Increasing 2D and 3D Imaging, Steering Clear of ESWL, and More AUA19 Updates

We urologists have always taken pride in our innovative mindset. The American Urological Association (AUA) 2019 Annual Meeting confirms it yet again: In Urology, innovation is alive and well.

Of course, Innovation comes in many flavors — and they were all on display at this year’s meeting. There are those who are pushing the envelope and finding new ways to refine our existing innovations. For example, there are endourologists who are exploring and refining ureteroscopy-assisted percutaneous renal access. (Speaking of which, hat tip to Dr. Michael Borofsky, who edged Dr. Jaime Landman in a great debate on pure fluoroscopic versus URS-assisted PCNL access. I was on Team Borofsky.)

Then, there are those doing game-changing research that may fundamentally change how we do our work, such as Dr. Trinity Bivilacqua. This year’s Gold Cystoscope Award winner, he presented his work on bladder tissue regeneration.

Finally, there are those who are looking for new utilization of existing disruptive technology such as using machine learning to grade prostate MRI lesions and/or improve prostate cancer margin prediction.

Our field is too vast to summarize all the incredible innovation that is happening, but here are a few things that struck me as particularly noteworthy. [Disclaimer: I’m a BPH and stone geek…]

The Great Laser Debate Continues

Low-power or high-power? What’s your pulse-width? Is MOSES worth it? And when do the “smart lasers” arrive?

Answers to these questions were aplenty at the plenary session moderated by Dr. Joel Teichman with panelists Drs. Khurshid Ghani, Michelle Semins, and Olivier Traxer. Next-generation lasers also come into play when we talk about HoLEP, which continues to look great on TV but has seen a slow-ish uptake in broad clinical practice.

My take: high-power lasers and longer pulse-width have taken some of the pain out of ureteroscopic laser lithotripsy of 1-2 cm renal stones, so we are seeing a slight down-tick in PCNL and ESWL for those patients. I’m not quite sold on MOSES, but I do think there is value in a high-power laser if case volumes are high. Interested to see what is up the sleeve of Big Device – rumblings of sensor-based smart lasers that automatically adjust to ideal settings based on real-time information on stone composition, fragment size, etc? There is likely more to come over the next few years.

BPH is Buzzy

The Friday plenary session on minimally invasive therapies for LUTS was must-see TV for anyone interested in the BPH landscape.

The space between medical therapy and gold-standard surgical therapy (TURP, laser prostatectomy, enucleation) continues to see robust competition, as prostatic urethral lift (UroLift) and steam-based thermal ablation (Rezum) continue to penetrate the market. There seems to be continued interest in urethral stents. As generational attitudes toward being on medication continue to shift, with many of our patients preferring NOT to be on medications, device therapy for BPH will become increasingly relevant.

My take: We have seen an explosion of technologies in the space between medical therapy and “gold-standard” treatments – and the winners are starting to scale. It will be interesting to see what the next few years bring for Rezum and UroLift. As more cases are done, the proof will be in the pudding – do the technologies have sufficient durability to stand the test of time? Or – is there an emerging technology that will eclipse them?

To borrow words from Dr. Steven Kaplan, sometimes the threat you don’t know about is the biggest. At the end of the day: big market, common disease, no perfect solution (yet)… BPH is an innovator’s dream and we will continue to see new stuff for quite some time.

Stay Tuned for More on 2D and 3D Imaging

In my opinion, this was one of the more interesting topics at this year’s meeting. Much of the endoscopic and laparoscopic work that we do is image-based. Current workflow is to view imaging in two dimensions, and then internally translate the images to what we are seeing in surgery, which is three-dimensional. If surgery is 3D, why are we still using 2D tools for planning purposes?

Doing a partial nephrectomy? One group at NYU is translating 2D cross-sectional imaging into 3D-printed kidney tumor models. Companies like 3D Systems are working with Intuitive Surgical on solutions in the simulation space, with potential direct applications to live surgery. As uptake increases and these solutions mature, we can anticipate improved physician experience, enhanced surgical outcomes, and better teaching tools.

My take: 2D 🡪 3D imaging is promising for laparoscopic and robotic surgery, but also has potential applications in the realm of percutaneous access, minimally invasive BPH therapy, and surgical solutions for female and male stress incontinence. Just as prostate fusion biopsy is enabling the rise of focal therapy for prostate cancer, real-time “fusion” of 2D and 3D images could be an innovation that opens to the door to even more innovation in the future. Stay tuned.

ESWL Under Threat?

I’m not a naysayer when it comes to ESWL, but the potential ESWL killers seem to be gaining momentum. ESWL killed open stone surgery and it too will one day be replaced. I see three factors on the rise:  high-powered lasers, disposable ureteroscopes, and democratization of percutaneous access. The barriers to performing complex endoscopy continue to fall – when high-powered lasers and disposable ureteroscopes become less costly, they will see increased market penetration, and there will be even greater pressure on ESWL. A more direct threat may come in the form of something like Applaud Medical’s microbubbles, which can be used for histotripsy of stones and could potentially reduce the capital expenditures and inconvenience of large lithotripsy machines.

My take: Don’t put away the ESWL machine anytime soon, but keep an eye on cost and availability of intra-renal technologies. And keep your other eye on emerging extra-renal technology.

See You Next Year

Urologists should be proud of the fact that our specialty continues to be at the vanguard of innovation. The work of many great minds from around the world was again on display at this year’s AUA meeting. While most urologists are not “working on something”, all of us can certainly be involved by keeping an sopen mind as we look to adopt new tools to practice.

Adam Kadlec, MD is a board-certified urologist. He is the innovation medical director at Advocate Aurora Health. He is a former Doximity fellow and writes frequently on the topics of innovation, physician burnout, and health care leadership.



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