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

Karen Nash

Preston C. Sprenkle, MD, says, "[Ablation] allows us to treat where cancer is located without having to treat the entire prostate yet feel comfortable that we are [managing] 80% or more of the cancer.”

“One item is the significant interest in ablation technology, a less invasive way of [managing] prostate cancer by using energy rather than our current gold standards—surgery and radiation.

Interest in ablation recognizes the importance of preserving quality of life. There are actually studies suggesting men are willing to give up quantity of life to preserve quality of life through reducing treatment [adverse] effects.

We’re incrementally seeing more good outcomes, but the main drawback is that ablation is not quite as effective as traditional treatments. Ablation leaves surrounding tissues and nerves in place, so it doesn’t have as much impact on urinary function. The impact on sexual function largely depends on the location of the cancer, so we can potentially target the cancer location with less damage than with surgery.

There’s less impact on quality of life, but also a risk of leaving cancer cells behind to recur.

Our failure rate is about 20%, so men who have repeat biopsies, which should be almost all men who have an ablation procedure, should be included in a registry. We’re tracking outcomes, biopsies, and quality of life.

It allows us to treat where cancer is located without having to treat the entire prostate yet feel comfortable that we are [managing] 80% or more of the cancer.”

Says Leonard G. Gomella, MD, “We increasingly see the evolving role of ‘precision medicine’ in urology, using genetic and genomic testing to guide [management] for a variety of diseases, particularly bladder and prostate cancer."

“We increasingly see the evolving role of ‘precision medicine’ in urology, using genetic and genomic testing to guide [management] for a variety of diseases, particularly bladder and prostate cancer. Unfortunately, in our training, historically anybody who trained more than 10 years ago had virtually no training in genetics, genomics, and precision medicine.

Fortunately, today we’re introducing this evolving concept of precision medicine, not only to medical students but to our residents and fellows too. The benefit is being able to pick the best treatment and medications for the patient. It matches which patients are going to do best with treatment ‘A,’ who have certain genetic or genomic characteristics.

This is major for us. No longer do we just throw spaghetti against the wall and see what sticks. We try to identify the best treatment for patients with certain conditions. Today, most of it is in the area of oncology, but coming on very strong in precision medicine are ‘SNPs,’ single nucleotide polymorphisms. Those genetic tests are exploding across other areas such as responses to erectile dysfunction medications, overactive bladder medications, etc.

It’s a better way of diagnosing and treating patients because you can be very specific for patients’ individual conditions, which are often revealed by genomic/ genetic testing, not just give generic treatment to everybody.

A lot of urologists trained before 10 years ago. That could become a big problem, but several professional organizations are offering courses for [clinicians] to learn about this. Urologists have to go to the AUA and other meetings to learn about this.”

Michael S. Cookson, MD, MMHC, says "New PET scans are much more able to identify small volume metastases that we were never able to see before, so it adds complexity to [the disease] management, and treatments can be individualized.”

“One updated localized prostate guideline marks an increased awareness of the role of germline testing in patients who are diagnosed with aggressive or high-risk prostate cancer.

Historically, we would look for a family history of prostate cancer. Now we know that the genes altered in men that can increase the risk of prostate cancer and aggressive prostate cancer, those germline mutations are also seen in colon, pancreatic, ovarian, and lung cancers. We need to ask about other cancers in the family history.

It will affect how urologists practice in a couple ways. For patients who [don’t succeed on] treatments [for] localized disease, there are therapies directed at those mutations in those situations.

But there’s also a cascade effect because patients need to be counseled and their families need to be counseled—there’s about a 50% chance their relatives can carry the same mutation and could pass it on.

Again, it’s not just screening for prostate cancer, it’s screening for all those other baskets of cancers. If their children are at an age where they are at risk for developing these cancers, they need to be informed so they can decide whether they want to be tested earlier rather than waiting for something to occur.

Another new item concerns molecular imaging to stage high-risk men for metastatic disease. Guideline No. 7 gives the clinician the ability to use evidence-based molecular staging in patients, especially those with negative conventional imaging.

New PET scans are much more able to identify small volume metastases that we were never able to see before, so it adds complexity to [the disease] management, and treatments can be individualized.”

Articles

"We increasingly see the evolving role of ‘precision medicine’ in urology, using genetic and genomic testing to guide [management] for a variety of diseases, particularly bladder and prostate cancer," says 1 urologist.

What new guideline or presentation from the 2022 AUA Annual Meeting will have the biggest impact on urologists?

“It’s all in the American Urological Association [AUA] guidelines. They’re all well described and have been considered and discussed ad nauseam in the AUA guidelines.

The little blue pill has been around since the 1990s and has been advertised on TV for decades, along with the over-the-counter copies. I don’t know if there are actually more ads now, but some of the alternative adverts are becoming more problematic because of these men’s health clinics.

The therapies have not been validated, such as platelet therapy and shock wave treatment.

I tell my patients, ‘Here’s the data on these therapies. These aren’t really known to be effective or there’s not enough information on them yet, so I don’t recommend them.’

I recommend what we have as standard of care, which includes pills, injections, penile prosthesis, and vacuum devices that we know work. Other therapies have not been included in the standard of care yet.

Low-intensity shock wave should be considered investigational. Platelet-rich plasma should be considered experimental. More work needs to be done and more data collected before these treatments can be considered anywhere near standard of care.

I have no idea what some of those others are, like infrared, to be honest. So, no, we’re not saying goodbye to the little blue pill yet…not even close.”

“Community urologists need to interact more intimately with academic urologists so all of us have a voice in this direct-to-consumer conversation.

Currently, numerous modalities are labeled experimental. Urologists must embrace new technologies so we can explain the therapies, the success rates, the risks…and include that in the shared decision-making process.

As urologists, we should be able to offer the full range of therapies, or at least discuss them, so patients are fully educated and can make the best decisions—with our guidance.

We can’t disregard this bombardment with advertisements. Community urologists must explore the research and data, and study AUA [American Urological Association] guidelines. We need to know what’s happening because patients come to us for first-line care in men’s health.

We also can provide personalized diagnostic data, identifying specific problems. Is it simply inadequate blood flow or is there also a blood-flow leak from the penis at the same time?

For example, shock wave therapy is usually best for younger guys [when] there are issues with arterial inflow into the penis. Shock wave can clean out the pipes. But we can provide additional data and tell Mr Smith, ‘You’ve also got a penis leak; this therapy may not be as helpful in your case.’

We must think beyond single-modality therapy, using multimodalities to treat problems from multiple angles.

Some ads are from people who don’t think holistically about the whole body. Erectile dysfunction is a canary in the coalmine; it can predict a cardiac event in 2 to 5 years. Those men should see a cardiologist. We service not only their sexual health, but their overall health.

Some urologists dismiss that stuff, but it’s here. We can’t change it, we must engage it. We’re not just a one-trick pony.”

“We are getting some good information from Europe on several of these therapies. There are a lot of data being collected there. The most promising seems to be shock wave therapy, but there is still a lot of work to do on that.

We don’t have all the detailed data yet on the best strengths to use or the length of time it should be used. I was hoping our university would buy a machine, but they want shock wave therapy to be approved for use in the United States before getting into that expense. I am applying to do a clinical study. I would like to see the results for myself, because shock waves do seem to be having a positive effect.

Sometimes men are using it in conjunction with the pills and then the results may be even better, so that too may be an option.

There are less data on some of the other therapies. Shock wave is considered investigational, whereas others are still considered more in the experimental stage. Sometimes a claimed benefit might even be more of a placebo effect, but that’s not necessarily bad. If men have a positive result, that’s the point of most therapies.”

“Community urologists need to interact more intimately with academic urologists so all of us have a voice in this direct-to-consumer conversation," says 1 urologist.

What do you tell your patients about all the new erectile dysfunction treatments being advertised to the public?

“I’m a bit more insulated because I started a new solo practice in August 2020 at the start of the pandemic when a lot of doctors went to hospitals and big groups for security. I’m doubling down on ‘smaller’ and customer service. I see colleague burnout, I hear about it, but I’m not experiencing it, nor is my team.

I’ve never been happier. Part of my frustration [with] being part of bigger private practices, hospital employed, and multispecialty groups was I didn’t have autonomy, so it’s been fantastic opening my own practice.

We’ve had no trouble recruiting because we focus on creating a positive culture with our team.

That being said, I’m in Nashville, where everybody and their mother are moving to. Our practice has a unique, family feel that people find different than other organizations. People like to be appreciated.

Much of my office staff works from home. Being flexible with people’s work-life balance helps me find and retain good people.

I hear doctors are unhappy and that’s trickling down to the staff. More administrative burdens, increasing overhead, and decreasing reimbursements. I have colleagues who have decided they made enough money and are going to retire.

An excellent urologist in the Southwest had to [close] his office completely because he had no more employees. A lot of young urologists are unemployed by choice. Some are doing locums work and doubt they’re going back to traditional practice because of these issues.”

“More people are retiring or leaving for something else than in the past, although it’s hard to quantify that.

One reason physicians are unhappier is the loss of autonomy. Physicians join hospitals or large groups, but in doing that, they’re losing autonomy.

I’m one of 12 urologists in a multispecialty group of 150 providers. I was part of a 4-person, private-practice urology group. Joining the large multispecialty was the only way to have any say against Intermountain Healthcare. They try to control everything, and unless you have enough doctors together, you have no say at all. It’s not like we’re going to push them around even now, but at least they have to deal with us. Otherwise, they’d just pick everybody apart and do whatever they wanted. If we could do what we preferred, we would probably be just a urology group.

We are definitely losing staff people. Some go to other jobs because they can make more money because other practices can’t find people either. No doubt, that’s been a challenge for us.

To try to keep or recruit staff, we’ve had to increase our pay and then try to be nice to them—I mean, we always try to be nice, but we try not to give them any reason to leave.

More than the pandemic, it’s a general trend—you have big systems telling everybody what they can do. Doctors feel like they’re working harder and making less, yet making more money for the health systems. That’s not a recipe for satisfaction.

A lot of people joined hospital staffs during the pandemic for the stability. But then they were told, ‘You aren’t working as much, so we can’t pay you as much,’ even though the hospitals were collecting a lot of federal money.”

“We’re actually the third largest medical group in the country, with close to 9000 physicians across 7 states. We’re not seeing the turnover reported nationally, but we’re seeing an uptick. Historically, we’ve had 6% to 7 % physician turnover, but in 2021 that was closer to 11%, higher among advanced providers.

Even before [COVID-19], we had increasing levels of burnout year to year, but [COVID-19] intensified many variables, putting pressure on clinicians. We’re trying to reduce those pressures.

There’s no magic solution. We’re working to decrease administrative burdens on physicians. We’re testing AMBE [advanced multiband excitation] dictation [so that] doctors can actually look the patient in the eye; the entire appointment is recorded. Artificial intelligence generates a note the doctor reads and signs off on. It decreases busywork for doctors and gives them the opportunity to connect with patients in a way [that has been] lost because of the burden of the EMR [electronic medical record].

With the pilot program, we’ve seen a 40% to 60% decrease in documentation time. Doctors are saving 1 to 2 hours a day—which can mean getting home for dinner with your family. There are material benefits to it.

We’re also working to retain nursing and other staff with a program called, ‘Our Caring Way,’ which is a platform to reinforce with our caregivers why they come to work every day [and] why they went into health care. We are focusing on retention. We want to be known as the best place to both get care and give care.”

"We’ve had no trouble recruiting because we focus on creating a positive culture with our team," says 1 urologist.

Are you seeing more health care workers planning to leave medicine?

“The urologist I trained with was an incontinence expert and was a big proponent of the bladder-neck, autologous fascial pubovaginal sling. Then came the tension-free vaginal tape, still multi-incision, and the trans-obturator urethral sling—another multiple-incision procedure.

Now, we’re down to single-incision, small slings placed with just 1 small incision in the vagina. A recent review showed the efficacy of this mini single-incision sling was equal to the much more involved urethral slings.

We’ve seen real improvement there. For the patient, it’s a much shorter operation because they’re going behind the pubic bone fascia. Risk of injury the bladder significantly decreases. It’s safer, it’s faster, and, if it’s showing equal efficacy, it’s a great advancement for patients.

We also know now that with bacterial infections for UTIs, there’s absolutely a need for genetic evaluation

both on the bacteria, because not only do we find more information about the bacteria, but also about the person’s individual susceptibility and their ability to fight off infections. We can determine, too, if there is a familial susceptibility to specific UTIs.

With urge incontinence, the biggest advantage over the past few years is the emergence, and the proven efficacy, of the β-3 agonists, which are much better medications than the anticholinergics.

The β-3 agonists present no risk of mental status changes associated with anticholinergics, and a lot of people I treat with those medications are quite happy with them.”

“With regards to incontinence from my practice standpoint, I think I’ve seen a change in the different medication profiles we can choose since I started practice. They came out with Myrbetriq and now there’s Gemtesa [vibegron]. They are more expensive medications and sometimes it’s harder, but we are generally getting them covered by insurance.

Other incontinence treatments could be coming soon. Those are MRI-compatible neurostimulators.

As far as the overall treatment, there’s nothing really different per se yet; we abide by the same concepts for treating incontinence. The overall system is stable in my practice. But the medications have been improved and cause less side effects.

For UTIs, from my standpoint, the approach has become a more detailed look at the actual infection in regards to those cases that are more difficult to treat, with neurogenic testing and the more elaborate tests they have now. Testing comes into the forefront, especially for UTIs that aren’t responding to antibiotics. We get better details on the actual microbe with regard to what they’re susceptible to so we can provide a little better treatment.

Genetic testing to determine familial connections is also being talked about, although I’m not using it a lot in my practice yet, but those evaluations can come into play with difficult or recurrent cases.”

"With urge incontinence, the biggest advantage over the past few years is the emergence, and the proven efficacy, of the β-3 agonists, which are much better medications than the anticholinergic," says 1 urologist.

Karen Nash

Articles

What new guideline or presentation from the 2022 AUA Annual Meeting will have the biggest impact on urologists?

What do you tell your patients about all the new erectile dysfunction treatments being advertised to the public?

Are you seeing more health care workers planning to leave medicine?

What’s been the biggest change in treatments for UTIs and/or incontinence over the past decade?