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

Karen Nash

“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.”

Articles

"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.

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

“Certainly, I think it depends on the age of the patient. If you have patients on active surveillance, you can already extrapolate that a lot of them will be younger and perhaps will be in good enough shape to do a high-intensity workout. Those workouts are not for the faint of heart. They’re not for people who are not active to begin with.

Will that be possible among that group of patients? I suppose it could be.

Certainly, my experience with patients who are on surveillance, who meet the criteria for active surveillance, [is that they] tend to be younger and healthier patients, so I don’t see why not. I certainly think it’s a reasonable thing to tell them.

As far as the concept of high-intensity interval training, I would have to know more about the science behind it and how they make the science work with that.

But…some men would definitely be willing to do it. Certainly, I think a lot of the men who go on active surveillance are patients who are healthy enough to do those types of workouts. I think they would be able to, and I think if they’re willing to watch the cancer in active surveillance that they would be willing to make the effort to control it even better with high-intensity workouts. I don’t see why they wouldn’t.”

“Over the years, we’ve all done general urology, although I haven’t done a lot of prostate cancer for a couple years.

Certainly, I think most men with prostate cancer are very into researching prevention of recurrence and progression. So most men, if they’re physically able, would probably be interested into looking into any kind of research like that and moving forward.

It could depend on the patient’s age, comorbidities, and ability. [From] past [experience], I know a lot of men…would be willing to investigate any kind of adjuvant therapy they could find that would reduce the risks, because if they are on active surveillance, they want to keep it that way. They don’t want any progression of the disease. So if there’s something that actually gives them a little bit more ownership of their disease process, and that they can do to help prevent the cancer from progressing and having to move on to active treatment, a lot of the men would be willing to pursue it.

As far as the concept goes, prostate cancer aside, anytime you’re increasing your physical activity and increasing that cardiac stress, that’s good for every patient, [whether they have] prostate cancer, benign prostatic hyperplasia, [or] prolapse. Anything increasing your physical health overall is beneficial.”

“The confounding factor, of course, is that people who work out are healthier and have better cardiovascular health anyway. It would be very important to separate out individuals with good cardiovascular health, normal body mass index, normal cholesterol, normal blood pressure, and no diabetes.

If men are already active, the question is how much more this activity would help them vs somebody who was marginally obese, actually lost 20 to 30 pounds, and who lowered their cholesterol.

Also, it depends on the genetics of the prostate cancer. Individuals are going to get tested. And to be honest, if those tests show less than a 1% risk of metastatic disease in 10 years, why would they go and exercise?

Because we have genetic tests, which is the genetic behavior of the cancers, this might not even have a marginal impact on the progression of the prostate cancer.

If the patient is obese, but the genes are telling him he’s low risk, what incentive has he to lose weight?

If the patient is intermediate risk and decides on watchful waiting, then loses 45 pounds due to high-intensity interval training and is suddenly determined to be low risk, that would be profound. You’d be reversing the course of the cancer by doing exercise. If gene testing already categorizes men as low risk, I don’t see the enormous incentive for them to exercise unless they are already motivated, to be honest.

It’s fine for heart health. There’s a colloquial thing we used to say: ‘Anything that’s good for the heart is good for the prostate.’

Obviously, it’s not a guarantee that solves all prostate issues but I think exercise would have marginal impact in light of the genomics that are widely available.

For sedentary individuals, if genomics show they’re low risk, it will be hard to convince them they have to work out so their prostate cancer risk will be even lower. “

1. Kang D-W, Fairey AS, Boulé NG, Field CJ, Wharton SA, Courneya KS. Effects of exercise on cardiorespiratory fitness and biochemical progression in men with localized prostate cancer under active surveillance: the ERASE randomized clinical trial. 

2021;7(10):1487-1495. doi:10.1001/jamaoncol.2021.3067

"My experience with patients who are on surveillance, who meet the criteria for active surveillance, [is that they] tend to be younger and healthier patients, so I don’t see why not," says one urologist.

Do you think patients on active surveillance would be willing to participate in a high-intensity interval exercise training program?

“I like to get a baseline PSA [prostate-specific antigen] for patients in their 40s, particularly if they’re seeing me for a prostate issue. As patients gets into their 70s, I start the conversation about stopping PSA testing because it loses value.

If a PSA level goes up and, as importantly, if there’s a change in PSA velocity, we may do a course of antibiotics then recheck the PSA. It may come down because inflammation was involved. If it doesn’t, the patient has time to adjust to the idea of a biopsy.

We don’t want to go back to the days before PSA testing because then we clearly saw much more advanced disease with much less we could do about it. The PSA has been valuable, but as with any other tool it may be overused at times or misunderstood.

The PSA screenings we used to do in September—big events getting men who…wouldn’t come in otherwise—have fallen by the wayside, reasonably so, because in the last years of those screenings, many men already had had [their PSAs checked] and were just coming for a second one.

There’s been a shift in the individuals getting treated for prostate cancer. They’re living a better quality of life, provided we catch them early enough.”

“I use PSA testing to make sure patients with high-risk prostate cancer, specifically, and advanced prostate cancer, or even metastatic prostate cancer, don’t go undiagnosed. Prostate cancer remains the No. 2 or No. 3 cancer killer of males in America. So PSA is an important adjunct to DRE [digital rectal exam] in efforts to give those patients a diagnosis earlier. We don’t get as clear a benefit with intermediate- and low-risk prostate cancer.

Every patient with urinary issues should have a physical exam, including a DRE. The PSA should be considered at age 40, even in the absence of risk factors, and absolutely at 40 with risk factors—positive family history, African-American individuals, genetic predisposition. Then we can talk about monitoring frequency.

I follow the guidelines. Being mindful, a really healthy 70-year-old man may live to age 95. Anybody in practice 25 years knows our patient demographic has changed. Patients used to be in their 60s. Now they’re routinely in their 70s and 80s, if not 90s. I would like consensus among urologists that high-risk prostate cancer in otherwise healthy males should be treated.

Do I do PSAs on patients older than 70? Yes. Annually? As a rule, no.

PSA shouldn’t be considered simply a screening test; it’s actually part of the diagnostic work-up. If a patient is 80 years old and has trouble urinating, PSA helps ensure it’s not advanced prostate cancer that I might have missed as a result of not doing PSA testing.

I’m using PSA as I always have. I followed patients with lower-risk cancer before it was recommended. Simple math showed that most of our patients weren’t dying of prostate cancer.”

“Most men are being referred to me because their PSA levels started increasing. Anyone with prostatic symptoms, voiding symptoms, etc, warrants a PSA check. If the PSA falls within range for the age group, I may recheck it right away or in 3 months to determine the trajectory of the PSA levels and whether there’s a need for further investigation.

Nowadays, if some of our primary care doctors see an elevated PSA or abnormal DRE, they’ll order an MRI. It’s not common among primary care doctors, but ours do it because they know the MRI is being utilized more in prostate cancer screening. Often patients come to me, as a robotic surgery specialist, already prescreened with a PSA level and/or an MRI.

MRIs help catch intermediate- to high-risk prostate cancers more likely to benefit from treatment vs lower-risk [cancers] you should probably just watch with active surveillance.

We still follow patients with a negative MRI or biopsy, just not as closely, to make sure their PSA isn’t increasing at an alarming rate. I’ll probably do a PSA test every 6 months for a couple years, then push it out farther if the PSA stabilizes.

Typically, if someone comes in with an elevated PSA, I recheck to make sure it’s a true value, then get PSA levels every 3 months to determine data points to check the trajectory of the PSA’s velocity, whether it’s increasing at an alarming rate or it’s steady and their PSA is always high.

Coupled with their physical examination, family history, race, those are all factors included in determining how to manage people.”

"I use PSA testing to make sure patients with high-risk prostate cancer, specifically, and advanced prostate cancer, or even metastatic prostate cancer, don’t go undiagnosed," says 1 urologist.

What is the role of prostate-specific antigen screening in your practice?

“That’s a fair question, but I’m not sure how you define the right amount. There’s a lot of research. Industry does a lot in the field of voiding dysfunction and incontinence in men and women—that’s my specialty. I think they have done a nice job. I can’t really comment on kidney stones and bladder infections, but there’s no question that probably, head-to-toe, cancer gets a lot of research and financial emphasis, and maybe it should. There is, of course, is a lot of basic science research more affiliated with oncology than perhaps other disciplines.

As far as industry goes, I think they’re becoming more biased toward things that third-party payers have difficulty in saying no to, that they have to cover them. So there’s a lot of emphasis on oncology treatments vs quality of life therapies.

As I say, industry has to make money, and I only know my specialty. They go after what they would perceive, I’m assuming, can [affect] the customers— the patients and the doctors, but also what will drive economics based on the current market and demand.

I’m sort of spoiled. I do a lot of neuromodulation and overactive bladder [cases], and it appears there’s a lot of emphasis on that right now, so I’m pretty happy.”

“It’s a great question. The world of cancer certainly attracts research dollars and focus…Bladder cancer—there are genomics and testing and other types of chemical instillations for bladder cancer that’s refractory to BCG. So other genitourinary cancers get their due in terms of attention and research dollars.

Alternatively, to be honest, there’s a lot of attention, time paid, and investment in what I would call the lucrative, office aspect of urology…because that helps boost the urology bottom line.

Robotic surgery is costly, in time, for the doctor and the hospital. So [although] it’s important to cure cancer, that’s not what’s carrying practices. Practices are carried by smaller, more lucrative, less time-consuming items that have plenty of research and interest in corporate industry investment.

For marginal problems such as interstitial cystitis, which doesn’t have a high interest among urologists, you’re not going to get a lot of interest or research dollars into that because basically it’s a pain. You’re not curing cancer, and it’s not a big moneymaker. If you’re not [curing cancer or bringing in a lot of money], you’re not going to get a lot of interest.

The science of stones is well-studied, so I don’t think it’s true that prostate cancer sucks up all the oxygen in the room. It’s very common, so you have a lot of [investigators] interested because they could make a name for themselves.

But there are many aspects of urology that get equal attention. Cancer will always attract attention and dollars, but it’s trickier to solve.”

"There are many aspects of urology that get equal attention. Cancer will always attract attention and dollars, but it’s trickier to solve," says 1 urologist.

Karen Nash

Articles

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

Do you think patients on active surveillance would be willing to participate in a high-intensity interval exercise training program?

What is the role of prostate-specific antigen screening in your practice?

With all the attention paid to prostate cancer research and treatment, do other aspects of urology get the research they need?