The Fox Chase–Temple Urologic Institute delivers expert care for both complex oncologic and benign urologic conditions. Backed by a team of renowned urologic specialists, we are recognized regionally and internationally for offering innovative, leading-edge treatments.
In this patient case discussion, Drs. Alexander Kutikov and Jay Simhan reviewed complex cases and treatment. This session highlighted the multidisciplinary management of malignant and benign urologic conditions, focusing on patient-centered care and collaborative treatment planning.
Objectives:
To illustrate the role of reconstructive surgery in the continuum of care for cancer survivors.
To understand the complexity of kidney cancers and minimally invasive treatment options
To showcase the collaborative, multidisciplinary approach of our urology team.
Good evening and welcome to the Broadcast Med webcast. Um, my name is Alexander Kurukoff, and I'm the chair of uh urology at the Fox Chase Cancer Center and one of the co-leads for the Fox Chase Temple Uurlogic Institute. And today, we will uh present complex neurologic oncology and complex advanced benign neurology cases. This is my partner and very old friend Jay Simhan, who, go ahead, hopefully I'm not too, too old, but, um, you know, uh, my name is Jay Simhan. I'm the chair of urology at Temple University. Hospital and the Louis Cat School of Medicine at Temple University. Uh, as Alex was saying, it's our privilege to be here and to be able to present, um, some of our perspectives in both oncologic and benign neurology, um, and, and again our honor to do that on behalf of Broadcast Med, um, uh, to this forum. uh, just, just to. Few housekeeping things to talk through. Um, this whole webinar is being recorded and so for anyone who's interested in watching it again or if you have a friend or a colleague that might want to see this, um, you know, uh, this presentation will be available probably in roughly a two-week period on the broadcast med platform. And then for, for those of you that are listening actively right now, we've reserved time throughout this one hour presentation for you in the audience to ask us questions and the way to do that would be on the bottom left hand corner of your screen under the questions tab, click on the tab and then sort of send in your question and throughout our presentation of cases, we'll, we'll be happy to sort of address that in real time and, and try to, um, you know, uh, hopefully make a worth. I'll answer for you and for your consideration. Um, all right, Alex, you want to get started? Absolutely. Jay, why don't you kick it off. All right, perfect. So, so as Alex and I were thinking about this, what we really wanted to do was try to focus on benign and cancer-based cases. But really, I, I, I think what we see at our urologic Institute is that the patients don't really read the textbooks, right? They're coming in with a benign problem, but they might have a cancer history or vice versa. They, they might not have any cancer history and their benign problem might then progress to a cancer-related issue. And so, let's sort of talk about the first case. First case is a really a quote unquote benign uh case. And, and my practice, I think really delves into reconstructive urology and procedures, prosthetic urology procedures as well. And, and so this is a gentleman who presented for uh for reoperative artificial urinary sphincter surgery with recurrent stress incontinence. He was 7. had an artificial sphincter cuff that was um placed 44 years ago along with the other components. It was a 4 centimeter cuff. The patient though represents with 4 pad per day leakage, has concomitant erectile dysfunction, and a history of radiation therapy. And, I want to interrupt you here. I mean, this is, you know, just a level set it for folks. This is a rare occurrence after mostly prostate cancer surgery, sometimes bladder removal surgery. And, you know, an experienced hands, this doesn't happen very often, but you and our constructive partners really see this from across the region. So there's a high volume of this, but in reality, this happens rarely. Absolutely. Can you comment on the fact that, you know, there's more and more data that are coming out that are really a patient who's had a prostatectomy has been dry and potentially dry for years, after they get radiation therapy, this can be a little bit of their. Destiny where with time they do get incontinent and need this um intervention. Yeah, I think that's, that's uh it's the nail on the head where patients, I think, generally do well with localized prostate cancer treatment and there's this very small percentage of people in in the realm of cancer survivorship that might present with an issue of incontinence that develops years following initial therapy for localized prostate cancer. And, and that's I think. Alex is getting at, and, and I think that's a real thing. And, and, and also, you know, there, there are patients that may undergo for other reasons, a urologic procedure, um, um, following a remote history of localized prostate cancer treatment where they then after a treatment, they might need sort of a kidney stone removed and following a kidney stone removal with a history of radiation, they then start leaking and, and they might not have. had any problem, but then they do develop this issue and, and an artificial sphincter is often not done um by many urologists because it's not necessary in a large proportion of patients. But there are people that I think really would benefit from getting an artificial sphincter. And this, this person in this case was one of those people and, and in that, you know, one part of the consideration and sort of managing these. These folks is, what is the artificial sphincter look like on interrogation with cystoscopy in the office and you can see that this is someone who had a cuff around the urethra, but it wasn't coopting well enough and, and you can see that there's sort of like this little hole there in the urethra that that permits urine to flow through. And here, here are some of the other questions before you delve in. I mean, you think overall, you think this is which you know, from where I sit, I think. At least in the community, I, I think it is the urinary sphincter is underutilized. Yeah. I think people are walking around without having the appropriate referral to a specialist like you who can give them this option, right? Yeah. No, I think there are people that would benefit from getting an anti-incontinence procedure. Some of it I think might be related to an unfamiliarity or hesitancy, um. To sort of undergo these kinds of procedures. In short, though, you know, it centers that do a fair amount of incontinence, uh, these are not major operations. These are minor procedures that are probably anywhere between 30 minutes to an hour to do this type of an operation, and, and they have a very short sort of convalescence period for recovery. And, and I think, you know, some of that, again, a lot of that is for quality of life. Improvement. And, and so getting getting to this gentleman, here are the various things that run through my mind when I sort of see these patients, um, you know, who placed the device, when was it placed, was it, was it several years old? If there is prostate cancer, has that management been uh sort of uh optimized of their cancer treatment? Um, is, is there an insurance issue? Now most insurances cover the artificial sphincter, um. You know, or a, a male urethral sling for that matter. And is this a persistent problem or a gradual problem? Or is there anything else like sort of a, uh, an overactive bladder situation that patients are facing as well. Now, in this case, this was someone who underwent a prior artificial sphincter, and when you sort of look at it and examine the patient, you see that their artificial sphincter cuff was actually high up in the perineum because it was actually placed through a penis scrotal approach. Usually our goal is to try to find a different place for that cuff to go around. Usually the more proximal you go, the better. And so here are some live sort of photos that we took in the operating room of someone where their urethra had the cuff in more distally. We then repositioned the cuff more proximally, and then, you know, we, we did an exchange. So exchange of a cuff is something that you could do to sort of optimize their continence. Sometimes we don't exchange and we do a complete device removal replacement. But what if you're looking at just exchanging one of the other components, like, like a pressure regulating balloon or downsizing a cuff. I'll remind you this was a guy who came in after a sphincter was placed 4 years ago and had then development of new onset incontinence after having a good period of resolution. So maybe you can just exchange the balloon. There's some data out there that has shown that balloon exchange. To, uh, maybe a higher, um, pressure, pressure regulating balloon does reasonably for a period of several years. But another consideration might be maybe you look at the cuff. That patient had a 4 centimeter cuff. Maybe instead you downsize it and place a 3.5 centimeter cuff. You know, Alex, I would tell you, um, years ago, that cuff came out maybe in around 2014, and there were a lot of people that jumped on the bandwagon of, of placing a small cuff around a small. in order to get the urethra to coop properly and prevent sort of incontinence episodes and, and then of course as things happen, you know, this was something that we had looked at and published. We had demonstrated long ago that the 3.5 centimeter cuff had a role, that 4 centimeter cuff patients were being oversized, and that smaller urethras do better. But then, you know, friends and colleagues at other institutions really demonstrated that the 3.5 centimeter cuff had uh some mechanical problems and that the mechanical malfunction rate of smaller cuffs was actually dramatically higher. And, and then no less after we placed a fair amount of 3.5 centimeter cuffs, we demonstrated that those cuff sizes actually resulted in a much higher rate of um artificial sing. erosion. And so erosion itself, I would say is the most devastating and feared complication of the artificial sphincter, and I think it really changes that person's life trajectory once they get an erosion. So it's my job as, as a cancer survivorship sort of specialist to avoid that patient to graduating to an artificial sphincter erosion. We hope for them to never have that happen. And and the reason for that is these are challenging situations. Once we see an artificial sphincter erosion, again, that's when there's a hole in the urethra that that is caused by pressure from the device and you can see it. On cystoscopy and you can see parts of the device transluminally. That's usually a really bad sign because the urine then moves throughout the entire circuit of the device. And so it'll move from the cuff to the balloon to the also, of course, the pump and the scrotum and that's why that patient had such an angry appearing scrotal examination. And, and ideally, you would say, well, In the real world, you know, this is a damage control procedure, but ideally maybe why can't you just re-approximate the urethra when you take out that infected device that's infected with, you know, contaminated urine. Well, that's actually much harder in real life, you know, this is a damage control situation where this is how that looks. You know, it's a very inflamed area. You have to bring the urethra together. And, and we've been able to show that when you do that, um, the, the urinary stricture rate is much lower, but it is hard. It is hard to do and we've had some like sewing tissue paper. Yeah, I mean, it's like sewing, you know, sewing not only tissue paper, but the thinnest of thinnest tissue paper together in a hostile environment. And, and, you know, those things, you know, are things that we've been able to accomplish. But again, I'm not saying it's easy at all. I, I think we've struggled to, to, to sort of do those kinds of repairs. And nevertheless though, once you, once you're able to get someone through a repair like that. Their urethra actually looks pretty good when you bring them back several months following an erosion attempt, and, and sometimes people may feel that an erosion might lead to not getting an artificial sphincter ever again in the future. No, we will then usually tackle at least 1 or 2 times trying to get a device back in. With the goal of avoiding them getting another erosion in the future. And so here's the urethra, here's the corporal body. Many times we then look to placing a transcorporal artificial sphincter. So, so if you put it all together, I would say, you know, the Artificial sphincter really remains the gold standard. There's a low threshold for cystoscopy when you assess or revision artificial sphincter. For us, we ordinarily, for people that have had um a device for more than 2 years, if they develop more incontinence. We, we would ordinarily remove and replace the entire device. Again, in the United States, uh, insurance covers the surgery. So, um, we don't wanna face a malfunction of another component if we exchange just one component. Within 2 years or so, though, we will selectively exchange parts of a device. So that patient, if, if they had presented 1 year after initial placement, we would have no problem placing a different, different cuff in that person. We might avoid the 3.5 centimeter cuff, um, but we would place maybe a 4 centimeter cuff or a different size cuff in a different part of the urethra. And then in the end, you know, revision is really a delicate balance between cuff repositioning, PRB exchange, which is pressure regulating balloon exchange, or total device replacement. And, and I think that requires some level of nuance, consideration, and, and um then conversation. Um, so I don't know, Alex, uh, what, what are your thoughts about all of this as it relates to, you know, uh, the population of patients that you see? Yeah, no, I mean, I think this is rare. I think this is something when you counsel somebody for prostatectomy, you say it's possible. It's, you know, in experienced hands, it's unlikely, but this certainly happens. Again, especially in my practice, I've seen this in patients who've had a prostatectomy and then had radiation as the years roll on, all of a sudden their continence is not as good as it was, and, uh, there we are. I send them to you or one of our partners and uh to get that addressed. Um, but maybe perhaps, you know, we can, there's a quick question in the chat, maybe you can speak to, you know, some of the primary care providers who are listening to this, you know, what what's the perioperative, uh, kind of a lessons? What, what does it take? You know, how long is the patient in, in the hospital? How, how long do they stay with the? catheter, what does it take to get this done? Yeah, so, so at least for our protocol, you know, an artificial sphincter is usually a 30 or 40 minute operation. Um, you go home the same day. There is no catheter um after the patient wakes up. Sometimes we have a catheter during the actual dissection. Um, it's two small incisions, one in the right lower abdomen, one underneath the scrotum, where we place all of these components, the balloon, the pump, and the cuff. Um, and then once those components are placed, again, very small incisions, very quick recovery with all absorbable sutures, the patient goes home, has no heavy lifting requirement for around 2 to 3 weeks, and a pain sort of threshold for probably 5 to 7 days. And, and then, you know, the device itself uh needs to heal. Uh That we then teach the patient how to manipulate their sphincter one month after the operation. And so overall I would say patients do pretty well when they graduate to needing it. And, and many people I think remember sort of going through a cancer operation with prostatectomy, which of course has an emotional toll and trauma that that takes and and and there's no question that people recover from that in different ways. This is a very different recovery that we, we have found had good success at getting people through. Perfect. So, let's Switch gears a bit and uh do an oncology case. I wanted to do one that's on the topic of prostate cancer and really speak to some of the decision making, uh, you know, I think one of the things we like to say at the uh at the Fox Chase Temple Rain is that decisions are far more important than incisions. It's, it's the decision that is made with the patient in the room that really determines destiny and some of, you know, some of These complications, for instance, some of these adverse effects of cancer surgery can really be avoided in that room with the patient at the initial consultation. And so I just wanted to present a quick case of a 65-year-old patient who I met, uh, now nearly 15 years ago. He had a PSA of 4.7, he had a 68 g gland, and he went, uh, underwent a prostate biopsy. At an outside hospital. Now, let me ask you this, that I think is actually really common. I see this in my practice because I mostly see patients who are getting their cancer managed by my cancer colleagues. But, but what do you make of that? A 4.7 PSA is, you know, conventionally someone would say that's high, but in a 68 g gland of a 65 year old, how do you, what's that mean to you? And how do you, how do you look at that in this, in this person? Right. So this is, this is exactly the point I was going to make is that this is an opportunity. Yeah. That was missed. This is an opportunity to not biopsy that patient. Actually, that patient's PSA density is absolutely normal. This is, uh, if, if you take the PSA you need to, excuse me, um. divided by the prostate volume, then the PSA density needs to be less than 0.15. In other words, in this patient, the prostate volume, the number of cells in that prostate justify a PSA being elevated above the above the 4 threshold, which is normally considered normal. So this patient's PSA is actually normal. Perhaps in 2025 we would get an MRI here after a discussion, which would again, uh, you know, the MRIs cut both ways. They, about 25% of men with an abnormal PSA they will. Uh, have them avoid a biopsy because their MRI's are normal and their prostate volume demonstrates that the prostate size, uh, explains the elevated PSA. But also the way the other way it cuts is that if you see a lesion, then the biopsy you you do perform is more accurate. So MRI, multiparametric MRI is deployed in this space, uh, almost universally, uh, at this point. But this patient did undergo a biopsy and he had an adverse outcome, in my opinion, as adverse outcome, he, we found a Gleason 6 prostate cancer. Gleason 6 prostate cancer, there's a, you know, debate that rages out there whether to even classify this as cancer because the Gleason 6 prostate cancer actually. Doesn't metastasize. However, now this patient needs to be surveilled and have repeat biopsies, repeat MRIs, repeat PSAs. And that's a challenge. This is what, you know, in the cancer space we term overdiagnosis. This patient's chances of dying of prostate cancer are 1 in 1000 over the next two decades. But however, now they are sort of in the web of this, you know, what now is necessary care where they need to be either treated or surveilled. And, you know, this patient underwent surveillance and now this is, um, You know, 12 years later, still on surveillance, he's undergone a number of biopsies, a number of MRIs, but he didn't require artificial urinary sphincter. He didn't require a revision. That's right. He, you know, he maintained uh erectile function that was appropriate for his age. He's fully continent. So, you know, you know, and I sort of I make these comments while Working with a group and working in a, in a, in a, uh, you know, at a health system where we have that 11 of the highest volumes of prostate cancer surgery in the region, uh, where we pride ourselves on some of the highest quality uh cancer surgery. However, again, incision, decisions more important than incisions, there are lots of opportunities to de-escalate care for men who don't need treatment. Now, it's complex, and you know, I just had a chance to comment on recent news where, you know, there are men who get diagnosed with aggressive prostate cancer. This is actually a um a small percentage, about 7 to 8% of men present with sort of a very advanced metastatic disease. What, you know, how you deploy treatment, how you deploy. Screening is a little bit beyond um this webcast, uh, however, what I can tell you is that at a tertiary referral center like ours, this is a conversation that happens every day where we discuss, uh, screening, we discuss treatment, and we calibrate that screening and treatment with patient appropriately, uh, because if you deployed in both treatment and uh screening, a lot of men get harmed, uh, completely unnecessarily. So let me ask a quick question on that. How do you then sort of manage the patient that I, I sometimes see and that I'm sure it comes to your clinic with, you know, the 76 year old, not this person on active surveillance, but the 76, 78 year old. Who, you know, might have had the accidental PSA draw by their primary care physician or a very overexuberant patient that wanted to get a PSA um at the age of 78 or 80 years old. How do you sort of one manage that conversation, and two, how do you manage the PSA when an 80 year old walks in with a PSA of 6.5? Yeah, I mean, it's, it's a challenge, uh, and it's, you know, that this topic, you, you know, debate rages into how to best manage it. Um, I think it's a conversation with the patient. I think you, uh, sort of inquire about goals, about the risks of even getting an MRI, there's a risk, because if you find a lesion, you have to biopsy and all of a sudden you are down the rabbit hole of treatment. Um, for some men, it's very important to, you know, really eliminate risks of prostate cancer. For some men, it's very important for them to avoid any sort of side effects of treatment. So I think that it's a conversation and, uh, ultimately, I, I believe in patient agency and, you know, and, um, Sort of, uh, decision making that involves, uh, both the patient and myself, and, uh, uh, I think it's, it's very different, different, different decisions are made by different patients with the same information so. Uh, you know, there's some, there's some folks that are, you know, if you don't work that up and you don't do that MRI, don't do the biopsy, just even the anxiety that is associated with the diagnosis will significantly reduce the quality of life for that patient, and it's important to make sure that their fears are alleviated. So, uh, certainly, once the PSA is drawn, it is difficult to sort of walk away from it. Yeah, no, I, I think that's very respectable. No, I think that really is. Well, to, to continue in the vein of sort of diagnosing things that need to be diagnosing and diagnosed and treating things that need to be treated, I wanted to present sort of a simple case of a, of a renal mass. And so it's a definition of a small renal mass. This is a mass that's less than 4 centimeters. Here you can see it on the right kidney, on this cross sectional image, and this mass, the biologic potential of this mass that's less than 4 centimeters, and especially the data are very strong for masses that are less than 3 centimeters, is that this mass poses very, very, very little risk to the patient. The rates of metastatic disease are exceedingly small for masses that are that are less than 3 centimeters. However, as I show on the, on the slide, you know, that mass in an elderly frail patient uh has uh a very different significance than in a young non-comorbid patient. Young noncomorbid patient, we obviously proceed with treatment, but again, decisions more important than incisions. We have one of the largest active surveillance data sets and active surveillance programs in the world here at, you know, Fox Chase Temple Neurologic Institute, where we pride ourselves on de-escalating care and not treating these patients and not putting them through unnecessary surgery when um treatment can be safely avoided. Yeah, I mean, what I think I'm hearing is Treatment comes at risk. Non-treatment comes at risk. And you really just need someone to help contextualize the risk, whether it's treatment or not. And, and, you know, try to, try to sort of answer some of the unknown questions that people come in with when they, when they have those types of challenging diagnoses. That's at least what I'm hearing. Correct. I, I, you know, I talk to patients all the time. I, I say balance of risk is The same with a diagnosis as it is anywhere in life. And people have different risk tolerances on both sides of the equation, and it's a conversation and it's a very personal decision about what you would like to do. I, I have 75 year olds that once I contextualize this, they're incredibly comfortable of just monitoring and getting every 6 to 12 months imaging, but at the At the same time, I do, you know, rarely do you see a patient that regardless of sort of how, how, you know, long of a conversation you've had with them and telling them that this is likely doesn't need treatment, they're anxious and there are some strategies that we'll discuss in a second uh where we can give them more information, uh, where we can um sort of alleviate some of the fears of aggressive cancers, etc. um, so. Just wanted to go through some of the things we've done here, uh, at the institute. This is, uh, some work we've done, and this was, uh, you know, done a few years ago, but some of the seminal work on, um, competing risks of death. When you see renal masses, even with the larger masses, the risks of competing, uh, cancer, uh, of the competing, uh, sort of comorbidities, uh, far outweigh risk of uh of Kidney cancer death, even at, even at large kidney cancer, uh, size. And so we've quantified that and we've, um, we've been able to uh provide the community with predictive models, um, like this one that, you know, these nomograms obviously are difficult to deploy at the point of care when you're actually seeing the patient, nobody's sitting there with a rule or counting points, right? So we've, um, I just want to highlight a resource that we have um at the institute, which is Cannomograms.com, where these predictive models, both ours and uh those that we feel are the strongest out in the literature, are um operationalized in a little web widget that can, you know, that is uh compatible with a mobile device where you can very quickly Radio buttons sort of figure out what the patient's risks are. And I invite you to visit cancer nomograms.com, uh, both, you know, for really kidney cancer, but also for all the other, uh, urologic oncology spaces. And, uh, if there's a nomogram or predictive model that you don't see there, please email us and we're glad to add it on there. We sort of figure out, uh, figured out a mechanism to put these, um, Uh, predictive models onto the web without having the, uh, uh, the original, um, uh, the original data. This is just from the published data, we've, uh, figured out how to make these widgets. So, um, glad to operationalize something that uh you are using and you could, uh, so we could lower barriers to that. Um. You know, I wanted to talk a little bit about decision making in kidney cancer. As in any cancer, first decision is whether to treat or not to treat. The second decision is how to treat a tumor. Um, this is, you know, something that we've written about, uh, uh, a lot at the center, you know, uh, partial nephrectomy. Do we really need to take out the whole kidney? Um, or on the other, on the flip side, do we need to put elderly frail patients through more complex surgery when, you know, radical nephrectomy versus a partial nephrectomy can be a much simpler operation. Obviously, we deploy thermal ablation appropriately when needed. And decision number 3 is really the decision of uh open versus minimally invasive surgery, laparoscopic and robotic. We still use laparoscopy a lot here. Um, we use robotics, um, obviously, at very high volumes. But also, you know, sometimes the redo cases, they, you know, I have a case coming up and a young man with um Then hapolindo syndrome, who has over 10 tumors in each kidney. You know that that's an operation that gets done open in order to remove each, you know, multiple tumors, uh, from, from a kidney. Uh, well, so I get the sense that patients sometimes might look at decision 0.3 before decision 0.2. And, and at least my sense in talking to certain patients over the years is that they might get enamored perhaps with how cancer is treated instead of perhaps what the treatment needs to be. And, and so, what are your thoughts on that? And how do you, how do you sort of, you know, contextualize that for a patient? Yeah. So, I mean, it's a great lead into my next slide actually is these factors that influence decision making. So, you know, first, You sort of you, you, and, and I do this in the, in the clinic all the time with patients. I tell them, hey, my goal number one is oncologic efficacy, which, you know, I describe as I want to make sure I get rid of this cancer, right? The goal number 2 is I want to preserve your kidney if possible and if the risk, uh, if the risk balance makes sense. And 3, I want to do this minimally invasively to expedite recovery. But if doing this minimally invasively compromises the first two goals, hey, we're gonna do this with an incision. These days it's exceedingly rare. We're so adept at the robotic surgery that, you know, over 90% of kidney surgery now is done minimally invasively. Um. But you know, there are various factors that influences decision. There's patient-specific factors. There's age, there's uh competing risks, which we discussed. There is, you know, is this part of a familial syndrome? Is the patient on anticoagulation comes up a lot. There's a fresh diluting stent, uh, well, a complex partial is made. Not the right answer for them. Maybe they need a simple radical nephrectomy, especially when their contralateral kidney is completely normal, um, you know, contralateral kidney status, um, you know, what is their overall kidney function, and then there's tumor size, anatomic complexity of a tumor, which I'll mention in my next slide real quick, um. Location in the kidney, growth kinetics, multifocality, etc. And then there's structural factors, there's surgeon skills. I mean, this is, you know, this is a place that is one of the highest volumes in the world for partial nephrectomy. We're comfortable, you know, I, I always tell our fellows who come train with us, you can do partial on anything. Do you need to do it? And is it the right good idea? That's a different question. That's right um. You know, can this, can the medical center and can the health system support a complex operation? In other words, for instance, sometimes the rare complications need interventional radiology or experienced. When we have those folks here. Perhaps some of these surgeries should not be undertaken and somebody with, with poor interventional radiology support. Uh, and you know, access to multidisciplinary care, we're very lucky to have incredible colleagues in, uh, medical radiation oncology, radiology to support, to support this kind of care. Um, just wanted to say, you know, a few words about anatomic complexity. What is that? This is, you know, how the tumor relates to the rest of the kidney. Um, you know, this is, um, this was written when we were both training, um, and this is, I believe, the highest cited, uh, paper in kidney cancer space. This is basically we provided a tool to be able to objectify and quantify reporting of kidney, uh, location as it relates to. The rest, uh, uh, kidney mass location as it relates to the rest of the kidney. I won't, I won't sort of delve into the details, but this is used throughout the world and, uh, it's been cited over 2600 times. Papers come out sort of every day, almost citing the score as ubiquitous score we're proud to sort of originated this here at the Fox Chase Temple urologic Institute. Um. Want to just for last few minutes of this case, talk a little bit about cystic masses. This is something that we've uh been really interested in. These masses have historically been determined to be very low risk. However, um, we've Sort of kept stumbling on upon very high grade tumors, and very aggressive tumors. So let's see if I play this video. This is a Bosniak 4 mass that is considered to be very low risk. You know, we, we did, I did a robotic partial nephrectomy on this patient and um Uh, here's the mass and pathology. We're sort of opening it up. You can see what that looks like inside. Obviously, when you resect this, very important not to get into it. And you can see this is all necrotic. This is a necrotic tumor, very high grade. Um, and so we had a series of these observations that these, these cystic tumors sometimes actually harbor. Um, a more aggressive disease isn't aside, I'll just show you how this is done. This is a this is a transperineal robotic partial nephrectomy when we go through the belly and then we move off the colon and go, um, and go and find the blood vessels to the kidney. But what we really pride ourselves here is we have, we do this retroperoneoscopic approach, which is, um, Um, this is, you know, this is a patient with colostomy, for instance, who otherwise would receive an open operation. We can go behind the bowel sac in a retroperitoneal, uh, approach and, um, Um, and avoid a big incision here. You know, I'll, I'll skip this video. This is basically, um, a little video showing how we do this, um, you know, it, um, as you can see basically what the, what, what just still shows you, it's a sea of adipose tissue, but with experience, you find the blood vessels and, um, You, um, See if I can get the slide to go. Um, yeah, and, and, and you can take out these masses very safely. The, our experience with cystic masses, we actually just recently published, uh, it was on the cover of the Journal of Urology, which showed that these masses are not always um indolent, and I invite you to sort of see this paper, um, but, um, you know, the The, um, 23% of these radiographically cystic lesions were actually high grade, and we're continuing to do work here at Fox Chase to be able to better risk stratify these cystic masses. What's important in this paper is that we showed when we do have active, we do active surveillance on these masses, they behave, uh, they're very slow to spread. Nobody spread on our active surveillance, even if we use delayed intervention. And so this is one of the big research interests here at Fox Chase right now. Um, Jake, maybe I'll kick, we'll, we'll switch gears again and go to a benign case. No, I think that's great. I think, um, you know, my, my big takeaway with any cancer treatment here at least is that You know, you have to look at patient goals and, and also treatment goals, right? For, for the given cancer. And it seems that, you know, our, our approach has always been, you know, put patient needs first, but try to contextualize a full-based conversation on, you know, is therapy needed, is the incision needed, or is, is, is surveillance appropriate? And, and, and I think this sort of speaks to the nuances on both sides of that. OK. So shifting into another case here, um, you know, we talked a fair amount about incontinence and, you know, I think this too sort of speaks to an incontinent patient, but also mixes in uh another topic which I think many, many practitioners struggle with both in the primary care arena as well as in um. which is erectile dysfunction. And so here's a patient who, 71 year old, again, like this is a benign problem, but look at their history. They had an open radical prostatectomy back in 2005. They had a biochemical recurrence and salvage radiation therapy in 2012, and they present years later with Urinary incontinence at roughly 3 pads per day and complained of erectile dysfunction, refractory to phosphodiastase inhibitors and intracavernosal injections. And I, and I'll pause and say that you know that the AUA used to really say that there's 3 or 4 lines of um erectile dysfunction treatment. And what they meant was they said first line therapy was phosphodiesterase inhibitors, second line therapy was sort of um sort of what I would call enhancing non-surgical therapies that weren't oral medical therapy. So what is that? That's penile injection therapy, that's intraurethral suppository. and that was vacuum pumps. And then the third option or the third line therapy was um erectile dysfunction implants, uh, penile implants, inflatable implants, or malleable implants. And, and now though the American Neurologic Association has come together and said no, no, no. You know, there are patients that really meet criteria for any of these medicines or treatments that aren't first line, second line, or third line based. All of them should really be on the same line. So, so when you look at a patient, Again, like cancer colleagues, we've, we have, I think evolved to a point where we really should be looking at what patient goals are in order to advance our treatments. So there are, there are patients on nitrate therapy, for example, that can't take a phosphodizedase inhibitor, then they probably shouldn't be offered one. Very similarly, there might be patients that have poor dexterity, that might not be able to do intracavernosal injection therapy, then they probably shouldn't. Or if you have Fear of needles, for example, or if you're on anticoagulation. And even that, I would say it's a, it's a relative contraindication. And, and, you know, again, with risk, we can talk through what the risks are for patients if they really want to move forward with penile injection therapy. But, but again, you know, that's a conversation. I think one that we're happy to have with folks. And so for this gentleman, this patient failed phosphoesterase inhibitors. And failed incavernosal injection therapy and, and really was talking about both incontinence as well as erectile dysfunction. When you go through their history, look, they also have this chronic constipation in their past medical history, which becomes important later in their story and, and, you know, other routine sort of medical issues that that are managed sort of conventionally. When you examine this person, they had a standing cough test that was positive. It's a very Simple physical exam where you have a patient stand, have them cough, and if urine comes out during cough on a, on a physical exam of a gentleman, then, then that's, that's a surgical problem if it's not amenable to pelvic floor physical therapy or if it doesn't improve with pelvic, uh, pelvic floor physical therapy. So in this person, they had an exam that demonstrated standing cough test positive. It was confirmed with a urine. Dynamics evaluation that also showed stress predominant incontinence, cystoscopy demonstrated no stricture, and the patient said, well, I also struggle with these erections. Can I undergo both an artificial sphincter and a penile implant? And, and some providers choose to stage that operation. Some providers choose to do it sort of, um, you know, in a simultaneous uh fashion. Again, I would say that it really depends on what the patient is willing to undergo. You know, the recovery from doing either operation is shorter, the recovery from doing both is longer, but it's one operation, so some patients might say, listen, I'd rather have a longer recovery. I'll do both. And, and, and again, you know, that's, that's sort of a nuanced conversation that, that people have to be willing to sort of have. And Jay, let me ask you, in cancer, there's been a very strong relation between volume and surgical volume and patient outcomes. Has that been shown in the prosthetic space? Yeah, absolutely. I think in, in prosthesis, I think just as much as in cancer, you know, and, and, and probably true in any surgical field in medicine. If there is a surgical center that does more of a given operation, the patient outcomes have, have routinely been shown to do better. And, and that's the same in penile implant uh surgery. That's the same in artificial urinary sphincter surgery. The more you do, or the more a given center does of that operation, the nursing protocols uh are built sort of a certain way. The provider experience is such that they're able to do it. But again, it takes a village, you know, so it's not necessarily just the actual surgeon, but it is the, it's the center, you know, and, and the health system that sort of offers that treatment. Generally, patients end up doing better because they've consolidated a pathway for patients to benefit. And so this is, this is in this gentleman, someone who, you know, their clinical course was that they received both surgeries at the same time, they received the artificial sphincter and the penile implant. Again, another 4 centimeter cuff was placed in that person. penile implant was placed, an inflatable device was placed, so they had sort of a pump for their artificial sphincter which is a very small rectangular pump in in one hemiscrotum and the other opposite side of the scrotum, a penile. Implant pump was placed. And so that was done. The patient did well, was discharged, had some issues, of course, with their chronic constipation. So we sort of gave them an aggressive bowel regimen, but then several weeks later developed urinary retention. And that actually wasn't from their surgery, it was from their history of constipation, and constipation I think is tied with bladder dysfunction as well, and this was someone that had constipation and unfortunately, Went to a local emergency room and despite sort of their their uh plea to their uh emergency room physician, unfortunately had manipulation of their urethra and had a large Foley catheter inserted. And you might say, what does that mean? You know, in fact, there was really nothing that was published in the literature on this. of, you know, an analysis or even a description until recently. And so again, you know, here at our center and through the institute, we published sort of what the, what the ramifications were for artificial sphincter devices when they had instrumentation like either bedside procedures like cystoscopy or procedures like cystoscopy, but also even simple manipulations that happen in an emergency room. And, and some of the recommendations that we came out with were that if you're gonna place a Foley catheter, those devices really need to be deactivated and turned off. And there are ways to do that that are actually pretty easy for any provider to be able to do it, not just a urologist. Now, now this patient though didn't have that. And ultimately had trauma to their urethra and needed removal of their device. Now I've already told you how we manage that, so I'll sort of quickly say that this patient had their artificial sphincter removed. It was eroded and removed, and our conversation was, do we also remove the penile implant? Do we repair the urethra? I've told, I've told you in the previous case, we would try to repair the urethra because we don't want stricture to form, but that's a tough repair to try to undergo that. And, and look here, this patient had a urethral repair, but then weeks later their urethra still had not healed. We wait a little longer, the urethra still doesn't heal, and weeks later they developed perineal drainage. So they really developed a fistula of the urethral repair. But, but in short, this is a patient that underwent the urethral repair because they developed fistula from an artificial sphincter removal. And we didn't have to remove their penile implant, which I think was, you know, an important save for this gentleman, but he still came back incontinent, you know, and, and how do you manage that? And, and I sort of, uh, gave a little bit of an indicator to that in the first case where we would undertake a repeat artificial sphincter placement in these types of patients and I guess, you know, our standard approach in this would be to place a transcorporal cuff, again, challenging scenario because there are penile implant cylinders in place and so we then need to, you know, create a plane between the corporal body and the urethra, but not violate the penile implant cylinder, which we were able to do in this patient. And so, uh, you know, ultimately, that patient years later is doing well, is potent, and still has, um, sort of one pad per day leakage or less, and they're very happy. Anyway, Alex, let's move. Yeah, these are certainly very challenging scenarios, um, that, uh, you described and, uh, you know, I see you manage these things, you know, on a weekly basis and um it's, uh, you know, um. It's impressive how your team sort of handles some of these cases that really come from all over the region, um, to, uh, to get handled here. So I, you know, one of the programs here at the Fox Chase uh Temple Uologic Institute that's near and dear to my heart is our adrenal program, and I wanted to highlight that in the last few minutes that we have left. This is, um, Uh, this is a program that, uh, you know, involves again, minimizing overtreatment of patients who a lot of the time don't need anything done, but I did want to present a case of a person who absolutely needs, um, Uh, need surgery and surgery sort of emergently. This is a 36 year old woman with a, you know, with basically a newborn who uh is found to have a left, uh, 17 centimeter adrenal mass. She was seen here, uh, you know, now 3 years ago almost. And, uh, you know, she has no hirsutism, but she has an elevated testosterone in, um, And some of the other uh adrenal androgens that are elevated, um, She undergoes an open um adrenalectomy. Uh, her kidney is removed as well on block. The it's actually very important that for somebody who's suspected of having an adrenal cortical carcinoma, very rare, uh, cancer. That minimally invasive surgery is not done. This is, you know, um, this is guideline-driven recommendation where we know that minimal invasive surgery here can actually uh cause carcinoma, it can be, uh, is associated with a higher risk of carcinomatosis than open surgery, and this is where we really deploy our open surgical skills. Um, now, having said that, sometimes we, you know, just in the last couple of months we've had very large pheochromocytomas, which are different adrenal tumors. They're from the medulla. They're not, uh, often very rarely are they malignant, and those we tackle minimally invasively, robotically or laparoscopically, but this patient underwent an open, um. Uh, adrenalectomy and concomitant nephrectomy. You can see the kidneys sort of just, uh, on the outside of this, uh, of this mass. You can see the kind of dissection that this takes. This is actually, um, where the patient's head is to the right of the screen, the, uh, uh, the feet are to the left. And you can see that this is the aorta here. This is the celiac axis. This is the mesenteric artery. And here it's hard to see, but the, the renal artery has been taken in these eclips here. So this is the kind of dissection has, these are, you know, um, the surgeon's hands, uh, here, uh basically pulling away the pancreas that was, um, I was actually uh dissected away from this adrenal. But these are, you know, highly complex surgical cases um that we tackle here quite often and, and, and I'm proud to, you know, help the Philadelphia region's patients, uh, uh, with, with these sort of situations. Um, this is, um, this is a patient who had a high high 67 in the recent clinical trial. This is one of the big drivers to recommend, um, um. Uh, to recommend, uh, adjuvant midotane therapy. And so the patient received midotane, she completed 4 cycles and, um, Uh, and, uh, you know, she actually received some adjuvant cisplatin-based chemotherapy, uh, midotaine was discontinued, uh, you know, about a year ago, and as of May of 2025, she's now 2.5 years out. This is a 30, you know, was 36 year old woman at presentation who's still alive from adrenal cortical carcinoma, who is, um, uh, who's still alive, which is, which is really terrific. Um, quick question then. So, so I think what most physicians see, at least I see it so many times on a CAT scan report, is the idea of an adrenal incidentalloma where a patient basically gets through an emergency room for one, a totally different reason. And, you know, they're diagnosed with an incidental finding of a 2 centimeter adrenal nodule or a 1.5 centimeter adrenal nodule. How, what, what's your take on that? How, how can that patient then be counseled about what the next steps are? Yeah, so incidental, uh, adrenal nodules are, uh, not that uncommon. Once you get to the age of 70, about 7% of patients have them. That's a lot. Yeah, so, it's a big number. So it's a lot of folks. They're often ignored. Um, however, incidental does not mean insignificant, but you know, nearly 20%, about 18% of them are surgical lesions. They're either cancer, uh, or More frequently they're hormonally active. They're either they're either producing cortisol about 5% of the time or uh adrenal uh or catecholamines. So that's crazy. 1 in 51 in 5 of adrenal incidentals are surgical surgical uh indicated removal. Yes, very important to work them up. There's health system, uh, based, um, you know, reports and literature. Some of the best health systems in the country when you look at how many adrenal incidentalommas actually get appropriate workup, it's less than 25%. 0 wow, yeah, yeah. And, and, and who then should do that workup? Is that a primary care physician? Is that an endocrinologist? Is that a urologist, you know, a surgeon, a general surgeon? Who does that? How does that look? And, and what exactly is that workup? What does that entail for a patient? Yeah, so I think all of the above, it's, it's your comfort level. Uh, some of this is a little bit complex and people sort of shy away from doing this workup. In reality, it's quite, uh, it's quite straightforward. Um, we try to educate the community out there. I, I lead one of the, um, uh, one of the efforts, um, for rare general urinary tumors group, and if, um, if you go to adrenal mass.org, that's a website that we manage and uh now I've actually. Given the reins to one of our past fellows who's in Connecticut who runs a very busy adrenal program, Benristow. We're an adrenal mass.org. We have evidence-based guidelines. There are scripts that you can print out to do these workups, and at the point of care, you can, it's an easy reference for folks to know what to do if you face, uh, a patient with an adrenal mass. But in reality, if you know, uh, an adrenal care provider like us at the institute, if you see an adrenal mass, we're glad to just work up that patient. Uh, and a lot of these patients are gonna be told that they don't need any follow-up, that everything is normal. This is a benign mass, and, um, they, they actually, you know, just get, uh get reassured. But, uh, as we said, you know, 20% of them will need some intervention and, you know, some of the, you know, one of the most gratifying surgeries one can do is an adrenalectomy where you take folks off 567 anti-hypertensive medications that they've been on for years. Because of this small aldosterinoma or a cortisol producing, um, adenoma or pheochromocytoma, uh, and people feel better, uh, they, you know, improve their quality of life and improve their life expectancy. Some of these things are just, uh, really terrible metabolically. Yeah, I mean, I mean this case that you've presented just now is someone who didn't have that, right? Had a huge adrenal tumor, and I think, you know, adrenal cortical carcinoma usually presents as big tumors, right? It's usually a big tumor, but these functional adrenal nodules usually aren't huge, right? They're much, much smaller. And, and I think surgical removal of them, I gather then isn't that complex. No, it's a, it's an overnight stay, sometimes even same day discharge, but, uh, yeah, those are, you know, in, inexperienced hands, those are non-events, very quick surgeries that uh patients recover from very quickly. Um, but yeah, it's, I mean, again, the vast majority of these patients don't. anything sometimes, unfortunately, uh, when there's a hammer the world's nail, people do take out adrenal tumors that don't need to be taken out. Um, again, we pride ourselves here to really calibrate care and only do surgery on those patients who need them. Yeah. Well, I, you know, I, I would say that I, uh, always feel like I learn a lot when I get to listen to Alex here speak about cancer and, and I think for, for those of you who've been listening, I think hopefully we've been able to shed some Light on not only benign or cancer-based care, but, but, but also, you know, how, how we have processed some of those problems, you know, uh, throughout the neurologic Institute here. I see that there is a question, um, that, that sort of came through, which is what is the role of AI in decision making at present. So, I, I would say Alex is a urologist during the daytime and at night he's an expert at AI. So, so I'll, I'll have Alex answer that one. Um, I think AI is, is certainly a tool that is to be harnessed. Um, I think it is a great reference tool, uh, you know, there, I'll give a plug for open evidence, which is just a really powerful new tool out there. They can educate one on the current guidelines, on, you know, on some gaps in knowledge that you may have about this or that disease. Now, Having played with it, especially trying to use it on edge cases where, you know, you have very deep expertise in this, um, uh, in, in the management of a disease and asking it sort of some tough questions. There are limitations. I mean, this is, this is general guidance, I think the, you know, to make uh treatment decisions just based on AI uh I think we're not there yet, but we will be there. I mean, this is, uh, these tools are very powerful. Um, and, you know, they still make mistakes. I think we still have to be very careful, but, uh, you know, quick and easy questions on how to start a person on this or that antibiotic treatment for this or this that condition that you may not treat every day. I, I mean, they're very good with, um, with, uh, routine medical problems. I think the edge cases, the rare, the rare birds, uh, they're still sort of, you know, the, the, the model breaks down a bit. Yeah, not, not there for those, right? Yeah, so. So, yeah, I think, I think more to come on sort of what AI means, uh, not just in GU but for all of us in medicine. Um, you know, in short, though, I would say I really enjoyed the past hour of being able to talk through some of these complex cases that we see routinely here at our urologic Institute. I, I also think that urology is such a great field because of how dynamic it is, not just in terms of how the Field evolves, but how various conditions really do intertwine with each other and it gives us an opportunity to work collaboratively amongst ourselves, uh, within our team and within our unit, but also to learn more from, from one another. And so, um, you know, uh, with that said, I, I want to conclude our event uh for today and I really enjoyed doing it with Alex and and thank you again for tuning in. Yes, thank you. Thank you for joining us.
