Aditya Bagrodia
Appearances
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
practical implementation strategies to study new ideas in a way that's safe effective and perhaps not overly onerous as well so before maybe if you don't mind share a little bit about you know how your interest in clinical trials and moving the needle kind of began
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Yeah, I love that. I mean, you know, to maybe exaggerate a little bit. And if we took that same study and did it kind of through a more typical mechanism, let's just say the patient's been decided they need a prostatectomy and you have to get all these tests, audiometry and liver function chemistries and whatever. Then you get randomized.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Then you have research assistants that support these trials for three years. You have kind of all this stuff, this clutter, if you will, baked in, which makes it onerous to the research staff. The cost can become prohibitive immediately. And you end up saying, is it worth spending $2 million to try to answer this question? Not only is it worth, can I get somebody to pay that?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
which is another tricky one. But it's almost like if we can just use a little bit of common sense, there are checks and balances to make sure this doesn't go rogue, I suppose. And it sounds like there's a kind of an oversight committee. You can answer questions that are worth answering without making it so intensive, laborious, cluttered, as you say, so that it never gets off the ground.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Yeah. I mean, it's one of those things that's obvious and it's not. I mean, this is separate, but perhaps related. At many institutions now, a blanket IRB for retrospective studies that pose zero risk to a patient are disallowed. Or biospecimen collection protocols may be challenging to get through. MTAs, DTAs between institutions can be a little bit complicated. And
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
I guess, you know, just reflecting back in America, I think a few bad apples can really screw it up for everybody. You know, a perfect example is, in my opinion, when you go through the airport, you can't take something more than three ounces. You got to take your shoes off because somebody once upon a time did some stupid stuff with shoes and a small bottle of whatever. I mean, is that it?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Are we kind of handcuffed in so many ways because some of these things have gone awry when providers are given latitude?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
I mean, it sounds simple and it's genius. You saw me smiling. For our listeners, they obviously couldn't see me smiling because it is tough, right? When you're approaching somebody for a trial and you're excited about the new and you're trying to couch that in a balanced type of discussion, it's challenging. Yeah. Yeah, I love that.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
So, you know, just to kind of maybe dig into this a bit further, the consent is actually taking place at that first introduction of the concept that we may reach out to you about interventions to improve the biopsy experience or the systo experience. And then... Your recording outcomes, which seems to be a critical common theme here. Then you intervene.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Maybe that's warm irrigation for a Sisto versus room temperature. Maybe it's headphones. Maybe it's, you know, I don't know, picking their favorite playlist on Spotify and you go with it. And then at that time of the intervention, so to speak, the system, the biopsy, the whatever, music in the OR, you're saying, okay, now we're going to intervene. Is that still okay? You're excited about it.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
You collect the outcome and you're cruising. Does this sound about right?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
No, I mean, these are tremendous pearls before. I mean, the clinical integration of trials, the two-stage consent. What are some of the other things that you feel have been particularly effective in your illustrious clinical trials enrollment career?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Makes sense, right? I mean, you see perfect examples of that. You know, one recent one that comes into mind is the recent BRIDGE study comparing BCG versus gem dose C for non-most invasive high-risk bladder cancer. The study PI did a small pilot at their home institution. It went well. And then through the cooperative groups, we're able to get something substantial moving.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
I don't see it as a sellout to test the waters and see how it's going to go, you know, because we've seen amazing, ambitious trials, a dime a dozen, unfortunately, answering really critical questions that just never got off the ground. Fantastic before.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
So, you know, as we approach an hour here, you know, I wanted to maybe just have you run through, you know, lessons learned, things that work, things that didn't work. You've touched on some of the pearls and some of the pitfalls, but any that we didn't cover?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
I love it before. And I can think back to the early days when I was just starting and kind of knew that germ cell testis was going to be my primary area of interest. And the SEMS trial was just kind of getting going. And I reached out to SIA. We opened it there. And I was literally so thrilled to put four patients on. And that did give me some validity within my own kind of institution, region.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
kind of got things going. So I think it's super sound advice, whether it's multi-institutional IITs, co-op group trials, get out there, see what is exciting to you, interesting to you, and then you knock it out of the park. And maybe I'll just also add, I think in the spirit of always improving, don't be intimidated. It doesn't need to be, like you said, a grand slam from the get-go.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
It could be a QI project that you're like, huh, that seems compelling. I would like to disseminate this. And then you can look at different mechanisms. Well, before, you know, thanks. I knew it was going to be a thoughtful, reflective conversation on other things that have worked well and some of the pitfalls as well. So I appreciate your time.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
It is a process and it's laborious. And I guess it's intimidating enough that many people don't ever give it a shot on the one hand. Then a lot of people try and they fail, on the other hand. I mean, I guess they learn something along the process. It's not a total failure. But it could be helpful to take a case example, perhaps one of your early clinical trials.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Great to see you again and look forward to connecting soon.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Our audio team is led by Kieran Gannon, with support from Josh McWhirter, Aaron Bowles, Josh Spencer.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
And let's just literally walk through it from, you know, you're familiar with the disease. prostate cancer, biopsies, surveillance, focal therapy, and you've come up with a question that you think is worth answering. Let's walk through the nuts and bolts of taking that question to a trial.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Hello, everyone, and welcome back to the Backtable podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com. This is Aditya Bagrodia as your host this week, and I'm very excited to introduce our guest today, Bifar Adai from Memorial Sloan Kettering, Department of Urology. Bifar, how's it going today?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Yeah, I mean, it's easy enough now to say that's a no-brainer. And a focal therapy trial conceived today on September 26, 2024, including grade group one patients would probably get a lot more pushback in terms of, you know, you're exposing folks that should do extremely well to some harm is generally, I think, accepted. So...
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
I mean, to me, it highlights an important point that, you know, getting it kind of right-ish off the gates, maybe even taking a bit of a gamble in terms of what's this going to look like. You know, it's so easy to look at a trial that was conceived 10, 15 years ago and slice and dice it to bits because of the methodology involved. back then, but it sounds like you made the right call.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
And I'm sure that was a big call. And if I may, I think these days, appropriately, the key stakeholders absolutely involve patients as well. It's really been nice to see over the course of our careers that having the advocates at the table, the stakeholders is key. All right.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
So you decided looking at essentially oncologic outcomes, quality of life outcomes in patients considering focal therapy was going to be the way that you go. Fair. And maybe one other question before, you know, this is something I kind of struggle with. It's like, do you provide a skeleton to keep the conversation moving? Or do you kind of leave it open ended with all the opinions?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
And many times, there's so many opinions that you never make any progress. Can you talk a little bit about that balance?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
It's great to see you again, Aditya. Yeah, pleasure's all mine. You know, I had the good fortune of training under Bafar when I was a fellow there. Very, very thoughtful clinician, exquisite surgeon, and, you know, my opinion has... properly, methodically moved our field forward substantially, particularly with prostate cancer.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Yeah. I mean, I was exposed to this where patients receiving prostatectomy, for instance, and I'm sure we'll talk about this, would basically, to over-summarize, sign a bit of a global consent for interventions that we would consider non-major, if you will. And that's clearly where some...
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
interpretive latitude is allowed and then they'd get their procedure and maybe they'd have their prostatectomy extracted via vertical incision or horizontal incision maybe they'd have a certain type of lymphadenectomy maybe you know some of the newer things ish coming through the pipe
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
Retzius sparing versus traditional posterior approach or anterior approach or hood sparing, you know, God knows what that is well within your right as a surgeon to try to offer the best oncologic and functional outcome. Now they've been properly studied.
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
So maybe I'll ask, you know, when you're thinking about this, if I've got it right, how do you kind of decide what is a reasonable shade of gray versus this is really something beyond a typical modification within a standard that needs separate consent, infrastructure costs, et cetera, that you're kind of alluding to?
BackTable Urology
Ep. 207 Integrating Clinical Trials into Routine Urology Practice with Dr. Behfar Ehdaie
So today we're going to talk about, you know, the technical title is Novel Methods in Clinical Trials. And maybe I'll just extend that a bit into...
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
And you visually just see them coming through. And that's got to be satisfying, just seeing your little jar fill up progressively with stones, especially like a nice 1.8 centimeter, 2 centimeter big boy. So that's cool. So you made a company. You partnered with industry or was this all homegrown?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Okay. So you got a little money, a grant funding, kind of typical routes as well? Yeah.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
I'm sure if you went to a World Congress of Endourology meeting and commiserated over some lemonade or other stone preventative beverages, everybody's like, yeah, Roger, we'll chip in some money for that. So you're at version two now. And basically a ureteroscope with suction capabilities? Yeah.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Roger, how's it going today?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
So why not like just, you know, you have a three channel ureter scope, put on like a 60cc syringe. You've done some basketing and just aspirate.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Yeah, we are good friends. Roger's had the, I guess, pleasure or displeasure of helping me get my sea legs on a surfboard. So he's taken us out. It's been super fun. You know, one of the things I've been most impressed with getting to know Roger is it's the clinical care. It's the innovation, problem solving, remaining non-intimidated by new technologies. And maybe we'll get into that.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
I love it. I love it. So, you know, over the last, I think at least since I've been a trainee, which is getting further and further away, but in my prime ureteroscopy days, it was baskets and it was lasers. That was 2010, 2011. So surely you're not the first person or only person that's thought about this and come up with something. Are there other suction devices out there? Are they all...
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Kind of similar or are they meaningfully different?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Okay. This one's a little bit harder for me to conceptualize. I'm thinking like, is it almost like a dual lumen? One is your suction element of it.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
So today we're going to talk about suction devices and suction technologies and kidney stone treatment. And I'm excited. You know, taking a walk down memory lane, largely it was lasers, fragment, basket retrieval for as long as that was required. Then dusting kind of came on the scene as like a new thing. And that seems to be kind of a...
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Exactly. Okay, okay. Yeah. So your scope has to be out for large fragments to actually come through. Exactly. Yeah, I'm sorry. So that's kind of like CVAC one. Yeah. Like you're deploying it ureoscopically wherever you want it.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
with this flexible tip, you've done your business, fragmented, et cetera, then you pull out your scope and ostensibly the sheath remains in whatever calyx of interest or the pelvis, suction's out, then you take a look back up. Did it do a good job or not? Maybe you basket a few things and call it a day. Totally, exactly. You gotta go back up there, take a look at it,
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Apart from the continuous irrigation and aspiration with CVAC, it's essentially a ureter scope with a larger working port. The DISC? Well, no, the disc sounds like it's a ureteroscope. It's a ureteroscope with two stopcocks on it. So that I get. I'm trying to understand how CVAC, which sounds like it's got a larger port to accommodate slightly larger fragments.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Like I'm envisioning, you know, you still have your camera, obviously. You have your light core light source coming through. And then you've got your suctioning and aspirating channels, and then ability to work through one of those.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
So what's the overall French of the CVAC system?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
ongoing debate in the minimally invasive endourology world. And then for PCNLs, it was like a cyber one, which was, I think, pulverized the stone and then somehow suctioned it up. Those were kind of the tools that I had in my toolkit, more or less. And maybe just ask you to kind of comment on, you know, what's transpired over the last decade or so.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
And is the CVEC system, is that reusable? It's a single use. Single use. Yeah. Okay. So I think you walked us through, you know, the mechanics of it. I think getting an access sheath up or an accommodating ureter without an access sheath, then you kind of do the work. Compared and contrasted some of the pros and cons of fans, discs, and CVEC.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
so i mean it all sounds compelling you know off the top of my head the main outcome of interest would be stone free rates as you've kind of outlined and then of course or times and then balancing that ostensible saving of over time with costs of a reusable you
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Okay. What does the data show? It's safe. You've done it in pigs. You've done it in humans. Reported your first in man. You're not doing anything that's unexpected with a, you read Roscoe with an access sheet.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Well, actually, I was thinking about this upcoming podcast and just...
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
That's cool. I mean, it's kind of like a PSA recurrence predates a metastasis predates cancer specific survival. And I think it's expected that a stone free, a better stone free status helps mitigate some of these unpleasant, you know, reoperations, ER visits, pyelonephritis, etc. Yeah.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Yeah, not just the volume, but the surface texture, you know, is it jaggedy? Is it smooth? Does that impact passability? Yeah. Then, of course, the patient-specific factors, you know, is there ureter-like? Is there any evidence of X, Y, and Z? Sure.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Well, I do still partake in some endourology, predominantly for upper tract patients, and it does seem like this could be a pretty cool application because it is so...
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
challenging many times to get biopsies and so forth or if you're doing an ablation whether that's laser or whatnot to have all those cancer cells immediately aspirate it sounds cool now with that being said by the way i have seen that done i i people using cvac it's not an indication for it but just sucking the tumor cells into the canister and there it is right there
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Hey, send that out to your pathologist and, you know, half of it for Cyto, half for pathology. Maybe I should get an idea of what you're dealing with. So if and when I want to do that, I mean, is this like going from open surgery to laparoscopy? Is this like fairly incremental? Could I do this having, you know, been out of... high-volume endourology for 8, 10 years? Oh, totally, yeah.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
If you had to take a step, what percentage of uretroscopic cases are using some type of suction platform currently?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
That's so cool. Now, I mean, obviously, patient outcomes, stone-free rates, decreased infection rates, those are ultra compelling and major, major outcomes of interest. What about OR time? I mean, every trip that you don't have to take grabbing a basket or every additional minute or two, you don't have to fragment as you're dusting.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Does it lead to a shorter OR time once you've kind of gotten beyond a learning curve? Is it longer? You know, obviously I've never done this. What's your kind of gestalt on maybe surgeon satisfaction and surgeon specific factors that could be improved?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Absolutely. Absolutely. So let's say that I am a urologist who does a decent bit of urology, ureteroscopy, excuse me, and I'm interested in this. Like I want to check it out, you know, CVAC, maybe have CVAC and fans, the dens, all those things.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Okay, but maybe something just to like transmit your video feed.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
All right. We got your, you know, adopting a new technology, helping prevent stones, downstream episodes, as well as infections. It kind of makes sense. I mean, it sounds like to me that it's revolutionary, at least in theory. And, you know, sometimes I'm sure it takes a little while for the traction to catch up. Actually, it's amazing. Just two weeks ago, I did an episode with Manny Menon on...
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
history of robotic surgery and he just kind of walked through his whole experience and i personally think it's amazing i mean you know you've distilled it down into a 45 minute conversation we had an idea we did this version one version two and now here we are with procedure specific cpt codes reimbursement and data that it seems to appear to really help out with patient centered outcomes most importantly but it sounds super duper exciting roger
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Yeah, that's awesome. Well, you know, I think for me a major takeaway is as clinicians and surgeons, we recognize our, let's call it pain points, opportunities, however you want to phrase it, in a way that's different from anybody else.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
And instead of letting it kind of continuously nag at you, trying to do something about it and not being intimidated by a process that seems daunting and foreign is amazing. That's been my major takeaway. But more importantly, we'd be interested in your final thoughts and messages for our listenership.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
I love it. I love it. Well, Roger, thanks for your time. Thanks for your insight. Thanks for your contributions to urology. I have no doubt they're going to be profound. They already are. And I also have no doubt that in about 10 or 15 years, we're going to be recording a Legends in Urology episode about how suction devices totally transformed ureteroscopy.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
So appreciate your time and your expertise, Roger. It was fantastic. Thank you, Aditya. I really appreciate you letting me speak here on Backtable.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
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BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Backtable is hosted by Aditya Bhairodia and Jose Silva.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Our audio team is led by Kieran Gannon, with support from Aaron Bowles, Josh McWhirter, and Josh Spencer.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Absolutely. Yeah, no, it's perfect. I mean, the three main approaches are percutaneous, and it still blows my mind that once upon a time, a couple of urologists decided to start harpooning through the back, aiming for a fairly small area, and just kind of seeing how that all went. Yeah.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
So, okay, maybe to bring it to a little bit more contemporary times, if we're talking about the endoscopic options, percutaneous nephrolithotomy or ureteroscopy, now we're looking at breaking stones up, removing them, fragmenting them to really teeny tiny pieces that ostensibly pass... Is that it or is there more going on here?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
You know, it's amazing. Before I committed to a career in oncology, one of my first mentors was Peggy Pearl, who's an amazing, very rigorous stone surgeon. And we wrote a paper on natural history of visual fragments after PCNL. I think you might be quoting ureteroscopy data, but it was spot on. And Peggy would, let's just say, diligently analyze
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
painstakingly get every residual fragments out because her belief was anything left behind was going to misbehave or certainly could misbehave.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Well, you know, on the provider side, you know, maybe two or three times a year, feeling reasonably well-trained in ureteroscopy over the course of my residency and fellowship, I'll do a stone case. And I always really appreciate the endourologist, too, who I think really hold themselves accountable to doing their level best with the stone because...
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
in my opinion not having this as my passion and my livelihood you know sometimes just chipping away at that little fella and if it's a hard hard stone having that What's the word I'm looking for here? That committedness to dust it, if that's the route that you're going to go, or to take 55 trips up to get those little fragments out with your basket du jour. It really is a commitment.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
It can be time consuming. You're also kind of eyeballing what's a clinically significant fragment. I have a caliper there that's saying that little fragment's 2.3 millimeters and this one's 1.6. So I think there's a lot of human nature. You know, if it's your birthday, it's a Friday and you want to get out of there and you're just chiseling away. Maybe you say, you know what?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Those, those stones should pass.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
So I think the fragment and basket retrieval, that's laborious. Dusting, I think that opens itself to quite a bit of interpretation. And dare I say that this kind of dilemma is what led to your interest in how do we do better?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Yeah, please do. I mean, I'm sure you weren't like, these are the, like you go get like a Hoover and make it teeny tiny and stick it on the back of a scope. Like.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Yeah, that's cool. I mean, some just general question. I'm sure this was like in the early science days, like there's got to be like a millimeters of mercury suction pressure where you collapse the whole system and create hickeys in the calyces. Did those things happen? And how did you actually... visualize what was like taking place.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
I mean, did you perk in on one side and your CVAC in on the other side?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
Hello, everyone, and welcome to Backtable, your source for all things urology. You can find all previous episodes on Apple, Spotify, YouTube, and on backtable.com. This is Aditya Bagrodia as your host this week. And I'm thrilled to invite our guest today, Dr. Roger Sir, who's one of my partners here at UC San Diego. He's a tremendous clinician, tremendous surgeon, great friend and partner.
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
And then just like random things, like without being an expert on this, like what if like a three millimeter fragment that's greater than the diameter of the hose, if you will, gets like lodged? Like, how did you determine what's going to be, you know, is this going to be six French? Because that's roughly your reader scope. Is it going to be... Well... How did you sort this stuff out?
BackTable Urology
Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur
So, well, I guess now, at least if you're seeing it, you feel like, okay, we can turn the suction off, let that stone drop out, maybe bust it up a couple of times or go gather up the rest of it and then come back and basket or do whatever we'd like.
BackTable Urology
Ep. 186 Blue Light Cystoscopy: Improving Bladder Cancer Detection with Dr. Suzanne Merrill
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend.
BackTable Urology
Ep. 186 Blue Light Cystoscopy: Improving Bladder Cancer Detection with Dr. Suzanne Merrill
Backtable is hosted by Aditya Bagrodia and Jose Silva.
BackTable Urology
Ep. 186 Blue Light Cystoscopy: Improving Bladder Cancer Detection with Dr. Suzanne Merrill
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BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
you know, people are just like, there's no way I'm going to do that. You know, there's going to be loss of muscle mass, increase in fat mass, or maybe some cognitive impact, some cardiovascular risk, osteoporosis, weight gain, loss of libido, erectile dysfunction, fatigue. I mean, do you like run through this?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Oh, it's a pleasure, Raina. I literally think every time I interact with you, I get inspired and I get smarter. And, you know, what you're able to do for our team and for the GU community is amazing. And I've got to take this opportunity to throw a little plug in. Raina is on the ballot for the nominating committee for ASCO elections this year.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, I think that's clutch. And, you know, the body dysmorphism, I don't know if I mentioned, but the gynecomastia that can be very troublesome to patients. And, you know, of course I do too. And I don't know necessarily why, but I feel like there's still this like surgery, radiation kind of situation. And I always feel like a little bit bad, like bad mouthing the other option. Yeah.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know me well enough that it's like, you should just understand all your options very, very well and then pick the one that suits you better. So maybe I subconsciously downplay some of the adverse effects that I don't want it to come across as biased, which is silly. You know, I think it's an...
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
An opportunity to empower the patients that while these things are being done to them, you can get vitamin D and calcium for bone health, get the DEXA scan, weight-bearing exercises, heart-healthy diet, sleep hygiene, supplements, maybe even potentially that you don't have to be like a passive victim in this, that there are things that you can do, plugging me in with sexual health counseling, a men's health team.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So, I mean, maybe for me in the events that I still do, vitamin D, calcium, baseline DEXA, run through it. And by all means, if they've got cardiovascular risk factors, that's where I'm going to probably engage a team. And you kind of mentioned there's some controversy around it. What do you think? You know, GnHRH antagonists, do they have some cardio protection? Do they not? Hard to say.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
There's literally I don't think anybody who's out there currently that's contributed so much to our field and oncology in general. So if you're a member, get out there and vote for Raina. She's amazing. You don't need me to tell you that. All right, Raina. So this is actually an episode that is kind of backed by request and popular demand.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, that's essentially my understanding. And I guess if there was going to be a difference that seems a little bit more real, if you will, it would be the testosterone recovery when you're on a, you know, non quote unquote lifelong plan, six months, you know, 12, 18 months of a GnRH antagonist versus let's say, you know, six monthly luprons.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Do you feel like they're similar in terms of testosterone recovery or different?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Makes sense. So is there any kind of meaningfully different counseling when it's favorable versus high risk? Let's just not, we would start with the ADT element, not necessarily the ASRIs and second generation and, you know, potentially triplets. You know, is your counseling for somebody who's basically intermediate risk or high risk, similar, comparable, different?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know, as prostate cancer, both in the localized and advanced contexts, gets more and more complicated, ADT, androgen deprivation therapy, still just holds such a central role. And maybe I'll ask you to just take a little walk down memory lane over the course of your career, how you've thought about ADT, how it maybe it's come more within your wheelhouse than other places.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And how are you following these patients in terms of, you know, labs, obviously, testosterone and PSAs, anything kind of beyond that?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And where do you like to see their testosterone levels kind of level out?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
doing this halfway thing is not really you know constructive yeah i mean it used to be like less than 50 then less than 20 then it's basically undetectable and i think you kind of hit the nail on the head and you know there's been just a explosion of medications really trying to eradicate any testosterone from any source you know beyond just the hypothalamic pituitary testis access
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And it kind of segues into, so, you know, maybe for finite favorable risk, of course, there's a counseling and it's kind of like, I just got to get through this and you'll be fine. For the higher risk, it's a longer duration. Maybe some of the metabolic elements become a little bit more front and center. And then there's kind of you're in the long haul and, you know, whether that's going to be.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
intermittent or continuous as very person-specific, disease state-specific, whether they're sensitive or resistant. But just talk a little bit about maybe how you think about continuous versus intermittent ADT when appropriate.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Can you share a little bit on that?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And intermittent, so you've got them on your ADT du jour, their cast rate, their PSA is undetectable, and then you decide to give them a little bit of a holiday. Can you talk a little bit about the triggers to get them back on treatment? Are they PSAs? Are they doubling time? Are they patient anxieties or provider anxiety? What does that kind of look like?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, I couldn't agree more. I mean, there's people that really get taken for a ride with ADT. There's people that it's not so noticed. There's people that really are upset with PSA levels at various thresholds, and there's people that are not. So I agree, it's individualized.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And like you said, you know, earlier PSMA PET scanning has kind of flipped everything on its head when it comes to detecting METs. Well, you know, I think this is a topic that can be reviewed enough.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I mean, I certainly learn plenty every time and, you know, not to, I absolutely think that a lot of people, you know, med-oncs, radoncs, urologists can safely and effectively prescribe ADT, but it behooves us to kind of stay up with it, make sure patients are well-informed and, you know, do everything we can at our end as well as the patient and to help mitigate side effects.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So maybe as we're kind of wrapping up here, Raina, any kind of parting thoughts for the audience on how you approach ADT or things you're excited about in the future?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
That sounds perfect, Raina. Well, thank you, as always, for your keen insights. Always a pleasure. And best of luck with the ASCO elections. Again, Raina is on the nominating committee. She's amazing. Vote for her. All right, Raina. Thank you so much.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Totally. And you know, I think as fortunately, in my opinion, as advanced prostate cancer management has gotten more complex, really digging into side effects, mitigating those side effects, explaining those side effects. You know, early on as a urology trainee, it was like, all right, we're gonna start you on Lupron. And the counseling might've been, you know, you might have some hot flashes.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Okay, we'll see you in six months with a PSA and a testosterone. And I'd like to think that, you know, it's a bit more advanced than that. So maybe you kind of alluded to it, you know, obviously this is prostate cancer. It is addicted to testosterone. We've got to get those testosterone level down to castrate.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Can you just talk a little bit about, maybe we start with disease states, early disease states, all the way to advanced disease states. When you think about this, how do you kind of think about when ADT might be appropriate? Yeah.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, and I think that really kind of perfectly captures that ADT kind of has a role potentially across the disease spectrum. And maybe just one question, primary ADT, is there a unique patient these days that that might still be an option?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
localized prostate cancer, really not a candidate for surgery, radiation. Are there patients that you might be considering primary agency for?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Totally. Couldn't agree more. And not to overgeneralize, many times it's the elder, sicker, infirm patients where they've still maybe got some gas left in the tank. You don't want to say good luck and good night, but surgery or radiation, you know, maybe due to their underlying urinary symptoms, et cetera, aren't going to be great options. Okay, fantastic.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So, you know, I love the way you mentioned that it's the duration, the intensity, and the kind of intent of therapy that are largely modulating this. And maybe we can start out with, you know, four to six months ADT for generally unfavorable intermediate risk prostate cancer. What agents, any kind of major preference? And maybe I'll just throw this out there.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know, once upon a time when I was prescribing a lot of ADT, I was like, let's give you a six month shot of Lupron. Let's be done with it. It's cost effective, rock and roll. And there's baked in compliance. Now, I'm not saying that that's the best route, but let's just talk about an intermediate risk patient that's getting ADT coming into your office. And what does that conversation look like?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know, while I think we like to get those durations of ADT in for the intermediate risk patients and for the high risk patients, it's kind of a little bit of a conversation, right? If they're completely miserable and life is not worth living, then it's not like we're going to strap you down and get you two years in.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
It might be, all right, you know, you're high risk, let's really try to get a year in and, you know, we can horse trade after that. Okay. So, yeah, you kind of mentioned, you know, there's injections, there's Degrelix, Erigolix, there's good old-fashioned ADT. Antiandrogens, do those have much of a role anymore?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
This is Aditya Bagrodia as your host this week. And I'm very excited to introduce our guest today, Raina McKay, who's one of my partners here at UC San Diego. Welcome back to the show, Raina. How are you doing today?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, I mean, I would tend to agree. And I think in those contexts, those kind of extreme contexts, cord compression, saddle paresthesias and so forth, it's pretty easy to use a GNRH antagonist and just kind of be done with it and get castrate, you know, in the order of hours. You know, I think that's also a context where bilateral orchiectomy still, you know, remains in the toolkit.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
All right, so side effects. You know, my usual, and it's always a little bit tricky, especially when you're talking to people with a new diagnosis of prostate cancer and they're a candidate for surgery or radiation and you're talking about hormones. I almost feel a little bit bad because when you run through the litany of stuff, it sounds so awful that...
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
I think at that time, it kind of seems like there is a critical energy mass accumulating for something special, something big. This is my sense, just learning a little bit about you. Is it accurate?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And can you talk a little bit about getting to Detroit and going from really important work in nephrolithiasis continually funded by the NIH to changing the way that urologic surgery and urologic cancer surgery is performed?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
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Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So things were working well, you've got experience in grant writing, funding, basic translational clinical research, now getting some administrative experience at your new position at UMass. And how long were you at UMass? I was a chair there for 14 years. All right. So that was a good early, mid-career experience. And what prompted the next change?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And the next stop was, of course, Henry Ford.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So obviously, or it seems obvious to me that that's really where all the pieces of the puzzle really started coming together in a major way to have such a dramatic impact. And maybe just walk us through that. I mean, surely it wasn't just you woke up one day and you said, I want to revolutionize the way prostatectomy is done. Here's how I'm gonna do it.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Or there's this new robot that you heard about, or there's this amazing foundation. Tell us a little bit about the Vatikuti Institute, of course. How did that develop organically, intentionally, serendipitously? Walk us through that, please.
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Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Visit their website or stop by Siemens Healthineers booth at the local and national American Urological Association and Large Urology Group Practice Association meetings.
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Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Now, back to the show. This is Aditya Begrodia as your host this week, and I'm very excited to introduce our guest today, Dr. Mani Menon from the Department of Urology at Mount Sinai Health Systems, where he serves as a professor and director of education and director of precision prostatectomy. Dr. Menon, welcome to the show. How are you doing today? Good to see you.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Yeah, you got to meet people where they're at at the end of the day, right? And we live 30 minutes from the border. There are cultural things undoubtedly that impact us. So you show up in Detroit and you've got somebody that you can relate to and put together a sound business proposal, a plan. You've got an idea.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Thank you for inviting me, having me here. It's an absolute honor. I had to really curtail the introduction because that could nearly certainly take the whole hour-long episode here.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Yep. That's a reasonable pilot program, so to speak. Yeah. Yeah. Well, and let's talk a little bit about Intuitive. You know, once upon a time, I think academics and industry were seen as difficult to coexist. But I would say now and certainly it would seem the relationship that you all had with Intuitive was extremely beneficial to all parties, starting with the patients.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Tell us a little bit about that, if you could.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
but without being hyperbolic here, Dr. Madden's absolute legend in our field, largely known as the father of robotic surgery, a gold cystoscope winner, recipient of an Indian presidential citation in the Smithsonian Institute as a part of a recognition of American immigrants. And I also learned the first Indian surgical trainee at Johns Hopkins University. Is this actually all true, Dr. Menon?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Well, that's important. I think maintaining that balance, especially when you're on the ground floor, so to speak. And all right. So, so they took a chance on, you took a chance on them. You've got your robot, you've got the support of the Institute and time to do something. And walk us a little bit through that. I mean, did you do some lab prostates and see how that went?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Did you have people come in and do some lab prostates? Did you travel? Did you do pig labs? I mean, or was it like, let's just find a patient, see how it goes? How did that whole process work to one day I'm going to try to do a robotic prostatectomy?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
But the rest of it is. Well, again, it's an honor. And I think it's worthwhile to start at the beginning. I would love to hear it. Why medicine? How urology transitioning from India to America? Can you tell us a little bit about that process? Well, it...
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Well, that's amazing. I mean, it shares so much humility that, first off, I can learn something from other people and a commitment, both at your end and at the end of your French guests that would ostensibly leave their status quo one week a month for up to a year. And then being open to receiving some input from a fellow, no matter how naturally talented and gifted they may be.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And it sounds like it worked, you know, that maybe four or five cases in, it's like the first time you get out to play golf and you hit a decent shot, you're like, I think I'd like to keep coming back because that felt really good. Yep.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So those were the early days, and I love you kind of walking through that in some degree of granularity. Did you ever think about quitting? Did it ever seem like, you know what, this is brutal, this is a beat, this is not going anywhere?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Oh, that's a, yeah, I mean, that would get you thinking once or twice when you get in there and try something new, particularly, especially perhaps if there were skeptics. And I'm curious, were there skeptics?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Early adopter.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So it sounds like maybe around case 1820, you were starting to kind of understand and appreciate that you touched upon something potentially disruptive. And on the one hand, the rest is history. On the other hand, it's been nearly a quarter of a century since then. And maybe I'll ask you to reflect a little bit on the changes.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
I mean, clearly the market share of robotic prostatectomy is an obvious one, but the changes kind of in terms of the operation and how it's been refined, is that meaningful? Is it incremental? And perhaps ask the same question about the technology. and how it's advanced. Is that meaningful? Is it incremental? First, let me talk about the technology.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Okay, so the first spot that you landed was Philadelphia. Is that right?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
That's a perfect analogy. We were just in Tucson for the Arizona Electric Society and I rented a car. It was a Corolla, a 2024 Corolla compared to my 2008 CR-V. I felt like I was in a luxury car that was incredible with all types of bells and whistles and safety features. So the technology's advanced and as somebody who's been in urology for, gosh, almost 15 years, I certainly see it advance.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And sometimes I say this is a big change and sometimes it seems a bit more incremental. Maybe just to put something kind of concrete out there, The new DaVinci platform, is it exciting to you? And the, I would say, renewed interest in other robotic platforms, is it exciting to you?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So just for a minute, let's maybe think back to the time. This is pre-email, smartphones, maybe a letter here or there, international flights, leap of faith. I'm heading to Philadelphia with a few bucks in my pocket. Just walk us through a little bit of How old were you? What stage of your life? What were you thinking? And what does this actually look like in a somewhat granular fashion?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
It's a timeless question, even for anybody just starting out their career and they're asked that inevitable question of how many of these have you done? Yes. I mean, first off, I think you got to be honest, starting out with training. Here's where the kind of numbers come from. In this particular instance, I would tell them that my experience with
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
open surgery, and an effort to improve patient outcomes. We're exploring things that are novel, disruptive. But with that, there come some unknowns, some risks, explicitly risks specific to laparoscopy, to not having your hands in there, being able to feel to do something a I would try to quantify that. I think my general style is to prepare for the worst and hope for the best.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And I think that's precisely what I do for the patient. And then ultimately say, kind of got our workhorse, which I'm familiar with, and we've got something new that I'm exploring and can look you in the eyes and say, I think I can help you and likely not hurt you through this novel approach. What appeals to you? And we go with that.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
I mean, I love that. And it really does come back to the patients. And I think a lot of us practice in different environments with different demographics. And again, I think meeting people where they're at. And sometimes when you have the ability or lack of ability to do a lot of shopping around, you have a specialist type of relationship and that's tremendous.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And I would say, you know, the rest is history. It seems like you became the destination to learn about, to refine robotic surgery. I mean, you know, literally, honest to God, this morning from eight to nine, I gave a lecture to the radiation oncology residents and staff, GU staff. And we talked about advances in surgery and the last 20 minutes was a narrated robotic prostatectomy that I'd done.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And we just kind of walked through it and to show that, to teach that, to talk about the intrafascial planes, the extrafascial planes, the hood sparing, show them that anatomy, when to stay close and far from the urethra. was so cool. So I think for education, for outcomes, for refinement of a surgery, it's been just absolutely massive, not just in urology, of course, but across the way.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And with that, when you reflect at this stage of your career on what you've been able to do Maybe I just ask you as we come up on an hour to talk a little bit about, you know, the best parts of your legacy. I think it's the people I've trained.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So there's no periodic wows these days. Those are maybe he sticks to that's interesting.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Maybe a couple of additional contributions, but I can tell you as a urologist, as a open and robotic surgeon, as an Indian American urologist, the impact that you've had on our field directly, indirectly as a part of your legacy, the Mennonites, if you will, that are out there spreading the gospel is tremendous. So this has been an absolute honor for me to spend an hour with you and hear about the
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
genesis of this massively, massively important tool in our toolkit. And let's see what the future holds.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Absolutely.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Well, let's see what the future holds. So thank you. Thank you, Dr. Bhandari. Bye. Bye.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Our audio team is led by Kieran Gannon, with support from Aaron Bowles, Josh McWhirter, and Josh Spencer.
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Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So it was not too much to take at that point. Yes. How about specifically... Put us in the shoes of being an international medical graduate in the early 70s. Do you recall, were Indians favorably considered as hardworking, integrated? Culturally, did you fit in? Were there lingering racist undertones?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Well, yeah, I think that's a... open perspective, certainly. I can imagine some of those experiences could lead to some persistent anger, irritation, discontentment, but it sounds like you were able to see the silver linings, maybe get a little bit of a benefit of the doubt, particularly at Hopkins, where it seems like your academic career really started accelerating under the mentorship of
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Dr. Walsh, Dr. Catalona, and some of the absolute thought leaders in her field. And tell us a little bit about that. Being there in that environment, did it mold you? Was it consistent with the way that you operated?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
All right. So in general supported, you'd mentioned earlier that you'd fallen into some disfavor with the chairman of surgery at your home institution. And I was curious, was this disruptive behavior? dynamic energy always kind of a part and parcel of your MO? Or was this something that was cultivated and developed? Those were just the cards that were dealt to me.
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So transformative experience at Hopkins. And I have to imagine you were offered to stay there for as long as you wanted, but you went out to seek your own fortune, so to speak. Is that right?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
And initially it sounds like your interest was both in nephrolithiasis, kidney stones, as well as cancer in the early days. Is that correct, Dr. Menon?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Okay. Okay. And then across your path, particularly maybe in St. Louis, you cross-pollinated with some of the other notable greats in laparoscopic surgery. Did that happen? Kavusi, Klayman, did you all overlap?
BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Hello, everyone, and welcome to Backtable, your source for all things urology. You can find all previous episodes on Apple, Spotify, YouTube, and on backtable.com. Now, a quick word from our sponsor. From concept to completion, there's a lot to consider when building a theranostics or PSMA PET-CT imaging program.
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Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
So amazing pedigree, awesome self-starter story coming from India, starting at a community program, winding up at Hopkins, you know, certainly at the time, unequivocally, probably the greatest. Urology program in the country, in the world, moving on to places like WashU, incubators of a lot of development.
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Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
This week on the Backtable Podcast.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And, you know, I think once you get to that four or five-year mark, as you alluded to, that conditional risk of relapse decreases, the risk of dangerous relapse decreases. But I always feel it's tough, right? Because they want to hear it. They want to hear that they're cured or in a deep remission or however you want to phrase it.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Because the Decipher score is derived solely from the genomic characteristics of the tumor, it provides information not available through already known clinical and pathologic factors. Decipher high-risk patients generally benefit from earlier or intensified treatment, while Decipher low-risk patients may be ideal candidates for monitoring or less overall treatment.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I also am reluctant to use that type of terminology because, you know, when something pops up in seven, eight years, that's extra not fun.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
No, I just feel like it's setting somebody up for a deep disappointment. I mean, you know, internally I'll feel pretty good. They don't come across, you know, if it's like organ confined, negative margins, negative nose, and they're a couple of years out, they can see it in my body language and the way I'm interacting that I feel pretty good. I would like to think. All right.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So you kind of counsel them, the high risk patients, your higher risk. And when do you practically first get, well, let me back up staging wise, who all is getting kind of contemporary PSMA PET scans and so forth in your practice?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Okay, maybe just to dig in a little bit, like 8 out of 12 cores, 3 plus 4 equals 7, 5% pattern 4, MRI is not offensive. No, no. Okay.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Well, let me kind of flesh this out a bit. So I guess what I'm getting at ultimately is when we get that PSA and if it is an unfavorable endometrial risk patient and it's persistently elevated or pops up, like, I'm like, man, I think I wish I'd gotten that on the front end.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And literally I got a text message from a referring provider the other day saying I'm sending you a guy for a prostatectomy, high volume, 3 plus 4 equals 71, a PSMA PET scan. I said, no.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Right, right.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Decipher Prostate is the most validated gene expression test in localized prostate cancer with level one evidence in national clinical practice guidelines and more than 70 peer reviewed publications, including more than 65,000 patients. Visit Verisight.com slash Decipher to learn more. Now back to the show.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
A thousand percent that I mean, I guess if it was an extramedial lymph node that popped up after surgery, I would be really disappointed because I'd like to think that at least did a somewhat of a limited lymph node dissection. All right, I don't want to veer off too far off course, but the short answer is the same thing over here.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
If it's like MRI was kind of nasty, higher volume, four plus equals seven, PSAs are getting up there. I think it's nice and to have that PSMA PET scan. Okay, so first post-op PSA, roughly,
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, same, six to eight weeks. I mean, usually I get a cath removal and they have a visit with us in six to eight weeks. And, you know, Pat's been discussed in some form or fashion. Ultrasensitive, standard sensitive?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So what about like six, eight weeks out, 0.02, 0.03? What does that conversation look like?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah. We're fine. Nothing kind of like starting to...
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Okay.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
0.1?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
This is Aditya Bagrodia as your host this week, and I'm very excited to introduce back to the show Todd Morgan from University of Michigan, where he heads up the urologic oncology section. Todd, how's it going today?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah. I mean, so when, when you have a lower risk patient and you're hugging the bladder neck and you're hugging the nerves and you're hugging the apex, I mean, obviously you're not trying to leave any prostate cells behind. You're not trying to leave any gross volume of prostate behind, but what's your opinion on that? Like what is actually taking place?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So maybe let's just kind of parse out persistently elevated PSA. I hate that clinical state. It's so disappointing for everybody. I had a guy the other day who T3A, grade group three, negative margins, PSA wasn't particularly offensive. His six weeks was 0.2 and six weeks later is 0.4. And I'm just like, oh my gosh, this is... You know, this is super real.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So let's say that guy walks into your office and he's a consult for me. You got a second opinion from San Diego coming out to Michigan. What are the critical bits, pathology, PSA, history, et cetera? And what are additional tests that you want to get at that point?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Well, thank you, Todd. Your previous episode on germline testing is still one of my favorites. We actually just published a paper on ordering TENS in men with high-risk prostate cancer. Much of that was inspired by our conversation.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So it's in urologic oncology. And, you know, long and short of it, we got our hands on the Invitae database and indication, who's ordering tests, med-onics, radonics, medical geneticists, and, you know, kind of looked at things over the last... five or seven years. And as maybe would be expected, urologists are getting more familiar with testing.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Perfect. Spot on. So just a couple of thoughts. You mentioned the Gleason score, the margins, the time. Those are all kind of makes really good sense. If this patient were to use them as a case example. I also typically would still order MRIs of the pelvis post prostatectomy. Is there something that might not be quite as PSMA PET visible? Any opinions on that?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah. Okay. So then, I mean, hopefully they've met with a radiation oncologist somewhere along the way to kind of run through all their options. I mean, obviously some patients are like, I want surgery and they get surgery and they may have had an opportunity to take advantage of the multidisciplinary team.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
A lot of times we try to get them in to see our pelvic floor physical therapists, even before the operation, just to kind of get all that optimized and everything.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
whatever maneuvers you can to get their functional status tip top ship shape if they're super high risk i'd like to float the idea on the front end that we're not gonna do anything for six months it's generalization but that way they're not like oh my god my psa is undetectable this dude honest to god he's dried you know it's he's ahead of hood sparing and it was all kind of favorable anatomy and
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
But I get it that, you know, they want to start doing something like day before yesterday and they're still healing, recovering, so on. Can you just comment on the timing conversation and how you're like, this is something that needs to be addressed, but we may not be addressing it for some time?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So Todd, when you're thinking about Doing something salvage, let's say now the patient's recovered, whether they're persisting, elevated or a post prostatectomy, undetectable to detectable. And you think about salvage treatment, what are the kind of modifiable elements to that?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And especially as, you know, the NCCN guidelines has advised for high-risk localized prostate cancer patients to get tested. We're doing more of it, helping out our colleagues kind of down the pike, so to speak. So check it out if you haven't got a chance.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Based on a PSA.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah. So that's exactly how I think about it. And, you know, it seems like on the one end of the spectrum, it's like, let's just sit tight and we're not overly concerned.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
The other end of the spectrum is, you know, maybe even extrapolate from some of the stampede data where it's radiation, hormones, Abby, and, you know, you can make a case in a young, healthy person, aggressive disease that, that, and even doing an advent setting is not totally off the wall. I think again, extrapolating,
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So we recently reviewed in one of our journal clubs, how do we kind of personalize this beyond PSA, doubling time, leasing score margins and so forth. And there seems to be some emerging data on biomarkers. Are you guys using that at all to inform timing, PSA levels, ADT, yes, no? Or do you think that's still kind of early phase?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Exactly. Deciphering Arteria. You got it.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Perfect. So today, you know, it really is an honor, Todd. You had the distinct pleasure, I would imagine, of kind of spearheading the AUA-ASTRO consensus, SUO consensus on biochemical recurrence guidelines. And maybe just talk a little bit about that process. I mean, it's a big deal, right? We're like, we want to get in the guidelines, we want to get it paid for. And here's the guidelines.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So clinical trial through music coming to you, coming soon to a site near you, probably?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
That's awesome. That's awesome. So you mentioned timing, and I think, you know, I take that to mean PSA level, you know, so functionally they're there. Talk a little bit about who, when.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So I don't know if this comes across your desk periodically, post-prostatectomy, let's say maybe three, four years ago, biochemical recurrence, they've been staged and they've got a pelvic lymph node and they really, for whatever reason, are averse to radiation. Can you talk a little bit about salvage and lymphadenectomy, what your thoughts, opinions are? Oof sounds about right.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, yeah. I would say more early on in my career.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
No, I agree. I mean, I think when I was a young hotshot straight out, I was pretty excited. And the data that's kind of seared in my head is that Swarty's eight year biochemical recurrence free rates of about 8%. That kind of killed my enthusiasm. The cases are, are not terrible, not super, you know, you can get some surprise that your orders are tethered in after surgery. And, um,
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Anyways, but I mean, I think there's might be, if I was going to do it in a highly select motivated patient who's just feels like this is it for them, or maybe radiation is a contraindication. It's really gonna be like we're kicking ADT down the road. And maybe in some post prostatectomy, BCR, radiation. second biochemical recurrence, pelvic node only.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I think you can like have that conversation again to like kick it down the road, but I'm not like very enthusiastic about this anymore. So does that sound okay?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Okay. So we've talked a little bit about when to do it, getting them optimized, PSA levels, earlier is better, that this is a generalization. You're taking into these decisions, the preoperative risk of kind of a bad actor, ADT, nodes, metastasis, directed therapy. I mean, these are going to be multidisciplinary conversations, right? Where you want to have the whole gang in and
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So is there anything about the current kind of state of affairs? And we'll keep it to post-prostatectomy. I mean, I think focal therapy, post-radiation, those are whole separate conversations. I actually did a recent podcast with Amar Kishan on post-radiation, and it was mind-blowing, as always, such a bright guy.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
But how about just, you know, for us as good country urologists, urologic oncologists, is there anything that I'm missing here?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, I appreciate it. Thanks for kind of hammering the PSMA pet part. I feel like I maybe took that as a foregone conclusion, but it's important to specifically mention that. And I also think it's worth mentioning that if a PSMA pet is negative, that doesn't mean you shouldn't receive treatment necessarily.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah. It's always like a bit of a interesting thing when I read like a report or I hear that we're in a wait for the PSA rises a bit to get the PSMA pet. I'm like, right now we're just doing our due diligence, like box check. You don't have any obvious mess. Let's let's go. Okay, perfect, Todd.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And then maybe, you know, we kind of talked about some of the things that are coming to the pike that are going to allow us to personalize these intriguing, fascinating, complicated decisions, which are nearly certainly only to get more complicated, which is a good thing in the future.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
What makes you excited about the future of management of patients with the biochemical recurrence after prostatectomy?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, I mean, it's things like they're moving at such an exciting and breakneck speed. And sometimes I think it's a little bit hard not to get super excited about the newest and the latest and the greatest. And, you know, one of the things that always strikes me with the Music Michigan group is how you all are thoughtful and the cart doesn't seem to get ahead of the horse very often.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
You know, we've got the Indicate study, which I think is a great study, you know, in this exact clinical space over here, because I think we start doing things because it makes sense. It seems like that's where the data is heading.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And maybe even to the, you know, the folks out here that are interested, you know, some of these questions about how do we responsibly bring in new tests, new elements are still super ripe for research. And And with the higher grade stage cancer that we're treating, I think we're going to see more biochemical recurrence would be my sentiment.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Well, Todd, you know, appreciate your time, appreciate your efforts. You know, it really is a tremendous guideline. I encourage everybody to take a look at it. And always a pleasure to pick your brain. Thank you so much.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Backtable is hosted by Aditya Bagrodia and Jose Silva.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Well, that's super cool. And this is the first BCR salvage therapy guideline, right? This is not a iteration or update. This is this is a tabula rasa.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
It's awesome. It's super helpful. And, you know, I kind of half the time feel like guidelines are so vague, they're just like completely useless. But this one I thought was really, really tremendous, Todd. And I'm not just saying that. I've been fortunate to sit on a couple guidelines committee, and I feel like I'm the lucky guy that gets to fine tooth comb like an already like amazing document.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And my contributions are usually fairly incremental, I would say.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Did you put the pen to the paper? I mean, like, here's the draft, send it out.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Awesome, man. Well, let's jump into it. And before we started recording, I'd asked when you kind of came through and finished up, and I think we're roughly in the same vintage. And my opinion is it's been a very exciting time with, you know, tremendous advancements in our understanding, diagnostics, et cetera. And maybe I'll ask you, Todd, to take a walk down memory lane and
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Even back to trainee, you know, how you thought about post-prostatectomy, biochemical recurrence to now. And that's a huge question. So, you know, don't overthink it.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Hello, everyone, and welcome back to the Backtable podcast, your source for all things urology. You can find all previous episodes of our podcast on Apple, Spotify, and at backtable.com. Now, a quick word from our sponsor. This discussion is brought to you by VeriCyte, provider of the Decipher Prostate Genomic Classifier.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Totally. And, you know, if I may, like early on, like as like a resident, like seeing somebody in clinic who had like a biochemical recurrence, I was like so freaked out. I was like, this is like nothing could be worse. Like it dreaded the conversation. It was just like, so you felt like the patients are just... living and dying by those PSAs. And, you know, I imagine it was somewhat similar.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
This is in an era to sound like a dinosaur where, you know, certainly everybody with grade group two disease got treated, still plenty of prostatectomies for grade group one disease. So there's probably been a shift in biology. But, you know, Bogrodia circa 2010 was freaked out. Then Bogrodia was more like, okay, everything's going to be okay.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And now, 10 years into practice-ish, the people that we're operating on are such higher risk, generally speaking, that I might be coming full circle to...
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
semi not freaked out but you know biochemical occurrences aren't just like oh this is nothing don't sweat so and yes you know of course adjuvant for all practical purposes outside of like you know maybe young node positive particularly offensive scenarios as as fallen by the wayside So I think a lot of this, this kind of resonates what you're saying and well, let's, let's jump into it.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I mean, first things first, when you're sitting down talking about surgery with the patient, did you bring this up or, or what's your kind of style on this Todd?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Decipher Prostate is a test for patients with localized prostate cancer that can help personalize treatment. Every patient and their prostate cancer is unique, and Decipher Prostate can provide meaningful insight into the aggressiveness of each individual patient's tumor.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And when you talk to patients on the front end and you're talking about the efficacy, do you use words like cure just out of curiosity or, you know, what do you actually say to the patient?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, no, spot on. I mean, like for one of the areas that I have some interest in is testis cancer, and it's kind of nice. You can tell a patient, you know, two years into a pretty good deep sigh of relief and, you know, 95% of recurrences will come in.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Backtable is hosted by Aditya Bagrodia and Jose Silva. Our audio team is led by Kieran Gannon, with support from Josh McWhirter, Aaron Bowles, Nick Shellcross.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
The content in this podcast is the opinion of Dr. Julie Riley and does not represent the opinion of Boston Scientific.
BackTable Urology
Ep. 193 Bladder Cancer Innovations: ESMO 2024 Highlights with Dr. Andrea Apolo
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend.
BackTable Urology
Ep. 193 Bladder Cancer Innovations: ESMO 2024 Highlights with Dr. Andrea Apolo
Backtable is hosted by Aditya Bagrodia and Jose Silva. Our audio team is led by Kieran Gannon with support from Josh McWhirter, Aaron Bolz, Josh Spencer. Design and digital marketing led by Brian Schmitz.
BackTable Urology
Ep. 187 Urology Trends: AUA 2023 Census Report Highlights with Dr. Amanda North and Dr. Matthew Nielsen
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend. If you have any questions or comments, DM us at underscore Backtable on Instagram, LinkedIn, or Twitter. Backtable is hosted by Aditya Bagrodia and Jose Silva. Our audio team is led by Kieran Gannon with support from Josh McWhirter, Aaron Bowles, Nick Shellcross.
BackTable Urology
Ep. 187 Urology Trends: AUA 2023 Census Report Highlights with Dr. Amanda North and Dr. Matthew Nielsen
Thanks again for listening and see you next week.
BackTable Urology
Ep. 188 Testosterone Therapy Today: Clinical Advances and Safety with Dr. Abraham Morgentaler
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BackTable Urology
Ep. 188 Testosterone Therapy Today: Clinical Advances and Safety with Dr. Abraham Morgentaler
Backtable is hosted by Aditya Bagrodia and Jose Silva. Our audio team is led by Kieran Gannon, with support from Josh McWhirter, Aaron Boles, Josh Spencer. Design and digital marketing led by Brian Schmitz.
BackTable Urology
Ep. 196 Biodesign Insights: Embracing Risk and Innovation with Dr. Christopher Kinsella
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BackTable Urology
Ep. 196 Biodesign Insights: Embracing Risk and Innovation with Dr. Christopher Kinsella
Backtable is hosted by Aditya Bhairodia and Jose Silva.
BackTable Urology
Ep. 192 Closing the Gender Gap in Urology with Dr. Yahir Santiago-Lastra
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend.
BackTable Urology
Ep. 192 Closing the Gender Gap in Urology with Dr. Yahir Santiago-Lastra
Backtable is hosted by Aditya Bagrodia and Jose Silva.
BackTable Urology
Ep. 192 Closing the Gender Gap in Urology with Dr. Yahir Santiago-Lastra
Design and digital marketing led by Brian Schmitz.