The Metamorphosis of the Clinical Urologist

Raoul S. Concepcion, MD, FACS

The first of July ushers in a new batch of newly graduated physicians to begin the arduous journey of residency training in their chosen field, a process that began a full 2 years prior as third-year medical students. Thinking back, what are the determinants that influence this choice? For myself, and many others, it was an exposure very early in life to family members who were healthcare providers. I suspect that if a survey were to be administered across generations of physicians to explore these factors, there would be a litany of reasons, depending on the age of the respondent. One that goes underappreciated is how an individual was treated as a medical student by the resident physician(s) on a service. Did they take the time to teach? Did they show a passion and seem to really enjoy their specialty? And with that, did they encourage others to enter that same field?

Ultimately, the choice of specialty, with a few exceptions, comes down to the following: internal medicine, surgery, or pediatrics. Urology has always represented a true hybrid specialty. To succeed, one must possess both cognitive and technical skills as we tend to be a sign/symptom-driven field. The majority of us who go into urology truly enjoy the surgical side of medicine. I believe that many others would choose a surgical specialty, had they been given adequate exposure. We have also historically been on the vanguard of technology and quick to incorporate that into our clinical practice. Specifically, think lithotripsy, percutaneous procedures, and robotics to cite just a few examples. Due to our willingness to be early adopters, our patients spend fewer days in the hospital and have a quicker return to their preoperative functional status. We have improved patient care and quality of life, which should always be paramount as the cornerstone of our practice.

However, embracing technological advancement and minimally invasive procedures has resulted in a significant transformation of our beloved specialty over the past 10 to 15 years. If I had the ability to incorporate an audience response system into this column, it would be interesting to ask the following: Which of the following procedures have you personally performed over the past 10 years?

1. Open retroperitoneal lymph dissection for testicular cancer
2. Anatrophic/coagulum pyelolithotomy
3. Adrenalectomy through a supra 11th rib incision
4. Open ureterolithotomy via a Gibson incision
5. Open simple prostatectomy for benign disease

These and many other procedures are now relegated to textbooks for historical perspective. It has given way to an entirely new breed of urologic surgeons. It is not better or worse, just different.

The significant advances that take place in medicine occur almost daily. Take, for example, the management of hormone treatment-naïve, metastatic prostate cancer. What started as androgen deprivation therapy (ADT) alone, the mainstay of treatment for half a century in these patients, has moved to ADT and 6 cycles of docetaxel chemotherapy for high-volume disease^1,2 to most recently, based on the updated STAMPEDE and LATTITUDE trials, ADT and abiraterone acetate.^3,4 Is this the new standard of care, as espoused by some? It is hard to determine at this point as all this has taken place over the short period of 2 years.

What is very clear to me, however, is that we are becoming less surgically inclined. Active surveillance for low-risk prostate cancer patients is appropriate. Newer agents used in an earlier setting may render the need for extirpative surgery obsolete, whether it be in prostate, bladder, or kidney cancers. Just as we have in the past incorporated newer surgical techniques and modifications, so must we be more adroit in our offering of nonsurgical therapeutics to take better care of our patients. We also must recognize our role as the thought leaders and maintain our leadership in managing these disease states, even if at times we are not standing at the operating room table with scalpel in hand. Being a Luddite in the field of medicine will only guarantee 1 outcome: obsolescence.

References

1. James ND, Sydes MR, Clarke NW, et al. Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial. Lancet. 2016;387(10024):1163-1177. doi: 10.1016/S0140-6736(15)01037-5.
2. Sweeney CJ, Chen YH, Carducci M. et al. Chemohormonal therapy in metastatic hormone- sensitive prostate cancer. N Engl J Med. 2015;373(8):737-746. doi: 10.1056/ NEJMoa1503747.
3. Fizaxi K, Tran N, Fein LE, et al; the LATITUDE investigators. LATITUDE: A phase III double-blind, randomized trial of androgen deprivation therapy (ADT) with abiraterone acetate (AA) plus prednisone (P) or placebos (PBOs) in newly diagnosed high-risk metastatic hormone-naïve prostate cancer (mHNPC) patients (pts). J Clin Oncol. 2017;35 (suppl; abstr LBA3). abstracts.asco.org/199/AbstView_199_181729.html.
4. James ND, DeBono JS, Spears MR, et al. Adding abiraterone for men with high-risk prostate cancer (PCa) starting long-term androgen deprivation therapy (ADT): Survival results from STAMPEDE (NCT00268476). J Clin Oncol. 2017;35 (suppl; abstr LBA5003). abstracts.asco.org/199/AbstView_199_186716.html.