AUA 2015: PSA paper, tough live surgery are lasting memories

Dr. RosevearOn my flight home from this year’s AUA, I decided to write down a few valuable lessons I took away from my time in New Orleans.

Read: Complications bring out urologists’ ‘human’ feelings

A couple notes about the host city: First, it’s New OR-lins, not New or-LEANS. (It took me nearly 40 years to figure that one out.) Second, when a waitress asks if you “want that to go,” she may not be talking about what’s on your plate. Apparently, walking down the street with an open container is legal. (There is even a phrase, “geaux cups,” to describe the small plastic cups they use for this purpose.)

More seriously, to the AUA staff, well done. The 2015 AUA annual meeting was an incredible opportunity not only to listen to the true thought leaders describe the state of our field, but also to hear and even watch some of the up-and-coming stars show us where the field is heading. In that respect, I thought the new "Second Opinion Cases" plenary session was particularly useful.

While numerous abstracts caught my eye, three in particular seemed to resonate. First, some self-validation was provided by Dr. Werntz et al in abstract PD44-02. This paper confirmed a trend that I had suspected and discussed previously in this blog but wasn’t clever enough to prove. The authors showed a significant 50% decrease in the use of PSA testing by a group of primary care doctors after the U.S. Preventive Services Task Force recommendations were released in 2012.

This finding is terribly important for a few reasons. First, it is confirmation that we are entering a new era (returning to a previous one?) when prostate cancer patients will walk into your office not simply with an elevated PSA but with symptoms. Second, since I, as a small-town plumber, am unable to change the government’s opinion on the importance of detecting early-stage prostate cancer, this abstract stresses how important it is for urologists to educate the primary care physician community that if you’re not going to check PSA, advanced prostate cancer now needs to be included in your differential for all patients who present with either obstructive voiding symptoms or back pain.

The next two abstracts I found interesting immediately changed the way I practice medicine.

NEXT: Robotic vs. open RP, predicting recurrence after urethoplasty

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In abstract PII-LBA5, Dr. O’Neil and colleagues used population data to show better sexual function scores after robotic versus open prostatectomy. This is important because in residency, I was taught that the only clinically proven difference in outcomes between a robotic and an open prostatectomy was blood loss, but since leaving residency, I have learned that isn’t quite the case. In counseling patients before this AUA meeting, I would state that, even in hands like mine, which are by no means the most experienced, patients can expect to have a significantly decreased risk of bladder neck contracture with robotic prostatectomy versus the open procedure (Prostate Int 2014; 2:12-18). Now, after reading Dr. O’Neil’s abstract and doing a quick PubMed search, I am confident in saying that robotic surgery has a better chance of preserving potency too! (As an aside, I invite anyone who thinks they have the most experienced set of hands to read this presentation by Dr. Patel, who has done more than 7,000 robotic RP cases.)

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The second practice-changing abstract for me was PD14-06, from a group led by Dr. Erickson, one of my mentors from residency. Monitoring for recurrences after urethroplasty is challenging, as good techniques short of a cystoscopy are lacking. While that technique certainly works, it is invasive and expensive for the patient. On the other hand, I am not comfortable with simply waiting for failures to present, because quite honestly, I would much rather identify a recurrence in my office and not at 2 AM in the emergency room. Dr. Erickson found that by combining some noninvasively obtained data from a preoperative survey and uroflow and comparing that to postoperative data, he could accurately predict recurrences. Assuming this technique withstands further investigation, Dr. Erickson just made a lot of patients very happy.

NEXT: "Exceptionally valuable" live surgery

The last session I wanted to highlight was one of the live surgeries I watched, a robotic partial nephrectomy by Dr. Eun from Temple University. A brief disclaimer: First, the mass Dr. Eun was attempting to resect was not easy, and in my hands, that case was a laparoscopic nephrectomy from the start. Second, Dr. Eun is good; I’ve seen his videos and read his papers, and he is one of the few surgeons I know who actually had a good chance of succeeding, so in no manner do I mean any disrespect.

In summary, Dr. Eun was presenting his technique for a robotic partial nephrectomy for a large renal mass. I don’t remember the exact size of the mass, but it had to have a RENAL score of 9 or 10 at least. What I loved most about this case was that it didn’t go as planned. During the dissection of the mass, while on clamp, he encountered what he though might be tumor in the collecting system (Dr. Abaza from The Ohio State University was in the audience and suggested it might be tumor thrombus in the vein).

Regardless, the audience was able to watch him make a very tough intra-operative decision: continue with the case or simply remove the kidney. And to his credit, he removed the kidney in order to maximize oncologic principles. For those of us who are still new at this job, who haven’t experienced that decision point often, being able to watch as he talked his way though his decision was exceptionally valuable, and I applaud Dr. Eun for the case he presented. I would like to see his renorrhaphy technique live, so maybe the AUA could invite him back again next year for a repeat case.

While this blog certainly isn’t meant to summarize all of the incredible material presented at the 2015 AUA, I believe that the abstracts and presentations I’ve highlighted stood out from the crowd and changed the way I practice urology. I hope to see everyone at next year’s conference in San Diego.

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