Volume 23, Number 2 - Reviews in Urology

I’m thrilled to share a recap of our successful March 2024 DC Fly-In, where LUGPA members gathered in Washington, DC, to advocate for the crucial health care reforms outlined in our 2024 Legislative and Regulatory Agenda.

LUGPA News

Celeste Kirschner Evan R Goldfischer

As the leading voice of independent urology group practices in the United States, LUGPA educates policy makers on the benefits of integrated urologic care. LUGPA’s Health Policy and Political Affairs committees drive grassroots efforts by developing thoughtful analysis and engaging public officials through comment letters on major legislative and regulatory proposals, and other news.

Prostate Cancer

Real-World Comparison of Deep Prostate-Specific Antigen Response in Patients With Metastatic Castration-Sensitive Prostate Cancer Treated With Apalutamide or Enzalutamide

Benjamin H. Lowentritt Ibrahim Khilfeh Dominic Pilon Shawn Du Carmine Rossi Frederic Kinkead Lilian Diaz Jill Korsiak Patrick Lefebvre Gordon A Brown

Deep prostate-specific antigen reduction of at least 90% (PSA90 response) after androgen receptor pathway inhibitor initiation to treat metastatic castration-sensitive prostate cancer (mCSPC) is associated with longer survival. This real-world study evaluated the proportion of androgen receptor pathway inhibitor–naive patients with mCSPC who achieved PSA90 response 6 months after initiating apalutamide or enzalutamide.

Prostatic neoplasms Prostate-specific antigen (PSA)Prostate-specific antigen Prostate-specific antigens Castration Androgen receptor Androgen receptor antagonists treatment effectiveness

Bladder Cancer

Management of Adverse Events From Checkpoint Inhibitors in Urologic Practice: Where Are We Today?

Caroline Branch Daniel Canter Gautam Jayram

Urologic oncology has seen a tremendous impact from the emergence of checkpoint inhibitors in the management of malignant conditions of the urinary tract. These therapies are now in the nonmetastatic setting, and there is ample opportunity to integrate them into urologic practice. The most common barrier to starting a checkpoint inhibitor therapy program is concern about immune-related adverse event management. The evaluation and management of immune-related adverse events can be part of the treatment protocol and centralized to promote safety and success. The key components of implementing an in-office infusion program that includes checkpoint inhibitors are the use of a team-based approach, with a champion physician; appropriate patient education before and during treatment; and timely evaluation and treatment of all adverse events, with subspecialty consultation, if needed.

Immunotherapy Urology urinary bladder neoplasms

Bladder Cancer

Integrating JELMYTO (Mitomycin) for Pyelocalyceal Solution Into Community Practice: Practical Tips for the Urologist

Michael J. Shannon Sandip M. Prasad

Treatment options for upper-tract urothelial carcinoma are based on whether the patient has high-risk or low-risk disease. Low-grade tumors can be managed with nephron-sparing approaches, including ureteroscopic resection and ablation, although most patients undergoing endoscopic treatment of upper-tract urothelial cancers face a risk of recurrence. Mitomycin gel for pyelocalyceal solution provides an effective alternative therapy. In OLYMPUS, a phase 3, single-arm, open-label study, 58% of patients with low-grade disease experienced a complete response to induction therapy at 3 months. Kaplan-Meier analysis revealed an estimated 12-month durable response rate of 82%. The most common treatment-emergent adverse events were ureteric stenosis, urinary tract infection, hematuria, and flank pain (grade <3). Mitomycin gel offers a novel, kidney-sparing, nonoperative approach to managing low-grade upper-tract urothelial carcinoma.

Mitomycin Urology Drug therapy Urinary tract Carcinoma Urologic neoplasms urinary bladder neoplasms

Business of Urology

Meet the Expert: Lillie Shockney, RN, MAS

Joelle Hamilton

Discussions with patients with cancer who are facing metastatic disease progression must be handled with empathy and compassion. In this interview, Lillie Shockney, RN, MAS, the University Distinguished Service Professor of Breast Cancer and a professor of surgery at the Johns Hopkins University School of Medicine, shares her approach to handling delicate end-of-life conversations with her patients.

Neoplasm metastasis advanced care planning terminal care patient-centered care

Editorial

Advanced Practice Providers, Urology Workforce Challenges, and Reviews in Urology

Kenneth A. Mitchell

In 2015, the American Urological Association published the Consensus Statement on Advanced Practice Providers (APPs) with the goal of providing up-to-date information on the training of APPs, the scope of practice legislation, and examples of APPs in urologic practices.1 This statement was co-written by an experienced team of physicians and APPs whose purpose was to provide a unique and collaborative perspective on urology APPs. The paper was inspired by a report from an American Urological Association ad hoc committee assembled in 2008, which concluded that there were substantial workforce shortages in urology and that physician assistants and advanced practice registered nurses would provide the “best solution” for the declining urology workforce.2 In 2009, reports estimated that there were 3.1 urologists per 100 000 people in the United States and that urology was the second-oldest surgical subspecialty, with a workforce median age of 52.5 years.2 A published update in 2021, which used data from 2018, revealed that there were 3.89 urologists per 100 000 people in the United States, with 65% of urologists reporting that they were “interested” in the integration and use of APPs; 72.5% of urologists reported already incorporating an APP into their practice, accounting for nearly 41% of a physician (ie, MD or DO) full-time equivalent.2 More recent data showed the use of APPs was lowest in practices with the youngest and oldest subgroups of urologists and was highest in urban urology practices, which represent groups most likely to be affected initially due to the disproportionate geographical urology patient population density.

Physician assistants nurse practitioners health workforce

Case of the Quarter

Case of the Quarter: Kaposi Sarcoma in a Patient With Testicular Germ Cell Tumor and HIV: A Case Report and Literature Review

Daniela V. Castro Donald Hannoun Tanya B. Dorff Alexander Chehrazi-Raffle Wesley Yip Abhishek Tripathi Benjamin Mercier Regina Barragan-Carrillo Hedyeh Ebrahimi Salvador Jaime-Casas

Testicular germ cell tumors are the leading cause of cancer in male patients 15 to 39 years old. Extensive treatments are available, and the regimen of choice depends on clinical, laboratory, and histopathologic characteristics. Patients with HIV are at increased risk of developing solid malignancies, including testicular germ cell tumors. All patients with HIV should start on highly active antiretroviral therapy, but the drug interactions between chemotherapy for testicular germ cell tumor and highly active antiretroviral therapy have not been extensively evaluated. This case review highlights the importance of optimal therapeutic agent selection in patients with HIV and solid malignancies.

Testicular neoplasm Germ cell HIV Testicular neoplasms Sarcoma

Coding Corner

Coding Corner: Healthcare Common Procedure Coding System Code G2211, Visit Complexity Inherent to Evaluation and Management

Jonathan Rubenstein Mark Painter Celeste Kirschner

For this issue, we reviewed the Healthcare Common Procedure Coding System (HCPCS) level 2 code G2211. Though the code has existed for a few years, Medicare began reimbursing physicians for reporting the code in January 2024. The code is used to describe the complexity of an evaluation and management (E&M) visit associated with an ongoing, longitudinal care relationship, focusing on a circumstance rather than a specific service. The circumstance described in this code differs from the prolonged services described by Current Procedural Terminology (CPT) codes 99358 through 99418; the case management services described by CPT codes 99366 through 99368; and the chronic care management services described by CPT codes 99490, 99491, and 99437 through 99489:

Benign prostatic hyperplasia Evaluation and management services Current Procedural Terminology codes

Main Content

Top Content