2023 Meeting – Take Aways – Arizona Urological Society

AZUS 2023 Post-Meeting Take-home Notes

By Aqsa Khan, M.D., AZUS Secretary/Treasurer
Assistant Professor
Mayo Clinic, Department of Urology

Many thanks to Dr. Khan for her thoughtful capturing and sharing of these points during the sessions.

Arizona Urological Society 2023 Annual Meeting
El Conquistador Resort; Tucson, AZ
August 4-6, 2023

-------------------------------------------------------------------

August 5, 2023 (Saturday):

Dr. Matthew Gretzer [State of the Art Lecture: Thanks for the Referral: Urology Reconstruction Cases from Around Arizona:

Penile Amputation:
- Penis should be wrapped in moist gauze and kept on ice
- Interrupted sutures in the corpora
- Scrotal flap if possible to allow placement of a prosthesis (testicles and/or IPP) in the future
- Venous congestion is expected if poor restoration of neurovascular bundles (can use leaches to alleviate)
- Necrosis of the skin edges is to be expected, try to wait to allow it to declare itself
- Thicker skin grafts for the penis are preferable, graft from the thigh.
- SPT can allow earlier removal of the urethral catheter
- Keep the patient intubated x 48 hours to avoid pain and thrashing
- Consult all ancillary colleagues: psychiatry/psychology evaluation necessary
- Reviewed AUA Urotrauma Guidelines
Urethral stricture:
- RUG is very important to visualize the length of the stricture
- To do a RUG, put a cone tip catheter into meatus and inject. Don’t need to put in a catheter and inflate the balloon (1cc = 32F)
- Length of the stricture is strongest prognostic indicator
- Multiple urethrotomies/dilations don’t improve outcomes
- Don’t DVIU in the urethra in the penis. Balloon dilate if you have to.
- Avoid “cut to the light”
- Review of reconstructive options
  - Reviewed augmented urethroplasty (buccal grafts; island skin flaps)
  - Reviewed proximal, penile, and fossa navicularis strictures
- Reviewed AUA Stricture Guidelines
Peyronies and waistbanding
- Excising plaques leads to venous leak -> ED
- Plication is preferable
- Extra-tunical grafts (prefers bovine pericardial graft)
- Preferable method for induced erection: papaverine injxn at the start of the case

Dr. David Wilkinson [Guest Expert Lecture: The Urolift System: a Catalyst for Optimizing BPH Care]:

Urolift designed as a less invasive option to eliminate the need for medication.
- Enhance the patient experience so men will elect disobstruction earlier and preserve bladder function
Poor adherence to medications, poor rates of follow up.
Catheters kept in patients >24 hrs if have a large median lobe, live >1hr away, or radiated
1 year re-treatment rate: 5%
Early intervention predicts better outcomes
Don’t do glands over 50gm glands
Don’t do on patients with large median lobes

Dr. Jack Andrews [State of the Art Lecture: Current State of PSMA: What does a Urologist Need to Know]:

PSMA is a cell surface glycoprotein with minimal expression in other organs asides from prostate.
Review of molecular imaging (C-11 Choline PET, fluciclovine PET, PSMA PET)
PSMA PET has three different FDA approved radiotracers currently approved for: initial staging and biochemical relapse
Stage migration means we are able to more accurately stage patients from our updated testing modalities. This has likely improved our outcomes.
Metastasis-free survival is the only valid surrogate endpoint for Overall survival
Change in treatment is not a valid endpoint
Delaying time to systemic therapy is not a valid endpoint.
Nodal staging:
- Ga-PSMA not drastically better than conventional imaging.
- Pylarify
- rhPSMA PET (just recently approved) – including unfavorable high risk patients
Bone staging: beware of isolated rib lesions, can likely ignore that.
PSMA is better at bone imaging.
Overall, PSMA PET is likely better at staging than conventional imaging.
Do not omit a PLND because of a PSMA PET study
No studies have looked at change in management due to PSMA PET findings
NCCN Recommendations:
- Can be used to stage unfavorable intermediate or high risk CaP
- It might change treatment, but we don’t know if it will change the outcome
Might be helpful if MRI hasn’t been helpful and trying to localize disease
BCR patients:
- POUND trial (1999): without treatment from BCR to radiographic mets to death: 13 years
- Adding PSMA PET has the potential to reduce the time to identifying radiographic mets, which could extend death out to later.
- Metastasis-directed Therapy without ADT: the use of PET imaging in BCR can guide change in treatment
PSMA Theranostics (LU-177 PSMA)
- VISION Trial
- Lutectomy Trial – patients are not on ADT
- NAUTILUS Trial: currently submitted to FDA
Future Trials:
- Adjucant Lu-177 PSMA – ALPS Trial
- BiSpecific PSMA Immunotherpies – BiTE Trial
- Alpha Emitters
- Development of biomarkers (predict response)

Dr. Andrew Hung [Keynote Expert Lecture: Artificial Intelligence in Surgery]:

Artificial Intelligence
- Machine Learning
  - Deep Learning
- Surgical AI the use of AI technologies in surgery to assist and enhance surgeons.
  - Guidance
  - Assessment
  - Patient outcome prediction
- Uses:
  - Pre-op
    - Radiomics
    - Patient selection
    - VR simulation
  - Intra-op
    - Navigation
    - Intelligent assistance
    - Real-time feedback
  - Post-op
    - Pathomics
    - Oncologic outcome
    - Functional recovery
  - Imaging, Segmentation, Feature Extraction, Model Training, Validation: The key is identifying recurring patterns
  - AI in Diagnostics:
    - Examples: using AI for fusing US images into MRI for MRI fusion biopsies (instead of doing manually)
    - Can outperform human reads and interpretations of imaging studies
    - Being used in pathology (Paige prostate software)
    - Computer vision (identify malignant areas on cystoscopy, identify what kind of stone is present, more specific needle placement and targeted treatment during PCNL)
  - Surgeon Assessment:
    - Kinematic, Technical Skills, Surgical Gestures
    - Better ways to provide 360 degrees evaluation for a surgeon
    - Automated Performance Metrics
      - Predicting length of stay in the hospital (85% accuracy)
      - Predicting when continence will return after surgery
    - Automated Assessment for Robotic Suturing Utilizing Deep Learning Algorithms (R1 grant)
    - Predicting outcomes from surgery based on gestures done during surgery

Dr. Adri Durant vs. Dr. Jonathan Seaman [Point-Counterpoint Debate: Robotic Cystectomy – the New Standard?]:

Adri Durant (Dr. Mark Tyson):
- Robotic surgeries have improved post-op outcomes without compromising outcomes (fewer transfusions, fewer DVTs, earlier discharge, improved aesthetics), patients prefer robotic surgery, ergonomics for the surgeon is better
- Rebuttal: Cost is an issue, but no one bats an eye about robotic prostatectomies which is also more expensive. Surgical time will go down and we become more proficient and well-trained on the robot.
Jonathan Seaman (Dr. Juan Chipollini):
- Robotics might be equal to open, but not enough data to say it is superior and the standard of care. Cost is substantially more, access to care is limited, time per case is longer (could affect the ability to do more than 1 cystectomy/day). ERAS + open surgery improves LOS and makes it close to robotics
- Rebuttal: “technophilia is widespread in urology.” We should make sure what we’re doing is better for the patient and not for the enjoyment of the surgeon.”

Dr. Przemyslaw Twardowski [Lunch Symposium: Olaparib + Abiraterone with Prednisone or Prednisolone as Initial Therapy for Patients with BRCAm mCRPC]:

Amanda Sheinson & Dr. Amish Shah & Dr. John Hansen [Legislative Update]:

Request to Speak system: allows you to share your opinion on legislation.
https://apps.azleg.gov/account/SignOn to make an account.
- Can make comments on passed legislation.
Major Legislation:
- Breast cancer screening guidelines
- Oversight and licensure requirements
- Physician Assistants collaborative practice
- Defeated a number of bills:
  - International Medical Graduate licensure
  - Medical malpractice filing deadline extension
  - Repeal of sunrise report
  - Removal of liability of protection for health care institutions and providers
- Payer Transparency and Accountability
  - Timely and accurate pay
  - Prior authorization
  - Credentialing
- 2024 Budget
  - AZ Health Insurance Program (CHIP)
  - $5M for primary care residency positions in community, rural, and tribal communities
  - $1M to support Collaborative Care Model (mental health)
- HB2474 Strengthening Medicare for Patients and Providers Act
- Noncompete Ban
- No Surprises Act
- Medicare Advantage Plans
- Looking ahead:
  - Scope of practice battles
  - Medical title misappropriation
  - AHCCS Coverage/Reimbursement
  - Insurance Reform
  - Workforce shortages
  - Access to care (rural, underserved)
  - Artificial Intelligence

Resident Research Presentations (Part 1):

Lacey Elizabeth Culpepper (U of A): 24-hour urine abnormalities amongst patients with infection renal calculi
Daniel Salevitz (Mayo): Developing an artificial intelligence model to predict differential renal function using contrast-enhanced CT scans
Kyle Garcia (U of A): Robotic partial nephrectomy for Stage pT3 renal cell carcinoma: oncologic and functional outcomes
Adri Durant (Mayo): BCG therapy is safe and effective in NMIBC patients with immunosuppressive conditions

-------------------------------------------------------------------

August 6, 2023 (Sunday):

Dr. Andrew Hung [Keynote Expert Lecture: Simulation & Metrics for Surgical Training]:

Tie our performance in the OR to patient outcomes. Ultimate outcome in all studies is patient-reported outcomes.
Reviewed studies looking at data obtained from suturing.
- Prostatectomy anastomosis: compiling data from all USC surgeons (faculty and trainees); made recommendations on best way to perform the anastomosis from all this data (efficiency, good outcomes)
- Positive surgical margins; urinary incontinence (patient factors vs. surgeon factors)
Machine learning research: start with easier outcomes (e.g. length of stay) to get comfortable with the research processes before tackling more difficult outcomes.
Recent publications (Nature BME, NPJ, Common) show that surgical AI system for skills assessment works, is fair, and is explainable
Gesture classification system: looked at renal hilum dissection, looked at dissection of the neurovascular bundle during prostatectomy
In the future, deep learning to assess nerve-sparing during the robotic prostatectomy. Can we change the paradigm/dogma about how we perform the surgery to positively change the outcome of the surgery?
Surgeon feedback
- Have done various assessments (e.g. biometrics, EKGs)
- Goal of providing actionable feedback
  - Real-time feedback study (operated on a clementine).
    - End points (amount of bleeding; juice leakage).
    - Surgical errors identified (e.g. tissue puncture), received pre-recorded audio feedback
    - Showed improved outcomes if provided feedback.
    - System usability score asked of the med students. Those that found it to be useful did improve more than those that didn’t.
  - Providing praise with the feedback improves the chance of making the change.
  - Goal in the future is for this to be automated.

Dr. Nathaniel Oswald vs. Dr. Kyle McCormick [Point-Counterpoint Debate: Elevated PSA – Standard Template Biopsy vs. Prostate MRI]:

Nathaniel Oswald:
- Cost: MR fusion biopsies cost 150% of the standard template
  - National average $2500
  - 1-1.2 million biopsies/year (added cost of $2-3 billion/year if mpMRI widely used)
- Availability: standard is more available
  - 21% of hospitals routinely perform mpMRI
- Accuracy: false negative rate of 20%
- Is there a way to decrease false negative rate (how MRI got introduced)
  - PRECISION Trial 2018: 28% of men in MRI group avoided biopsy; clinically significant cancer in 38% vs 26%; fewer low-grade cancers detected
    - Radiologists that read the MRIs had 5 years of experience and read 300 MRIs/year
    - Urologists were also experienced and academic (>750 standard template, >100 MRI guided)
  - Can prostate MRI itself diagnose cancer? No
    - Negative predictive value of mpMRI: 56% -92.8%.
  - There is a disagreement between reads of MRIs by 54% between community read and tertiary centers.
  - AUA Guidelines 2023
  - Rebuttal: even if MRI is done, a fusion biopsy makes things more complicated (e.g. equipment, etc), a standard biopsy still needs to be done.
- Kyle McCormick
  - PRECISION trial
  - PROMIS trial: compared rates of clinically significant prostate cancer detected by MRI vs TRUS biopsy (mpMRI more accurate)
  - European Society of Medical Oncology guidelines state biopsy can be omitted in patients with negative MRI
  - If patient undergoing repeat biopsy, MRI should be performed beforehand (21-60% with have GG2+ cancer).
  - Rebuttal: don’t stop offering something to the patient just because it’s a bit more difficult; cost can be mitigated because using MRI can reduce the number of systematic biopsies being done, and can also miss clinically significant cancers in 13-20% of cases ;

AZUS Business Meeting

Total # AZUS members 165
Total unpaid 63 (56%)
Total assets from 2023: $97,572 (increased by $24,630 in 2022)
Total revenue from 2023: $91,274 (mostly industry support)
Total expenses from 2023: $66,644
Net income: $24,630
Budget for this year expected to gain ~$20,000

Resident Research Presentations (Part 1):

Daniel Heidenberg (Mayo): Device-related adverse events during BPH surgery: review of the manufacturer and use of facility device experience database
Charis Royal (U of A): Determining optimal kidney stone culture microbiology protocols
Mouneeb Choudry (Mayo): The impacts of standard versus early apical release HoLEP technique on post-operative incontinence and quality of life
Kyle Garcia (U of A): Decrease in length of stay following robotic partial nephrectomy to 1.5 days does not increase readmissions within 30 days or ER visits

Interesting Cases:

- [Dr. Tyson]: management of complex metastatic testicular cancer patient
- [Dr. Chipollini]: management of complex metastatic testicular cancer patient