AUA 2016: Reflections on mentors, MRI fusion, and more

The AUA annual meeting provided learning experiences for me on multiple levels. Here are eight observations I brought home from San Diego.

1. Mentors matter.

None of us would be where we are, whether that’s in the trenches of urology practice or in the hallowed halls of academia, if it was not for our mentors. In San Diego, I was again reminded of the permanent and indelible mark that one mentor left on me. Richard D. Williams, MD, was my chairman in residency and the man who first taught me to be a urologist. More than once he told me that it was every urologist’s responsibility to make a contribution to the field of urology, even though he was well aware that most of us would not end up in academia.

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He would be turning 71 this October if he hadn't passed way too early. The University of Iowa is raising money for an endowed chair in his name, and I would ask that, if anyone else like me owes the man his residents referred to simply as “The Boss” a debt, please consider making a small donation to the Iowa Foundation in his name. From all of his residents, and all of us who miss the Boss, thank you.

2. Reps also matter.

My practice is currently trying to decide between two competing urologic products. The product is a common urologic medicine with only minor differences in delivery method. I was visiting the Science & Technology Hall while at the AUA and stopped to visit the booth of the first of these products. I chose this booth first for no other reason than I found it first. After having my questions answered, I went to find the other product and as it turned out, it was next door. The rep in that display was less than helpful. She at first denied that her competition offered a patient tracking software system, which they do, and then accused me of being a bad doctor for considering cost of the medicine as part of my decision (even after conceding that they are basically identical products).

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I had no strong opinion on either product before going to the AUA, having used both in my short career. But I left San Diego with a strong opinion. Advice to reps: I really don’t care how short your dress is if don’t know your product well, if you insult me, or if you lie to me.

3. MRI fusion.

As I mentioned in my pre-AUA meeting article, one of my goals was to learn more about MRI fusion biopsy. My conclusion? Jay Bishoff, MD, the proctor at the plenary session (MRI Fusion Prostate Biopsy: The New Gold Standard for Diagnosis and Staging), nailed it when he stated that MRI fusion biopsy was the future of prostate biopsy; it’s just not quite prime time yet. The data behind its use in the setting of a rising PSA after a negative biopsy is impressive, but I’m unsure how a small practice justifies the six-figure cost when there is no reimbursement for it.

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I also am not sold on its use on first-time biopsy patients, although I concede that the ability to get an MRI after the fact and then fit your biopsy tracts onto the image to see if you missed a suspicious area is fascinating. I also can see how a large, vertically integrated system such as a university would love the technology because if it increases the use of MRIs and increases the number of biopsy specimens being done, that certainly would defray the cost of the machine.

As for me, I intend to follow the white paper that was introduced at the AUA (MRI-Targeted Prostate Biopsy After Prior Negative Biopsy: An SAR-AUA Consensus Statement), which allows for cognitive fusion to be used for now. If and when the AUA changes its opinion on the technology, I likely will too.

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On a different note, one of the more intriguing concepts that came out of my courses on MRI fusion biopsy was an attendee question at Eric Klein, MD’s course on prostate cancer (Management of Prostate Cancer: A Case Based Approach with Emphasis on Integrating New Molecular Diagnostics into Clinical Practice). The attendee asked if it was appropriate to move straight to definitive treatment simply based on a PI-RADS 5 lesion on prostatic MRI. I thought this was a great question because if the accuracy of prostatic MRI approaches 80% to 90% for clinically significant cancer in a PI-RADS 5 lesion, that is similar to the accuracy of a contrast-enhanced CT for renal masses and no one would fault me for removing a 5-cm enhancing renal mass without biopsy, would they? So why can’t I remove a prostate for a PI-RADS 5 lesion on prostatic MRI? A question for my academic friends.

4. The future of urology is in good hands.

I had intended on listing all of the great young minds I met while at the AUA but even this online blog has word limits, so I am forcing myself to name only three. (Like awardees at the Academy Awards, I should name everyone because I did not attend a session I did not find incredible.)

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First was Daniel D. Eun, MD, from Temple, who did an amazing job presenting his experience with upper tract robotic surgery (Robotic Upper Urinary Tract Reconstruction: A Top to Bottom Approach). I also thought the state-of-the-art lecture on lichen sclerosus (I still call it BXO) by Brad Erickson, MD from Iowa was great, though even for a urology presentation, there were a lot of photos of penises. Lastly, I think the entire team who presented on “Ureteral Perforation During Ureteroscopy” was great, and they and the AUA deserve credit for highlighting this complication, which those of us who specialize in bread-and-butter urology risk on a daily basis.

All in all, with future leaders like these (and many others), the field is in great shape.

5. PSA screening.

Anyone who follows this blog knows I have a strong opinion on PSA screening. I simply don’t understand how, in the long run, ignoring prostate cancer will do anything but return us to the pre-PSA days when the majority of our patients diagnosed with prostate cancer presented with metastatic disease. It boggles my mind.

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Dr. Klein (Management of Prostate Cancer: A Case Based Approach with Emphasis on Integrating New Molecular Diagnostics into Clinical Practice) furthered my concerns. He stated that only 13% of men aged 55-69 years in his system are being screened. This news was shocking to me as Dr. Klein practices at one of the leading urological centers of excellence (Cleveland Clinic), and if he can’t get his primary care providers to check PSA, how does this small-town plumber have a chance?

6. Urethral mesh sling.

With the removal of numerous mesh urethral sling products from the market for legal reasons, I was pleased to learn while talking to one of the true thought leaders in the field that the AUA is currently drafting a white paper supporting the use of mesh for urethral slings for stress urinary incontinence. I applaud this effort and look forward to reading the final product.

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While this certainly won’t provide 100% legal coverage to urologists who continue to use this excellent surgical technique, it still will be nice to have some guidance.

On a related note, can anyone explain to me why a vendor hasn’t come up with a cadaveric product that incorporates the trocars that the mesh products use? I was taught to harvest my own fascia for a sling, and one of the greatest downsides of this is that I have to create a retropubic tunnel to support the sling. If a company offered a pre-made product that allowed me to do a single-incision cadaveric sling (similar to the Adjust, for example), even though I would have to concede the durability of cadaver is inferior to mesh, I’d be very tempted to use it.

7. RunPee app.

On a lighter note, I have to share this incredible app, which I heard about at the AUA. Many of our patients have urgency and/or frequency, and one common complaint is that they can’t go to the movies for fear they’ll miss something important when they get up to use the restroom. Never fear, RunPee is here. This website reviews movies and publishes a list of 3- to 5-minute long scenes (timed to allow you someone to make a run to the restroom) in the movie that are selected not to include plot twists or action scenes. They even have an app you can download for discrete usage while in the movie theater. I love urology.

8. The experience.

I love the AUA annual meeting. I don’t hide that fact. For the general urologist, no other conference comes close in terms of breadth of topics covered and the experience of the speakers. Plus, who can complain about spending a long weekend in San Diego? Unfortunately, I am still looking to meet a urologist who practices in Antarctica to complete my goal or meeting a urologist from every continent. There is always Boston next year!

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