What’s wrong with urologists!!?

[Beerus]

Why don’t prostrate cancer and other GU cancers Such as bladder ca gets fair multidisciplinary approach? Yes Im aware they make a lot of money out RP, but patients deserve better!!!
I see a lot of insane surgeons that still operate on HR prostate patients and sadly we salvage them.

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[deleted1180461]

My referring urologist does not do prostatectomy. I’m sorry you’re dealing with this.

 

[Palex80]

I see a lot of insane surgeons that still operate on HR prostate patients and sadly we salvage them.

"I get paid more money for 33 fx when doing salvage than for 20 fx when doing primary".

 

[elementaryschooleconomics]

I've seen just like...wild stuff from our scalpel-wielding colleagues.

I've seen high risk patients put on active surveillance (as first line/recommended by Urology).

I've seen an open/non-robotic prostatectomy done as recently as 2022.

I've seen...well, you get the idea...

 

[ramsesthenice]

Why don’t prostrate cancer and other GU cancers Such as bladder ca gets fair multidisciplinary approach? Yes Im aware they make a lot of money out RP, but patients deserve better!!!
I see a lot of insane surgeons that still operate on HR prostate patients and sadly we salvage them.

That sounds annoying but it’s not a universal truth. Whenever a specialty can diagnose and treat unilaterally, there will naturally be more of this. I can’t speak for your specific situation but I do feel like greed takes a lot of credit for ignorance. Plenty of folks don’t stay current much past when they finish training. Others remain firmly convinced surgery (or say…protons) have to be the best option for most patients and don’t know/willfully ignore any data that suggests otherwise. Unfortunately, there are going to be a lot of things in your career that are just out of your control. I’m not saying roll over every time, but recognizing which ones are true lost causes and not worth your time or energy is an undervalued skill for maximizing professional satisfaction.

 

[ramsesthenice]

I've seen just like...wild stuff from our scalpel-wielding colleagues.

I've seen high risk patients put on active surveillance (as first line/recommended by Urology).

I've seen an open/non-robotic prostatectomy done as recently as 2022.

I've seen...well, you get the idea...

The worst of all the crap I see pulled are the ones who get RP, then fail, then get observed and started on ADT alone until the develop castration resistance before getting sent for salvage (or ARI therapy). There is no gray zone here. It’s frank malpractice.

 

[Reaganite]

approach? Yes Im aware they make a lot of money out RP

Pay for RP isn't that great actually. The big pitch from spaceoar reps back in the day was that spacer + fiducials paid more than RP.

 

[elementaryschooleconomics]

The worst of all the crap I see pulled are the ones who get RP, then fail, then get observed and started on ADT alone until the develop castration resistance before getting sent for salvage (or ARI therapy). There is no gray zone here. It’s frank malpractice.

Dude

What is with the absolute ALCHEMY that some Urologists seem to invent around ADT?

Obviously, it's one thing when there isn't a clear "right" answer/treatment and there are disagreements in terms of practice patterns.

Then, there are treatments that you could argue as "wrong" but at least you can piece together how that "wrong" treatment was recommended.

The two that really get me, and seem to be common with Urologists (with/without ADT):

1) When the same doctor will have zero consistency around the wrong treatment for the same types of patient. One high risk patient gets started on ADT....5 months before the referral to RadOnc. The next high risk patient gets put on ADT monotherapy (and may or may not find their way to RadOnc eventually). The next high risk patient gets put on 3 months total ADT. And on and on and on.

Just be consistent!

2) But the worst is obviously the wrong treatment where you absolutely cannot figure out the logic behind it. Stuff like, guy with a screening PSA of 4 gets sent to Urology, Urology elects to monitor patient because "it's not that high". Then, Urology monitors the guy with PSAs for like, two years, each time the PSA rises. Gets above 10, gets to like 14, patient sees a different doctor for something else - let's say, a Radiation Oncologist for a Stage I lung cancer who treats this patient with SBRT. Then, when the Radiation Oncologist is seeing the patient in follow-up for surveillance of the lung cancer, he is rooting around the patient's chart for something else and stumbles upon these years of rising PSA values, sends the patient to a different Urologist who immediately does the biopsy to diagnose high risk prostate cancer.

Meanwhile, the same Urologist will biopsy any other patient this Radiation Oncologist knows about with a PSA of 4 or above.

This Radiation Oncologist is concerned about the number of potential guys walking around with a PSA of 20 that have never had a biopsy but see that Urologist every 6 months or so.

(It's me, I'm the RadOnc in these stories)

 

[ramsesthenice]

Dude

What is with the absolute ALCHEMY that some Urologists seem to invent around ADT?

Obviously, it's one thing when there isn't a clear "right" answer/treatment and there are disagreements in terms of practice patterns.

Then, there are treatments that you could argue as "wrong" but at least you can piece together how that "wrong" treatment was recommended.

The two that really get me, and seem to be common with Urologists (with/without ADT):

1) When the same doctor will have zero consistency around the wrong treatment for the same types of patient. One high risk patient gets started on ADT....5 months before the referral to RadOnc. The next high risk patient gets put on ADT monotherapy (and may or may not find their way to RadOnc eventually). The next high risk patient gets put on 3 months total ADT. And on and on and on.

Just be consistent!

2) But the worst is obviously the wrong treatment where you absolutely cannot figure out the logic behind it. Stuff like, guy with a screening PSA of 4 gets sent to Urology, Urology elects to monitor patient because "it's not that high". Then, Urology monitors the guy with PSAs for like, two years, each time the PSA rises. Gets above 10, gets to like 14, patient sees a different doctor for something else - let's say, a Radiation Oncologist for a Stage I lung cancer who treats this patient with SBRT. Then, when the Radiation Oncologist is seeing the patient in follow-up for surveillance of the lung cancer, he is rooting around the patient's chart for something else and stumbles upon these years of rising PSA values, sends the patient to a different Urologist who immediately does the biopsy to diagnose high risk prostate cancer.

Meanwhile, the same Urologist will biopsy any other patient this Radiation Oncologist knows about with a PSA of 4 or above.

This Radiation Oncologist is concerned about the number of potential guys walking around with a PSA of 20 that have never had a biopsy but see that Urologist every 6 months or so.

(It's me, I'm the RadOnc in these stories)

Inconsistency? Like when they put a guy through surgery who instantly recurs and they decide not to refer because “he’s not going to die of prostate cancer.” In which case, why did we operate in the first place exactly?

I love the guys at our institution. The two private groups in town and near 2 of our satellites are (mostly) great too. We all have each others cell phones and do a great job coordinating. But there are a couple folks in our state who I just…I can’t. It’s everything you said. Starting someone on AS when low risk and not triggering therapy when they cross the high risk threshold etc. I honestly don’t know how they don’t get sued with some regularity. In our world, the roadmap to getting sued is willfully omitting/with holding SOC therapy that can reasonably be inferred to compromise a chance for cure.

 

[elementaryschooleconomics]

Inconsistency? Like when they put a guy through surgery who instantly recurs and they decide not to refer because “he’s not going to die of prostate cancer.” In which case, why did we operate in the first place exactly?

I love the guys at our institution. The two private groups in town and near 2 of our satellites are (mostly) great too. We all have each others cell phones and do a great job coordinating. But there are a couple folks in our state who I just…I can’t. It’s everything you said. Starting someone on AS when low risk and not triggering therapy when they cross the high risk threshold etc. I honestly don’t know how they don’t get sued with some regularity. In our world, the roadmap to getting sued is willfully omitting/with holding SOC therapy that can reasonably be inferred to compromise a chance for cure.

Yup.

Just because I know a lot of Urologists lurk here hahaha -

I don't want to imply I experience or perceive the majority, or even half of Urologists are bad.

I work with some amazing, amazing Urologists.

It's just the handful of bad ones are...goblins.

 

[RadOncMegatron]

Dude

What is with the absolute ALCHEMY that some Urologists seem to invent around ADT?

Obviously, it's one thing when there isn't a clear "right" answer/treatment and there are disagreements in terms of practice patterns.

Then, there are treatments that you could argue as "wrong" but at least you can piece together how that "wrong" treatment was recommended.

The two that really get me, and seem to be common with Urologists (with/without ADT):

1) When the same doctor will have zero consistency around the wrong treatment for the same types of patient. One high risk patient gets started on ADT....5 months before the referral to RadOnc. The next high risk patient gets put on ADT monotherapy (and may or may not find their way to RadOnc eventually). The next high risk patient gets put on 3 months total ADT. And on and on and on.

Just be consistent!

2) But the worst is obviously the wrong treatment where you absolutely cannot figure out the logic behind it. Stuff like, guy with a screening PSA of 4 gets sent to Urology, Urology elects to monitor patient because "it's not that high". Then, Urology monitors the guy with PSAs for like, two years, each time the PSA rises. Gets above 10, gets to like 14, patient sees a different doctor for something else - let's say, a Radiation Oncologist for a Stage I lung cancer who treats this patient with SBRT. Then, when the Radiation Oncologist is seeing the patient in follow-up for surveillance of the lung cancer, he is rooting around the patient's chart for something else and stumbles upon these years of rising PSA values, sends the patient to a different Urologist who immediately does the biopsy to diagnose high risk prostate cancer.

Meanwhile, the same Urologist will biopsy any other patient this Radiation Oncologist knows about with a PSA of 4 or above.

This Radiation Oncologist is concerned about the number of potential guys walking around with a PSA of 20 that have never had a biopsy but see that Urologist every 6 months or so.

(It's me, I'm the RadOnc in these stories)

OMG I thought you were doxxing me lol

 

[Palex80]

The worst of all the crap I see pulled are the ones who get RP, then fail, then get observed and started on ADT alone until the develop castration resistance before getting sent for salvage (or ARI therapy). There is no gray zone here. It’s frank malpractice.

This is likely going to be more of an issue in the future. There are a number of adjuvant ARPI trials reading out soon.


For instance:

https://ascopubs.org/doi/10.1200/JCO.2019.37.15_suppl.TPS5100

 

[deleted1180461]

The worst of all the crap I see pulled are the ones who get RP, then fail, then get observed and started on ADT alone until the develop castration resistance before getting sent for salvage (or ARI therapy). There is no gray zone here. It’s frank malpractice.

Common what I see is all new diagnosis put on Casodex sometimes for years before they proceed with definitive management. Lots of gynecomastia!!!

 

[medgator]

Common what I see is all new diagnosis put on Casodex sometimes for years before they proceed with definitive management. Lots of gynecomastia!!!

So many things... Upfront cryo or hifu for low or int risk disease, inappropriate RP on metastatic disease, not sending for salvage for N+ disease with persistent PSA post op etc.

 

[ramsesthenice]

This is likely going to be more of an issue in the future. There are a number of adjuvant ARPI trials reading out soon.


For instance:

https://ascopubs.org/doi/10.1200/JCO.2019.37.15_suppl.TPS5100

What you linked isn’t adjuvant and I’m totally ok with it. Conceptually, there is no reason ADT shouldn’t help high risk surgical patients. The fact that longterm is superior to short term with RT strongly suggests to me the effects are not just in the primary. If ADT helps control micromets with radiation, it probably helps with surgery. I don’t personally believe the limited nodal sampling we typically see does that much to help disease control (and I’m not advocating for more aggressive PLNDs).

There are adjuvant trials and I don’t have an issue with that approach either. It’s part of why I even snuck mention of these drugs in my post. ADT alone for otherwise healthy people is palliative. We already know that and just slapping someone on lupron without clearly telling them it’s palliative and that there are potentially curative options is wrong.

 

[Palex80]

Well, it's perioperative.

It's 6 months prior to RP, followed by 6 months afterwards. So it's neoadjuvant + adjuvant.

I believe it will push more high-risk patients towards surgery. Or let's say it will give the urologists another tool to push more patients towards RP.

 

[ramsesthenice]

Well, it's perioperative.

It's 6 months prior to RP, followed by 6 months afterwards. So it's neoadjuvant + adjuvant.

I believe it will push more high-risk patients towards surgery. Or let's say it will give the urologists another tool to push more patients towards RP.

PYL scans pretty well did that for us already. Negative scan…knives out! If they are going to operate anyways, it would be good to at least give adequate systemic therapy to give a better chance at being done.

 

[yesmaster]

the ones who get RP, then fail, then get observed and started on ADT alone until they develop castration resistance before getting sent for salvage (or ARI therapy). There is no gray zone here. It’s frank malpractice.

I see this all the time, mostly from urology but sometimes from med onc too. High risk patients on ADT +/- Xtandi or salvage post-RP patients with PSA 1.0+ who are told ADT “slows down the prostate cancer” and they decide to wait and wait deferring RT/RT referral until they metastasize or become castrate resistant

 

[radoncftw]

Pay for RP isn't that great actually. The big pitch from spaceoar reps back in the day was that spacer + fiducials paid more than RP.

the good thing is where i practice the surgeons are employed.
When they get a whiff of 1) poor KPS 2) high-risk features, they are quick to refer

 

[DoctwoB]

Addressing a few misconceptions on this thread:

1. Prostatectomy ain't how we bring in the $$$. A two prostate day with LNDs is about 60ish RVUs. then you need to see them in the global period which replaces 5-10 RVUs of other visits . I can pull 80 in a clinic day no problem. There are rare urologists who will line up 4 RALPS/day 2-3x/week with PAs to see all their follow ups and yes that will make $$$, but that is the exception and requires an extremely rare referral pattern. . As the homies say, robots for show, clinic for dough.

2. There are a lot more things to beat your chest about then RP in high risk prostate cancer, which is a SOC per AUA and NCCN guidelines. Yes it can be done well, with good counselling as to likely being part of multimodal therapy, or done poorly, with patient's expecting a 100% cure rate then shocked they need salvage or adjuvant therapy.

3. Totally agree that we are headed towards a future of neoadjuvant/adjuvant therapy with prostatectomy, whether it is with ARSI or LuPSMA. We also may be headed towards an era of molecularly guided surgery, with intraoperative PSMA based tissue visualization which will (hopefully) reduce margins and/or local failure post prostatectomy in high risk patients.

4. An Open RRP in year 2024 is not malpractice, but should really only be done by a select few. If done extremely well, an RRP can equal a RALP. very few can do an RRP extremely well.

 

[Radadabbadoo]

Addressing a few misconceptions on this thread:

1. Prostatectomy ain't how we bring in the $$$. A two prostate day with LNDs is about 60ish RVUs. then you need to see them in the global period which replaces 5-10 RVUs of other visits . I can pull 80 in a clinic day no problem. There are rare urologists who will line up 4 RALPS/day 2-3x/week with PAs to see all their follow ups and yes that will make $$$, but that is the exception and requires an extremely rare referral pattern. . As the homies say, robots for show, clinic for dough.

2. There are a lot more things to beat your chest about then RP in high risk prostate cancer, which is a SOC per AUA and NCCN guidelines. Yes it can be done well, with good counselling as to likely being part of multimodal therapy, or done poorly, with patient's expecting a 100% cure rate then shocked they need salvage or adjuvant therapy.

3. Totally agree that we are headed towards a future of neoadjuvant/adjuvant therapy with prostatectomy, whether it is with ARSI or LuPSMA. We also may be headed towards an era of molecularly guided surgery, with intraoperative PSMA based tissue visualization which will (hopefully) reduce margins and/or local failure post prostatectomy in high risk patients.

4. An Open RRP in year 2024 is not malpractice, but should really only be done by a select few. If done extremely well, an RRP can equal a RALP. very few can do an RRP extremely well.

Good points, thanks for helping a productive discussion.

 

[medgator]

Addressing a few misconceptions on this thread:

1. Prostatectomy ain't how we bring in the $$$. A two prostate day with LNDs is about 60ish RVUs. then you need to see them in the global period which replaces 5-10 RVUs of other visits . I can pull 80 in a clinic day no problem. There are rare urologists who will line up 4 RALPS/day 2-3x/week with PAs to see all their follow ups and yes that will make $$$, but that is the exception and requires an extremely rare referral pattern. . As the homies say, robots for show, clinic for dough.

Akin to brachy honestly... Way more financially renumerative to just be in clinic and do ebrt. Brachy is a time suck and doesn't pay well, was shocked when I looked up the CPT for t&o, pays like $300-600 professionally.

There's definitely those high volume RP guys who are getting paid by industry and having fellows etc who are crushing it, agree that's the exception not the rule

 

[deleted1180461]

Akin to brachy honestly... Way more financially renumerative to just be in clinic and do ebrt. Brachy is a time suck and doesn't pay well, was shocked when I looked up the CPT for t&o, pays like $300-600 professionally.

There's definitely those high volume RP guys who are getting paid by industry and having fellows etc who are crushing it, agree that's the exception not the rule

Brachy pays well if you are paid per wRVU