An interview with Drs. Drew Freilich, Mehrdad Alemozaffar, and John G. Pattaras
Advancing technologies and noninvasive treatments, along with more open communication between physicians and patients, are improving the lives of people with urological conditions and diseases, from incontinence to cancer. Atlanta Medicine recently spoke with specialists who are excited to share their knowledge of the changing landscape of urology.
Minimally invasive procedures for benign prostatic hyperplasia
A growing number of older and younger adults are willing to seek out treatment for chronic conditions that have had a long-term negative impact on their quality of life, says Drew Freilich, M.D., a urologist with Urology Specialists of Atlanta.
“We’re seeing a trend of patients of all ages who are willing to be more aggressive in the treatments they want. They don’t want to continue using catheters and they are more open to accept the risks of undergoing anesthesia for procedures that can help them,” he said. “We’re also finding that cardiologists are more open to clearing older and sicker patients to go into the O.R.”
One example is men who suffer from an enlarged prostate, which causes inability to urinate and often requires them to stay catheterized and/or to take multiple medications. Freilich cites some minimally invasive procedures that are effectively reducing prostate size in cases of benign prostatic hyperplasia (BPH).
“Historically, in cases of benign prostatic hyperplasia, if the prostate grew to a certain size — over 80 grams — open surgery would be performed to remove it. Today, we use a GreenLight laser to remove prostate tissue,” he explained. “The laser technology has been around for several years now. The procedure involves inserting a small fiber into the urethra through a cystoscope and basically ‘vaporizing’ the tissue. The procedure has lower risk of bleeding than previous treatments and improves urinary flow immediately.”
Freilich says two newer procedures — UroLift and Rezūm — are also effective treatments for relieving the symptoms of BPH with minimal risks for the patient.
“UroLift is sort of a ‘glorified stapler.’ We place implants that hold the enlarged prostate tissue out of the way to relieve compression on the urethra,” Freilich said. “Rezūm is an ablation procedure that uses radiofrequency general thermal therapy, or ‘hot steam,’ to destroy the extra prostate tissue that is causing the symptoms.”
Freilich says both procedures quickly improve urinary flow and have minimal side effects.
“UroLift and Rezūm both have good long-term outcomes,” he said. “The low risks and fast recovery time make this procedure popular with both older and younger men.”
Freilich adds that a large part of his practice is comprised of people who have finally sought help after suffering long-term from conditions such as BPH, urinary incontinence and erectile dysfunction.
“Many of them don’t know there is help for their conditions or have been too embarrassed to bring it up,” he said. “As physicians, we must be more proactive about having open discussions so that patients will understand there are options available to them that can improve their quality of life.”
Robotics improve cancer treatments
“Almost every case I’ve done this week has used a scope,” says John G. Pattaras, M.D., Associate Professor of Urology at the Emory University School of Medicine and Chief of Emory Urology services at Emory Saint Joseph’s Hospital. Pattaras, who started the laparoscopic and robotic urologic surgery at Emory 17 years ago, adds that technology has evolved to make a wide variety of surgeries — including those for kidney, prostate and bladder cancers — more effective.
“Robotics allow us to see better inside the patient. It’s not just diagnostic; it’s changed our ability to do reconstructive surgery,” he said.
Pattaras says that robotic surgery has made treatment of kidney cancer, in particular, more successful.
“In the last several years, we have seen mounting evidence that if we could remove the cancerous tumor from the kidney and spare the organ itself, the patient has a longer life expectancy. For certain size and stage tumors, removing the kidney itself has equal outcomes as far as cancer control. But this is not a good option for people who have only one kidney,” he said. “Robotic surgery gives us the precision to remove tumors, curing the cancer while preventing further deterioration of the kidney.”
For prostate cancer, the surgery that has employed robotics for years, improvements have also occurred as the technology has evolved.
“This is a very compact operation, with a complex reconstruction process to restore urination and erectile function. The robot became popular about 10 years ago as an alternative to open surgery for prostate cancer,” Pattaras said. “With today’s technology, we are able to do bigger surgeries with the same number of small holes and we’re managing more aggressive cancer. Robotics allow less invasive, lower morbidity surgeries.”
New methods for detecting and treating cancer
Mehrdad Alemozaffar, M.D., urologic oncology surgeon and Assistant Professor of Urology, Emory School of Medicine, says there are several recent technologies that now allow urologists to more easily detect and successfully treat various cancers.
“Bladder cancer is a good example of how a new technology is helping us locate and treat cancers more effectively. Sometimes we have difficulty finding tumors in the bladder because they can be very small and might not be readily seen using a standard cystoscope,” he said. “But we now have blue light cystoscopy, which is an enhanced imaging procedure that increases our ability to detect cancers that might be missed under regular light. It involves injecting a fluorescent agent into the bladder an hour before the procedure. The blue light cystoscope then picks up areas where the fluorescence has been taken up, which is preferentially cancerous cells.”
Alemozaffar cites another technology, targeted biopsies, as a very important tool in diagnosing prostate cancer.
“When a patient comes in with an elevated PSA (prostate-specific antigen) level, the only way we can truly diagnose cancer is with a biopsy. Traditionally the way we have done that is to take tissue samples from 12 different areas of the prostate in a somewhat ‘blind’ method,” he said. “Today, we have the ability to target actual lesions seen on an MRI. The MRI determines the probability of cancer using the prostate imaging reporting and data system (PI-RADS). We are then able to see inside the prostate using a combination of the MRI and ultrasound imaging and can zoom in on the targeted area to obtain a much more precise biopsy.”
Alemozaffar adds that the targeted biopsy, which allows him to see three-dimensional images of the prostate lesions, has been a game changer for detecting prostate cancer.
“I’m able to find more clinically significant cancers using this technology than I did in the past with the blind sampling biopsy,” he said.
Fluciclovine PET/CT improves radiotherapy targeting for recurrent prostate cancer
A clinical investigation article in the March 2017 issue of the Journal of Nuclear Medicine demonstrates that the PET radiotracer fluciclovine (fluorine-18; F-18) can help guide and monitor targeted treatment for recurrent prostate cancer, allowing for individualized, targeted therapy.
“This is the first study of its kind demonstrating changes in post-surgery radiotherapy target design with advanced molecular imaging in recurrent prostate cancer, with no demonstrated increase in early radiotherapy side effects,” explains Ashesh B. Jani, M.D., of the Winship Cancer Institute of Emory University.
According to the American Cancer Society, one in seven men will develop prostate cancer in his lifetime. In 2017, more than 161,000 new cases of prostate cancer are expected to be diagnosed in the U.S., and about 26,730 deaths from the disease are anticipated.
For the study, 96 patients were enrolled in a clinical trial of radiotherapy for recurrent prostate cancer after prostatectomy. All patients underwent initial treatment planning based on results from conventional abdominopelvic imaging (CT or MRI). Forty-five of the patients then underwent treatment-planning modification (better defining the tumor-targeted area) after additionally undergoing abdominopelvic F-18-fluciclovine PET/CT. No increase in toxicity was observed with this process.
The Emory researchers determined that the inclusion of F-18-fluciclovine PET information in the treatment planning process leads to significant differences in target volumes (the areas to receive radiotherapy). It did result in a higher radiation dose delivered to the penile bulb, but no significant differences in bladder or rectal radiation dose or in acute genitourinary or gastrointestinal toxicity.
These are preliminary results in a three-year study, which hypothesizes that there will be an increase in disease-free survival for patients in the F-18-fluciclovine-modified treatment group over those in the standard treatment group.
This study could have implications beyond prostate cancer. Jani points out, “Our methodology is readily applicable to other novel imaging agents, and it may potentially facilitate improvement of cancer control outcomes.”