"As someone once told me, if you make a change in your golf swing and it is easy, more than likely you have not changed anything," writes Raoul S. Concepcion, MD, FACS.
For the most part, for progression to take place, change is inevitable. And change is often very difficult. As someone once told me, if you make a change in your golf swing and it is easy, more than likely you have not changed anything. The urology community has been very progressive over the decades, embracing changes in our clinical world that have led to optimizing patient care while maintaining control, if you will, of the disease states we are accustomed to treating. Although at times this has resulted in fewer operative procedures, which for many physicians is the reason we entered the field, the end result has been better patient outcomes.
Advances in technology generally are the driving force behind these changes, and fortunately, many forward-thinking urologists have been keen in applying them to our field. In the early 1920s, William T. Bovie, working alongside the acknowledged father of neurosurgery, Harvey Cushing, MD, was one of the first pioneers to demonstrate the advantages of electrocautery to stem bleeding in the surgical field.1 A decade later, a urologist in South Carolina, Theodore M. Davis, MD, was able to adapt this technology and incorporate both a cutting and cautery feature into the modern endoscope.2 Thus the birth of transurethral resection of the prostate, which continues to be the gold standard in which all newer therapies, including medical and minimally invasive, must show noninferiority.
For those of us who trained before 1990, prostate biopsy could be considered a form of medieval torture. Blind and either transrectal or transperineal, its complication rates of bleeding and sepsis were extraordinarily high, not to mention the suboptimal sampling due to the lack of imaging and inability to obtain quality samples. Fortunately, a number of our predecessors were prescient enough to adopt prostate ultrasound and template sextant biopsy, which have now led to MRI fusion techniques, again driven by our colleagues. Somewhat forgotten in this discussion is the perseverance of many during that time frame to have practicing urologists trained in prostate ultrasound, wrestling that away from our radiology colleagues. Had those efforts not been successful, it is unclear to me how our current practices might look today.
As alluded to earlier, many of us chose the field of urology for the surgical aspect of the specialty. From an oncologic perspective, mastering the art of nerve-sparing radical retropubic prostatectomy was key to developing a surgical practice. Identification of the neurovascular bundle obviously is a mandate, but controlling bleeding from the Santorini plexus early in the course of the procedure is truly what makes the procedure possible for adequate visualization in a relatively bloodless field. The principles remain the same, but open surgery has now given way to robotically assisted extirpation, which is what most patients opt for when they choose surgical intervention. But as our understanding of the biology of prostate cancer continues to evolve, we must also understand and accept that all prostate cancers do not necessarily need immediate treatment and that active surveillance is truly an option. It is somewhat against our surgical mentality, but it is the correct option for the appropriately identified patient.
In line with this theme, the late 2000s saw the emergence of new therapies for patients with advanced prostate cancer. Many urologists and practices were (and still are) slow to incorporate them into their model for a number of reasons. Probably the most commonly cited is the lack of expertise in prescribing such agents, which was not part of surgical training and belonged more to a “typical” medical oncologist. This paradigm continues to change with the realization that the urologist is perfectly suited to and capable of prescribing and managing these drugs. More importantly, however, our patients have a certain comfort level within the practice.
Part of the shift for many will be incorporating and understanding genetic and genomic testing. Currently, this is heavily weighted to prostate cancer management, but data and literature continue to come forth for both urothelial and renal cancers. That being said, there is no doubt that we will all need to have a working knowledge of molecular testing for risk assessment, family counseling, and therapeutic options. To that end, as a publication, we have opted to include an article in each issue that covers a certain aspect of genomic testing. Our goal is to demystify this area and make it more comprehensible to our readers to achieve better uptake at the provider and practice levels, which currently is very minimal. This, once again, seems to be multifactorial, and we are hoping that educational pieces can assist physicians in their use of such testing and hence their efforts to deliver personalized care.
Concepcion, Chief Science Officer for U.S. Urology Partners, is editor-in-chief of Urologists in Cancer Care™.
1. O’Connor JL, Bloom DA. William T. Bovie and electrosurgery. Surgery. 1996;119(4):390-396. doi:10.1016/s0039-6060(96)80137-1
2. Goddard JC. That silly operation! The introduction of TURP into Great Britain. The British Association of Urological Surgeons. Accessed May 19, 2021. https://www.baus.org.uk/_userfiles/pages/files/museum/Final%20-%20That%20Silly%20Operation.pdf