more prone to misinformation.---RESOURCESReviveRxhttps://reviverx.com/Man Up Podcast“The broad reach and inaccuracy of men’s health information on social media: analysis of TikTok and Instagram” (Dubin, 2022)https://www.nature.com/articles/s41443-022-00645-6“Never Eat Alone: And Other Secrets to Success, One Relationship at a Time” by Keith Ferrazzihttps://www.penguinrandomhouse.com/books/227558/never-eat-alone-expanded-and-updated-by-keith-ferrazzi-and-tahl-raz/