Our laser prostate surgery research is in this month's British Journal of Urology

We're happy to share with the world our work in this month's British Journal of Urology.

Pubmed citation

Full Paper

The paper deals with laser prostate surgery for benign prostatic hyperplasia (BPH), commonly known as an enlarged prostate.

Our experience with the procedure reveals that it is safe to perform this surgery with a discharge within hours of the procedure. This case series is important because having an ambulatory pathway can reduce hospital resource utilization, allow patients a more comfortable recovery in their home environment, and avoid further exposure to hospital based problems such as infections, errors, and falls.

In a laser prostatectomy, a laser fiber is used to destroy prostate tissue that is blocking a man's urinary flow.  An advantage from a laser based approach is less blood loss due to the sealing action of the laser.  This allows patients the potential for a same day surgery. 

The classic, surgical approach to BPH is the TURP or transurethral resection of the prostate.  As a opposed to a laser fiber, a cutting loop is used to shave away the obstructive prostate tissue.  Due the amount of bleeding postoperatively, patients are generally admitted to the hospital for at least one day with a bladder irrigating catheter.

Our research group is currently studying other aspects of advanced laser prostate surgery as well as the use of mobile apps in urology....so stay tuned!  More abstracts and papers to come...

Sharing our research at the NEAUA Meeting

Entrance to the Meeting at the Westin in Boston

I was at the 81st New England American Urological Association Annual Meeting in Boston last week.  The meeting was well attended with participants hailing from not only New England but also from many other parts of the US.  I had a great time catching up with colleagues as well as former residents I trained who are now colleagues (!).

At this year's meeting, I was also active as a member of the Scientific Program Committee, reviewing abstracts and helping the Program Chairs outline the format for the sessions.

My research group had a podium abstract at the meeting about laser prostate surgery.
Check out this prior blog post for more details about the abstract as well as my meeting involvement.

Drs. Ben Herrick (right) and Ron Yap (left) after our presentation.
See how relieved Ben looks?

Dr. Ben Herrick did a great job presenting our findings in the session.  The abstract was favorably received and marks the 4th time he has been able to share our research at a scientific meeting.  At this past American Urological Association Annual Meeting in May,  Dr. Herrick was first author on three abstracts for my group.  This is no small feat for such a large and competitive international meeting.  So kudos, Ben.  Keep up the good work!

Presidential Proclamation on Prostate Cancer Awareness Month

As a urologist, I'm in the front line everyday with my patients in the battle against prostate cancer.

Despite the controversy regarding PSA based screening for prostate cancer, the fact remains that prostate cancer is a leading cancer for men as far as incidence and mortality.  This disease is also the cause of much suffering in the world.

I'm pleased to see President Obama issue a proclamation yesterday acknowledging the burden of prostate cancer on American men, their families, and the healthcare system.

I urge my readers to check out this statement and spread the word about September being Prostate Cancer Awareness month.

Here are some suggestions for the month:

• Attend an educational event in your area about prostate cancer
• Consider a donation to a prostate cancer related charity
• Raise money to support prostate cancer research
• Talk to your doctor about prostate cancer   
• Talk to a family member or someone you know with prostate cancer and give him your support

If you have any other suggestions to support prostate cancer awareness please drop in a comment!

New Statement from the American Academy of Pediatrics on Circumcision

Today, the American Academy of Pediatrics (AAP) has released a new Circumcision Policy Statement. This release is an update to their last statement in 1999, reaffirmed in 2005.

I've linked to the primary sources in the medical literature because I think it's the best way to parse out any changes.

Here is a critical passage from today's statement (2012):

"Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV."

This is a more definite statement when compared to the 1999 statement:
"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision;"

Today's policy statement explicity highlights the medical benefits of circumcision and notes that overall the benefits outweigh the risks.  However, the statement stops short of recommending the procedure to all males.

The new policy statement's recommendation to have access for the procedure addresses the current lack of coverage for Medicaid subscribers in 18 states.

My analysis:
The circumcision debate has very entrenched camps for and against.  This issue is not simply a medical one.  It also involves the social, spiritual, and religious realms.  As a urologist by trade, my expertise lies with the medical.  There is burgeoning evidence that is hard to refute as noted in the AAP statement regarding the health benefits of circumcision.  However, ultimately, the decision as to whether or not to circumcise lies with the patient and family whilst receiving the appropriate informed consent from their physicians.  Families that elect to have circumcision should have appropriate support from insurers to due to its health benefits.  The health benefits of circumcision may cause the procedure to be classified as a preventative service.

Additional references/sources and for further reading:
LA Times Article (Brown)
USA Today Article (Painter)

Check out the Men's Health Checklist by the AUA

The American Urological Association recently released a "Men's Health Checklist" as a pamphlet and as mobile apps for Apple and Android.


Here is a link to the pamphlet. 


Here is a link to the app for Android.


Here is a link to the app for Apple.


The checklist breakdowns the health concerns by age: (18-39, 40-49, 50-69, 70+) as well as "Urology Specific" vs. "Related Health".


I think it's a great reference for men and healthcare providers alike. So, check them out and share them with the men in your lives!

What is a urethral or "Foley" catheter?

A urethral or "Foley" catheter is used to provide continuous bladder drainage. The catheter is named after a Boston urologist, Dr. Frederic Foley, who was instrumental in creating the catheter in the 1930's.


Here are some reasons why a patient would have one:

• monitor urine output
• alleviate urinary retention or severely dysfunctional voiding
• realign the urethra and bladder after urologic surgery or trauma
• help stop lower urinary tract bleeding

They are sized on the  French scale.  The diameter of the catheter x 3 = French size.  Here is a good link on Wikipedia on this scale. The most common sizes for routine use are 16F and 18F.

Urethral catheter
 Source: Wikimedia Commons/Olek Remesz
Creative Commons Attribution-Share Alike 3.0 Unported License

The catheter is placed inside the urethra and allows the bladder to continuously drain via a closed drainage system.  One the left side of the diagram there is a balloon port and a urine drainage port. The balloon port is where a syringe is placed to fill the balloon with fluid at the right side of the diagram.  The balloon is needed to keep the catheter in the bladder.  Without the balloon, the catheter would simply slip out.


The urine drainage port is connected to a drainage bag.  There are two types of drainage bags:


Leg Bag- a small bag with elastic straps that can be placed on the leg.  This allows the patient to discretely wear the bag under pants and move about.


Overnight Bag - this bag is larger and is usually used at night because of its capacity.  This is placed at the side of the bed, attached to an IV pole, or carried by a patient.


There are many other catheters out there that urologists primarily use.  One noteworthy example is a 3-way catheter that is used to treat urinary tract bleeding.  This catheter has an additional inflow port that is used to irrigate the bladder.  This fluid then goes out the drainage port with the urinary output.  


Reference: http://en.wikipedia.org/wiki/Foley_catheter

Radiation oncologists against new USPSTF prostate cancer guideline

The United States Preventative Services Task Force issued a new guideline in May recommending against PSA screening for prostate cancer altogether.  This government based panel has been getting the deserved pushback from the American Medical Association (AMA) as well as from the American Urological Association (AUA).  


Here's a prior blog post with my thoughts on this as well as the AUA response with current PSA screening guidelines from the AUA as well the American Cancer Society.


I wanted to share in this post a statement from the American Society for Radiation Oncology (ASTRO).  These doctors are on the front lines with us (urologists) in fighting prostate cancer.  ASTRO also has lined up against the new USPSTF guidelines.  

ASTRO statement

My analysis:


I agree with Dr. Gunderson's quote on this issue.  There certainly is an over diagnosis issue with prostate cancer.  However, as active surveillance is becoming a viable method to keep track of the disease, advocating for a wholesale cessation of PSA based screening is like throwing out the baby with the bathwater.


Dr. Sandler also makes a great point in the release. The prostate cancer screening issue is not a problem that a cookie cutter approach can solve.  With multiple factors such as age, expected longevity, race, symptoms, and family history, each situation is unique and each man should have the opportunity to make an individual informed decision on the matter with his physician.

Bladder Pal supporting overactive bladder awareness on AUA Foundation site

The American Urological Association Foundation (AUAF) has launched a site to increase awareness of overactive bladder (OAB).  The web presence is part of a multifaceted patient outreach initiative entitled - "It's Time to Talk about OAB."


In the site is a link to Bladder Pal for Apple and Android under the "Assess Your OAB Symptoms" heading. 


The site also has high quality information regarding OAB facts, symptoms, treatment options, and a resource to find urologic care.


I'm happy to partner up with the AUAF on this effort and am glad that many more people around the world have access to Bladder Pal to track their urologic health.


This OAB outreach initiative coincides with the release of new clinician guidelines for OAB that was disseminated at the AUA Annual meeting in May.

NEAUA 2012 Meeting - my involvement and podium abstract

My American Urological Association annual section meeting (New England) will be taking place in Boston at the Westin Boston Waterfront from September 6-8.   I've been involved with this meeting as a member of the Scientific Program Committee.  My duties on the committee have been to review abstracts as well as participate in planning discussions.  It has been a fun and gratifying experience to shape the structure and content of the meeting.


Here is the preliminary program.


My research group has an accepted podium abstract at the meeting!
It is entitled: "Laser Prostatectomy in the Severely Ill - Outcomes and Feasibility of a Rapid Ambulatory Discharge Pathway".  Dr. Ben Herrick, intrepid Dartmouth Urology resident, is lead author on this study. We show in the abstract that patients who are considered to be "severely ill" by American Society of Anesthesiology classification system can safely and effectively have a rapid ambulatory discharge from the hospital after laser prostate surgery.  In fact, 80% of patients benefited from the ambulatory pathway, 8% were admitted for 23 hour observation, and 11% were in the hospital for longer than 23 hours.


Laser prostate surgery for BPH has reduced bleeding compared to transurethral resection of the prostate (TURP) because of the sealing action of the laser.  As a result, it is feasible to send patients home the same day of surgery with a urethral catheter.  In contrast, patients are routinely admitted to the hospital after TURP.  Such an ambulatory pathway decreases utilization of hospital resources and allows the patient to recover in the comfort of his home.  Decreasing a patient's exposure to a hospital setting also decreases the possibility of hospital based or "nosocomial" errors, falls, and infections.  Though it would seem counterintuitive to send higher risk surgical patients home from surgery the same day, I believe that it is actually safer to do so because of such an avoidance of the hospital environment.  Our data shows that this can be done in a safe and effective manner.


I encourage all those out there to "save the date" and support this meeting in September!

AMA tells USPSTF to incorporate specialists in guideline creation

Resolutions were passed at the American Medical Association House of Delegates Meeting admonishing the USPSTF regarding their screening guidelines on mammography and PSA screening.


Here are the passed resolutions: (Source: AUA e-mail alert)

RESOLVED, That our AMA expresses concern regarding recent recommendations by the USPSTF on screening mammography and PSA screening and the effects these USPSTF recommendations have on limiting access to preventive care for Americans.

RESOLVED, That our AMA encourage the USPSTF to implement procedures that allow for meaningful input on recommendation development from specialists and stakeholders in the topic area under study.

Here is coverage from ABC News on the topic. 


The recent USPSTF guidelines for PSA screening were done without the input from the American Urological Association.  This is a big tripping point for me on the guidelines since we urologists are the main doctors who take care of men with prostate cancer.


Further, the USPSTF membership lacks oncologists and urologists. Here are the current members of the USPSTF: 


I applaud the AMA for taking a stand on this. Specialists represent a great resource for the crafting of these guidelines and need to be involved at the ground level, not after the fact.  Not involving main stakeholders who implement such guidelines reduces buy-in from the medical community as well as patients.

Men's Health Week table debrief

Last week, I hosted a Men's Health Week table at the Concord Hospital cafeteria on June 12th, 2012.  

The purpose of the event was to increase awareness of the Men's Health Week celebration as well as distribute educational materials regarding men's health concerns.  

We had free granola bars and popcorn at the table, courtesy of the Society of Urologic Nurses and Associates (SUNA).  Special thanks to New Hampshire SUNA Chapter President Kris Green, RN, CURN for the support.

Me at the table

At the table we had free information on:

• Prostate health
• Testicular self exam
• Fatherhood
• Low testosterone
• Mens and women's health checklists
• What women should know about men's health
• Highway safety

A plethora of free giveaways was graciously provided by the NH Highway Safety Agency.  Many thanks!  Did you know that the #1 cause of death for young men in America is "unintentional injury"?  I have a prior blog post about this issue.

The event was a success with about 150 people coming by.  I had many good conversations with people about men's health issues and was happy that people were not shy about approaching the table.
It was such a good experience that I hope to make this an annual event.

My Men's Health Week message in the Concord Monitor

This week, I wrote an op-ed piece regarding Men's Health Week and submitted it to my local papers.

Thank you, Concord Monitor, for publishing the letter.

Here is the article. 

Earlier in the week, I hosted a Men's Health Week awareness table at my hospital that went very well.  I'll post about that later, since I have several nice pictures of the event.  Stay tuned.

Hope you are all having a good Men's Health Week, and Happy Father's Day in advance!

Next week is Men's Health Week 2012!

Do you know when Men's Health Week is?  It's easy to remember.  It's the week up to and including Father's Day.  This year it's June 11-17, 2012.  Actually, the whole month of June is designated as Men's Health Month.


Here is a link about Men's Health Month and Men's Health Week from the Men's Health Network - a great resource for men's health advocacy.


On Tuesday, June 12th I'll be hosting a Men's Health Week table in the Concord Hospital cafeteria in Concord, NH from 8am to 2pm.  There will be free munchies, swag, brochures about men's health conditions as well as injury prevention materials (check out this prior post on young men and "unintentional injury").  If you are reading this and can drop by please do so to support our efforts!


Going into the week here are my public service messages:


Men - Get medical care and be responsible for your health - not only for you but for your loved ones too.


Women - Tell the men in your lives to get medical care and be advocates for their health needs.

Zytiga (abiraterone) for advanced prostate cancer before chemotherapy - ASCO 2012

Testosterone is a major fuel for prostate cancer growth.  Despite use of agents to induce clinical castration, men can continue to have advancing disease.  Zytiga (abiraterone) is pill that directly suppresses the synthesis of testosterone at multiple points in the body to further decrease testosterone production.   It is currently FDA approved for advanced castrate resistant prostate cancer after use of Taxotere (docetaxel) chemotherapy.  This indication restricts to use of this agent to the most advanced cases.


At this year's American Society of Clinical Oncology (ASCO) meeting, there was an exciting abstract about treating men suffering from advanced castrate resistant prostate cancer with Zytiga (abiraterone) before using chemotherapy.  Abiraterone caused improvement in progression free survival, time to narcotic use, time to use of chemotherapy, time to deterioration in clinical performance status, and time to PSA progression.  The study was terminated early due to the degree of improvement at interim analysis.


Here are links to media coverage of this abstract:
Reuters for a general audience.
Medpage Today coverage - more technically inclined.


This will likely lead to an expanded FDA indication in the future for use prior to chemotherapy.  Men will then have earlier access to this oral agent to combat the disease.

My take on USPSTF final prostate cancer screening guidelines

The US Preventive Services Task Force (USPSTF) released its final prostate cancer screening guidelines on May 21st, 2012, during the American Urological Association Annual Meeting (curious timing...in my opinion).


The task force recommended against PSA-based screening altogether for prostate cancer by giving the practice a "D" rating.  From the USPSTF grade definitions site this means: "The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits."  The task force suggests that healthcare providers: "Discourage the use of this service." This recommendation is no different than the draft recommendations issued in October, 2012 despite vocal opposition from many sources.


The American Urological Association (AUA), American Cancer Society (ACS), and National Comprehensive Cancer Network (NCCN) have issued guidelines recommending men to have discussions with their healthcare providers regarding the risks and benefits of prostate cancer screening.


AUA Guideline
ACS Guideline
NCCN Guideline


The AUA has expressed its vigorous opposition to the the final USPSTF recommendation.  AUA President, Dr. Sushil Lacy, released this statement about it on behalf of its members.  The AUA also has a website about the issue and prepared a fact sheet about PSA testing for its members.


My take:
The PSA screening controversy is a complex issue.  There are many factors involved in screening such as age, expected longevity, race, family history, and urologic symptoms.  I believe that at this time, the USPSTF blanket recommendation is too simplistic.  I urge men to talk further with their healthcare providers regarding this issue and consider referral to a urologist if there are still lingering questions about prostate cancer screening.  Also, the diagnosis of prostate cancer does not necessarily mandate treatment.  Depending on the clinical scenario, monitoring of the disease or "active surveillance" can be a viable option for many men.

Useful prostate cancer video from NH Prostate Cancer Coalition

A very informative video from the New Hampshire Prostate Cancer Coalition (NHPCC) about prostate cancer and prostate cancer screening was just uploaded to their website.  It features Dr. William Santis, my partner, who is Director of Prostate and Urologic Cancer at Concord Hospital.


He honestly explains in layman's terms prostate cancer screening as well as the screening controversy.  The video has a nice diagram of the lower male urinary tract as well as useful facts about prostate cancer.


Please check out the video and post any feedback so I can relay this the NHPCC and Dr. Santis.

Thank you Memorial Sloan-Kettering for referencing Prostate Pal

I'm happy to share this link from the Memorial Sloan-Kettering Cancer Center (MSKCC) Library Blog.

They have referenced "Prostate Pal" as a mobile resource for patients dealing with prostate cancer.  MSKCC is one of the premier cancer hospitals in the world. I think it's great to have such a prominent instution advocate for mobile apps as a way to further empower patients and increase efficiency of care.

Their library also has a reference page for other healthcare apps for patients and their families.  The resources were selected by their staff librarians.  I encourage those who are interested in mHealth to look at the site and check out the apps.

Caricatures of men's health in the media

I just read an interesting article on KevinMD regarding men's health issues on TV.

If you read the comments after the article, I chimed in on the piece, but also wanted to drop it in my blog because I think it's quite topical with Men's Health Week coming up.

My comments:
Great article, Joel.  As a urologist who deals with the conditions you referenced, I can relate to the lack of respect for male health at times in the media.  There needs to be more constructive awareness of men's health concerns from reputable medical professionals, not just caricatures and off colored jokes.
Here is a challenge. When is Men's Health Week?  Answer - The week up to an including Father's Day (June 11 - June 17, 2012). I doubt that most in the blogosphere knew of such a celebration. 
It is up to us in medicine to get out there and increase advocacy for male health concerns!

Bladder Pal at the AUA Annual Meeting

Entrance to the AUA Meeting - Georgia World Congress Center
Photo Credit - Ronald Yap, MD

I recently returned from the American Urological Association Annual Meeting in Atlanta.

I did a few things at the meeting, but wanted to focus this post on "Bladder Pal".  If you want to read about what I was doing altogether at the meeting please check out this prior blog post.  For more background info on "Bladder Pal" check this post out.

On Sunday, May 20th, I demonstrated "Bladder Pal" to members of the AUA Foundation (AUAF) and Overactive Bladder (OAB) Expert Panel.  New guidelines for the management of OAB were released at the meeting and the AUAF is doing a patient outreach initiative to increase awareness and treatment of this condition.  To help support this effort, "Bladder Pal" will be highlighted as a tool to empower patients to track their urologic health in conjunction with their healthcare providers.  I'm honored and excited to be working with the AUAF on this and hope that "Prostate Pal" can also be helpful to the Foundation in the future.

Me demonstrating "Bladder Pal" at the AUA Foundation Booth
Photo courtesy of Alaina Willing - AUA Foundation

As you can see from the picture, my tie looks quite short.  Prior to my booth appearance, I taught a "hands on" course on laser prostate surgery and had to tuck it in my tie to keep it out of the way.  The only problem is that I forgot to untuck it and was walking around most of the day with it looking like that.  I was talking to all sorts of people with that thing tucked in and no one said a thing!  

On Tuesday, May 22nd, "Bladder Pal" was discussed during a podium presentation at the meeting.  The reception was very positive and the downloads skyrocketed after the presentation.  The abstract even made it to the highlight reel for the meeting.  Click on the Urodynamics/Female Urology link and "Bladder Pal" is profiled starting at 7:53.  

I'd also like to give some kudos to Dr. Ben Herrick, a Dartmouth Urology resident, who presented the "Bladder Pal" abstract and two other abstracts with me at the meeting.  He has been part of my research group for the past year and has been doing one heck of a job.  

What is BPH?

The term BPH or an "enlarged prostate" is commonplace, but what exactly is it?

BPH is an acronym for Benign Prostatic Hyperplasia:

• benign - noncancerous
• prostatic - in prostate
• hyperplasia - multiplication of cells

In BPH, the prostate cells increase in number and are packed closer together. This causes enlargement of the prostate gland and closes the urethra through which urine passes between the bladder and penis.
 

Left - normal prostate             Right - prostate with BPH
Source Wikimedia Commons and NCI

BPH starts early and insidiously, usually in the 40's with an incidence proportional to age.  That means that a 50 year old man has about a 50% chance of having BPH.  Therefore, in general, BPH is an issue of when it will happen rather than if it will happen.

 
Why is BPH a problem?

As the prostate enlarges it closes the voiding channel.  This can cause urinary symptoms including frequency, urgency, hesitancy, feelings of incomplete emptying, nighttime urination.  BPH can also cause urinary tract infections, urinary retention, hematuria, and even kidney damage.

Please see this prior blog post for more info on urinary symptoms.

Therefore, BPH can affect a man's physical health and quality of life.

What causes BPH?

One significant factor in prostate growth is the male hormone testosterone, or more specifically dihydrotestosterone (DHT).  DHT goes into prostate cells and causes an increase in cell multiplication.  Though male hormones are a big factor, medical science has not identified all the factors that are involved in prostate hyperplasia.  Identifying other mechanisms for this disease process are breakthroughs waiting to happen.

ACPE "Share Your Story" session up on their website

The American College of Physician Executives have placed all the posters from the "Share Your Story"
session from the recent 2012 Annual Meeting on their website.  The poster session highlighted various ways physicians are changing healthcare at their institutions.

I was honored to present in this forum regarding mobile healthcare technology.  Through "Bladder Pal" and "Prostate Pal", to date several thousand users have been empowered to track their urologic health.

With the American Urological Association Annual Meeting presentations coming up, there will be more awareness of the apps and hopefully increased usage of these helpful tools.

Preventing young male death in America

The Centers for Disease Control and Prevention (CDC) website has a plethora of statistics regarding the health of America.  I have reviewed the site and found the tables for male all cause mortality by age particularly enlightening.

Predictably, the number one and two causes of death for males 45+ is heart disease and cancer.  These diseases are well known in the public eye with significant resources put towards the prevention and treatment of these conditions, and rightfully so.

The eye-opener for me is this statistic for young males. The number one cause of death for males from age 1 to 44 is "unintentional injury".  This trend is also seen in females with "unintentional injury" the leading cause of death from age 1 to 34.   Unintentional injury is used rather than "accident" because public health officials believe that many can be potentially preventable.

Though a death at any age is difficult, the demise of a young person is especially tragic.  In addition, the loss of productive years of work and reproduction are also quite a loss to society at large.

Some things that come to mind for young men to prevent such tragedies are:

• Don't drink or use drugs and operate machinery
• Don't speed
• Wear your seatbelts
• Use good firearm and hunting safety practices
• Wear a helmet for bikes, motorbikes, ATV's
• Wear a life vest when using watercraft 
• Be aware of workplace safety

Obviously, this list is far from comprehensive...

On Tuesday, June 12, I will be distributing unintentional injury prevention materials at the Concord Hospital cafeteria to celebrate Men's Health Week - more on that celebration in another blog post.

Happy Nurses Day/Week!

Today is National Nurses Day.

It also kicks off National Nurses Week - a celebration of the many contributions of nursing to society.  It is the week up to May 12th which is Florence Nightingale's birthday - recognized as the founder of modern nursing.

There are so many nurses I interact with in the clinic, ward, OR, and conference room that I can't thank you all by name.  This holiday also extends into my personal life since my mother is a nurse practitioner.

So... I'd like to extend my thanks to all nurses everywhere for their multifaceted work!

Gearing up for the 2012 AUA Annual Meeting

The American Urological Association (AUA), has its annual meeting coming up this month from May 19-23.  It's a huge convention with over 11,000 attendees from all over the world.  The topics cover the entire spectrum of urology.  There are so many things going on during the meeting that it is important to be systematic and selective about your learning goals.

For those who have never heard of this meeting, it's probably shocking to know that there will be 11,000 urologists in one city at the same time. Since most urologists are male, I can also tell you that it's one of the few times I've seen the bathroom line being longer for the men's room than for the ladies'.  Leave it to a urologist like me to make such an observation!

It will be a busy meeting for me this year.  Here's what I'll be doing:

- I will help teach a class on laser prostate surgery for BPH  (108HO: Modern Alternatives to TURP: Lasers and Bipolar Sunday, May 20, 2012, 8 – 11 a.m.).  

- From 11a - noon that day, I'll will be at the AUA Foundation (AUAF) booth in the exhibit hall to talk about the Bladder Pal app.   I'm very excited to announce that the AUAF has approached me to collaborate via this app on their new overactive bladder awareness campaign.  By working together we will be able to increase recognition and patient empowerment for this condition.  

- Later in the week, I will be presenting 3 abstracts:

1. Abstract 1548: "Bladder Pal" - Empowering Patients to Monitor Urologic Health with Mobile Technology
2. Abstract 2010: "Prostate Pal" - Empowering Patients to Monitor Urologic Health with Mobile Technology
3. Abstract 2170: It Is Safe to Teach Residents Laser Prostatectomy in the Private Practice Setting

Here is a link to the abstracts if you want to read them.

I hope to catch the BPH and men's health related sessions and as many plenary talks as I can since they are particularly informative and contemporary.

If you are reading this and will be at the meeting, please grab me and say hi!

Talking about prostate health at NP conference tomorrow

No rest for the weary.
After just coming back from the ACPE Annual Meeting in San Francisco, I have a talk about prostate health at the 19th Annual Northeast Regional Nurse Practitioner Conference tomorrow afternoon (5/3 at 2:30pm).

Here's a brief on the talk from the conference brochure:

"SEMINAR 12:

PROSTATE HEALTH SCREENING/

PROSTATE HEALTH

Ronald Yap, MD

The issues and recommendations related to this topic continue to evolve.

During this session, we will discuss two common issues affecting the aging male:

prostate enlargement (BPH) and prostate cancer screening. We will review current national guidelines. Up to date research, management options and controversies will be discussed."

It will be a jam packed talk.  Last year, I talked about BPH alone and took up the entire time.

Given the recent stories regarding screening involving Warren Buffett's prostate cancer, USPSTF guidelines, and evolving clinical studies, adding the prostate cancer screening part will hopefully clear up some confusion about this issue. 

I have the talk as a .ppt file and have thought about putting some videos up with my lecture material on You Tube at some point in the future.  If this is something you'd like to see please comment.

ACPE meeting debrief - Make your life more like a casino

Just got back from the American College of Physican Executives Annual Meeting.
It was a very enlightening time.  I really enjoyed meeting physicians from all over the world with a deep interest in shaping the future of healthcare.

I presented a poster on my mobile apps - Prostate Pal and Bladder Pal that was very well received!  I got some great feedback for future directions of the apps...as well as my career with respect to mobile healthcare technologies.  Thank you to all those who came by and engaged me about this.

I'd like to focus a little bit on our keynote speaker - Peter Sims, author of the book "Little Bets: How Breakthrough Ideas Emerge from Small Discoveries".  He gave a great talk about making small low risk pilot projects and prototypes to drive creativity.  Some references he used to support this process were Frank Gehry's extensive use of models to create new buildings, Pixar's way of creating films, and the comedian's use of small venues as a lab to create new material.  After his lecture, we participated in fun exercises to demonstrate the "Little Bet" principles that really let our creative juices flow.

Thanks to the meeting,  I feel more empowered to take more creative stabs at things and approach life like a player in a casino rather than a nervous soldier in a minefield!

New drug approved by the FDA for ED

The FDA has just approved a new agent for male erectile dysfunction -  Stendra (avanafil).

This medication is in the same class as Viagra (sildenafil), Levitra (vardenafil), and Cialis (tadalafil) - phosphodiesterase type 5 inhibitors, or PDE-5 inhibitors.

How does this new agent compare to the existing drugs?   Avanafil's reported time to maximal blood level or Tmax  is 0.593 hours compared to 1, 0.7, and 2.0 hours for sildenafil, vardenafil, and tadalafil respectively.  The reported half-life is 1.19 hours compared to 3-5, 4-5, and 17.5 hours for the other three respectively.
Reference: Drug Des Devel Ther. 2011;5:435-443

Based on this pharmacokinetic data, avanafil should work faster then be more quickly eliminated from the body compared to the other currently available drugs.  It's targeting the end of the market where people want a fast onset of action and only have the medication in their system for the least amount of time.

Tadalafil targets the other end of the market where a man can take a daily formulation (2.5 mg or 5 mg) to be ready at any time or an as needed formulation (10 or 20 mg) where he can be ready for up to 36 hours.

It's too early to say what the differential impact will be between all of these drugs clinically.  In the end, as some of the older drugs come off patent in a few years and the US market is flooded with generics, the relative cost of each agent will likely be a significant driving factor as to what oral agent patients choose.

Why is the testis called the testis?

I have a pet peeve.  Over the years, I've heard many people call or spell the testis a "testi" or "teste", perhaps from seeing testis or testes and removing the "s" thinking that it's plural.  Since it's a latin word, the singular form is testis and the plural is testes.

So where does testis come from?  Well, there is a commonality between the male gonad and a court of law.  No, this is not a lawyer joke.  Let me explain...When you are a witness in court you testify and in a man's scrotum are testicles or testes.

They share the same root word, testis, which means a witness.

Some related words from Wiktionary are:
test
testament
testify
testimony

How does this word relate to a the male anatomy?  This root word was applied to the male gonad because it is a "witnesses for a man's virility".

It's funny how I've been involved in urology for many years and didn't know all these details about the word until now!

Union Leader Forty Under 40

I've recently been named by the New Hampshire Union Leader as one of the Forty Under 40 for 2012!

Union Leader profile

The awards ceremony recently happened at the Manchester Radisson.
It was a great occasion with the Governor presiding over it.

Here's pic with me and the Governor (right) and someone from Citizen's Bank (left)

Unfortunately, it's only a preview picture!  I had to spend $7.50 to get a digital copy for my home photo album. The commercial one-time digital right to post a real pic on this blog was $100!  There's also other merchandise for sale on the site.  I'm sure all of you out there in the blogosphere are dying to get your hands on a coffee mug of the event! ;)

All that minor griping aside, I'm definitely honored to be part of this year's class and thank the Union Leader for bestowing it on me.  It's gratifying to see mobile healthcare technologies, urology, and male health  being spotlighted through this award!

Warren Buffett and President Obama vs. USPSTF guidelines

As an 81 year old man, it's ironic that Mr. Buffett is in the demographic that the United States Preventive Services Task Force (USPSTF) recommends against screening.  The current official recommendation from this body is that people aged 75 years of age or older should not be screened.

USPSTF prostate cancer screening guideline - 2008 (in revision)

This guideline is old and their current draft guidelines advise against screening altogether.  This new proposed guideline was released in October, 2011 and had two comment periods after release.  Their final recommendation is pending.

USPSTF draft guideline against all screening for prostate cancer

The new proposed guideline has drawn the ire of many groups, with the American Urological Association leading the way.

AUA page with USPSTF response

I too have been involved in the response, sending an editorial to the Concord Monitor.  In particular, I detail the interesting fact that while this controversy is going on that President Obama just had a PSA test. If the new draft guidelines were used, he would be advised against having the test.  I feel that he should have the test and continue to do so, especially since he's in an at-risk demographic by being African-American.

As stated in my prior blog post about Warren Buffett's cancer, I think using age alone is a very simplistic cutoff.  Prostate cancer is quite complex and the medical data is still evolving.  There is little controversy that there is a problem with the over diagnosis of prostate cancer.  However, diagnosis does not necessarily mean treatment.  One good aspect of this controversy is that there is more awareness that many men have very low risk disease and can be managed with active surveillance.

The bottom line is that we currently don't know which patients with prostate cancer will die of that disease.  Until this issue is further clarified with more clinical studies or a breakthrough in prostate cancer detection, men should have an informed discussions with their doctors regarding this issue on a case by case basis.  It is premature for the USPSTF to issue such a blanket statement that affects the health of millions of men in the United States.

Warren Buffett's prostate cancer disclosure and treatment

Since Warren Buffett's recent disclosure of prostate cancer has made a lot of headlines, I thought I'd share some commentary on it today.

Mr. Buffett's letter to shareholders revealing that he has prostate cancer.

My thoughts as an outside observer:

It seems that he has T1c or prostate cancer detected by PSA testing alone.  Since we don't know his PSA history, Gleason score (a number that tells us how aggressive the prostate cancer cells are), or number of cores positive in his biopsy, it's difficult to know exactly how much disease he has in the gland or how risky it is.  Warren Buffett's treatment with 2 months of external beam radiation therapy is a mainstream option for someone electing to be treated for this disease.

It is controversial in the medical community as to whether nor not a man of his age (81 years) should have been screened in the first place.  Since Mr. Buffett seems to be a man in excellent health with a likely expected longevity of 5-10 years, such screening may have been reasonable.  In my opinion, a chronologic cut off for who should and shouldn't be screened seems overly simplistic.  There are many factors aside from age such as anticipated longevity, family history, and race that also need to be taken into account.  Therefore, I encourage men to have an individualized discussion with their doctors regarding the risks and benefits of prostate cancer screening. 

Mr. Buffett's prognosis is excellent.  Since we don't have his cancer specifics, we can rely on general prostate cancer survivorship data.  From the American Cancer Society, his 5 year relative survival rate is nearly 100%, his 10 year relative survival rate is 98%, and his 15 year relative survival rate is 91%.  Plenty of time for him to work out a succession plan for Berkshire Hathaway.

American Cancer Society survivorship page for prostate cancer

Best of luck to Warren Buffet and his family as he embarks on his treatment.

What is a urologist and how do you become one?

The public, my patients, and even some colleagues ask what a urologist does.

Here is some general information regarding the speciality of urology, including some material gleaned from the American Urological Association (AUA) and the American Board of Urology (ABU) websites:

What is urology?

Urology is a surgical specialty that deals with diseases of the male and female urinary tract and the male reproductive organs.  This includes organs such as the kidneys, bladder, and prostate gland.  In addition to surgical knowledge, urologists also must be familiar with specialties such as internal medicine, pediatrics, and gynecology to care for the broad spectrum of problems that affect these systems. 

What is particularly enjoyable about this specialty is that we can care for patients of all ages.   Many medical students are drawn to urology because of our stereotypical easy demeanor and our facility with both the medical and surgical treatment of genitourinary diseases.

How does someone become train to become urologist?

Urologists complete at least 4 years of medical school after college to obtain a MD. Thereafter, urologic graduate medical education occurs at training hospitals.  This consists of 1 to 2 years of general surgery followed by urologic training for a total of 5 to 6 years after medical school.  Some urologists do fellowships ranging from 1 to 3 additional years of training to further subspecialize.

 

The AUA has identified seven subspecialty areas within urology:

• Pediatric Urology
• Urologic cancer such as prostate, kidney, bladder, and testicular cancer
• Kidney Transplantation
• Male Infertility
• Stone disease of the urinary tract
• Female Urology 
• Neurourology

How is a urologist certified? 

In America, board certification is done by the American Board of Urology.  There are generally correlate bodies in other countries of the world.

The certification process consists of two parts:

1. First part - qualifying written examination as well as a review of credentials, education, and training.
2. Second part - After passage of part one and a minimum of 16 months of practice, candidates can then submit a practice log and undergo peer review and review by the board.  If the candidate is qualified, he or she can take the second oral certifying exam.

Beginning in 2007, ABU has initiated a maintenance of certification process for those who become certified or recertified.

Here are the reference links:

American Board of Urology

American Urological Association - What is urology?

We’re quite enthusiastic about our craft and enjoy discussing it with any interested party. So please talk to one of us for further information!

NCCN cancer guidelines for doctors and patients

The National Comprehensive Cancer Network (NCCN) is a consortium of 21 leading cancer centers across the country.  They write clinical guidelines for oncologic care with panels of doctors who are some of the best minds in cancer care.  As an active clinical urologist, I use their guidelines frequently to give my patients the most up to date, evidence based care.

If you are a clinician or interested patient here is a link to their clinical guidelines:

NCCN Clinical Guidelines

They encompass all major human cancers and are listed by site.  Since I'm a urologist, I almost exclusively use the prostate, bladder, kidney, and testicular cancer guidelines.

The NCCN has also produced an excellent guideline for prostate cancer patients.  Here's the link:

NCCN Patient Guidelines

It uses very clear language and starts from the basics.  With so many treatment options out there, it is nice to have an unbiased resource for patients during such a difficult time in their lives.

Describing your urinary symptoms to your doctor

The urologic system can be quite a mystery to many people.  When you see your doctor for urinary issues, it can be difficult to find the right words to describe your symptoms.

In this post, I'll review some symptom terminology so that you can communicate more effectively with your healthcare provider.

"Urias":

• dysuria - pain with urination
• hematuria - blood in the urine
• nocturia - night time urination
• pneumaturia - passage of air with urination

Leakage:

• urge incontinence - urinary leakage due to feeling like you need to urinate and not making it to the bathroom in time
• stress incontinence - urinary leakage due to coughing, straining, laughing, or other strenuous activities

Symptoms:

• frequency - how often you urinate
• urgency - how rushed you feel when you feel the need to urinate
• hesitancy - a difficult to start urinary stream
• intermittency - starting and stopping stream
• retention - sense of incomplete emptying after urination

Knowing a few buzz words can really expedite your visit and let your doctor know how empowered you are about your urologic health!

Sharing the Apps at the ACPE 2012 Annual Meeting

I will be speaking about patient empowerment through the use of the Prostate Pal and Bladder Pal mobile apps at the American College of Physician Executives (ACPE) Annual Meeting in San Francisco.

Here's a link to the meeting

If you don't know about the apps here are my previous blog posts about each of them:

What is Bladder Pal?

What is Prostate Pal?

It will be a poster presentation during the "Share Your Story" session on April 28th from 12:30 pm to 1:30 pm.

For those who won't be at the meeting, here is the poster:
(my apologies if the font is real small, it was hard to get it to fit within the borders of the blog text box)

ACPE 2012 "Share Your Story" Poster

Over 3,000 users have visited the apps over 10,000 times from countries all over the world!
It's quite gratifying to see that many people use the app to facilitate the tracking of their urologic health.

About me and the ACPE -
Since I have a deep interest in medical management, I've been a member of the ACPE for several years. The organization is at the forefront of physician leadership empowerment. With healthcare in turmoil, I'm happy that the ACPE is giving doctors the training and encouragement to be difference makers and facilitators of change. I'm currently working towards an MBA through the ACPE and U. Mass - Amherst.

About 2/3 of the way through!

Creating Bladder Pal

When Prostate Pal came out, there was a great launch.  The media attention related to the Associated Press article really made the downloads happen.  Due to the buzz, many women became aware of the app and asked for an app that would be more pertinent to their needs.  No woman was understandably interested in downloading Prostate Pal for their own use! 

I received lots of great feedback from Prostate Pal and sought to improve it with a second version.  At the same time, it made sense to spinoff a unisex version that women could use as well.  It turned out later that parents of children suffering from urologic conditions also found Bladder Pal very helpful.  

So soon after release of Prostate Pal, the work started on the update and the Bladder Pal app.  Once again, the LeBaron Foundation was the crucial funding in this endeavor through the Concord Hospital Trust and 9Magnets, LLC was the app development partner.  The main things I wanted to add to the app was leakage data, incontinence pad data, and an export function.  In May 2011, the updates were complete and Bladder Pal joined Prostate Pal in the App Store!

Bladder Pal has the following components:

• Bladder Diary - This is used to track fluid intake, urine output, urinary leakage, and incontinence pad changes.  The information that is logged will help your healthcare assess your urinary health and response to therapy.  Containers to measure output can be purchased at your local drug store.
• AUA Symptom Score - This is a questionnaire produced by the American Urological Association. It has been validated with numerous medical studies.  The list of questions are used to help men and women in conjunction with their healthcare providers assess their urinary symptoms and response to therapy.

Bladder Pal Home Screen

I'm particularly proud of the e-mail button as well as the clear home screen which includes daily leak and incontinence pad data.  9Magnets did a great job on the implementation.

Here are links to the Bladder Pal:

Bladder Pal for Apple

Bladder Pal for Android

Prostate Pal Initial Reception

When the app was submitted, it only took a few days for the Apple team to review it and clear it for distribution on the App store.  It was definitely gratifying to see it go live for the world to download!
Upon release, it was even listed as a "New and Noteworthy" app in the medical app section. That was an unexpected surprise.

Soon after release, an additional surprise was being approached by a reporter at the Associated Press for a story about the app!  It was exciting to relay to them my vision for utilizing mobile healthcare technology to improve doctor/patient communication and increase efficiency of care within urology.

Things truly move fast in the internet age because I spoke to the reporter about Prostate Pal in the morning and it was released on the newswire that afternoon.  Soon, it was carried by tons of news outlets and was all over the internet. When I was driving home from work that day, I even heard the story on the radio!

Short form of story

Long form of story

So the initial reception was truly beyond my wildest dreams.  I was just very happy that the increased exposure meant that more men would be aware of such a tool for their mobile devices and feel empowered to use it to improve their health.

Secondarily, by getting the app out there and having such press, I hoped that the stigma of prostate diseases can be lessened somewhat.  As the story revealed, many men believe that you should just live with prostate conditions....when in actuality proper urologic care can improve quality of life and be life saving in some cases.

Prostate Pal Mobile App

With the mobile technology revolution in full swing, I believe that this is an opportunity for healthcare to harness this energy to further empower patients, facilitate doctor/patient relations, and improve the efficacy of care.

Since I'm a urologist, I naturally think about such things within my realm of expertise.
For men, prostate disorders impact millions of men throughout the world.  In an effort to marry mobile healthcare (mHealth) with these interests, I came up with Prostate Pal.

Prostate Pal is a free app.  By free, I mean the real free - no in app purchases, "liteware",  or banner ads. By releasing the app in such a manner, the goal was to give men worldwide the ability to track their urologic health.

It's available on Apple and Android platforms:

Prostate Pal for Apple Devices

Prostate Pal for Android

The app consists of three parts:

• Bladder Diary - This is used to track fluid intake, urine output, urinary leakage, and incontinence pad changes.  The information that is logged will help your healthcare assess your urinary health and response to therapy.  Containers to measure output can be purchased at your local drug store.
• AUA Symptom Score - This is a questionnaire produced by the American Urological Association. It has been validated with numerous medical studies.  The list of questions are used to help men and women in conjunction with their healthcare providers assess their urinary symptoms and response to therapy.
• PSA Tracker - Prostate specific antigen or PSA is a blood test that is used to screen for prostate cancer and monitor response to prostate cancer therapy.  The tracker has a table and graph format.

Prostate Pal Home Screen

I first came up with the idea in early 2010.  Initially, I tried to program it myself with the Apple Software Development Kit.  However, the programming was too time intensive as well as too complex for me to fully implement my vision for the app.

Thankfully, two things happened that allowed the app to come together.  First, I received funding from the LeBaron Foundation and Concord Hospital Trust for the project.  Second, I ran into Cameron Banga and Mike Phelps from 9Magnets, LLC - an app development company. They did a great job executing the app and it was first released in January of 2011!

In other posts I'll talk about the further development of the app and stuff that happened after the release, It's been a pretty crazy ride since I thought about this app in my living room on a cold, New Hampshire winter night!