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Clinical Focus

Robert Dreicer, MD, MS, MACP, FASCO; Neal Shore, MD, FACS; Michael Morris, MD; Alicia K. Morgans, MD, MPH

Medical Crossfire®: How Will Emerging Data Inform Treatment Planning for Patients With Prostate Cancer in the Community?

Howard I. Scher, MD; Scott T. Tagawa, MD, MS, FACP; Mary-Ellen Taplin, MD

Medical Crossfire®: How Does Recent Evidence on PARP Inhibitors and Combinations Inform Treatment Planning for Prostate Cancer Now and In the Future?

Jason Hafron, MD; Aaron D. Berger, MD; Arpeet Shah, MD

Medical Crossfire® in Adjunctive Testing: Charting a New Course in Prostate Cancer Risk Assessment

® Assistant Editor Janelle Hart spoke with 

. She discusses why the misconceptions of sexually transmitted diseases and infections are hindering patients from seeking appropriate care, and how urologists can help to rid of these misconceptions. Winter is a urologist at Kaiser Permanente in Portland, Oregon.

“We need to just approach STIs as the medical conditions they are because until we do, and until we take those stigmas away, people will truly have resistance to discussing it, hesitance to discussing it, and resistance to diagnosis and intervention,” says Ashley Winter, MD.

Destigmatizing Urology: Dr. Winter discusses STDs/STIs

 He discusses the common misconceptions associated with interstitial cystitis, specifically from the mindset of the patient. Furthermore, he gives an overview of the MAPP study, which has helped to destigmatize the condition in major ways. Clemens is an Edward J. McGuire professor of urology, an associate chair for research, and fellowship director of female pelvic medicine and reconstructive surgery at the University of Michigan in Ann Arbor.

“I think people can feel like they're all alone, or they have something that's uncommon, and it may not be,” says J. Quentin Clemens, MD, FACS, MSCI.

Destigmatizing Urology: Dr. Clemens discusses interstitial cystitis

article, Treatment of urethral stricture disease in women: A multi‐institutional collaborative project from the SUFU research network, for which she served as a study author. Lane is a fellow in female pelvic medicine and reconstructive surgery at the University of Michigan, Ann Arbor.

On the latest episode of the Speaking of Urology podcast, Dr. Giulia Lane discusses her recent study evaluating treatment of urethral stricture disease in women.

Dr. Giulia Lane discusses urethral stricture disease in women

"Teixobactin, and more broadly, the iChip approach to novel antibiotic discovery, is an exciting development in infection control," write Philip Abbosh, MD, PhD, and Kate Gessner, MD, PhD.

Novel antibiotic discovery tool holds promise to uncover more natural compounds

"The objective of this study was to assess baseline knowledge about urinary tract infections, interest in health resources, and platform preferences for health information acquisition and dissemination," says Stephanie Gleicher, MD.

Study examines patient knowledge of urinary tract infections

"This study reinforces our role as physicians to guide patients away from costly supplements with little or no benefit," said Wai Lee, MD. 

D-mannose found to be ineffective for prevention of recurrent UTI 

"What we believe is happening is women are seeking the help of female urologists, and therefore, because of the nature of the condition, the female urologists are absorbing the burden of the care of these patients, particularly the non-billable burden," says Debra L. Fromer, MD. 

Burden of care for recurrent UTI is higher for female urologists

Glenn T. Werneburg, MD, PhD, discusses 2 abstracts from the 2024 SUFU Winter Meeting.

Dr. Werneburg discusses research evaluating machine learning algorithms’ potential

Dr Moro discusses “Cranberry Juice, Cranberry Tablets, or Liquid Therapies for Urinary Tract Infection: A Systematic Review and Network Meta-analysis.” 

Dr. Christian Moro on education regarding UTI prevention

Christian Moro, PhD, BSc, BEd, MBus, SFHEA,

 paper, “Cranberry Juice, Cranberry Tablets, or Liquid Therapies for Urinary Tract Infection: A Systematic Review and Network Meta-analysis.” Moro is associate dean of External Engagement and an associate professor of Biomedical Sciences and Medicine within the Faculty of Health Sciences and Medicine at Bond University, Gold Coast, Australia.

What is the take-home message for the practicing urologist?

The idea, I guess, is to try and...educate patients as well that their lifestyle...can very much influence UTIs. There's a lot of stress and anxiety about UTIs. People are concerned about them. They change their underwear choice. They don't swim in dirty water. So people are aware of it, and there is a bit of that anxiety around it, which is a concern to a lot of people. However, the benefit is just to keep educating. If they don't like cranberry juice, increase fluids, perhaps recommend certain things. There are things [such as] dietary interventions that we can do that do seem to have some benefits, and part of that is getting that education out there, and the more that we can educate in ways to look after ourselves and at the very least avoid chronic dehydration, things that were already recommended anyway. It's one of those things that the aim here is to try and avoid the infections and then avoid that reliance upon antibiotics if we can, in an area where there's so much microbial resistance. It's growing and enlarging in what these bugs are resistant to every year.

Scientifically, it makes a bit of sense. There are some chemicals that do influence bacteria adhesion to the wall, so it's something that there does seem to be an effective basis, or at least a theoretical basis behind cranberry. But once again, the fact that the promising thing there, that even increased fluids, it wasn't as effective. But increased fluids did help as well. So just keep people hydrated, keep them making sure they're looking after themselves. We are finding more and more information and evidence to support recommendations to try and reduce the infection rates, but then also the impact of these sorts of infections.

Videos

“We are finding more and more information and evidence to support recommendations to try and reduce the infection rates,” says Christian Moro, PhD, BSc, BEd, MBus, SFHEA.

Dr. Moro on “Cranberry Juice, Cranberry Tablets, or Liquid Therapies for Urinary Tract Infection: A Systematic Review and Network Meta-analysis.” 

Investigator discusses need for further research on cranberry products and UTI

What are the next steps for this research?

There are a couple of things that were brought up. A lot of studies were done in a way that weren't randomized. It's one of the problems whenever you look back into systematic reviews, you often find, "I wish we'd done more studies that were consistent." But the 2 things were lacking effective controls. The follow-up times were also a bit variable. There's no answer, how long do you follow up?…And then also funding. A number of studies were funded by companies with conflicts of interest or authors [had] conflict of interest. So still, as often is the case, there's that real need for independent, randomized control studies to really find this out. We think it's worth doing because although it's been done in a way that it would be a benefit in any of these non-drug interventions and looking at clear studies to try and assess what's happening. That was something that didn't surprise us. Mind you, there were a number of them that weren't funded. We sometimes look at areas where every study is funded by someone in the group. We had a medium confidence for most of the findings in regards to are they reliable or not, with some of verging them upon the low due to funding.

This transcription was edited for clarity.

"A lot of studies were done in a way that weren't randomized," says Christian Moro, PhD, BSc, BEd, MBus, SFHEA.

Dr. Flores-Mireles on “Initial Antimicrobial Testing of a Novel Reusable Intermittent Urinary Catheter System and Catheter Reprocessing Device.” 

Dr. Flores-Mireles outlines advantages of a catheter reprocessing device

 discusses the reusable intermittent urinary catheter system and reprocessing device evaluated in the 

study “Initial Antimicrobial Testing of a Novel Reusable Intermittent Urinary Catheter System and Catheter Reprocessing Device.” Flores-Mireles is the Janet C. and Jeffrey A. Hawk Collegiate Associate Professor in the Department of Biological Sciences at University of Notre Dame in Notre Dame, Indiana.

Can you elaborate on the long-term implications of this technology? Are there any potential drawbacks or limitations to consider?

One of the major issues that we have in this right now is that there is a lack of standardization. We have single-use catheters only; again, there is a lack of standardization; how to tell the user how to clean this to actually avoid a contamination and a possible UTI. The other thing is affordability. Patients cannot buy single-use catheters or just use them 1 time, because it's really costly and also, it's ecologically bad, because you're producing so much waste. There are so many catheters that are single use; people use them and then they go directly to the trash. So we see with this technology that we're bypassing all these issues.

What are the good things? We're actually standardizing how to clean the catheter, because the system tells you exactly [how]: just put it here, let it run, and then it's clean. All the solutions that we use have been cleared by FDA, so they are safe to be used. Not only this, but some intermittent catheters have no-touch features, so they reduce the contamination. But those are 4 times the price as a normal intermittent catheter would be. I'm a scientist; I'm not involved with the company. I just collaborate with them. I just did my job to test something to make sure that this was safe and that we can remove the bacteria. The idea that they have is that the price of these catheters will be similar to the standard catheters that you have outside. So we actually don't see any drawbacks, because the fact that they have been able to optimize the material to make sure that that is able to survive all the washes that we did, that we're able to remove the pathogens—if you go back to the paper, we tested every single part of the catheter to make sure that we didn't have any bacteria hiding in places. We checked everything to make sure that we don't have these hidden contaminations. And the fact that the company has been working with the FDA to get a clearance, having this oversight increases the value of the device. So to be honest, I don't see any drawbacks, because the company has been working with the FDA to have all the compliance to make sure they are safe, and in my case, as a scientist, my job was to disprove their hypothesis. I was not disproving anything with this catheter. These catheters were clean after the processing. We tested them 100 times. They survived. So far, in my point of view, with the study that we did, there are no drawbacks, and the fact that they are communicating with the FDA just increases the value of the device.

"We're actually standardizing how to clean the catheter, because the system tells you exactly [how]," says Ana Lidia Flores-Mireles, PhD.

Dr Moro on “Cranberry Juice, Cranberry Tablets, or Liquid Therapies for Urinary Tract Infection: A Systematic Review and Network Meta-analysis.” 

Dr. Christian Moro on cranberry products and liquid therapies and UTI prevention

What were some of the notable findings? Were any of them surprising to you and your coauthors?

There's a range of studies doing something along these lines, and there were about 20 clinical trials that we could use. There were a lot of other studies that just weren't done as randomized, and some were just hypothetical or single-case studies. We ended up with 3091 participants overall, and 3 trends came out that were significant. The first was that people that had increased fluids, so just drinking more water, did have a reduced prevalence of UTIs. Now, people that were taking cranberry compounds, so just cranberry tablets or tablets that had cranberry compounds in them, also had slight benefits, but the best was mixing them together, so cranberry compounds and tablets with increased fluid or cranberry juice, and we found that was about a 54% lowered rate of UTI. The second, then, was reduction of antibiotic use. Cranberry juice and cranberry won't treat a UTI, but we're looking at, rather than treatments, does it reduce your reliance on antibiotics? Can it reduce the infection rates? We found that the cranberry juice lowered the necessity of using antibiotics by about 59%. Increased fluids was also helpful at about 25% but not as good as cranberry compounds with increased fluid. Cranberry compounds, by themselves, didn't have any effect on antibiotic use, so perhaps there's something in the increasing the fluid seems to be a big thing there, but then adding the cranberry compounds also helps. The last, then, was symptoms of UTI. Taking cranberry compounds in any form—liquid or tablet—reduces the symptoms of UTIs by 5 times. But once again, the symptoms of UTIs was the one where we sort of had the lowest confidence in the evidence, because there are different ways of collecting that data in different studies. But either way, there's definitely some sort of benefit there, at least trending toward that benefit in reducing the symptoms of UTIs.

"We ended up with 3091 participants overall, and 3 trends came out that were significant," says Christian Moro, PhD, BSc, BEd, MBus, SFHEA.

Dr. Moro on Cranberry Juice, Cranberry Tablets, or Liquid Therapies for Urinary Tract Infection: A Systematic Review and Network Meta-analysis

Network meta-analysis evaluates cranberry products, liquid therapies for UTI

Please describe the background for this study.

One of the things that's been identified is over 90% of the UTI presentations have found bugs that are antibiotic resistant, antimicrobial resistant. And so there's a real interest in trying to alleviate the requirement for antibiotics, and even then, trying to reduce and alleviate the incidence of UTIs would be ideally the way to solve this. With that concerning increasing rate of antibiotic resistance, we wanted to look at what's currently known? One of the things that has been suggested, and there's been a bit of research into it, is whether cranberry juice works to reduce UTIs. There's been some evidence showing that cranberry juice works. There's also evidence showing that fluid works. We know if you are dehydrated, it increases the risk of UTIs, and if you increase fluids, it does help to clear them out, and does have some benefits for UTIs. What hadn't been done, though, is putting the different groups together. So is it fluids, or is it increased fluids with cranberry? So to do that, we had to do a bit of statistical magic in a process called a network meta-analysis. A network meta-analysis is like a systematic review, but there are multiple groupings; rather than just compare between two, we're comparing between multiple groups. We looked at, for example, no treatment vs increased fluids and no treatments vs cranberry compounds, and then no treatments vs cranberry compounds and fluids, like in cranberry juice. And then we looked at those 3 comparators all against each other, and compared them. It was a different way to look at it, to say, look, is cranberry juice simply the same as what we see with increased fluids? So it was worth doing, and something interesting.

"One of the things that's been identified is over 90% of the UTI presentations have found bugs that are antibiotic resistant," says Christian Moro, PhD, BSc, BEd, MBus, SFHEA.

Dr Flores-Mireles on “Initial Antimicrobial Testing of a Novel Reusable Intermittent Urinary Catheter System and Catheter Reprocessing Device.” 

Expert describes development of reusable intermittent urinary catheter system

When I was assistant professor, the company contacted me, because I have produced many different papers that they were really interested in. [They wanted] to create a device that would be able to allow people to reuse catheters and minimize UTI incidence. Talking with them, we were able to apply for 2 grants...basically to develop devices, or in this case, [what we call a] reprocessor. Basically, we started talking with them [about] how can we better maximize a device or optimize a device that everybody can use [that] could be low cost. One of the issues that we have with intermittent catheters is that basically every single one, in the label, it says this is for single use, because the FDA [has not] approved any of these catheters to be reused. There is a lack of standardization protocols to guide the patient or the user on how to clean the catheters to reduce bacterial contaminations that at the end may lead to urinary tract infection. So talking with them, we had a really clear idea...[We were looking at] how we can better optimize the system for cleaning. One of the strengths in my lab is that we actually work with urine. We work with pathogens. They are highly pathogenic. They are really good at causing UTIs. And we grow them in a condition that will make them like that. So we brought everything in urine. The majority of the companies, when they are testing antimicrobials, they always put them in a happy medium. But the more we study these pathogens, we know that they can behave differently depending on the environment. When the environment is really stressed...they will develop this pathogenic system [that] allows them to survive...The way that we paired with the company was, they will bring their material development side. They have a lot of collaborations with other people, and we would test those catheters. The idea was to have a catheter that can go over 100 cycles of cleaning, so the patient can actually use the catheter 100 times without any worry. The most important thing is that we want to have a catheter that is a no-touch catheter, so that means that when the catheter [goes] inside, it won't have any external contamination. So we worked with them, and we had a really clear goal. The goal was to clean the catheter in the most efficient way with the [safest] detergents and minimize contamination or residual bacteria on the catheter. We tested it many times, we [worked on it for] 2 years. It was a lot of optimization based on material development. [If] the pressure was too high, we needed to reduce the pressure without affecting functionality, so that we're actually killing the pathogen. That was the concept that we started working with, and I think that we have a really good partnership. We work with these 2 catheters, when they were able to get funding for developing the material and for us to test whether this is possible or not.

"We had a really clear idea...[We were looking at] how we can better optimize the system for cleaning," says Ana Lidia Flores-Mireles, PhD.

Juan Fulla, MD, MSc, discusses an artificial intelligence-based chat system that can assist in the follow-up of patients with urological conditions

Dr. Fulla highlights an AI tool for patient follow-up for urologic conditions

, discusses an artificial intelligence (AI)-based chat system that can assist in the follow-up of patients with urologic conditions. Fulla is the chief of the robotic program and an associate professor of urology at the University of Chile in Santiago, Chile.

I would like to mention an innovative project I'm working on. It's called UroAssist; it's a platform that will integrate various urological conditions. Currently, it focuses only on kidney stones and also BPH. Our goal is to support patients throughout their entire journey with an intelligence chat system that not only evaluates them, but also answers many questions when their treating physician is not available, which is very common. This is very relevant, for example, in the post-operative follow-up, where many patients are unable to retain all the information given at a discharge. And often, they have numerous questions that could be easily addressed. This, we think, allows physicians to save time and of course, focus on more critical tasks. UroAssist serves as a follow-up tool, basically, by asking patients questions through questionnaires to monitor their progress very objectively, but also providing physicians with clear evidence of the patient's evolution over the time.

This transcription has been edited for clarity.

“Our goal is to support patients throughout their entire journey with an intelligence chat system that not only evaluates them, but also answers many questions when their treating physician is not available, which is very common,” says Juan Fulla, MD, MSc.

Dr. Briony Varda highlights key take-home points on the need for better diagnostic tools in UTI management

Dr. Varda on challenges in the diagnosis of urinary tract infection

, discusses the key take-home messages from the study, “Antibiotic Overtreatment of Presumed Urinary Tract Infection Among Children with Spina Bifida,” for which she served as the lead author. Varda is a pediatric urologist, the co-director of the spina bifida program, and the director of clinical research at Children’s National Hospital in Washington, DC.

What are the key take-home messages from this study?

The thing that was glaring to me is that patient symptoms should be the first and most important thing that we use to determine whether or not we treat our patients with spina bifida for a urinary tract infection. The testing just is not good enough yet to distinguish what's a true infection vs what represents chronic abacterial cystitis or bacterial colonization. So, my big take-home was to lean into symptoms. I think in terms of symptom elicitation, it's important to be systematic so that we don't shortchange certain populations when we try to figure out what their symptoms are.

Is there anything else that you’d like to add?

I think we're in dire need of a better diagnostic tool for urinary tract infections. We did a separate study using the same data and found that no matter what threshold of white blood cells you use for the urine, it was no better at predicting true UTI. So, I hope and know that many people are working in the lab to try to develop better tests. I would really just continue to encourage that. And then I would work with your institutional, emergency room, hospitalist, etc, antibiotic stewardship, to really ensure that this patient population isn't getting over treated and developing antibiotic resistance.

“I think in terms of symptom elicitation, it's important to be systematic so that we don't shortchange certain populations when we try to figure out what their symptoms are,” says Briony K. Varda, MD, MPH. 

Adity Dutta, MSN, AGACNP-BC, gives an overview of her clinical practice

Urologic nurse practitioner describes her clinical practice

 gives an overview of her clinical practice. Dutta is a nurse practitioner with Georgia Urology.

Please provide an overview of your clinical practice.

So, to start with, I can say that I do see a vast number of different types of patient populations, starting with the kidneys; for example, kidney stones, hydronephrosis. We do take care of post-operative management for urinary stent, lithotripsies, and then post-procedure management of those patients. Renal masses, renal cysts, how to manage complex cysts, how to track those people. Coming to the bladder, for example, UTIs, recurrent UTIs, overactive bladder, interstitial cystitis. I am proud to say that I have seen the largest number of patients with UTI in the Georgia Urology pod last year. I also do take care of [patients with BPH], elevated PSA, prostate cancer management post radiation treatment. [I also see patients with] erectile dysfunction, hypogonadism, any kind of scrotal or testicular issues going on—scrotal trauma, testicular mass or testicular growth type of situation.

"I can say that I do see a vast number of different types of patient populations," says Adity Dutta, MSN, AGACNP-BC.

Dr. Gleicher on “Assessment and Acquisition of Knowledge Regarding Urinary Tract infection among Adult Women in the United States.” 

Next steps for improving patient knowledge of urinary tract infections

 discusses the significance of the findings from the recent 

paper “Assessment and Acquisition of Knowledge Regarding Urinary Tract infection among Adult Women in the United States.” Gleicher is a urologist with Northwell Health in Garden City, New York.

The study showed a preference for health care professionals as a source of UTI information, but also identified a perception of complex medical language as a barrier. How do you see these findings informing future patient education strategies?

I think these findings are critical in helping us craft educational resources that would be easily understood and easily disseminated by trusted health care providers. The goal would be to design materials that are evidence based, but comprehensible. And so like I said, this is really just the start of further research that we need to do to better understand how to craft those materials and distribute on a large scale.

Could you discuss what kind of information or format you envision would be most helpful for patients with recurrent UTIs?

Based on the feedback we received, information should be easily delivered by their health care providers in a clear, concise manner. I think, again, further qualitative research with maybe a more well-rounded group of women would be very helpful for us. The interesting thing that we also captured in our data was that really, almost everyone has a smartphone. And so that really opens the door to interactive app-based resources. But again, because we were using data from a web-based survey, we don't know if that reflects the general population and accessibility to technology. So I think, overall, it would probably be some sort of combination of hard-copy materials that you can leave the doctor's office with, as well as maybe web-based materials that would optimize information dissemination.

What are some next steps you see for improving public understanding and preventing UTIs?

I think the next step would be, again, additional research to better fine tune what effective UTI information dissemination looks like to a more generalizable audience. I think, though, on a small scale, as a provider who treats a lot of patients who suffer from recurrent infections, it's really just my job to promote evidence-based information about UTI prevention and management within my practice and community.

"I think these findings are critical in helping us craft educational resources that would be easily understood and easily disseminated by trusted health care providers," says Stephanie Gleicher, MD, MPH. 

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