GLOBAL CONNECTIONS A PUBLICATION OF THE AMERICAN UROLOGICAL ASSOCIATION
VOLUME 9
EXTREME UROLOGY: PRACTICE ON THE EDGE
save the date! Abstract Submission Site is Now Open! Registration Opens in December.
www.AUA2016.org
CONTENTS 4
U P C LO S E & P E R S O N A L
AUA Chair of Global Initiatives, Inderbir S. Gill, MD
7
FE AT U R E
Extreme Urology: Practice on the Edge
11
CO L L A B O R AT I O N S
AUA and SBU Partnership Global Connections is published twice-yearly by the American Urological Association Education and Research, Inc. (AUA). The AUA believes that the information in this newsletter is as authoritative and accurate as is reasonably possible and that sources of information used in preparation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any kind are disclaimed. This newsletter is not intended as legal advice, nor is the AUA engaged in rendering legal or other professional services. For comments or questions email us at communications@AUAnet.org.
14
FE AT U R E
Focal Therapy for Localized Prostate Cancer
18
BY T H E N U M B E R S
AUA’s Membership Around the World
U P C LO S E & P E R S O N A L
Q A
What made you want to apply for the position of AUA’s Chair of Global Initiatives?
I have personally benefitted from the AUA and organized urology in my career and I now feel a calling and desire to give back. I look forward to forging new relationships and strengthening existing friendships with colleagues around the world.
Inderbir S. Gill, MD AUA Chair of Global Initiatives
INDERBIR S. GILL, MD AUA CHAIR OF GLOBAL INITIATIVES
GLOBAL STRIDES Dr. Inderbir S. Gill has been selected to serve as the AUA Chair of Global Initiatives. The Chair, Global Initiatives (CGI) is responsible for helping to shape and execute AUA’s International Education Plan by providing key leadership regarding the organization’s international strategies and activities alongside the Secretary, Education Chair, Executive Director and AUA staff. The CGI assists in identifying new international opportunities and collaborations with various national and multi-national urological societies and maintains relationships with key urologists and other strategic partners throughout the world. We took a moment to ask Dr. Gill a few questions about his new position and how he envisions the future of AUA’s International Programs.
VO L U M E 9 • G LO B A L CO N N EC T I O N S
Q A
Now that you are on board, what are your goals for the AUA’s International Programs?
The first goal is to solidify and strengthen existing programs already started by Dr. Gopal Badlani and the International Programs team. Gopal truly did amazing work in starting over 20 international educational programs annually, and I would like to build upon these. I’m looking to expand our outreach with additional new partners and bring a more detailed level of conversation with existing partners.
Q A
What challenges do you envision in implementing your goals and how will you overcome them?
Everyone is busy, yet there is always a constant desire and thirst for expanding one’s knowledge. We would like to facilitate the spreading of new urologic knowledge globally in an efficient manner, so as to make it worthwhile from a time-balancing perspective. It is a challenge to tailor AUA’s offerings to different countries that have different needs and requirements and different ways that they can benefit from collaborating with the AUA. It is important to make sure that our interaction with our partners is
U P C LO S E & P E R S O N A L
meaningful, worthwhile and real. We can overcome these challenges by having intense one-on-one dialogues and listening carefully to our partners’ needs and tailoring AUA’s offerings to their needs.
Q A
edge advances have come by tapping into world-wide expertise and collaborations. To give an example, if you look at one of the the most prestigious scientific journals, the International Journal of Science & Nature, papers from countries other than the U.S. are increasing disproportionately. We all learn from each other – there is no other way.
As the new editor of Global Connections, how do you envision this publication evolving?
I would like to establish more ongoing involvement of our international colleagues in authoring articles for Global Connections. I would love to see the leadership of international societies publish opinion pieces and provide their perspective on urologic medicine. I envision Global Connections as a platform for differing opinions. We want to hear from and feature prominently our international colleagues.
Q A
What do you view as the AUA’s biggest strength internationally?
AUA is the world’s largest and most established urological association. The content and science that the AUA brings is unquestionably the world’s best. So, that’s our biggest strength. AUA’s membership is growing rapidly with 21,000 members in over 100 countries and this is a testament to our preeminence. AUA is an inclusive organization and it’s the best way to reach, teach and educate as many urology professionals as possible. AUA can play a serious role in connecting people and educating urologists.
Q A
How do you see technology impacting the delivery of AUA’s international education in the future?
The Internet, Skype and the ability to transmit live surgeries are just a few examples of how people everywhere can connect with the AUA, and the AUA can connect everywhere. Nowadays, not everyone needs to travel for their learning so we will use long distance technologies to increase our offerings. AUAUniversity is an amazing resource, which we will utilize to reach urologists across the world.
Q A
How do AUA’s international education programs benefit AUA members in general?
Everything is global today. Today, for any one entity to think they have all-encompassing expertise on a given topic is naïve. As you teach others, you learn from them as well. It’s a two-way street. Many of today’s cutting-
Q
As a seasoned traveler who has lectured all over the world, what do you see as the most important urological educational need yet to be addressed?
A
There is a strong thirst for ongoing learning and knowledge. My sense from being at multiple conferences and seminars is that urologists are keen to learn how they can improve their daily practice, both in the clinic and in the operating room. They are keen to incorporate guidelines-based management strategies into their daily practice, and they seek to improve their surgical skills by watching live surgeries and video-based demonstrations. And, in today’s environment, they are sensitive to the financial aspects of their practice as well.
Q A
How do you think globalized urology advances patient care?
What most individual urologists want to know is, “How can I take better care of my patient?” If we can streamline the knowledge base in actually making a difference in the day-to-day practice of a urologist, that will give us the biggest bang for the buck. We seek to provide knowledge that is easily transferable to the day-to-day practice of urologists. You never know from where a novel idea or concept will originate. Knowledge is meant to be shared.
Q A
What do you see on the horizon for global urology?
I see ever-increasing close friendships and partnerships between individual urologists around the world. Given today’s technology, folks can so easily reach out to colleagues across the world for any number of things, such as advice for a difficult case, asking a pointed question to improve their own knowledge or facilitating their trainees securing fellowship positions, etc. I see global urologic connections continuing to grow stronger. I think everyone is increasing the number of “speed dials” on their phone to include colleagues from all over the world.
G LO B A L CO N N EC T I O N S • VO L U M E 9
F E AT U R E
Urologists are in a unique position to hear the most intimate and private stories from their patients. They are trusted professionals, studying one of the most personal aspects of the human body. And as such, urologists see bizarre and out of the ordinary cases involving the urinary tract and its supporting system. Like Dr. Wirt Dakin in 1947 when he shared patients’ stories in his infamous Urological Oddities, we hope you find the following information (adapted from AUA’s Annual Meeting exhibit, Extreme Urology: Practice on the Edge) both interesting and educational. Factors—direct or indirect, self-inflicted or accidental—that affect the genitourinary system are themselves too great to count. As a result, today’s urologist is forced to practice with a heightened sense of awareness and consciousness. So no matter how odd a case may appear, you will likely approach a patient with not only your scientific mind but also with your compassionate medical heart, especially concerning body modifications and sexual practices. CO N T I N U E D O N P G 8 ▼
VO L U M E 9 • G LO B A L CO N N EC T I O N S
F E AT U R E
G LO B A L CO N N EC T I O N S • VO L U M E 9
F E AT U R E
in ing sub ndergo u y o b cent Adoles on s, Lond e Image m o c ll e W
cision ri
tual.
▼ CO N T I N U E D F R O M P G 7
BODY MODIFICATION An individual’s desire to physically modify an aspect of his or her own genitalia is a way to distinguish oneself from peers. Some of these practices may seem unusual, but as humans continue down the road of self-exploration, the boundaries of “normal” are continuously pushed, and the unusual becomes more commonplace. Body modification includes tattoos, piercings and subincisions.
TATTOOS After Captain Cook discovered the tattooed natives of South Pacific in 1776, his sailors brought this most exotic souvenir of their journeys back to Europe and North America where it became popular among the working class. In most societies today, the genital tattoo is a symbol of love and sexuality (e.g. a girlfriend’s name or exploding dynamite). Genital tattoos are less common than others and require a skilled artist and a stalwart client. However, as the population increases and people hope to distinguish themselves from the masses, it is likely that urologists will see more genital ink.
PIERCINGS The indigenous tribes of Borneo and the Philippines are believed to be the creators of the ampallang, a transverse piercing above the urethra and through the glans penis, which is performed using a wide variety of implements: pig bristles, bamboo shavings, coral, broken glass and metal pins, usually made of gold or brass. Genital piercing has become increasingly popular over the past few decades, with most national and international reports citing a prevalence of 1-3 percent. The reasons for piercing remain broad and varied, but are usually personal in nature. Sexual gratification, sexual expression and uniqueness are the most
VO L U M E 9 • G LO B A L CO N N EC T I O N S
common. In women especially, genital piercings have been cited as a means of reclaiming one’s body following sexual abuse and/ or violence. No longer is the practice reserved to the “fringe” cultures of the body piercing and sadomasochism movements. With genital piercing on the rise, it’s not surprising that the practice has become safer in recent years, with patrons more aware of healthy protocols. Yet complications do occur, including infection, allergic reaction, scarring, tearing, impotence, sterility, reduced sexual response, nerve damage, urinary diversion (in the case of a Prince Albert piercing), Founier’s gangrene and, in extremely rare cases, squamous cell carcinoma. It has been estimated that the complication rate for intimate piercings in general — both the nipples and genitals — may be as high as 10-15 percent. Yet in many cases, physicians are not sought out in the event of a complication. Instead, piercers, the Internet, friends and “common sense” are consulted, usually due to doubts concerning the physician’s clinical knowledge, a desire to leave the piercing in and a fear of being criticized.
SUBINCISIONS Subincision of the penis is a urethotomy, in which the ventral surface of the penis is incised and the urethra is split open lengthwise along the raphe of the penis. Subincisions vary in size and can extend from the external urethral orifice of the glans penis to the scrotum. The practice of subincision has been documented in Aboriginals throughout Australia and is still practiced today in more remote aboriginal communities. Ceremonies are often performed under a shroud of secrecy and seclusion, and outsiders are almost exclusively never permitted. Consequently, subincision procedures are currently performed without anesthetic, under unsterile conditions and by using rudimentary surgical tools, such as razor blades or shards of glass, that pose a significant health risk. CO N T I N U E D O N P G 10 ▼
F E AT U R E
CASE STUDIES
“FOR YOU” A middle-aged male patient consulted to my service due to a penile lesion to rule out cancer. In effect, he clearly had the lesion, but also a tattooed message for all! In the glans??!! WOW! His lesion was managed with an excisional biopsy conservatively so as not to damage his art. He was an inmate at the time of biopsy and never came back. Diagnosis was negative for carcinoma; the pathologist called the lesion a giant verrucae. William Roman-Torreguitart, MD, FACS Mayaguez, Puerto Rico
AN IRISHMAN IN THE OUTBACK
THE SWORD IN THE STONE: EXCALIBUR
An incontinent, moderately demented 93-year-old Irish missionary was referred from his nursing home for a catheter insertion to assist with long-term bladder management; a uridome was not suitable, as he was uncircumcised and had a wide urethral meatus. Upon close inspection of the glans penis, a subincision was noted on the ventral aspect of the glans penis, measuring 1.5 cm wide and extended 2-3 cm long.
The patient was a 22-year-old male who presented to the emergency room (ER) on New Year’s Eve with a history of intermittent hematuria. On physical exam, the ER physician noted a “rock-hard prostate.” The urologic consultant obtained additional history from the patient, who reluctantly told him that he had been drinking heavily at a New Year’s Eve party one year previous, and “an angry ex-girlfriend put a thermometer in my penis while I was passed out.” On repeat rectal exam, the urologist determined that the hard object was above the patient’s small prostate, probably within the bladder. KUB showed a thermometer and a large stone in the lower pelvis. The patient was prepped and taken to the operating room, where cystoscopy confirmed the diagnosis. The thermometer, encased in a large stone, was removed through a suprapubic incision.
The patient had worked for more than 30 years as a missionary with aboriginal communities in central Australia and described how he acquired the subincision during a riteof-passage ceremony approximately 60 years ago. He was held down on the backs of aboriginal men while another aboriginal elder used a flint stone to make the incision. The patient said these ceremonies were only performed on scorching hot days so the blistering sand and dirt could be used to tamponade the wound. He described how the blood from the wound was shared among the aboriginals, who ingested and spread the blood onto their bodies during the subincision ceremony.
Henry E. Parfitt, MD Fayetteville, North Carolina
Sanjeev Bandi, MD, and Brent Gilbert, MD Queensland, Australia
G LO B A L CO N N EC T I O N S • VO L U M E 9
F E AT U R E
▼ CO N T I N U E D F R O M P G 9
SEXUAL PRACTICES Because of the nature of their specialty, urologists can hardly escape the complicated physiological, psychological, societal, cultural and religious implications and inhibitions that affect sex and sexuality at any particular time or in any particular space. But even urologists can be surprised, and perhaps even confounded, by some sexual practices that present in their offices and in literature. One such practice is sounding.
RESOURCES 1. Mattelaer, Johan J.: From Ornamentation to Mutilation: Genital Decorations and Cultural Operations in the Male. Kortrijk, Belgium: Historical Committee European Association of Urology, 2004 2. BME: Mod Blog. Ampallangs and Apadravyas. Web. July 2014 3. Nelius, Thomas et al.: Genital Piercings: Diagnostic and Therapeutic Implications for Urologists. Urol, 78: 998, 2011 4. Nelius, Thomas et al.: Genital Piercings: Diagnostic and Therapeutic Implications for Urologists. Urol, 78: 998, 2011
SOUNDING
5. Caliendo, Carol et al.: Self-Reported Characteristics of Women and Men with Intimate Body Piercings. J Adv Nurs, 49:474, 2004
It is not unusual for a urologist — cystoscope in hand — to be confronted with a foreign body that has been inserted into the urethra and, sometimes, lost inside the bladder! In some cases, symptoms may not present for years; and in others, the damage can be quick and severe, leading to urethritis, hematuria, urinary tract infection, acute cystitis and urinary retention. An entire arsenal of treatment options, medical expertise and creativity are needed to remove the foreign bodies — which have been known to range from pens and pencils to knotted wire, paraffin crayons and live animals. But what compels a person to intentionally insert foreign bodies into the genitourinary tract?
6. Edlin, Rachel et al.: Squamous Cell Carcinoma at the Site of a Prince Albert’s Piercing. J Sex Med, 7:2280, 2010
The motivations behind insertion are many and just as variable as the foreign bodies themselves. Chewing gum and candle grease are commonly inserted into the male urethra as a means of contraception. Mental illness has also been implicated in foreign body insertion; in some patients, particularly prisoners and mental patients, self-insertion has been used to garner attention. In children, the insertion of foreign bodies is usually associated with curiosity, but as the Internet has become more accessible to younger individuals, imitation of adult behaviors has also played a role. Yet the most common reason for self-insertion is erotic in nature — allowing for urethral stimulation during masturbatory practices — and thus, the practice often develops into a life-long habit.
To learn more on the information or case studies found in this article, please visit http://www.urologichistory.museum/content/ exhibits/current-exhibit/. If you would like to receive a brochure, email tstevens@auanet.org with your name and mailing address.
VO L U M E 9 • G LO B A L CO N N EC T I O N S
7. Armstrong, Myrna et al.: Genital Piercings: What is Known and What People with Genital Piercings Tell Us. Urol Nurs, 26:173, 2006 8. Caliendo, Carol et al.: Self-Reported Characteristics of Women and Men with Intimate Body Piercings. J Adv Nurs, 49:474, 2004 9. Nelius, Thomas et al.: Genital Piercings: Diagnostic and Therapeutic Implications for Urologists. Urol, 78: 998, 2011 10. Dakin, Wirt: Urological Oddities. Los Angeles, California: Wirt Bradley Dakin, 1948 11. Ophoven, Arndt van & deKernion, Jean: Clinical Management of Foreign Bodies of the Genitourinary Tract, J Urol, 164:274, 2000 12. Ceran, Canan & Uguralp, Sema: Case Report: Self-Inflicted Urethrovesical Foreign Bodies in Children, Case Rep Urol, 1:1, 2012 13. Ophoven, Arndt van & deKernion, Jean: Clinical Management of Foreign Bodies of the Genitourinary Tract, J Urol, 164:274, 2000 14. Sinopidis, Xenophon et al.: Case Report: Internet Impact on the Insertion of Genitourinary Tract Foreign Bodies in Childhood, Case Rep Pediatr, 1:1, 2012 15. Kenney, Richard: Adolescent Males Who Insert Genitourinary Foreign Bodies: Is Psychiatric Referral Required? Urol, 32:127, 1988 16. Rinard, Katherine et al.: Cross-Sectional Study Examining Four Types of Male Penile and Urethral “Play,” Urol, 76:1326, 2010
CO L L A B O R AT I O N S
CONNECTING THE WORLD OF UROLOGY: AUA AND SBU PARTNERSHIP BY LORI AGBONKHESE
AUA’s collaborations continue to increase around the world and we would like to thank all of our international colleagues and partners for their friendship and collaboration to increase AUA education around the globe. As a globally-engaged organization with more than 21,000 members, one-quarter of whom practice in over 100 countries, the American Urological Association (AUA) represents the world’s largest collection of expertise and insight into the treatment of urologic disease. The AUA has always recognized the value of collaboration and interchange of urological skills, experience, and knowledge and since its inception in 1902, AUA has worked to advance urologic education and the highest standards of urologic care through exceptional educational offerings, publications, research, policy, and philanthropy. The AUA values opportunities to collaborate with the global urologic community and believes that this type of exchange is critical to the continued success of urology worldwide. One country where the AUA has seen dramatic growth is Brazil and this is due in large part to the close bond of friendship and partnership that has developed between the AUA and Sociedade Brasileira de Urologia (SBU) and the efforts of Host Country Liaison, Dr. Fernando J.W. Kim. Founded in 1926, the SBU has realized more than 80 years of evolution and technological advancement with its biennial meeting attracting more than 4,000 professionals from across Brazil and South America. While the AUA has always had a connection to Brazil and other national urological societies in South America, formal collaborations between the two organizations began nearly a decade ago and have evolved into lifetime friendships being forged. In fact, when asked to identify an accomplishment during his term as AUA Secretary that he was most proud of Dr. Gopal Badlani responded, “friendship with so many leaders from countries in South and Central America and the individual bonds that I developed with the Brazilians and the incredible surge in membership from Brazil.” Urologist and former president of Brazil, Dr. Juscelino Kubitschek, said “Quanto mais me dedicava à medicina, mais ela me apaixonava” [The more I dedicated myself to medicine, the more I fell in love.]
Top: Dr. Gopal Badlani shows off his Brazil jersey to SBU Past President, Dr. Aguinaldo Nardi. Bottom: SBU and AUA faculty/leadership celebrate the inaugural AUA Highlights program in Brazil.
CO N T I N U E D O N P G 12 ▼
G LO B A L CO N N EC T I O N S • VO L U M E 9
CO L L A B O R AT I O N S
This is also true of AUA’s activities in Brazil. The more times one visits Brazil, the more they fall in love with the culture and people of Brazil. Having one of the largest countries in South America as a key AUA partner has meant increased cooperation, exchange of residents, young urologists and faculty and these efforts will help identify the future leaders of both organizations to ensure the SBU-AUA relationship continues long into the future. Increased Brazilian membership has also resulted in an expanded presence at the AUA Annual meeting. The Brazilian/ Portuguese Urology Program began as a kick-off to the AUA/SBU partnership under the aegis of Drs. Robert Flanigan and Fernando Kim and will celebrate its 7th anniversary at AUA2016. AUA2015 also featured a hands-on training course on the use of Greenlight lasers and was presented in Portuguese in New Orleans. Dr. Archimedes Nardozza, SBU President-Elect, feels that the AUA Annual Meeting is so attractive to Brazilian urologists because it provides opportunities to get updated on the latest advancements in urology, learn new techniques and become acquainted with new technologies, network with the colleagues from around the world, and offers the chance to have fun discovering different cities within the United States. For Brazilian urologists unable to attend the AUA Annual Meeting in person, AUA and SBU partnered together to bring highlights from the meeting to Brazil. The Highlights of AUA program in Brazil will celebrate its 5th anniversary in 2016 and Dr. Nardozza commented, “I intend to maintain this program during my term [as SBU President] and I believe that it is one of the most important educational programs that we participate in together.”
Top: Dr. Fernando Kim, AUA Host Country Liaison, (right) discusses the value of AUA membership in Sao Paulo. Middle: Dr. Carlos Corradi, SBU President (center) enjoys dinner in Sao Paulo with AUA Exchange Scholars, Drs. Patrick Springhart (left) and Brian McNeil (right). Bottom: AUA and SBU leadership meet in New Orleans during AUA2015 to expand collaborations.
VO L U M E 9 • G LO B A L CO N N EC T I O N S
CO L L A B O R AT I O N S
The SBU has been hard at work planning for its upcoming meeting in Rio de Janeiro. Attendees can expect to see new techniques in prostate surgery using robotic assistance as well as a half-day SBU/AUA Joint Symposium. Dr. Badlani commented “The SBU meeting is by far the most exciting meeting if you are at the AUA exhibit booth at the SBU, as the traffic is non-stop. The Scientific meeting has improved with each visit and I was happy to see so many US urologists participating at the last SBU meeting.” So where does the SBU and AUA partnership go from here? Dr. Nardozza would like to see increased collaborations with resident education programs and academic exchanges while maintaining the AUA Highlights program and SBU/AUA Joint Symposium. Dr. Badlani commented “We can only build on the foundation that is so strong and a program for resident education was one thing I could not accomplish in my term that I would like to see happen.” Both SBU and AUA are committed to resident education. Existing educational collaborations for young urologists and residents will continue and both AUA and SBU are exploring ways in which to increase collaborations in this area. Arrangements are being finalized for the inaugural Lessons in Urology course for senior residents to be held in Brazil in 2016. It is clear that the future of the SBU and Urology in Brazil is very bright. Dr. Nardozza reported that some of the changes for Brazilian urology on the horizon will be the increasing number of robotic centers in Brazil and he feels that this will change the way Brazilians perform surgeries, such as prostate surgery.
For more information on AUA’s International Programs or to find a program near you, please email us at international@AUAnet.org or visit at www.AUAnet.org/ International. Top: Drs. Carlos Corradi, SBU President, (right) and Archimedes Nardozza, SBU President-Elect (left) sign the AUA-SBU Memorandum of Understanding to hold the 2015 Highlights of AUA program. Middle: Urology residents from the same training center in Brazil all become AUA members together. Bottom: Dr. Davi Voller Seishum Abe from Sao Paulo participated in the AUA/SBU Academic Exchange Programs and observed at Cleveland Clinic.
G LO B A L CO N N EC T I O N S • VO L U M E 9
F E AT U R E
Focal Therapy for Localized Prostate Cancer
Authors: Scott Eggener, MD, Associate Professor of Surgery; Co-Director, Prostate Cancer Program; Director, Translational and Outcomes Research, Section of Urology, The University of Chicago and Taylor Titus, Social Media Specialist, AUA.
VO L U M E 9 • G LO B A L CO N N EC T I O N S
F E AT U R E
Worldwide, prostate cancer (PCa) is the second most common non-cutaneous malignancy in men, with an estimated 1.1 million men diagnosed in 2012. According to the American Cancer Society, it is the sixth leading cause of death in men worldwide. Over the last few years, controversy regarding prostate-specific antigen (PSA) screening, as well as the known potential side effects of treatment, have served to emphasize concerns regarding over-detection and consequent overtreatment of patients who are categorized as having low-risk PCa. Today’s standard management options for men with PCa include active surveillance, surgery and radiation. The rationale of active surveillance for low-risk, low-stage prostate cancer is sound; however, under-treatment is an inherent risk. According to Dr. J. Kellogg Parsons, associate professor of surgery at the UC San Diego Moores Cancer Center, “about 15 to 20 percent of newly diagnosed men meet the strict criteria for active surveillance .” It is also recognized, however, those who are thought to be ideal candidates for active surveillance may later be recommended for further treatment once additional information is obtained. Surgery, including radical prostatectomy, is also effective; however, whole gland therapy approaches carry risks of postoperative complications, such as sexual, urinary or bowel dysfunction. Advances in imaging and successful completion of large randomized clinical trials have established paradigms that optimize treatment effectiveness while minimizing treatmentrelated morbidity. For example, in women with breast cancer, lumpectomy has become a standard treatment option and is recommended in ~80% of women with newly diagnosed breast cancer. This option, which treats just the area of cancer while leaving healthy tissue in place, has enabled physicians to successfully integrate patient quality of life without loss of treatment efficacy. Could this focal approach be better suited than a whole gland approach for certain men with prostate cancer?
WHAT IS FOCAL THERAPY? Men with localized prostate cancer face many of the same issues that women with breast cancer do, and in recent years the concept of subtotal therapy for the treatment of localized PCa has gained the attention of many urologists. Focal therapy is a generic term for a broad range of noninvasive treatments designed to identify and destroy localized malignant portions of the prostate, sparing noncancerous tissue and function in an CO N T I N U E D O N P G 16 ▼
G LO B A L CO N N EC T I O N S • VO L U M E 9
F E AT U R E
“THE NEW GOAL OF FUTURE INTERVENTION IN THE TREATMENT OF PROSTATE CANCER IS THE TRIFECTA CONCEPT, WHICH MEANS BEING CURED, CONTINENT AND POTENT” ▼ CO N T I N U E D F R O M P G 15
effort to preserve quality of life. It is an approach focal therapy pioneer, Hashim Ahmed, MD, PhD, senior lecturer at University College London in the United Kingdom, considers to have less morbidity compared to whole-gland therapy options, such as radical prostatectomy or radiation therapy. “Focal therapy is an image-guided prostate pathway for treating patients based on knowing exactly where the tumor is,” said Dr. Ahmed. “Having that degree of preciseness, which was missing up to this point, allows one to accurately target, then treat the section of the prostate gland containing the cancer rather than removing the whole prostate.” This enables men to retain a good quality of life while simultaneously aiming to eradicate meaningful areas of cancer. While focal therapy has a precedent in other cancers, including breast, kidney and bladder, its use in prostate cancer continues to be debated. In the United States, some experts refer to focal therapy as a “questionable scientific paradigm,” while to others it is an approach worthy of evaluation for treating prostate cancer. Since the introduction of focal therapy as a treatment for localized PCa, no uniform, systematic design of studies to evaluate pre- and post-treatment has been developed. This has evolved into uncertainties surrounding the ablative technologies being used to deliver focal therapy, as there is scant evidence showing long-term benefit and no data comparing specific modalities. Several of the technologies are currently undergoing clinical trials to determine their efficacy, safety and long-term benefits as each may have its own set of benefits, limitations and unknowns.
VO L U M E 9 • G LO B A L CO N N EC T I O N S
Although focal therapy is still in its trial stages throughout the world, many urologists believe it holds promise for the treatment of localized PCa and preserving quality of life. Potential advantages identified by urologists include the eradication of all “known” cancer; reduction in the anxiety of living with an untreated cancer (compared to active surveillance); reduction in the risk of over-treating indolent cancers; can be repeated; does not prevent subsequent radical prostatectomy or radiation therapy; lowers risk and severity of side effects, such as incontinence and erectile dysfunction; and is typically performed with minimal anesthesia on an outpatient basis or single overnight hospital stay. Many physicians, including Dr. Luigi Mearini from the Department of Urology at the University of Perugia; Ospedale Santa Maria della Misericordia, Italy; and Dr. Massimo Porena from the Department of Medical-Surgical Specialties and Public Health at the University of Perugia in Italy, believe focal therapy is a successful way to approach clinically localized prostate cancer. “The new goal of future intervention in the treatment of prostate cancer is the Trifecta concept, which means being cured, continent and potent,” Dr. Mearini stated. “This is the mainstay of minimally invasive therapy such as focal ablation,” Dr. Porena added. However, others believe it is a good idea in theory, but have some precautions regarding the approach. The Trifecta concept is very old and refers to all forms of prostate cancer treatment. “The idea that treating the index lesion is equal to treating the whole gland still needs to be scientifically proven.” Giannarini et al., JCO 32:1299-1301, 2014.
F E AT U R E
APPROACHES TO FOCAL THERAPY
WHAT’S ON THE HORIZON
Several focal therapy methods using different ablative mechanisms such as cryotherapy, microwave, laser and high intensity focused ultrasound (HIFU) have been investigated (cryo and HIFU have been used for >20 yrs). Cryotherapy is the destruction of cells by freezing using transrectal ultrasoundguided needles placed through a transperineal approach. Early results with cryotherapy and HIFU appear encouraging and long-term HIFU studies from Europe are available. HIFU deposits large amounts of energy into the prostate tissue, causing the destruction of cells by coagulative necrosis. US-guided HIFU, MR-guided HIFU and photodynamic therapy are used mainly in Canada, Europe, Mexico and a few other countries, but HIFU techniques have not been approved by the U.S. Food and Drug Administration for use in the United States. According to the Urological Society of Australia and New Zealand position statement on focal therapy, it concludes ‘focal therapy cannot be considered standard of care’ due to the lack of robust clinical data to supports its use and therefore ‘remains an experimental technique.’
“I think we’re going to see more and more interest in focal therapy over the next five years,” said Dr. Peter Scardino, Chairman of Surgery at Memorial Sloan Kettering. “Today we have imaging techniques, like MRI, that can really see the cancer much better than we ever have in the past and identify patients who are really candidates for focal ablations, but new therapies, designed specifically for the task of focal therapy for men with localized prostate cancer, are still waiting to be unveiled.” “Increasingly, we know that low-risk, low-volume prostate cancers may not behave like cancer at all, and if some lesions can be classified as low risk, they should be left untreated,” said Dr. Ahmed. “The minute you accept that, the potential for focal therapy becomes very real.”
“Currently in Japan, three potential focal therapy modalities exist for prostate cancer: focal HIFU therapy, focal brachytherapy and focal cryotherapy,” according to Dr. Shigeo Horie, Professor and Chairman, Department of Urology at Juntendo University, Graduate School of Medicine. “The success of focal therapy depends on the accurate localization and targeting of the tumor loci. TRUS-MRI fusion biopsy using mpMRI, was now introduced in Japan. However cancer foci which are detected by MRI tend to have higher Gleason scores, whereas HIFU may not be sufficient for treating high-grade prostate cancer. Therefore, we need to have a novel modality for treating higher-grade prostate cancer in the future.”
G LO B A L CO N N EC T I O N S • VO L U M E 9
BY T H E N U M B E R S
THROUGH THE LOOKING GLASS: A NEW PERSPECTIVE ON AUA’S MEMBERSHIP AROUND THE WORLD
TOP 5 COUNTRIES BY MEMBER COUNT (outside of the U.S.) Brazil
922
Canada*
693
Japan
570
Mexico*
565
India
415
* Those members in Canada and Mexico are considered domestic members residing outside of the U.S.
Over the past five years, the American Urological Association (AUA) has seen a robust rise in membership among urologists and residents outside of the United States (U.S.). With more than 21,000 members worldwide, one-quarter of whom practice in over 100 countries, there is no doubt that this growth is due to the relationship the AUA has built with our international colleagues by:
• Collaborating on educational programs and initiatives outside of the U.S., • Attending international meetings and exhibits, and • Developing streamlined processes to help those interested in becoming an AUA member through our partner societies.
VO L U M E 9 • G LO B A L CO N N EC T I O N S
INTERNATIONAL MEMBER COMMITTEE (IMC)
18 % 77
c ountries represented on the AUA’s International Member Committee (IMC), each with 75 or more AUA members. growth in total IMC country membership since 2010.
BY T H E N U M B E R S
GROWTH BY REGION OVER THE PAST 5 YEARS 183%
Africa 96%
South America 71%
North America
66%
Asia Australia Europe
31% 25%
TOP 3 HIGHLY RATED MEMBER BENEFITS FOR INTERNATIONAL MEMBERS (according to the 2014 AUA Member Satisfaction Survey)
1 2 3
AUA Annual Meeting (San Diego in 2016) Clinical Guidelines and Best Practice Statements (online) The Journal of Urology (online)
NEWEST MEMBERSHIP GROWTH (2013 – 2015) Brazil
671 – 922
Egypt Colombia Korea
There is value in belonging to the AUA! If you are interested in joining the growing number of AUA members around the world, visit AUAnet.org/Join.
Bangladesh Italy
149 – 353 87 – 219 142 – 247 0 – 102 137 – 234
G LO B A L CO N N EC T I O N S • VO L U M E 9
A SINCERE
Thank You
TO OUR INTERNATIONAL PRESIDENT’S CIRCLE PATRONS
™
an endo international company
MEDICAL