Gopal H. Badlani, MD

 editorial consultant, is professor of urology, Wake Forest Baptist Medical Center, Winston-Salem, NC.

Many institutions and large practice units create manuals or standard operating procedure for response during a variety of crisis situations. We take online training for simulation of chemical spill, radiation, and infection, but there is no manual to follow in this burgeoning COVID-19 crisis. The rules of the “game” have changed day by day, sometimes within hours. The email traffic with a variety of instructions is so heavy that it is difficult to keep your thoughts steady.

There is one aspect of caring for yourself and another directing traffic for those under your leadership. The situation is different whether you’re in an academic center, federal site, or large private practice group setting, as opposed to a smaller practice where all decisions are made by you.

In an academic institution, a command structure is developing the policy, whereas in the federal (VA) system, it is being directed nationally. Since I work at both places and lead at the VA in the same region, the experience is somewhat similar but not exactly the same.

 We all prepare how to deal with a large number of cases coming through our trauma unit or a natural disaster, and the ER being overwhelmed. No one prepared for how “not to do” surgery. The decision had to be taken away from individual surgeons after the initial request to cut down elective cases. It took time to learn, the goal was to preserve or save personal protective equipment, and the OR could be a conduit for spreading the virus through asymptomatic carriers.

The traffic and personnel involved in doing a single case can be substantial. Weighing patient harm by waiting versus immediate surgery, as wait times are unknown, created a heated debate for some. At the VA it was more a leadership decision, as the unit chief has the ability to make that decision.

 That most visits can be managed with telemedicine is the new reward from this crisis. As we get more accustomed to the process, I can see the patients and physicians both adapting to this new norm. The revenue/reimbursement is not being questioned during the crisis, but time and effort will need to be addressed if this becomes the new norm. The role of ancillary staff has been critical in the process and not recognized easily. Shifting the appointment to a televisit, initiating the visit, updating all the requirements of a visit and setting up follow-up after an electronic visit are all key tasks that are the pillars to the success of this visit.

 In caring for patients, we often forget the safety of staff and self. Thus, reducing traffic coming into the clinic has become as important as traffic entering the hospital. Depending on the location (near or in a senior center) or the type of patient population could require complete shutdown of the location and moving the clinic to a temporary location where multiple surgical units could be served by a rotating the ancillary staff and providers, so as to manage staff illness if it were to happen.

Staff and physicians over 65 should be isolated as much as possible. Although residents and fellows are young, they need the same concern and protection, once again by creating rotating teams and keeping the rest available at home.

 Although email notifications are generic and multifold, creating a text group for leadership for quick notification became important as remote access in the VA system can be patchy. Scheduled calls each week at a set time for weekly updates and concerns is the second approach. Use of Zoom or another video-based platform for faculty meeting/education lectures at the university setting has been very successful.

Programs across the country are seeking teaching rounds that can be shared. A live presentation across the world was done successfully in a scheduled meeting in India at the cusp of travel restriction. It will be the wave of the future.

In the end, leadership is all about elevating and protecting those around you. Their success and well-being is a measure of achievement. Perspective is a view from afar and the wider angle is needed to reassess oneself; otherwise we remain zoomed in on the narrow focus of today, which passes before you know it.

Articles

"We take online training for simulation of chemical spill, radiation, and infection, but there is no manual to follow in this burgeoning COVID-19 crisis," writes Gopal H. Badlani, MD.

Leadership tips for your urology unit during the COVID crisis

 Editorial Consultant, is professor of urology, Wake Forest Baptist Medical Center, Winston-Salem, NC.

The new AUA guidelines on surgical management of BPH reflect changes primarily in new minimally invasive approaches to the management of the enlarged prostate. In considering what is new, one should think about indications for a given procedure, the individual patient’s goals, surgeon’s bias and learning curve, availability, and affordability of the technology.

Patient bother with male lower urinary tract symptoms such as slow flow, hesitancy, and sense of incomplete emptying and retention are most common. However, men with overactive bladder, nocturia, post-void dribble, and “older male with prostate” as indications are less responsive to surgical therapy.

Patient factors such as medical risk for anesthesia, use of antiplatelets/anticoagulants, gland size, and gland anatomy play a role in selecting the type of procedure, as do patient expectations, such as desire to maintain antegrade ejaculation at the expense of long-term success, catheter duration, and time from treatment to improvement (transient dysuria/frequency/incontinence/recurrent retention).

Surgeon variables are training and familiarity with a technique, number of patients treated in a month to enhance the learning curve, and desire to be on the forefront. Availability of a team to deal with transient issues post treatment and ability to manage secondary bleeding as well as re-treatment are other variables.   

Availability of new technology is also dependent on clinical setting, such as a trial at a center of excellence or hospital partner/large group willing to support it. The surgeon bias is difficult to assess.

The individual technologies are discussed in the “Hands On” article in this issue (page 1), which mentions enucleation as a technique that needs to be considered when the gland is larger. It appears that many of the ablative technologies such as lasers and the bipolar device can achieve enucleation, albeit some require use of a morcellation device. Added indications for minimally invasive surgical therapies such as large glands and median lobe require an experienced practitioner.

Cost is a hidden factor in the United States and other countries where health insurance covers approved technology but is a real factor where cost is out of pocket. Hospitalization is expensive in the U.S. but a less important factor in other countries. Capital and disposable cost is a factor in low- and middle-income countries where traditional monopolar TURP still rules despite the safety of saline-based ablation devices.

After participating in a number of trials from balloon dilation to water ablation and publishing on them, my conclusion is to do what you know best, learn a new technology from an expert (preferably hands on), and consider participating in a clinical trial (based on patient volume and institutional support). Shorten your learning curve by accumulating cases and doing them in a short time, stay with technology to overcome initial hurdles, and be honest about your outcomes (not what is published in the literature by the expert).

“The expectations of life depend upon diligence; the mechanic that would perfect his work must first sharpen his tools.”-Confucius

"My conclusion is to do what you know best, learn a new technology from an expert, and consider participating in a clinical trial,” writes Gopal H. Badlani, MD.

Alternatives to TURP: Consider these variables

 is a fellow in female pelvic medicine and reconstructive surgery, and 

is vice chair and professor of urology, Wake Forest Baptist Health, Winston-Salem, NC.

From the time Lapides popularized the use of self-intermittent or clean intermittent catheterization 

 it has improved the quality of life of patients with neurogenic bladder due to a variety of conditions. Reuse of catheters for intermittent catheterization was the norm and still is common practice; it is in fact, the standard of care in some health care systems. In many developing countries, patients have limited access to medical supplies necessitating reusable catheters. It was not too long ago in the United States that insurances covered only four catheters per month, but in 2008 Medicare/Medicaid allowed for patients to receive up to 200 catheters per month.

The authors of a study by Madero-Morales et al provide answers to what many urologic providers and patients need (see article 

What was lacking in the literature was a head-to-head comparison of intermittent catheterization with single-use versus reusable catheters (cleansed with 0.5% benzalkonium chloride) with a primary endpoint of urinary tract infections (defined as having a positive urine culture and symptoms). In this study of 75 patients with an average age of 12.7 years, they found that the rate of urinary tract infection did not differ between the groups: 35.2% with single-use catheters vs. 36.8% with reusable catheters (OR: 0.877, 95% CI: 0.42, 2.76). Rates of asymptomatic bacteriuria also did not differ between the two groups.

Interestingly, being unable to walk and having vesicoureteral reflux grade 2 or higher were identified as risk factors for having a symptomatic UTI in both groups. In the reusable catheter group, male gender and presence of a bladder diverticulum were risk factors for developing a UTI.

One of the arguments against reusable catheters is the variability among cleansing methods and patient adherence to a sanitation regimen. In this study, the catheters were washed with plain soap and water, stored in a container with benzalkonium chloride, and used for 1 week. Although this regimen is simple enough, having protocols designed for patients who spend part of their day outside the home is needed.

A topic of interest and debate is the environmental impact of the waste that humans generate. It is estimated that the generated waste of single-use intermittent catheterization is between 26,500 and 235,400 pounds per day, with the vast majority of urinary catheters made from non-biodegradable materials 

 We should all be considering alternatives to help reduce waste going to our landfills. Perhaps with policies and protocols for reusable urinary catheters, we can help lower waste while maintaining patient safety. Reduce, reuse, and recycle!

Single-use catheters were introduced as a means to decrease the risk of developing UTIs, and many patients in the Western world cannot fathom the idea of a reusable catheter, especially when multiple health care providers are telling them this. However, the author of this study essentially calls this “fake news.” Patient perception is an important aspect of developing an effective treatment plan, and we should be able to arm patients with accurate data to help them make an informed decision.

If reusable catheters are going to be presented as an option, future research should be focused on determining the number of times a catheter may be reused, developing a protocol for sanitation, identifying additional risk factors that may contribute to UTIs, and calculating potential cost savings and affordability. With further insight into these factors, reusable catheters can again become a standard of care.

Also, while we are on the subject, use of antibiotics should be limited to symptomatic UTIs and not bacteriuria in patients performing self-intermittent or clean intermittent catheterization.

Send your comments to Drs. Smith and Dr. Badlani c/o 

"Patient perception is an important aspect of developing an effective treatment plan, and we should be able to arm patients with accurate data to help them make an informed decision," write Whitney Renee Smith, MD, and Gopal H. Badlani, MD.

Are reusable catheters safe? Study provides an answer

The AUA and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction’s guideline for overactive bladder was recently amended to include updates regarding patient factors and treatment selection as well as second- and fourth-line treatments. In this interview, 

 a member of the guideline amendment panel, discusses the rationale behind the amendment, the role of overactive bladder drugs in the treatment of nocturia, and treatment of refractory OAB. (To read the amended guideline, see 

Dr. Vasavada is urologic director, the Center for Female Urology and Reconstructive Pelvic Surgery at Cleveland Clinic. Dr. Vasavada was interviewed by Urology Times Editorial Consultant 

 professor of urology, Wake Forest Baptist Medical Center, Winston-Salem, NC.

What prompted the recent amendment to the OAB guideline?

Every time new data comes out, we assess the current guideline to determine whether there is anything we need to add. In this case, the guideline update was done because there was new data regarding second-line therapies, predominantly medication use. Specifically, the data indicated that the use of an anticholinergic in conjunction with a beta-3 agonist is an option for patients who perhaps didn’t get significant relief with either beta-3 agonist or anticholinergic monotherapy.

Does the guideline address the inability to prescribe beta-3 agonists initially, especially in the elderly?

It doesn’t directly address that. There is an ongoing national dialogue on the use of anticholinergics in the elderly especially that concerns its potential adverse effects on cognition. While beta-3 agonists work on a different nerve receptor, the issue of initial prescription also has to do with pharmaceutical coverage, and that is a tougher area to address.

How do you sequence treatment in a drug-naive patient who presents with symptoms of OAB?

Just like any other patient we see with OAB, we still want to go through the pathway sequentially. I think we would all agree that proceeding from least invasive to most invasive therapy is still best. We did keep a little bit of flexibility within this current guideline, but the main point is still starting with behavioral therapies and fluid management as well as pelvic floor exercises and continuing that to the second- and third-line therapies if initial therapies do not work after an acceptable period of time. That’s one of the points we’d like to emphasize.

What is the role of OAB drugs in a patient with predominantly daytime symptoms with minimal nighttime frequency?

They still have a strong role. You don’t have to have a lot of nighttime symptoms to merit the need for overactive bladder drugs, although OAB seems to have a day and night tendency for many. Regardless, some patients seem to have predominantly daytime symptoms. Again, we’d want to determine whether there’s a behavioral factor or something else going on during the day that is creating their overactive bladder. Is there a transient cause or another factor that’s perhaps creating the disparity between day and night? We can target our interventions at some of the behavioral factors in addition to using medications. We wanted to also emphasize this in the guideline.

Do drugs help patients with predominantly sensation-driven frequency?

I think the data would suggest there are some slight improvements, but not as much as we like to believe. The sensory symptoms are oftentimes quite challenging; you’re looking at different scales. Most data is on urge incontinence and frequency as harder endpoints. Still, the hallmark of OAB is urgency, pathologic urgency specifically, and it is still probably best assessed using a variety of validated instruments.

What is the role of OAB drugs in nocturia?

In solitary nocturia, unless there’s another cause, as often there is-fluid overload and other background factors-it can still have a role but probably less. But you have to be very careful, as anticholinergics especially can have a fair amount of side effects. We have to be considerate of that in a nocturia patient, where there may be another cause, whether it’s fluid overload, obstructive sleep apnea, edema, or any number of other causes. I would do my best to try to treat all of those attending causes before proceeding with an anticholinergic or for that matter a beta-3 agonist.

How do you define refractory overactive bladder?

I don’t believe it’s ever been formally defined, but typically a patient with refractory overactive bladder is one who’s tried and failed first- and second-line therapy and/or is intolerant to second-line therapy. Those patients then go on to the so-called third-line therapies. Again, I don’t think it’s ever been truly defined in clinical guidelines.

There are a plethora of treatments for refractory overactive bladder: percutaneous tibial nerve stimulation, sacral neuromodulation, and onabotulinum toxin. How do you sequence these treatments? Do you use an algorithm?

I don’t know if it directly falls into an algorithm because every patient has unique factors that might dictate a reason why one would be more apt to undergo one therapy over another. You have to individualize each patient scenario. Less often, determining which therapy is best for a patient would come down to a “coin flip.”

There are data suggesting that patients who fail neuromodulation then switch to Botox, and vice versa. Is that your experience?

When we ran a randomized trial, it was hard to enroll patients for whom determination of treatment came down to a coin flip. Oftentimes, there’s a specific patient factor that will guide the clinician’s choice of treatment. If a patient has bowel issues, perhaps you may lean more toward neuromodulation. For a neurogenic patient, you might tailor your recommendations toward onabotulinumtoxinA injections. If a patient doesn’t need anything more invasive therapeutically and is willing to make frequent visits, then you may consider tibial nerve stimulation.

As we learn more about OAB, it becomes apparent that particularly in the elderly, there are so many different factors to look at before you start treating the patient. What suggestions do you have for evaluating management options in this population?

I’d see if there’s anything else more easily remediable. Is there another factor? Is it stress incontinence? Is it prolapse, which often co-exists for some of these patients? Is it vaginal atrophy, which can have an effect in some patients in terms of overactive bladder symptomatology? Is it a fluid factor? If you work with your primary care colleagues to articulate what the real issue is leftover for the overactive bladder alone, you can tailor your therapy most appropriately.

Is there anything else you feel urologists should know about the updated guideline?

One of the important things we brought out with this new guideline is that one does not necessarily need to progress stepwise in order: one, two, three, four. We did codify the fourth line, which includes augmentation cystoplasty, urinary diversion, and catheter placement. The patient shouldn’t just be stopped at third-line therapy. There are, in selective situations, opportunities to deliver care with any of these slightly more invasive therapies. Perhaps someone may be cognitively at risk for using a medication, so we might consider tibial nerve stimulation earlier in the treatment pathway. Based on the guideline and expert opinion, we felt that that’s an option we wanted to leave our providers with.

In this interview, Sandip Vasavada, MD, discusses the rationale behind the recent amendment to the AUA/SUFU guideline for overactive bladder, the role of OAB drugs in the treatment of nocturia, and treatment of refractory OAB.

Author | Gopal H. Badlani, MD

Articles

Leadership tips for your urology unit during the COVID crisis

Alternatives to TURP: Consider these variables

Are reusable catheters safe? Study provides an answer

Combination therapy addressed in amended OAB guideline