New hospital budget approved. . .

Web sites launched Form

Ethics panel-When monetary and medical interests collide

MediBase projects seeks duplicate medical records

Nurses and hospitals agree to contract extension

Three associate deans appointed for academic affairs

New Cancer Center Breaks Ground

September 11 - Late night visit saves emergency physician

New training

Q: When should primary care physicians refer patients to you?

BROOKS: For conditions such as BPH [benign prostatic hyperplasia], voiding problems due to large prostates, there are some excellent standard guidelines out there to help primary care doctors initiate first-line drug therapy. If this doesn't work, it's usually time to refer - per guidelines. In the area of potency, Viagra has revolutionized the field, allowing family physicians to effectively treat patients. Prior to Viagra, a larger number of impotent patients were sent to the urologist.

SHORTLIFFE: Our options for impotence are expanding and we should continue to treat this disorder. There are three or four more drugs, some - like Viagra - some not, in clinical trials. At least one of the drugs is injectable, and our colleague here on the faculty, Bob Kessler, is working on combinations. On another issue, we would like to remind referring physicians to look at fertility from both the male and female perspectives initially. Stewart McCallum on the faculty does a lot of work with fertility, and there seems to be an undue emphasis on female fertility. In fact about 50 percent of infertility is in the male, and often this doesn't get looked at until female infertility has been exhaustively, and often expensively, ruled out.

BROOKS: To underscore that, male infertility is an area that is evolving rapidly and it's also a field that requires specialty training. The remedies can involve such highly specialized and delicate techniques as microsurgery and sperm aspiration. These are things that are not done routinely in many places. The male aspect of infertility is 100 percent in the Department of Urology at Stanford.

SHORTLIFFE: You can bypass in vitro fertilization if you can get the sperm at the right time. We have that service 24 hours a day. Bob Kessler and Stuart McCallum, another colleague, both do that.

Q: Do you tend to deal with lifestyle and general medicine issues more frequently than other surgical subspecialties?

PRESTI: Yes. Quality-of-life issues can be a particular concern in urology. Jim [Brooks] and I do cancer surgery, but we've got to look beyond the cancer-specific outcomes where continence and potency are sometimes as significant as the cancer. Just asking ourselves, "Did we cure the cancer?" is never good enough. If you take off a piece of someone's lung, it may have some impact on how that patient breathes so maybe the patient can't run a marathon, etc., but when we're talking about potency and continence, those are huge quality-of-life problems which we as urologists have to deal with on a daily basis.

BROOKS: The idea in the past that surgery was a horrible compromise of men's quality of life has changed quite dramatically with the ability to spare nerves. In radical prostatectomy we can spare potency two-thirds of the time and also we've gotten much better in terms of preserving urinary control.

SHORTLIFFE: With infants and children we constantly remind ourselves that the result of the surgery can have enormous lifelong psychological and lifestyle expectations. In the operating room we deal with issues as fundamental as young patients' lifelong gender identification. Often we must deal with this issue before the child can participate in decision making, although there has been a tendency in recent years to defer such decisions until the patient can participate more fully. Overall, urology is a little different from a lot of surgical areas, because we tend to provide a lot of outpatient care. We have patients whom we follow for primary care and other medicine needs because their urological and more general medical needs are so intertwined.

Q: Your specialty has a heavy oncological component, doesn't it?

BROOKS: Sure. Unfortunately, prostate cancer is the most commonly diagnosed cancer and second-leading cause of cancer death in American men - right behind lung cancer. We've been a leader in both research and treatment in this area. For example, the PSA (prostate specific antigen) test has been around since the 1980s. It was demonstrated as a clinical tool by [emeritus professor] Tom Stamey and others here at Stanford. Dr. Presti pilots a lot of that research now. By the way, I can't stress the emphasis on research in our field enough. I may be biased, but I believe that urology perhaps more than other surgical specialties has a longstanding tradition of basic science excellence. That's evidenced by the integration of basic science into our residency program.

Q: Do you have a full line of services?

BROOKS: Absolutely. We have a large practice in general urology that includes leadership from long-time faculty members Robert Kessler and Rodney Anderson. But most of us have highly specialized interests. For example, I only see clinically localized prostate cancer. That has allowed me to focus on surgical technique for what is a very experience-driven and nuanced operation.

SHORTLIFFE: We're not unique in our ability to deliver excellent surgery, but we do deliver it comprehensively. And I think we can make a case that for many rare procedures we can offer distinct benefits as a referral center. But that's not to say that other institutions, including many smaller ones, don't have people who have carved out a niche of excellence. This is especially true in prostate surgery. There are many people throughout the country who see high volumes and do superb work.

PRESTI: A benefit of working at a teaching center is that we are particularly prone to be plugged into new ways of treatment, new clinical trials and more prone to be plugged into dialogue with other academic centers.

SHORTLIFFE: A major clinical issue with us is "the next step." We see a number of patients whose procedures weren't successful and are looking for what they can do next. We can help patients explore options.

Q: How do you measure whether you're doing a better job?

PRESTI: I think it's been demonstrated that surgeons who do a complicated procedure frequently have better outcomes than surgeons who do just a few, but there are few standardized benchmarks in urology. Frankly, we often recommend that prospective patients talk to some of our patients who have undergone a particular procedure.

SHORTLIFFE: In cardiology or cardiothoracic surgery, for example, epidemiologists and other researchers have set benchmarks. They've looked at hospital volume and determined that higher complication rates may be related to a lower volume. But so far people haven't looked at much of urology in these terms, but they have started to.

BROOKS: In pancreatic surgery, for example, they've found that when case volume rises, complication rates drop and then expenses go down because the need for long-term treatment is reduced. From experience we know that's true in prostate surgery, where managing incontinence certainly raises costs - not to mention its devastating effect on the patient.

SHORTLIFFE: Patients and referring physicians need to take into account surgical volume when evaluating complication rates.

PRESTI: And you have to get far beyond acute complications in assessing success. We never forget that quality of life is crucial. In urology, we can sometimes strive to offer "value-added" procedures, such as orthotopic neobladders for cystectomies. We can use intestines to create a new bladder and hook it back up to the urethera. That's not commonly done in many places. It's not only important for primary care physicians to understand that this procedure exists, but to consider the negative lifestyle patients face if they have to rely on a stoma bag.

SHORTLIFFE: Some procedures offer significant variations and you need a rather large volume of patients before you can become familiar with the full range of options. For example, in pediatric hyperspadias there are hundreds of operations you can do to open the urethra to the tip of the penis. If you don't have a good volume of patients, you may be familiar with just a few of those operations. But you need a fair number of options to be comprehensive.

Q: It seems there is some similarity to plastic and reconstructive surgery in the sense that there are an almost infinite "artistic" variation in terms of possibilities for procedures?

SHORTLIFFE: I wouldn't put it like that, but some of our procedures do involve reconstruction and, as with hyperspadias, some require a wide palette of techniques. For instance, my colleagues Bill Kennedy and Jennifer Abidari and I may not select the same operation for the same situation yet still get excellent results.

Q: What changes or advances do you see in urologic surgery?

BROOKS: The face of surgery is changing dramatically, that's for sure. The move absolutely in urology is toward less-invasive surgery. I do hope in cancer surgery that preventive or noninvasive alternatives will ultimately render us obsolete, but I predict that won't happen. In the near and medium future, I think we'll even extend the indications for surgery. We may be able to operate on people with more advanced disease to debulk them, then treat them with a biologic or chemotherapy to eradicate the remainder. We're already formally working in multidisciplinary clinics with medical and radiation oncologists.

Q: Can you talk about changes in techniques?

BROOKS: Besides multidisciplinary or interdisciplinary approaches, we'll see more emphasis on laparoscopic approaches. In Europe they're already removing prostates laparoscopically and it's starting to catch on here. One strategic change we can anticipate in the not-too-distant future is that we are going to reap some of the benefits of the human genome project and molecular research in general. We're already starting to develop better markers. Colon and breast cancer are good examples.

PRESTI: However, right now most clinical markers are so basic that we can only make crude therapeutic adjustments. In the future, with reliable markers, we should be able to make better predictions which will allow us to tailor therapies. Thirty or 40 years from now I suspect we will not be removing as many organs and that the organs will be treated in situ and the disease process will be reversed in the body. And we may feel more comfortable watching and waiting on surgery for patients with a less-aggressive cancer.

SHORTLIFFE: What Joe says about waiting for less-aggressive cancer has parallels in other areas. A wait-and-see approach has become a larger strategy for some conditions after closely watching clinical trials at other academic centers or being part of those trials here. Parents whose 8- or 10-year-old children didn't need surgery are among our most grateful families. For example, we're finding that sometimes patients with multicystic displastic kidneys have no need for surgery; similarly children with vesicoureteral reflux may outgrow their problem. And some institutions that were performing prenatal interventions for hydronephrosis have stopped because it wasn't clear patients were benefiting. Longer term follow-up showed that some patients didn't improve the intervention.

PRESTI: And happily, prevention should play an increasing role. For example, I'm currently involved in a National Cancer Institute trial, called SELECT, which is looking at whether selenium and vitamin E can protect against prostate cancer.

SHORTLIFFE: Chris Payne in our department, who deals continually with the issue of who needs what treatment in the area of female incontinence, consistently uses urodynamics, a better way of studying complicated people and trying to determine who may respond to what. You can understand exactly the reason for leakage or incontinence so you can customize a procedure or drug. Again, as you get more tests it's highly likely that selection of treatment will become more effective.

PRESTI: I also think robotic surgery will advance quite rapidly in the next 15, 20 or 30 years.

Q: Why did you go into urology?

BROOKS: I went into urology completely by surprise. It was my first clinical rotation when I was a medical student here at Stanford. I had a blast. I liked that I could see a baby and then see a 99-year-old man with urinary problems. I liked the diversity of patients and problems. I also liked that I could come up with a diagnostic plan, do most of the testing myself and then customize treatment. And patients are almost always grateful because usually they do get better. If you can take someone who can't void and get them to do so, understandably they're very happy.

PRESTI: My father was a urologist, so I had some exposure to urology early on. But then when I got to medical school, I realized I did enjoy the field. I think I was inspired, as Jim was, by the diversity of the patient population and the problems that you face. I particularly enjoyed the surgery and the diversity of surgical types, going from major open surgery as we do in cancer, to endoscopic surgery. Urology offered technical challenges.

SHORTLIFFE: I never did urology in medical school because I somehow thought I'd never be interested in it. But during medical school I had trouble deciding between medicine and surgery, and I liked everything. I had planned to do plastic and reconstructive surgery, but urology was a way of integrating the medicine component. Another element that really drew me to urology was that it was probably the first surgical area that was not invasive because of prostatectomy and transurethral resection of the prostate. And even less invasive is extracorporeal shock waves - lithotripsy. Probably the clincher was that when I came into this department, I liked the people. Several faculty members, including Tony Schaeffer - now urology chair at Northwestern - and Fuad Freiha, convinced me I should be doing urology. I'm not sure how serious they were at the time. It may have been a joke. But I did it..

See Fact File