Practice Profile: Academic-based practice in functional and reconstructive urology

Urology Times’® Practice Profile series takes readers behind the scenes of US and Canadian-based urology practices. From solo practitioners to large groups, each installment highlights these practices’ unique qualities, successes, and challenges. To have your practice featured in this series, please email Hannah Clarke at hclarke@mjhlifesciences.com.

Jas Singh, MD, FRCSC

In this installment, Jas Singh, MD, FRCSC, highlights his practice in functional reconstructive urology at the Jewish General Hospital, which is a teaching-affiliate hospital of McGill University in Montreal, Canada.

Could you provide some background on yourself and your practice?

I was born and raised in Winnipeg, Canada. Following my bachelor of science degree in biochemistry at The University of Winnipeg, I attended medical school and completed my urology residency training at the University of Manitoba in Winnipeg. After I graduated in 2020 from residency, I went to Houston, Texas, where I did a 2-year clinical fellowship in urinary tract and pelvic reconstruction at The University of Texas MD Anderson Cancer Center under Dr. O. Lenaine Westney, Dr. Thomas G. Smith III, and Dr. William J. Graber. After I completed my fellowship training, I joined the urology faculty at McGill University in Montreal, Canada, where I started in September 2022. After completing my first year of practice, my focus has been on developing a broad spectrum functional and reconstructive urology practice, where I offer essentially all aspects of urological care that fall under that umbrella, also including neurourology.

Most of my work is done at the Jewish General Hospital, but I also conduct neurourology clinics at the Institut de réadaptation Gingras-Lindsay-de-Montréal, a rehabilitation hospital. In terms of my setup, I'm academic-based. So, I have both clinical work and conduct research. I’m also involved in teaching medical students, residents, and our fellow as part of our functional urology fellowship program.

What were some of the challenges that you faced in getting started, and how have you overcome those challenges?

Being in the second year of my practice, just the challenges that come with starting as a new attending; it's a very unique set of challenges that you're not really exposed to when you're in training. It can be challenging, but I think it's also been very rewarding to see the difference I have been able to make in the lives of patients. This is why we get trained for so long; the goal is to become capable and responsible surgeons.

Some other challenges were learning a new system. I didn't have the benefits of completing training in Montreal. So, learning a new system, new information technology, the way the patient flow works, the way the clinics work, and the way the hospital works were all unique when I started. It's not dramatically different than a lot of other places, but they are still new systems. I am grateful to have supportive colleagues who were very helpful in terms of making that transition. So, that helped a lot in overcoming some of the difficulties.

Also, when you're starting new, you're trying to develop what your practice will be like. Between hospitals, things may be done differently with respect to certain types of procedures and perioperative care. And sometimes, if you want to do certain types of procedures, that requires a lot of work if you're bringing in the technology, bringing in new equipment, and how that works with respect to hospital acquisition and funding. That's something that's been a steep learning curve, just because you're not exposed to any of this as a trainee.

We recently started up a HoLEP program here at the hospital; it had existed previously but went dormant for about a decade because of the need for updated technology. We were in the process this last year in bringing in the latest technology to allow us to perform HoLEP at our hospital. Now we can offer this to our patients, as this is a greatly needed area of care with an ever-aging population. The key to overcoming these challenges is being patient, because this process requires a lot of time; it's been over a year in the works from securing the funding to partnering with industry to acquiring the equipment and technology. So, that whole process requires a lot of patience. Ultimately, I'm glad to say that we are up and running and patients are benefiting.

What are some wins that you've experienced with your practice since getting started?

Along the lines of the HoLEP program, I think getting that started and having our patients finally getting the care that they much needed has been a win. These are patients who have struggled with bothersome [lower urinary tract symptoms] LUTS all the way up to patients who have had Foley catheters in for over a year now, waiting for some kind of definitive surgery. To get that going and get these patients treated has been extremely rewarding and a big win. Prior to us bringing in HoLEP, in order to accommodate patients, we started doing robotic simple prostatectomies for large prostates. Now, I'm glad to say that we can offer both options to patients, which I think is unique among urologists and different centers. Having the expertise with both HoLEP and robotic simple prostatectomy is unique in Canada as its usually one or the other (or neither). So again, to be able to offer both now gives patients the option rather than being told, “This is your only option.”

Along those lines, we've also added to our overall armamentarium for [benign prostatic hyperplasia] BPH. We're already doing GreenLight photovaporization and Rezum water vapor therapy. This is all possible through the generosity of the Jewish General Hospital Foundation, which provides the funding for these procedures so that they are fully covered while still in the public health system. In Canada, Rezum is mostly done on a private basis. So, for us to be able to offer that fully funded, it's also a huge win for our hospital and our division.

We were also the first center in Quebec and Montreal to utilize the new Medtronic InterStim X system, the latest generation device for sacral neuromodulation. Again, were able to offer the latest technology and treatment options to our patients while ensuring complete coverage so patients can receive treatment without having to worry about finances.

What I am especially proud of is bringing in the skills and expertise to offer definitive surgical care in patients who have long been suffering the devastating complications of cancer therapy. This is a big reason why I decided to obtain subspeciality training in urologic reconstruction. I wanted to be able to offer relief and restore quality of life in patients who didn't have access to definitive reconstructive care. Over the past year, I've completed several complex abdominal and pelvic reconstructive cases in patients who had very devastating complications from post-cancer treatments, whether it's urinary fistula, or devastated urinary bladders from previous radiation therapy. I've been able to successfully and very safely get these patients care and definitively treated. I've seen them in clinic and they're happy and they're catheter and nephrostomy tube-free. For them to be able to just live their life, not be in hospitals all the time dealing with issue after issue, and help restore their quality of life has been a huge win. I think of these patients as the “forgotten patients”, because they're too complicated; nobody knows what to do with them and so they get lost to follow-up, or they’re in and out of the hospital dealing with tube-related complications. This is a big focus that I had coming in. To be able to get the first several people that care has been my personal biggest success.

What conditions do you treat? What are some of the services that you offer?

I am able to offer treatment in all aspects of functional and reconstructive urology. I offer both open and, in some cases, robotic procedures. I have special expertise in urinary diversion, whether it's incontinent or complex continent urinary diversion, including Indiana pouch augmentation and ileocystoplasty. These are things that I can offer that are not necessarily widely available, particularly procedures like the Indiana pouch.

I treat all aspects of male and female incontinence, whether this be artificial urinary sphincter, the male sling, female sling, bladder Botox, or sacral neuromodulation. I also offer urethral reconstruction, so that's urethroplasty with or without buccal mucosal graft. I think we're one of the few centers who are also doing the Optilume urethral dilation. Fortunately, through our hospital and the foundation, we're able to fund these procedures for patients. We also offer a wide armamentarium for BPH treatment.

I mainly focus on functional and reconstructive urology. Outside of that, I offer a wide spectrum of general urology care including endourology and outpatient oncological care. I have colleagues who have special expertise in pelvic organ prolapse and erectile dysfunction and therefore I am able to refer patients who require these services to my colleagues.

A big thing that's unique to the Jewish General Hospital is that within the region of Quebec and Montreal, our hospital is a designated referral center for the management of women who have experienced complications related to synthetic mesh material implantation. This includes providing initial diagnosis and evaluation, pain-related therapy, physiotherapy, and surgical care, which typically involves mesh removal. This is something that is unique to our center.

What is the makeup of the staff and the roles associated with your practice?

In terms of staff makeup, we have an amazing group of clinical nurses. They're intimately involved in all aspects of patient management, whether it's from preoperative preparation to postoperative follow-up. If we need to do a retrograde urethrogram, we have a fluoroscopy suite that a couple of nurses help to arrange and do. They are also involved in providing postoperative sacral neuromodulation teaching for patients, as patients are working through the settings and helping them understand how the system works. We have residents as part of our teaching program, and we have a urology fellow. They're all instrumental in all aspects of patient care and postoperative management.

Our center is mainly focused on functional and reconstructive urology and oncology. So, I have urologic oncology colleagues who deal with more of the cancer patients directly. And we have a strong back and forth referral. So, if we get patients who are needing definitive cancer care, we refer them over to them and vice versa; patients needing validation and management for functional urological problems, we're right next door.

Our front desk staff and our secretaries are also an amazing and hardworking group of individuals, arriving in the very early mornings, and often staying even later than we are. They are the cogs that keep the machine churning and efficient.

What are some unique elements to your practice?

My goal is to offer a wide spectrum of surgical options and care for patients, specifically under the realm of functional and reconstructive urology. So, what makes my practice unique is that I can offer patients care definitively without having to do a lot of referrals. In the same week, I might do a [holmium laser enucleation of the prostate] HoLEP, an artificial urinary sphincter, sacral neuromodulation, cystectomy, Indiana pouch, urethroplasty with a graft, and then cap it off with a robotic simple prostatectomy. That might be all in just 1 week. I think that's unique in the Canadian system, especially. To offer that whole spectrum by 1 practice is unique.

I've had patients referred to me by non-urologists in the US who have somebody they know locally who needs urological assistance. I've been contacted by individuals in the states who say, "Hey, would you mind helping a friend of mine or a colleague of mine with this aspect of their care in which they're not able to get addressed locally?" I've met with these patients and worked towards a solution for their problems. That is ultimately my whole goal; to be able to provide the care that many patients need but are not able to receive. Anybody who needs help and who's willing to come, that's why I'm here.

Do you have a special area of interest with respect to research?

Being in academic practice motivates one to practice both clinically and excel in patient care but also to continue to evaluate outcomes and provide further understanding of urological questions. My research focus is centered on understanding patient related outcomes following procedures for benign prostatic hyperplasia such as Rezum, HoLEP, and robotic simple prostatectomy and evaluating the role of novel therapeutic adjuncts to the minimally invasive treatment of urethral stricture disease.

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

I pride myself in offering surgical solutions to patients who either are not able to obtain it, or they're not deemed good surgical candidates. In some cases, there maybe is not a lot you can do for the patient because of their medical status or medical condition, but if we can safely get you under an anesthetic, I can fix your problem. Nobody wants to live their life with tubes coming out of them. So, that's a huge focus; I like to help those patients regain control so they don't need these things and we can remove them. Nothing's more satisfying when you restore proper urinary flow. The look on patient’s faces when you tell them there is a solution, that's the whole reason for this.

You can learn more about Dr. Singh and his practice here.