BackTable Urology

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 NOTES First, 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 NOTES First, 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 NOTES Pelvic 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 NOTES First, 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 NOTES First, 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. --- RESOURCES Brikowski 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 NOTES First, 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. --- RESOURCES Center for Intimacy, Change, and Connection https://centericc.com/team/ Erectile Dysfunction Radio Podcast https://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 NOTES First, 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.

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 NOTES First, 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 Topol World Health Organization: Ethics and Governance of Artificial Intelligence for Health https://www.who.int/publications/i/item/9789240029200 Cacciamani 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 NOTES First, 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 SPONSOR Veracyte https://www.veracyte.com/decipher --- SHOW NOTES Shankar 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. --- RESOURCES Kidney Cancer Association: 2023 International Kidney Cancer Symposium (Nov. 9-11) https://www.kidneycancer.org/ikcs/2023-ikcs-north-america/ Decipher by Veracyte https://decipherbio.com/ WellPrept https://wellprept.com/