BackTable Urology

In this episode, guest host Dr. David Canes interviews Dr. Matthew Allaway about PrecisionPoint, his medical device for transperineal prostate biopsy, and his journey towards changing the paradigms of prostate cancer diagnosis.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/0Lmsku---SHOW NOTESDr. Allaway starts by outlining his path to medicine. The choice to pursue urology was largely influenced by his personal cancer diagnosis. He cites cancer as the greatest lesson in his life, since it brings an enhanced level of empathy to his patient care and inspires him to contribute to the field of urology. Throughout his career, he has always examined his procedures for logical sense – if a process was inefficient, he tried to devise ways to make improvements for patient care.In 2013, Dr. Allaway decided to switch from the transrectal to transperineal approach for prostate biopsies. With the traditional transrectal approach, he found unacceptably high rates of infection and failure to detect cancers in the anterior prostate region. He started performing transperineal biopsies with a freehand technique, using ultrasound in one hand and a biopsy probe in the other. He built a database of his own patients, which showed an increased cancer detection rate. His technique eventually evolved into the PrecisionPoint transperineal access system. He originally started marketing the device at American Urological Association (AUA) meetings, through booths and video competitions. Although Dr. Allaway works in private practice and not academia, he was able to form connections with institutions and key opinion leaders to encourage adoption of the transperineal approach. PrecisionPoint has been accepted by early adopters, and his team is now working to capture a larger share of the biopsy market. Importantly, they are also marketing the device to patients, since patients can also recognize the safety and diagnostic benefits, and being the ultimate consumers of healthcare, can influence urologists to adopt the device.Dr. Allaway also gives advice for budding entrepreneurs. He highlights the need to link the device to a specific clinical need, research existing devices, check the your device’s feasibility and pricing strategy, and find good mentors who will allow you to learn from their mistakes. In terms of product marketing, he encourages entrepreneurs to look beyond the United States and explore worldwide markets to increase the chances of product adoption. His confidence in PrecisionPoint grew when he received positive feedback from other urologists about the simple elegance of the device. Finally, Dr. Allaway discusses the importance of truly believing in your product. He says that if you are ashamed of your product’s price, you have priced it wrongly. He encourages entrepreneurs to focus on their product’s benefit to society, rather than profitability.---RESOURCESPrecision Point:https://perineologic.com/precisionpoint/American Urological Association:https://www.auanet.org/Zero to One by Peter Thiel:https://www.amazon.com/Zero-One-Notes-Startups-Future/dp/0804139296

In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with two fellow urologic oncologists, Dr. Timothy Clinton (Brigham and Women’s Hospital) and Dr. Eugene Pietzak (Memorial Sloan Kettering), about the management of BCG-refractory non muscle-invasive bladder cancer.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/h8YiBe---SHOW NOTESFirst, the doctors define BCG-refractory cancer from the clinical and FDA viewpoint. They emphasize the importance of determining the difference between BCG-resistant cancer and residual tumor from the primary resection. Blue light cystoscopy can help in confirming that the original tumor was totally resected. The doctors warn that although the initial response to BCG may be promising, there is still a chance of cancer recurrence. The success rate of BCG depends on the patient and tumor characteristics.Next, they discuss BCG-intolerant patients. BCG has many side effects such as frequency and urgency symptoms and bladder spasms. Some patients will have a systemic immune response resulting in flu-like symptoms. However, most of these side effects are self-limiting and should resolve after the induction course. They also discuss how to deal with the current BCG shortage. They first prioritize starting an induction course and view the maintenance course as a secondary priority.An erythematous and inflamed bladder can either be a result of BCG cystitis or a carcinoma in situ (CIS). The doctors agree that if the bladder is inflamed and the patient has a positive cytology, they would obtain a bladder biopsy to look for recurrent high-grade cancer. If the biopsy is positive, they would start a second induction course of BCG and introduce another form of therapy, like intravesical gemcitabine or an immune checkpoint modulator. If the bladder is inflamed and the patient has a negative cytology or a negative biopsy, they would continue with a BCG maintenance course and follow up.Cystectomy is a curative option for BCG-refractory bladder cancer. Patients with tumors with high risk features such as lymphovascular invasion and varying histology are good candidates for cystectomy. Patient comorbidities, age, and willingness are also important factors in the decision. Dr. Bagrodia also recommends getting a CT scan to check for nodal metastases. Both Dr. Clinton and Dr. Pietzak agree that it is beneficial to introduce the idea of cystectomy early and explain that the procedure does not prevent patients from living a fulfilling life.Finally, the doctors discuss recent BCG and gemcitabine clinical trials as well as new research about non-BCG therapies.

In this special episode, Dr. Phil Pierorazio (University of Pennsylvania) invites Dr. Rana McKay (UC San Diego) and Dr. Raquibul Hannan (UT Southwestern) about treatment options for renal cell carcinoma (RCC) patients in preparation for the 2022 International Kidney Cancer Symposium in Austin, Texas.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/ffUyI5---SHOW NOTESFirst, the doctors discuss their excitement for the 2022 IKCS. They have benefited greatly from participating in collaboration and networking, improving their wellness strategies, learning about new clinical trials, and debating difficult cases at academic conferences like IKCS.Next, Dr. Pierorazio presents four different difficult RCC classes to the doctors and asks for an outline of their treatment plans. He starts with localized disease and works towards more aggressive and nodally invasive cancer. For each case, Dr. McKay and Dr. Hannan explain recent developments in clinical trial data, side effect considerations, and the importance of assessing patient comorbidities. All three doctors draw conclusions based on their previous patients as well. Additionally, Dr. McKay explains why it is important to understand what the patient understands about their cancer diagnosis before presenting these treatment options to patients. Dr. Pierorazio has learned to ask patients about their greatest cancer-related fear in order to guide his treatment decisions. Dr. Hannan advises doctors to look at the failure rates of clinical trials along with the success rates.Cases presented:Localized clear cell RCC patient with 1 kidneyAdjuvant chemotherapy for a post-nephrectomy patient with T3a clear cell RCCPapillary RCC patient with a 10 cm mass and a 10 cm para aortic lymph nodeChromophobe RCC patient with an 8 cm renal mass and spinal metastasis

In this episode, Dr. Aditya Bagrodia speaks with Dr. Manoj Monga, chair of the urology department at UC San Diego, about his unique journey to becoming a urologist as well as extra-academic passions that have led him to understand the importance of advocacy.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/B9LqOK---SHOW NOTESFirst, Dr. Monga shares the story of his childhood. As an Indian born and raised in Belfast, Ireland, he had to adapt to living among a different culture and religion. In his childhood, he was surrounded by bomb scares and bomb drills because of the religious and political conflict in Ireland. His parents ultimately made the decision to move to Ontario, Canada for family safety. He finished his schooling in Ontario, Canada and noted that his decision to pursue medicine was more based on a path of least resistance rather than initial passion. He chose medicine out of practicality, but was interested in a musical career because he played the french horn, trumpet, and saxophone. He still plays musical instruments and has realized that many musical skills, such as practice and challenging himself, have translated into medical skills.He then speaks about his early career. Dr. Monga did not start out with an ultra-focused goal of becoming a urologist. He started as a categorical general surgery intern at Tulane because of his interest in trauma and reconstructive surgery. In his second year in Louisiana, he gained his first exposure to urology and decided to fill an empty spot in the urology residency program. However, he took a 1 year research gap at Tulane to study endourology, pyelonephritis, and andrology. He noted that this year helped him with aligning his career with his wife’s career and prompted him to think about an academic career. He finished residency and trained at a variety of institutions, such as UC San Diego and the Cleveland Clinic.Then, Dr. Monga reflects about his transition to UC San Diego as the chair of urology during the pandemic. It was difficult to leave his family at first, but he was impressed by the teamwork and selflessness of his department. Shortly afterwards, he became the secretary of AUA, a position that was fulfilling, but also one that challenged his time management skills.Finally, Dr. Monga explains why taking action and being an advocate is so important in his professional and personal life. Inspired by recent events, he has taken multiple trips to provide medical relief in Ukraine. He found that the refugee history he encountered abroad resonated with him and motivated him to create a better world for his kids by developing meaningful passions. He encourages using urology for social responsibility by advocacy and raising funds for important causes instead of stopping at social media to raise awareness.Finally, Dr. Monga sums up three big lessons he has learned. First, he is fortunate for the open paths and family/mentor support. Second, he has learned to temper his enthusiasm for simple answers to complex issues. Finally, he realizes the importance of sharing experiences to let people who are suffering know that they are not alone.

In this episode, Dr. Jose Silva interviews private practice urologist Dr. Jordan Luskin, a community urologist practicing in West Palm Beach, about special considerations for rural / community medicine urologists.---CHECK OUT OUR SPONSORReviveRXhttps://www.reviverx.com/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/tIgp4u---SHOW NOTESRural / community medicine urologists often do not have many urologist colleagues around to consult while in the OR, and some practices have minimal or no robotic surgery systems. Dr. Luskin and Dr. Silva emphasize that when the decision between whether to perform a procedure themselves or refer the patient to a bigger hospital system needs to be made, they must always think about factors other than surgery too. For example, the OR staff may not be adequately trained to assist in a certain procedure, and patients may need additional resources for supportive care after surgery that are not possible to obtain at a smaller practice. Additionally, having minimal to no RNs or advanced practice providers means that community urologists need to deal with every small issue that patients have. Dr. Luskin sees these responsibilities as an opportunity to learn about the road to post-operative recovery for his patients.Next, Dr. Luskin emphasizes the importance of always being up to date and learning new surgical techniques. When he transitioned to doing robotic prostatectomies, he kept in touch with his Georgetown residency attendings. He also uses Twitter to find recent scientific literature about different urologic fields.The doctors speak about OR mentality next. Dr. Luskin recommends avoiding doing more than one long case everyday, because it is mentally challenging to approach the second case with a good mindset if the first case was not ideal. He is self-aware of his mindset and has even canceled surgeries because he felt like he was not going to operate at his best. Dr. Silva also speaks about how to deal with frustration with OR staff, as turnover rates are high in community medicine. They both agree reframing can help overcome negative mindset. Dr. Luskin adds that teaching staff who are unfamiliar with a procedure can lead to more comfort and enjoyment for both parties next time the same procedure is done. Finally, Dr. Luskin encourages community urologists to pick and choose their procedures carefully by always balancing the costs and rewards.

In this episode, Dr. Aditya Bagrodia interviews pelvic floor therapist Vanita Gaglani from Vanita’s Rehab about the role of pelvic floor physical therapy for early continence recovery after prostatectomy.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/23I7tu---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESShe starts the discussion by explaining her schedule for seeing prostatectomy patients. She usually has the patient come in for a preoperative visit to counsel him on proper nutrition, hydration, and shows him how to do Kegel exercises correctly. She advises her patients against drinking tea, coffee, or soda because these liquids can irritate the surgical sites. She recommends doing complete Kegels involving the pelvic floor muscles around the rectum first because she believes these muscles are stronger. When the patient is ready to progress, she then advises them to practice Kegels with the pelvic floor muscles around the urethra. Her regimen consists of 6-8 sets of 10 quick repetitions, each held for 1-2 seconds. She also mentions that “hold” is often a vague term; male patients usually squeeze too hard and cause muscle fatigue, which causes the prostatic sphincter to lose control and leak more urine. Therefore, she emphasizes that Kegels must be done gently at first. Additionally, she encourages her patients to start Kegels at least 3 weeks before surgery.Then, she schedules the first postoperative visit 4-5 days after the catheter removal. During the first postoperative visit, she often hears the complaint that patients are continent while sitting but incontinent when standing up and walking. To teach her patients how to get up without leaking, she shows them how to sustain pelvic floor contraction while standing. She notes that this skill is more a result of endurance, not strength; overfatigue of the pelvic floor during the daytime is very common. She also evaluates lumbar and hip muscle strength too, as they both contribute to pelvic floor strength. Additionally, she discourages patients from getting up to use the bathroom frequently because this behavior may cause bladder capacity to decrease. To prevent this behavior, engaging in breathing exercises while in butterfly position and using thinner pads can help. By 10 weeks, 98% of patients should be completely dry. For the 2% of patients who are incontinent for more than 10 weeks, another factor (such as scar tissue, bladder spasms, and constipation) may be at play.Finally, Vanita discusses resources for patients seeking more information about pelvic floor physical therapy. She has her own website with information and journals as well as her own book, “Life after Prostatectomy and Other Urological Surgeries: 10 Weeks from Incontinence to Continence."---RESOURCESVanita’s Rehabhttp://vanitasrehab.com/resources/“Life after Prostatectomy and Other Urological Surgeries: 10 Weeks from Incontinence to Continence” (Vanita’s book available on Amazon)

In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses benefits and advice for effective mentorship with Dr. Andrew Winer, Chief of Urology at Kings County Hospital Center and assistant professor at SUNY Downstate.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/4jVfjs---SHOW NOTESFirst, the doctors define the purpose of mentorship as a relationship that serves to connect a mentor, with a certain skill set and knowledge, with a mentee, who wants to obtain the same skill set and knowledge. Dr. Winer considers mentorship a two-way street, since he has been able to learn a lot from his past mentees. He draws a distinction between coaching and mentorship; coaches give small pieces of advice sometimes, while a true mentor invests lots of time in the relationship. Additionally, he encourages mentees, especially medical students, to get rid of the fear factor of reaching out, as all mentors have been in their shoes before. He also emphasizes the importance of mentees showing up prepared for meetings out of respect for the mentor’s timeNext, the doctors discuss the requirements of being a mentor. Although both of them agree that there is no formal training requirement to be a mentor, mentors should possess certain qualities, like selflessness. They should not follow their own agenda–instead, they should focus on what their mentee’s interests are. Additionally, taking credit for mentee’s work is unacceptable. Next, mentors should be accessible to their mentees and let them know that they can remind their mentors about deadlines. Finally, honesty is very important. Mentors should be able to give their mentees constructive criticism.Then, they give practical advice for mentors who want to guide medical students and residents. Establishing a goal first and compartmentalizing their mentees’ journeys is always helpful. Mentors should serve as advocates, but have to be honest when writing recommendation letters for students and residents. Additionally, they explain that residents become organic leaders early on, as many of them take on the responsibility of teaching medical students. Attending leadership most commonly trickles down to resident leadership. They end the episode by discussing benefits of mentoring a mentee who is different from themselves, in terms of generation gap, gender, ethnicity, and life experiences.

In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses retroperitoneal lymph node dissection (RPLND) for early stage testicular cancer with Dr. Clint Cary and Dr. Timothy Masterson from Indiana University School of Medicine.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/dnRcbh---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESFirst, the doctors discuss how to approach T1 testicular cancer, which does not show elevated markers or nodal metastases. All the doctors agree that the best approach is just surveillance of the tumor without RPLND, unless there is evidence of somatic transformation. Because some patients have anxiety about just doing surveillance, they assure them that only 10-15% of T1 tumors progress. However, there are different warning signs for different tumor histologies. It is important to get medical oncologists on board quickly in order to have a balanced presentation of treatment options for the patient. The doctors agree that surgeons must counsel patients on the possible complications of RPLND, such as retrograde ejaculation, hernias, and lymphatic leaks, but the probability of these events is low.Next, the doctors discuss whether certain tumor markers can predict the relapse of an early stage testicular cancer. They agree that LDH is not an important marker to check, as it may be falsely elevated. An elevated AFP level can be concerning, but urologists should always put the value into context by comparing to the patient’s normal baseline levels and seeing if there is an upward trend. Finally, hCG levels can falsely be elevated by marijuana and hypogonadism. Then, the doctors share their imaging protocol. Standard chest, CT, and pelvic imaging is needed, and Dr. Bagrodia favors chest CT over CXR for better visualization. The doctors also note that more pre-operative imaging immediately before an orchiectomy is not always necessary if the surgeon already has recent imaging.Additionally, the doctors explore approaching T2 testicular cancer, in which there are positive nodes confined to peritoneal nodes. Dr. Masterson and Dr. Cary agree that axial CT imaging is superior. More preoperative factors would be considered such as the focality of the lymph nodes involved, the duration of surveillance time, primary histology of the tumor, and the size of mass. Depending on which lymph nodes are positive (i.e. paraaortic, pelvic. etc.), a surgeon can choose the best RPLND template (modified, unilateral, bilateral). The doctors then explain their intraoperative and postoperative anesthesia protocol. They do not routinely administer DVT prophylaxis before surgery because of the risk of lymphatic leakage. Additionally, they are careful not to disseminate disease by disrupting tumor, which can cause abnormal patterns of metastasesNext, the doctors share their post-operative advice for patients. With regards to diets, a lower fat diet will lead to quicker recovery. Ejaculatory function remains normal for patients with unilateral surgery, but should recover within 8-12 months in patients with bilateral surgery. Surgical pathology can determine whether the patient should start adjuvant therapy. For N1 tumors, no adjuvant chemotherapy needed. For N2 tumors, the decision depends on histology and patient factors. Additionally, the doctors explain that extranodal extension does not always mean relapse is inevitable. For this reason, it is important to consider the histology of the tumor. The doctors end the episode by discussing new research on seminoma relapse.

In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with urologist Dr. Anne Schuckman from the University of Southern California about advantages and advice for blue light cystoscopy, a procedure performed to identify bladder tumors during transurethral resection of bladder tumor (TURBT).The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/NOzQHU---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESBlue light cystoscopy causes the tumor cells that pick up dye to glow pink. According to Dr. Schuckman, urologists pick up 20% more tumors using blue light than they do with only white light. If they do not pick up these tumors with white light, the cancer is bound to recur because of unresected tumors. Using blue light cystoscopy during TURBT can lead to a more complete resection of the bladder tumor, therefore reducing the need for repetitive anesthesias events and resections, a reduction in bladder scarring and dysfunction overtime, and lessen the psychological impact of recurrent disease on patients. Blue light cystoscopy is most optimal in non-muscle invasive bladder cancer and carcinomas in situ but has not yet been extensively studied in muscle invasive disease.Next, Dr. Schuckman shares some practice building tips for using blue light cystoscopy. She always scopes the patient with white light in the clinic first in order to identify the location of the tumor before heading to the OR. At USC, every patient receives a blue light cystoscopy during TURBT because changing workflow for each patient is hard on their system. Thus, it is easier on the staff to standardize the procedure for everyone. She then discusses the necessary materials for introducing blue light cystoscopy into a urology practice. Urologists will need to obtain Cysview, the medication that is inserted into the bladder 30 minutes to 1 hour before the cystoscopy to dye the tumor cells. Additionally, a cystoscope with white and blue light, a resectoscope, a light box, and an image generator are also necessary. She estimates that a blue light cystoscopy system will cost around $80-100k, and advises urologists to have a couple sets on hand in case of malfunction.Finally, Dr. Schuckman shares technical advice for blue light cystoscopy. She encourages urologists to spend time washing the Cysview out of the bladder and avoiding bleeding when inserting the scope, as this can obscure the visual field. She performs a full white light cystoscopy and then a blue light cystoscopy in order to make a mental map of the bladder to determine the borders of her planned biopsy. She emphasizes that experience is the most important factor in gaining confidence with blue light cystoscopy, and notes that urologists can gain better white light cystoscopy skills through training with blue light cystoscopy as well. Finally, the two doctors agree that blue light cystoscopy is very sensitive and does have a greater false positive rate than white light cystoscopy.

In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with urologist Dr. Karim Bensalah from the Universitaire de Rennes and medical oncologist Dr. Rana McKay from UC San Diego about adjuvant therapy for advanced kidney cancer.---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/kI6PA4---SHOW NOTESFirst, the doctors discuss when to bring up adjuvant therapy. All three doctors agree that having the discussion early with patients is helpful to the patient and other specialties involved if the cancer is expected to be aggressive after reviewing initial imaging. Dr. Bensalah usually waits until the final pathology results arrive in order to determine the specifics of the adjuvant therapy treatment and refer his kidney cancer patients to medical oncology. He does not use nomograms if the patient does not ask for specific rates of recurrence. However, Dr. McKay uses nomograms often.Next, the doctors discuss different oncological factors that may convince them to start their patients on adjuvant therapy, such as a large tumor size, advanced tumor stage/grade, an IVC thrombus, extrarenal metastases, and nodal involvement. Additionally, patients with multiple comorbidities and elderly patients may benefit from adjuvant therapy. Both Dr. Bagrodia and Dr. McKay agree that genomic sequencing of tumors is not helpful in making the decision to start adjuvant therapy, as there needs to be more research around this topic. Dr. Bensalah then explains the difference between approval and billing of tyrosine kinase inhibitors (TKI) in Europe.Finally, the doctors discuss different clinical trials centered around the TKI Pembrolizumab (Keytruda). Dr. McKay notes that there have been very few positive trials and that she is reluctant to put her patients under a year of toxicity if there is a chance of overtreatment. Although many people have few mild side effects, severe side effects, such as diabetes, colitis, and fingernail necrosis, can be observed. Finally, the doctors discuss the importance of generating more research on the response of non clear cell renal carcinomas to adjuvant therapy. Currently, all these cancers are classified as one category but have different histology and response to therapies.---RESOURCESRegister for the 2022 International Kidney Cancer Society Symposium:https://www.kcameetings.org/2022-ikcs-north-america/