UT Medicine Urology: Delivering Advanced Urologic Oncology to South Texas

By: Thomas Crocker
Wednesday, August 26, 2015
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The UT Medicine Urology physicians treat routine and complex conditions, from kidney stones to rare cancers.

Patients with a variety of urologic illnesses, including kidney stones, pelvic floor disorders, erectile dysfunction, benign prostatic hyperplasia and urinary tract infections, will find a wide range of medical, minimally invasive and open-surgery therapies at UT Medicine Urology. The Department of Urology possesses particular expertise in the diagnosis and treatment of genitourinary cancer, including malignancies of the bladder, testes, prostate and kidneys. They coordinate care with the Cancer Therapy & Research Center (CTRC) and see patients across the street at the Medical Arts & Research Center (MARC) on Floyd Curl Drive as well as at the hospital-based clinic at the Robert B. Green Campus downtown.

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Building a Center of Excellence for a Rare Type of Kidney Cancer

Ronald Rodriguez, MD, PhD, Chair of the Department of Urology, completed residency and fellowship training in general surgery and urology at Johns Hopkins University and then remained at the university as a faculty member for 15 years before joining UT Medicine in 2013. During his time at Johns Hopkins, Dr. Rodriguez honed his expertise in treating genitourinary cancers, particularly those of the kidneys and prostate.

“In the years to come, two areas of focus for the Department of Urology are to better understand the urologic impact of diabetes, particularly on kidney dysfunction and voiding dysfunction, and investigate the urologic health disparities we see in San Antonio. Our department members serve patients at various clinics, and we see a much higher amount of high-grade, advanced prostate, kidney and bladder cancers that are out of proportion to what we’d expect for the number of individuals we treat. The higher stages and grades of these cancers suggest these individuals might not be seeking care as others would.”
— Ronald Rodriguez, MD, PhD, Chair of the Department of Urology at the UT Health Science Center San Antonio

One uncommon condition Dr. Rodriguez saw with some frequency while at Johns Hopkins — he treated more than 40 cases during his tenure — was inferior vena cava tumor thrombus resulting from renal cell carcinoma.

“In these cases, a tumor invades the inside of the renal vein, extends into the inferior vena cava, and can go all the way up above the diaphragm and into the heart, even into the right ventricle,” Dr. Rodriguez says. “Surgery for this cancer tends to be quite treacherous, so it isn’t done very often. In San Antonio, however, I’m completing as many as three to four tumor thrombus procedures per month.”

The reason: UT Medicine has become a referral center for tumor thrombus patients from throughout the region, thanks to the center’s excellent relationship with University Hospital in San Antonio.

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“We now have a dedicated tumor thrombus team that includes cardiac anesthesiologists, a cardiac surgeon, a vascular surgeon and a urologist, all of whom have operated with each other extensively on these cases,” Dr. Rodriguez explains. “This experience has allowed us to refine the techniques we use for these surgeries and develop a niche here in which we can do complex vascular work and have remarkably good outcomes. In many cases, patients have no evidence of residual cancer, or they have minimal cancer that we can then treat with chemotherapy. Ten years ago, these cases wouldn’t have even been attempted.”

Treating the Full Spectrum of Bladder Cancer

Multidisciplinary collaboration is also a key theme in the treatment of bladder cancer. Fellowship-trained urologic oncologist Robert Svatek, MD, MSCI, leads the department in treating patients with both superficial and invasive bladder cancers.

“On the superficial side, we’re specialists in deciding what combination and sequence of therapies to put into the bladder,” Dr. Svatek says. “On the invasive side, we perform a specialized operation called cystectomy, which is sometimes necessary for advanced cases. The challenge with advanced bladder cancer is that it’s a disease of older individuals, and many of these patients suffer from comorbid illnesses. We are putting them through a pretty advanced operation. Therefore, we integrate closely with cardiologists, pulmonologists and medical oncologists to minimize risks and avoid complications.”

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Dr. Svatek and colleagues perform bladder cancer surgeries using both open and robotic techniques using the da Vinci Surgical System. They also perform extended lymph node dissections and offer a variety of urinary diversion options. Many patients undergoing a bladder removal are candidates for construction of a neobladder — a new bladder made from a portion of the small intestines. It’s a procedure Dr. Svatek’s team performs routinely.

Bladder cancer surgery — a procedure that, historically, has had high complication and readmission rates — requires coordinated, integrated care to give patients the greatest chance of enjoying a successful outcome.

“We’ve created a preoperative, intraoperative and postoperative continuum-of-care plan for these patients that has allowed us to decrease readmissions and overall complications substantially,” Dr. Svatek says. “It’s been demonstrated that patients enrolled in clinical trials experience improved care, and many of our patients have come to us because of an interest in participating in one of our active clinical trials.”

Liberating Young Lives from Testis Cancer

After completing a urologic oncology fellowship at the UT Health Science Center San Antonio, Javier Hernandez, MD, MSCI, worked for many years at Brooke Army Medical Center in San Antonio before moving to UT Medicine. During his time at Brooke Army Medical Center, Dr. Hernandez came to specialize in performing surgery for testis cancer.

“Caring for these patients is rewarding because testis cancer is curable when treated correctly and caught in time, and I feel I can make a huge difference for these patients because they’re young men with full lives ahead of them,” Dr. Hernandez says. “The challenge with these patients is that, quite frequently, initial presentation is delayed for several reasons, including patient denial, and so they already have metastatic disease when they present.

“When this is the case, depending on the extent and subtype of disease, patients go through orchiectomy to establish tissue diagnosis, and then we have to decide, based on stage and histology, if they’ll need chemotherapy or retroperitoneal lymph node dissection,” Dr. Hernandez continues. “In some cases, we put patients on surveillance. In selected cases, radiotherapy may be necessary.”

Dr. Hernandez completes 15 to 20 retroperitoneal lymph node dissections per year, a high number for most urologists. When treating certain testis cancer cases — open surgery is the standard approach — Dr. Hernandez works closely with vascular surgeons, who may be needed to repair blood vessel damage following tumor removal if malignancy has spread into the vasculature of the abdomen.

“The infrastructure we have here in vascular surgery, anesthesiology, medical oncology and radiation oncology allows us to handle the most difficult cases,” Dr. Hernandez says. “We can cure these patients, thanks to the efforts of the entire team.”

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Innovating the Future of Bladder Cancer Treatment

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Robert Svatek, MD

The Department of Urology is a frequent participant in clinical trials initiated and organized by SWOG, formerly the Southwest Oncology Group. One such study is PRIME, an investigation of the efficacy of readying the immune system for intravesical bacillus Calmette-Guérin (BCG) therapy to treat superficial bladder cancer by using a pre-therapy percutaneous BCG vaccination. Robert Svatek, MD, is the trial’s principal investigator.

“Instilling BCG into the bladder is nothing new — it’s been around since the 1970s and is the standard of care for superficial bladder cancer,” Dr. Svatek says. “In this trial, however, we’re looking at a way to prime the immune system so that when we introduce BCG intravesically, the system will respond more robustly.”

The United States is currently experiencing a shortage of BCG. The primary domestic manufacturer has had production delays during the past year, forcing patients to search far and wide, and even leave the country, to find the drug. Dr. Svatek is working to introduce a Japanese-produced form of BCG, known as the Tokyo strain, to the U.S. market.

“We’re conducting a large trial to compare the Tokyo strain to the strain we have in the U.S.,” he says. “If the Tokyo strain is just as good or better than the domestic variety, we hope to get it into the U.S. within the next five years.”

Refining Prostate Cancer Detection and Risk Stratification

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Javier Hernandez, MD, MSCI

Javier Hernandez, MD, MSCI, Associate Professor in the Department of Urology at the UT School of Medicine, developed an interest in prostate cancer detection while completing a fellowship under the mentorship of another faculty member, Ian Thompson, MD. Dr. Hernandez is the principal investigator for the Finasteride Challenge Study, a randomized clinical trial seeking to determine whether treating men with mild prostate-specific antigen (PSA) elevation with finasteride instead of antibiotics could help clinicians determine which patients truly need a biopsy of the prostate, a procedure that carries significant risk of infection.

“We know that, in most men who have mild PSA elevation, benign prostatic hyperplasia [BPH], not cancer, is the culprit,” Dr. Hernandez says. “Many providers in the community think, ‘OK, we can bring PSA levels down with antibiotics and avoid biopsy.’ The problem with this approach is that part of the reason why we’re seeing increasing instances of infection after biopsies is that we’re selecting out more antibiotic-resistant organisms. This approach also presumes that mild PSA elevation is due to infection, which is much less common than BPH.

“We know from multiple studies that finasteride can lower PSA by roughly 50 percent within six months or so of treatment, with most of the decrease happening within the first few months,” Dr. Hernandez continues. “If you have someone with a mild PSA elevation, and you were to challenge that patient’s PSA with a short course of finasteride instead of antibiotics, could that help us determine — assuming there’s a predicted drop in PSA — whether this man truly needs a biopsy or not? This is what we’re trying to find out.”

Dr. Hernandez also collaborates with the Prostate Biopsy Collaborative Group, an international team of investigators seeking to determine the PSA threshold for prostate biopsy in patient populations around the world.

“Within this group, there’s a substudy I lead here locally that seeks to better integrate family history information into prostate cancer risk assessment,” Dr. Hernandez explains. “The widely used Prostate Cancer Prevention Trial risk calculator only accounts for whether a man has a first-degree relative with the cancer to assess his risk vis-à-vis family history. Studies suggest the number of first-degree relatives who’ve had cancer, prostate or otherwise, the number of second-degree relatives who’ve had prostate cancer, and the ages at which both first- and second-degree relatives were diagnosed all matter in determining prostate cancer risk. We’re collecting extended family histories on our patients and submitting them to the Prostate Biopsy Collaborative Group to assess the impact of detailed family history on prostate cancer risk assessment.”

Developing Novel Prostate Cancer Therapies

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Ronald Rodriguez, MD, PhD

Improving detection methods isn’t the only area of prostate cancer research taking place at the UT School of Medicine. Ronald Rodriguez, MD, PhD, Chair of the Department of Urology, and colleagues are devising new ways to treat the disease.

“We’ve been co-developing the use of a drug to administer intraoperatively that binds to prostate cancer cells and fluoresces in the near-infrared spectrum when it’s been induced and excited by a laser,” Dr. Rodriguez says. “We developed the light source, optics and imaging, and tested this approach in animal studies. We’re now actively pursuing clinical translation of this with a company to get this treatment to patients in the next year or two. The premise is that clinicians will be able to see prostate cancer as they operate robotically and identify lymph nodes that need to be removed. They will also be able to see whether cancer extends beyond the edges of the prostate to be sure all malignancy is removed, so there’s minimal chance of recurrence.”

Dr. Rodriguez is also actively involved in gene therapy and viral development.

“Recently, we developed a virus that could be turned on by the nonsteroidal antiandrogen bicalutamide,” he says. “We’ve demonstrated in animal models that we can combine this virus with radiation and get a synergistic effect of cell death in prostate cancer cells. Patients with high-grade, high-risk prostate cancer are usually treated with hormone therapy and radiation therapy. This treatment is designed for them.”

To learn more about the Department of Urology, visit UTMedicine.org/urology.