Karen Nash is a medical reporter and media consultant based in Monroeville, PA.

Karen Nash

“It depends on the situation. If it’s an obvious situation, where the urinalysis is normal, there’s no postvoid residual, and it seems like classic stress incontinence, I don’t necessarily do urodynamics.

We typically do urodynamics when something’s unclear and confusing. I don’t always do urodynamics before doing a sling.

In the majority of cases that need a sling, where they need fewer than 5 to 6 pads a day, if for some reason the history is not clear, I would do urodynamics. If the history seems clear and reasonable, and there aren’t other issues, I don’t do urodynamics because it doesn’t really help me decide. I don’t do urodynamics unless it’s going to influence my decision or help the decision process in some way.

The decision process could indicate a patient may not be a good candidate for a sling. If, for some reason, you’re concerned there’s some other issue—involuntary contractions or another type of neurogenic component in his bladder—urodynamics can help identify that a person is not a good candidate for a sling. But in a straightforward case, I don’t necessarily do it.

Obviously, if the patient had infection, high postvoid residual, or a history of neurological issues, whether it’s a previous stroke or some other neurological condition that could influence bladder function, it’s a good tool to have if used in the right place.”

“I use urodynamics in my patients for several reasons. I want an objective evaluation of the severity of their outlet incompetence, giving me an estimation of their leak-point pressure. It provides good objective proof that it’s stress incontinence. A lot of patients suffer mixed incontinence, and if there’s a significant overactive bladder component that hasn’t been adequately addressed, oftentimes I address that first, to see if we can get the patient to a point where they have satisfactory control.

It also really provides a baseline reference so if they develop recurrent incontinence after a sling or an AUS [artificial urinary sphincter], I can repeat the study and have a look before they have anything done to compare to data after.

I have no objection to the approach of not doing urodynamics if it’s demonstrated the patient has stress incontinence and empties well. It’s not a requirement, but it’s a reasonable adjunct. Moreover, for patients who are considering a male sling as opposed to an AUS, it’s important we delineate the severity of their incontinence because the literature is replete with examples that slings are for patients that fit some strict criteria regarding their degree of incompetence.

Urodynamics allows me to have more confidence that we have properly selected those patients.

Urodynamics itself is incredibly low risk. There’s a small risk of infection but it’s more objective support that we’ve made an accurate diagnosis and we’ve objectively evaluated the severity of that diagnosis to guide the decision-making of the sling versus artificial sphincter.”

“We usually do urodynamics prior to doing either a sling or a sphincter. It’s part of the work-up to assess the capacity and compliance.

My partner does the sphincters, but I’m sure there are some situations where they don’t have any preoperative lower urinary tract symptoms with a relatively normal-sized prostate [and] normal-sized bladder and everything looks fine, [and]where they had no symptoms pre-op. [In those cases,] maybe they may consider doing it without urodynamics. But if you can you do the urodynamics, there’s little downside to doing it. You might end up with someone who has a noncompliant bladder or similar issues that you could treat prior to a sling or sphincter that might improve their symptoms, and which might be a contraindication to doing a sphincter.

You don’t want to block up a bladder that has really poor compliance because then the pressure is just transmitted to the upper tract. Usually, that would be like a neurogenic bladder, somebody with a lot of symptoms pre-op, so that’s going to be unusual.

You can also give them an idea of whether they have an element that’s not going to be necessarily treated with the sphincter. Sphincters are going to treat all stress-related incontinence, but if there is an element of urge, the patients might need to be on medication after surgery, so you can counsel them about that as well.

You can use urodynamics no matter what procedure you’re considering, but the sphincter would provide more back pressure than the sling in general.”

is in group practice and is an assistant clinical professor at Texas A&M University in Dallas, Texas, 

an associate professor of urology at the University of Arizona, Tucson, and 

is assistant professor of urology at Albany Medical College and urology section lead at Albany Stratton VA.

Articles

"We typically do urodynamics when something’s unclear and confusing. I don’t always do urodynamics before doing a sling," says 1 urologist.

Do you use urodynamics when determining when to insert a sling following a prostatectomy?

 reached out to 3 urologists (selected randomly) and asked them each the following question: Do you prefer dusting or basketing when removing kidney/ureteral stones?

“I like a combination. Dusting creates less risk of injuring the ureter, reducing fragment size, so they don’t get stuck. It’s nice to have pieces for analysis so you can determine composition and figure out what to do in terms of prevention. Also, information is power, and most patients want to know the type of stone they have. Often, I dust as much as I can, basketing a small fragment to analyze. Fragments left after dusting sometimes aren’t always large enough to grab. Dusting is easier because it allows those fragments to pass without damage to the ureter.

Location makes a difference, however, especially if you have a larger stone up in the renal pelvis. Those are more amenable to dusting because no one wants to make a lot of trips up and down the ureter removing fragments. Dust them as small as possible and let that debris pass spontaneously.

Lower ureteral stones are easier to remove at times. I really don’t have to dust them as much to achieve a stone free status. Higher in the renal pelvis, dusting expedites the procedure because you don’t have to take the scope in and out as many times.

Everything comes down to patient selection and location of the stones. If it’s a smaller stone in the lower ureter, basketing it and pulling it out may be quicker than dusting it.”

“I’m doing a lot more dusting. I do a hybrid, but because we have a new-generation laser, the dusting really changed and became a lot faster.

I work in 2 hospitals. Last year, we got a new holmium at one, then we got a thulium laser at the other. They’re both much faster than what I had before. They use much higher frequencies to dust. They’re also a lot more efficient.

With lasers, sometimes, you would still have quite large fragments. With newer lasers, they turn everything to dust, and often, there’s nothing left.

I’ll still do a hybrid at times. If it’s a distal stone, I’ll out basket it because then I know for sure it’s completely out. If I have a ureteral access sheath, I’ll basket, easily removing everything.

You can reliably basket everything; then, you’re guaranteed to have 100% stone clearance rate. With an access sheath, you can go in and out of the kidney easily and get everything out.

I try to leave a fragment for stone analysis if I can, but I recently had a case with this new laser where I dusted, put a basket in, and nothing came out. I wasn’t able to get a stone analysis, but we can always do a 24-hour urine, so it’s not a terrible loss.”

“I prefer dusting. With basketing, stones can still get stuck or create tears in the ureter, whereas if you dust the stone, you can blow the pieces out more gently.

We probably all do some sort of combination, dusting the stone down until it’s an appropriate size where there won’t be tugging and pulling, and you can basket it through the ureter without scraping the sides.

The location of the stone also helps determine the technique choice. If it’s small and up in the kidney, you may basket it and know you’ve gotten it, whereas if the stone is already stuck in the ureter, you know you’ll have to laser it before basketing.

There are potential problems relying on just 1 method. Just dusting risks leaving microparticles that can form a new stone, and it’s a bit more time-consuming, whereas with the basket, it’s gone. But you have to ensure you can get through the entire ureter without pulling or scraping if you’re just basketing.

A significant influence from my residency, while I was a second year, my attending basketed a stone and pulled so hard he pulled the ureter down—which is probably why I’m not a fan of basketing.

Although it’s nice to have a sample to determine the stone’s composition, patients can make different stones every time, depending on what’s going into their urine. Mrs. Jones may have too much oxalate, whereas Mrs. Smith may lack citrate. So although the composition is important, doing the 24-hour urine test to advise the patient on dietary measures is really more important. So I don’t always treat the patient on a basketed sample anyway.”

"Everything comes down to patient selection and location of the stones," says one urologist.

Do you prefer dusting or basketing when removing kidney/ureteral stones?

Urology Times® reached out to 3 urologists (selected randomly) and asked them each the following question: What do you hope to see happening in urology in 2021?

“I’m just praying for it to go back to the way it was in 2019, honestly. This year has been an exhausting, trying, difficult-to-navigate year. It would be lovely to just be the way it was a year ago. I’m not looking for anything exciting; I’m only looking to be able to practice medicine where I’m seeing patients in my office and having lunch with my staff again.

We are doing a ton of telemedicine here in Philadelphia. We’re not doing a ton of operating, but we’re doing a ton of telemedicine, which is not as fulfilling as seeing patients in the office.

I’m not hearing about a lot of advances going on in urology right now. That doesn’t mean it’s not happening; I’m just not aware of it.

At least [coronavirus disease 2019 (COVID-19)] doesn’t seem to be affecting the urologic system that we’re of aware of right now. I’m just hopeful the vaccines can get us back to normal.

This is probably about the first year we haven’t really been looking forward to some decent advancements in urology. There may be some coming, but this has been such a bizarre year [that] I think most everybody’s just looking to survive and get through this year as best we can. Our practices are changing. Patients aren’t coming in. We certainly don’t have our staff. It’s hard to look to the future when you can barely function in the present.”

“I’m certainly hoping, obviously, that we can return to practicing safely and helping patients with their urologic conditions in a timely manner.

We’ve had a lot of stress [around] delivering care because of COVID-19. There [have] been delays for men with prostate cancer [and for] people suffering with prolapse or other issues who are having trouble getting into, or are afraid of seeing, urologists. I really hope that doctors and their staffs can serve those people safely this year.

When they talk about elective procedures being postponed or unavailable because hospitals are dealing with COVID-19, we’re talking about the lady who has prolapse or the man with the catheter. Those are elective, but they’re definitely critical to quality of life. I’m hoping we can get back to taking care of patients who need us.

As far as anything new coming out of research, it’s actually been difficult, at least in California. We’ve had trouble because [of the] stay-at-home order. Campuses were closed; research staffs weren’t allowed on campus. In the spring, we shut down a lot of our labs.

I do health services research, so we can work remotely more easily, but it sometimes involves encountering patients. That’s a problem. I have COVID-19 right now. I’m recovering, but I was pretty sick.

Research was getting back to normal, but now we have another surge so we’re having another lockdown.

There’s been less travel and more online conferences and meetings. That’s been a big change. There’s been more time, but there have been resource constraints around doing research at many facilities where campuses are not open.

Some interesting proposals are coming up [for] managing bladder cancer; some proposals are being developed around molecular subtyping of bladder cancer. There are also proposals around handling small renal masses—how to manage them without overtreating or undertreating them and the role of biopsy in those plans.”

“I’m excited for potential FDA approval of 2 intravascular therapies for high-risk, non–muscle invasive bladder cancer [that is] unresponsive to BCG. These include nadofaragene firadenovec, an investigational gene therapy by FerGene, and oportuzumab monatox, a recombinant fusion protein by Sesen Bio. These 2 therapies will join pembrolizumab [Keytruda], the first drug for patients unresponsive to BCG that was just approved this year that could allow these patients to avoid a cystectomy.

In prostate cancer, we should have the announcement of the phase 3 VISION trial results of the novel therapeutic drug Lu-PSMA-617, a prostate-specific membrane antigen–targeting agent used to deliver radionuclide therapy for the treatment of advanced prostate cancer patients with [metastatic castration-resistant prostate cancer]. This would add another new therapeutic with a distinct mechanism of action.

But I’m most excited about the FDA approval of the first and only oral [gonadotropin-releasing hormone] antagonist, relugolix (Orgovyx, Myovant Sciences), for androgen deprivation for patients with advanced prostate cancer. It offers enhanced cardiovascular safety and an enhanced mechanism of action as an antagonist. It has faster, more profound testosterone suppression and a shorter course of therapy.

Fortunately, our research program has not been deterred by the pandemic, and we’ve not experienced any setbacks in monitoring our patients or in accruing new subjects.

Our clinic, both outpatient and inpatient schedules, has been very busy. But personally, I haven’t been traveling anywhere near the degree I was, so it has allowed me to be more productive regarding my educational endeavors and
my research.”

"I’m just praying for it to go back to the way it was in 2019, honestly," says 1 urologist.

What do you hope to see happening in urology in 2021?

Urology Times® reached out to 3 urologists (selected randomly) and asked them each the following question: Do you listen to music in the operating room? What kind?

“I do listen to music and the type depends on what I’m doing. If I’m doing a high-stake portion of a case where I want my heart rate down, I actually listen to—I don’t even know what the genre is—but it’s what you listen to when doing yoga. So if my heart rate is going up and I’m doing something like 

 dissecting out a vaginal canal for gender affirmation surgery, I will use something like Pure Focus or a meditation mix.

Otherwise, indie rock is mostly what I listen to. That’s kind of my wheelhouse. Indie rock is my favorite by far. I would say in the last 5 years, my favorite is a group is one called Bon Iver.

If you ask me what music adds to the operating room, I would have to think. It’s a really good question. It calms me down and it shields me from a lot of the noise that could be distracting. My focus is reconstructive surgery and 80% of my practice is transgender surgery.

I think music can alter my emotional state and put me in a better frame of mind that lets me see more possibilities.”

“I listen to whatever my staff actually wants to listen to, except I say ‘no rap’—whatever they like—but no rap, and we’re okay. Usually during my robotic cases, we listen to music. They plug in their iPhones or the smartphones and stream whatever service they have, or whatever playlists they have, which is mostly classic rock, contemporary rock, some country.

I have some input, but they play what they want to play because if they’re happy, I’m happy.

Music keeps everything a little bit lighter in the OR. Silence can make the day drag on and increase stress levels. Music has been shown to decrease stress levels. Having it on all the time is good.“Usually, they play a mix of music, so most of what they play I like. I have a very diverse taste in music. I listen to blues, rock-and-roll, old stuff new stuff, country—more of a country rock. If I were to say who my favorite is—I’d have to say, it’s the group Boston. They came out with their first album in the 70s, and it’s probably my favorite album.

To be honest, nobody ever really chooses Boston for the OR, but I like a lot of music. If I’m sick of something I’ll tell them, but that rarely happens. They’re all younger, in their 20s and 30s. When I’m doing robot cases, I generally have the same crew. I know they want to listen to rap. They’ll start talking about a song, but they’ll say, ‘you wouldn’t like it.’ I’ll ask, ‘why? Because they drop F-bombs and call women derogatory names?’ They say ‘yeah,’ so there you go. I have 2 daughters so why would I want to listen to music when they talk that way?”

“I do listen to music in the OR. Honestly, I let my scrub tech and circulating nurse pick whatever they want to listen to. I’m not very picky.

I probably let them choose as an overall morale thing. I’m just not really very picky provided that it’s nothing too intense. As long as it’s regular music, I can listen to just about any genre, so I let them decide as a morale booster. The kind of music depends on who’s in the OR with me. We usually listen to a radio station. Sometimes it’s a country station, sometimes it’s pop. I listen to all sorts of music: 80s, 90s, country. I’m good with any of them.

My favorite artist is probably Michael Jackson, not that he comes up often on the stations we listen to.

I think music in the operating room relaxes everybody. I think if everybody is in a high tense mood, it makes the case harder and mistakes get made. If people are relaxed, they are more communicative and we seem to have a better flow. I think music leads to better results. I don’t think there are any studies on that, but I feel we get in a better flow. Overall, the days we listen to music versus the days we don’t, we just seem to get better results in the end. It just seems to be a better day.”

"I listen to whatever my staff actually wants to listen to, except I say ‘no rap’ " says one urologist.

Karen Nash

Articles

Do you use urodynamics when determining when to insert a sling following a prostatectomy?

Do you prefer dusting or basketing when removing kidney/ureteral stones?

What do you hope to see happening in urology in 2021?

Urologists discuss their music preferences for the OR