University of Rochester Medical Center | URology News

URology University of Rochester Medical Center | Urology News | Winter 2021

A Comprehensive, Efficient Approach to Kidney Stone Care pg. 4

URology

| Winter 2021

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Letter from the Chair Multidisciplinary Care for Stones

Jean Joseph, M.D., M.B.A., F.A.C.S. Winfield W. Scott Professor and Chair Department of Urology Professor of Oncology Wilmot Cancer Institute University of Rochester Medical Center

On the cover: Scott Quarrier, M.D., and Rajat Jain, M.D.

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With 2020 now in the rearview mirror and the world on the path back to “normal,” it is no exaggeration to say that health care has been both profoundly tested and transformed over the last 12 months. It is easier now with the passage of time to see the historic contributions made by the clinical and scientific community to respond with incredible speed to meet the coronavirus threat. However, it is important to remember the tremendous disruption starting last March as coronavirus cases and hospitalizations rose and many medical centers, including URMC, curtailed outpatient clinics and postponed elective surgeries.

While essential to “flatten the curve” and free up hospital beds, these measures created barriers between physicians and their patients that had to be overcome in order to continue to provide access to care, especially in acute cases. I am extremely proud of the hard work and dedication demonstrated by our physicians, nurses, and staff to rapidly stand up infection prevention protocols and establish systems that enabled us to maintain continuity of care for our patients. These efforts are described in further detail on page 4. Much of the innovation that was adopted to meet these challenges have caused fundamental changes to the way health care systems and consumers connect for care and many will outlast the end of the pandemic. Telemedicine, for example, has proven its value in increasing access to specialized care, is here to stay, and will continue to transform how we interact with patients and other providers.

The same effort to provide high quality and accessible care to our patients that drove the response to the pandemic is also at the core of two stories in this edition of URology. The first details the creation of the Comprehensive Kidney Stone Treatment Center, which was led Dr. Erdal Erturk for several decades. The center is multidisciplinary, all under one roof, and takes advantage of the | Department of Urology | urology.urmc.edu

medical center’s collaborative infrastructure.

With the involvement of members from urology, nephrology, and nutrition, we seek to address the entire spectrum of stone disease, delivering efficient care episodes. Our focus has also been on stone prevention, with a number of research projects under way targeting patient risk assessment.

Another piece details our efforts to increase access to care in rural communities in Upstate New York’s Southern Tier Region, which has long suffered a shortage of specialists of all types. Our commitment remains to grow the academic program while providing expert urology care throughout Rochester and beyond. We welcome Dr. Shlomi Tapiero, who joined our team after fellowship in minimally invasive urology at UC Irvine, Dr. Otto Sandoval, an experienced practitioner who joined us from Bassett Imogene in Cooperstown, and Dr. Jathin Bandari, who joined our department after a fellowship in oncology at UPMC, expanding our oncology clinical and health services research team.

And finally, this issue includes a tribute to the life of Dr. Irwin Frank, who passed in 2020 at the age of 93. While he spent his entire academic and medical career here at the University of Rochester, his impact was national in scope, as a urologist, physician executive, and ultimately serving as president of the American Urological Association. He was a close friend and mentor to many physicians, surgeons, and administrators who sought his counsel. We extend our condolences to his family and celebrate Dr. Frank’s role in shaping the field of Urology.

Dr. Frank’s career and the struggles our field had to overcome in 2020 remind us of the role that we all play in the never-ceasing effort to raise the bar and improve the care we provide our patients – or, in the word of the University of Rochester’s motto Meliora, make the world “ever better.”

URMC Creates Model to Prioritize Cases During Pandemic The spread of COVID-19 brought unforeseen, yet not insurmountable, challenges.

Across major cities, outpatient visits plummeted, elective surgeries were postponed and the availability of hospital beds rapidly disappeared.

URMC quickly adopted a strategic approach to meet acute care needs while protecting patients and staff, and the institution’s valuable resources.

“For non-emergent care, we established a panel to prioritize surgical schedules. Twice each week, faculty advocated for their patient’s procedure,” said Jean V. Joseph, M.D., chair of Urology. “We reviewed each case to determine if timing was critical, would a delay cause harm or diminish outcomes, and was it a justifiable use of resources – time and supplies – or risk to staff.”

The department developed a prioritization dashboard to guide decisions on what cases are deemed essential, from a patient centered approach, during a pandemic.

Naturally the majority of in-person care and surgery focused on emergencies and oncology cases, though the panel had significant discussion of a fertility case.

J. Scott Gabrielsen, M.D., Ph.D., sought to begin male infertility treatment for a patient who, with his 44-year-old wife, wanted to start a family. Given their ages, a pandemic delay in his therapy could “close the window” for them to follow up with in vitro fertilization.

“I pushed to allow us to evaluate these patients in person. The sooner we can get them on medication and determine what they need, the sooner we can move forward with treatment,” Gabrielsen said.

While the panel debated ethical issues surrounding the couple’s situation, state health leaders simultaneously determined fertility care is essential therapy, allowing Gabrielsen to proceed with the planned care.

Joseph is pleased with the outcome of the process and plans to publish a report on the dashboard that enabled the department to oversee and prioritize cases, to serve as a guide during unforeseen shutdowns.

“I’m most proud of the team’s ability to adapt and evolve during a difficult situation,” Joseph said. “We all knew the dangers of COVID-19. We took precautions and continued to provide high quality care.

“We showed how nimble we are and that we are able to make the most of our commitment to care for our patients during this difficult time.”

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URology

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A Comprehensive, Efficient Approach to Kidney Stone Care Creating a more efficient system for treating patients suffering from kidney stones was the goal in creating the Comprehensive Kidney Stone Treatment Center at the University of Rochester Medical Center.

The journey to create the center began with the vision of Erdal Erturk, M.D., who believed in a collaborative approach to the management of urinary stones. With state of the art, noninvasive surgical options coupled with preventative therapy, URMC’s Kidney Stone Treatment Center has become nationally recognized, and it is the only one of its kind in Western N.Y. and the Finger Lakes region. Erturk built the center into a clinical powerhouse, performing nearly 1,000 kidney stone surgeries per year.

Building on Erturk’s legacy, the center has expanded its team to meet the emerging needs of patients. Today, the center includes kidney stone specialists Rajat Jain, M.D. and Scott Quarrier, M.D., M.P.H., along with integral team members nurse practitioner Jamie Allen McKeown and nurse coordinator Lisa Fedele. Jain and Quarrier both completed subspecialty endourology fellowships at Cleveland Clinic and University of Wisconsin, respectively.

Other members active in the management of stone disease include Ahmed Ghazi, M.D., director of the Simulation Innovation Lab, and Shlomi Tapiero, M.D., who recently joined the department after fellowship training at the University of California at Irvine.

What makes URMC’s kidney stone center unique is an integrated team approach to patient care all under one roof. Kidney stone specialists work in collaboration with nephrologists David Levy, D.O., and Rebeca Monk, M.D., as well as registered dieticians to provide comprehensive kidney stone disease care. All treatment options are tailored to the individual patient, with the objectives of reducing and eliminating the suffering associated with a kidney stone, limiting

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long-term kidney damage and enabling patients to return to normal activities.

A one-stop shop for patients with kidney stone disease, the center is equipped to handle all types of kidney stones, from the smallest to the most complex. Surgical procedures conducted at the center range from the non-invasive Extracorporeal Shockwave Lithotripsy (ESWL), to the Ureteroscopy and Percutaneous Nephrolithotomy (PCNL) and mini-PCNL. Utilization of PCNL to remove larger-sized stones is greatly expanding at the center.

The main benefit is that a patient can have a large stone removed and then return home after just a 23-hour hospital stay.

URMC’s center boasts a free-standing ESWL and endoscopy suite with dedicated staff. The suite has allowed the Center to set up the Kidney Stone Hotline (1-877-51STONE) for referring practices and patients such that most can be evaluated and treated within 24-48 hours.

Stone-Prevention Strategies

Because of the high recurrence risk of kidney stone – as much as 30% to 50% within five years – the center’s staff also focuses on metabolic treatment options working with nephrologists and dieticians.

“Surgical management of kidney stones and prevention go hand in hand,” Quarrier said. “Patients come to the center with an acute event and following treatment the goal shifts to preventing the next acute event, and developing a customized strategy is crucial.”

Prevention strategies involve dietary management, behavioral and/or pharmacological changes. Future stone risk may be decreased through nutritional changes, for example, by decreasing

| Department of Urology | urology.urmc.edu

sodium intake. Special patient populations such as bariatric patients are at higher risk for kidney stone disease, and require modulation of oxalate intake and the addition of supplements.

Behavioral changes can involve a patient increasing fluid intake to avoid dehydration, a leading cause of kidney stones. However, because studies show that patients do not always follow the fluid-intake recommendation, supplemental methods are used to remind patients.

These include encouraging patients to carry a water bottle and the use of phone apps that remind a patient to drink water or gamify the process with rewards for drinking fluids.

Medication can be used as a tool in the arsenal to target stone-forming risks. For example, pharmacological solutions can change a patient’s pH balance and decrease calcium excretion or cystine buildup in the urine. Whenever possible, URMC’s clinicians emphasize prevention and behavioral treatments over pharmacological ones.

URMC’s kidney center also helps avoid contributing to the opioid epidemic by offering a hotline that patients can call to get immediate care. By calling the hotline 24/7, patients can reach expert medical staff to gets answers to questions or treatment and referral recommendations.

Embracing Telemedicine for Greater Efficiency Besides helping patients avoid kidney stone recurrence, the center’s clinicians also are incorporating telemedicine into the clinic to serve more patients and to increase care efficiency.

The 24-hour urine study can be performed by a patient at home. Once the

urine and bloodwork samples are collected, a clinician reviews the results during a virtual visit. Telemedicine appointments such as this have enabled the center to expand its reach and better serve patients in Buffalo, Corning, Elmira, Syracuse and New York State’s Southern Tier region.

“We rely on three-dimensional imaging to view the size, location and density of a stone,” Jain said. “Much of a patient visit is spent going over what we see on the CT scan and the treatment options. This can now be done through a telemedicine appointment.”

Jain added that virtual appointments dramatically increased during COVID-19, but the benefits of these appointments have made them part of the center’s ongoing work, which now holds a virtual patient clinic every other Friday for both new and established patients.

Patient-Centered Research Jain and Quarrier are working to maintain the center’s clinical leadership position while expanding its role in kidney stone research. The center is involved in several

research projects with collaborators in the Departments of Urology and Public Health Sciences. Recently, Jain has led the initiative to enroll URMC as a site for URIROX-2, a worldwide, multicenter Phase 3 clinical trial for a novel enteric hyperoxaluria drug. Given its massive patient database, the center hopes to recruit several patients for this groundbreaking study.

Bringing expertise gleaned from his University of Wisconsin fellowship studying under world-renowned urologist and former URMC resident Stephen Nakada, M.D., Quarrier is looking to focus future research on patient-centered outcomes and the disparities of stone formations based on socio-economic status, as people with lower incomes are more likely to develop kidney stone requiring aggressive therapy such as PCNL.

URMC’s team also plans to incorporate the work of Ahmed Ghazi, M.D., M.Sc., of URMC’s Simulation Innovation Lab., a well-established leader in producing patientspecific 3D-printed organs that allow for efficient surgical training models. The kidney center’s specialists believe they will be able

Drs. Timothy Campbell and Scott Quarrier in the ESWL and endoscopy suite at Strong Memorial Hospital.

to use the models developed by Ghazi to improve surgical training for residents as well as in rehearsals of complex procedures.

Recruitment is underway for a clinical study to help patients lower their urinary sodium levels, a known risk factor for kidney stones. Working with software developer Gian and its HealthCartTM app, Jain hopes that study participants will be better able to follow a low-sodium diet. In concept, while shopping, the app will inform a participant that that the food product they are considering buying is high in sodium and also offer an alternative. The researchers will evaluate whether using the app will improve patients’ knowledge of sodium’s role in kidney stones and improve their adherence to a low-sodium diet.

Cutting-edge research and continued clinical excellence will further build on the foundation created by Erdal Erturk. Going forward, URMC’s Comprehensive Kidney Stone Treatment Center will continue to provide the highest-quality patient care and to enhance its breadth of services, to reduce the suffering patients experience from kidney stones.

Erdal Erturk, M.D.

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Access to Urology Care in Rural Settings a URMC Priority The URMC Department of Urology has made it a priority to increase access to care in rural communities within its service area in Upstate New York. Particular emphasis has been placed on the state’s Southern Tier Region, which has long-suffered a shortage of specialists of all types.

The University of Rochester Medical Center has prioritized providing high-quality, highly specialized care close to home,” said Jean V. Joseph, M.D., chair of Urology. “For our team, we have been able to grow our presence with additional clinic and surgical locations, adding providers who bring worldclass, comprehensive urology care close to home for patients who otherwise would be forced to travel several hours to see a specialist.”

Partnering with affiliate hospitals Noyes Memorial, St. James and Jones Memorial to offer medical and surgical treatment at the local level, the Department of Urology has

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created a successful model that guides each patient’s care, with an ease of referral to Strong Memorial, URMC’s flagship hospital, if more complex care is required.

“We want to ensure that all patients who need care are able to get it,” Joseph said. “Access should not be dependent upon an individual’s zip code.”

Providers recruited specifically to increase access in the Southern Tier of New York consist of: • Zaheer Alam, M.B.B.S., who practices in Dansville and Wellsville; • Divya Ajay, M.D., M.P.H., in Hornell; • Otto Sandoval, M.D., in Geneseo and Wellsville; • Chelsea Jones, P.A., in Dansville and Wellsville.

Volume increased by 216% between FY19 and FY20. Projections show a 20% volume increase is expected for FY21.

| Department of Urology | urology.urmc.edu

Zaheer Alam, M.B.B.S.

Divya Ajay, M.D., MPH

Otto Sandoval, M.D.

Chelsea Jones, P.A.

Research

In Memoriam

Developing Ultrasensitive Technologies for Early Cancer Detection and Surveillance

Irwin Frank (1927-2020)

The lab of Jonathan Flax, M.D., is bringing together urologists and engineers from the University of Rochester and the Rochester Institute of Technology to develop and study new rapid, non-invasive, and ultrasensitive technologies to detect bladder cancer and predict a patient’s responsiveness to therapies.

Flax’s approach exploits the diagnostic utility of vesicular packets secreted by most cells into blood and urine. These packets, known as extracellular vesicles (EVs), contain proteins from the cells that produce them, including cancer-specific proteins. Using a nano-membrane technology developed at the University of Rochester, high resolution single EV imaging, and machine learning, Flax and his colleagues are seeking to overcome some of the major challenges of using EVs for the detection of tumors. This process, if successful, could have important clinical implications. Conventional methods for purification and molecular detection of EVs and cancer biomarkers become overwhelmed by the abundance of EVs produced by healthy cells. The process developed by Flax and colleagues called “Catch and Display Liquid Biopsy” (CAD-LB) – can detect protein markers on individual EVs from blood and urine out of a pool of millions of EVs, raising the possibility of recognizing the presence of small tumors that produce only a limited number of EVs with cancer markers.

Education Profile

Thomas L. Osinski, M.D. Thomas L. Osinski, M.D., is a fifth year Urology resident at the University of Rochester. Osinski’s research interests include the role of alternative polyadenylation in urologic malignancies, prostate cancer imaging with MRI, and bladder cancer outcomes. He is also working on a randomized clinical trial being conducted at URMC which will evaluate if a medication can reduce erectile dysfunction and incontinence after radical prostatectomy.

Osinski has served as a resident representative on the Wellness Committee at the University of Rochester and is interested in addressing burnout in healthcare from a system’s aspect. He is also co-chair of the Resident and Fellow Section for the Committee on Quality and Patient Safety through the American Medical Association. Osinski completed his B.S. at Cornell University and his M.D. at the University of Rochester.

Irwin N. Frank, M.D. – one of the most influential urologists in the last half-century – has died at the age of 93 at Strong Memorial Hospital in Rochester. Frank, who spent his entire academic and medical career at the University of Rochester, served in senior positions in some of the nation’s leading medical organizations.

Frank enjoyed a highly distinguished career in medicine. During the 60 plus years he spent as a faculty member at the University of Rochester Medical Center (URMC), Frank served as the chair of Urology, senior director and medical director of Strong Memorial Hospital, and senior associate dean for Clinical Affairs in the School of Medicine and Dentistry. He recently held the position of Professor Emeritus of Urology at URMC.

The son of first generation immigrants, Frank was born on March 24, 1927 at Strong Memorial Hospital. He immediately enlisted in the Navy after high school, serving during World War II in the South Pacific until 1946 as a radio operator and repairman. After the war, Frank attended the University of Rochester on the GI Bill, where he received both his undergraduate and medical degrees. He completed his internship in surgery and residency in urology at URMC.

Frank’s influence on the field has been national in scope. He has served in leadership roles that helped advance research and patient care, and provided oversight of the U.S. health care system. He is a former president of the American Urological Association (AUA), a founding member and past president of the New York State Urological Society, and past president of the Northeastern Section of the AUA. Frank also served for more than a decade as the surgical representative on the executive committee of the Board of Commissioners of the Joint Commission on the Accreditation of Healthcare Organizations.

Frank was author or co-author of more than 50 journal publications and numerous textbook chapters on the topics of prostate, kidney, and bladder cancer.

Irwin is survived by sons Gary (Lisa), Steven (Robin), and Larry (Eric); brother Bertram Frank; and granddaughters Casey, Amy, and Rachel Frank. He is predeceased by his wife Marilyn of 63 years.

The family requests any donations to honor Irwin be sent to the URMC Department of Urology: www. urmc.rochester.edu/ urology/donations URology

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University of Rochester Medical Center Department of Urology 601 Elmwood Avenue, Box 656 Rochester, NY 14642

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DEPARTMENT OF UROLOGY FACULTY Jean V. Joseph, MD, MBA, FA, CS Professor of Urology and Oncology Winfield W. Scott Professor and Chair of the Urology Department Divya Ajay, MD, MPH Assistant Professor of Urology Zaheer Alam, MD Assistant Professor of Clinical Urology Jathin Bandari, MD Assistant Professor of Urology Jonathan Bloom, MD Assistant Professor of Clinical Urology Jimena Cubillos, MD Associate Professor of Clinical Urology and Pediatrics Director of Quality Improvement Thomas Frye, DO Assistant Professor of Urology and Oncology Associate Director, Clinical Trials

Joseph Gabrielsen, MD, PhD Assistant Professor of Urology

Joy Michaelides, MD Assistant Professor of Urology

David Gentile, MD, FACS Professor of Clinical Urology Chief of Urology, Highland Hospital

Jeanne H. O’Brien, MD Professor of Urology Associate Chair of Faculty Development and Resident Education

Ahmed Ghazi, MD, MSc Assistant Professor of Urology Co-Director, Endourology, Robotic/MIS Fellowship Director, Simulation Innovation Lab Rajat Jain, MD Assistant Professor of Urology

Ronald Rabinowitz, MD Professor of Urology and Pediatrics

Yi-Fen Lee, PhD Professor of Urology, Oncology, Pathology and Laboratory Medicine

Hani Rashid, MD Professor of Urology and Oncology Director of Residency Program

Diane Lu, MD Assistant Professor of Clinical Urology

Otto Sandoval, MD Assistant Professor of Clinical Urology

Edward M. Messing, MD, FACS Professor of Urology and Oncology Director, Clinical Trials

Annette E. Sessions, MD Assistant Professor of Clinical Urology

Jamie Connor, NP Jason Donovan, PA Karrah Gantz, NP Diane Giordano, PA Cassandra Gregoli, PA Kim Hoadley, PA Shawna Hyland, NP

William Tabayoyong, MD, PhD Assistant Professor of Urology Shlomi Tapiero, MD Assistant Professor of Clinical Urology Jared Wachterman, MD Assistant Professor of Urology Gareth Warren, MD Assistant Professor of Urology Guan Wu, MD, PhD Professor of Urology and Oncology Director of Urologic Oncology Co-Director, Fellowship in Robotic Surgery Shu-Yuan Yeh, PhD Professor of Urology, Oncology, Pathology and Laboratory Medicine

DEPARTMENT OF UROLOGY RESIDENTS/FELLOWS

ADVANCED PRACTICE PROFESSIONALS Meredith Abbasi, CPNP Jamie Allen, FNP-C Katie Bates, PA Dan Barney, PA Amy Beyrle, RPA-C Steve Blount, PA-C Mariya Canham, NP

Scott Quarrier, MD, MPh Assistant Professor of Urology Assistant Director Residency Program

Paul Shapiro, MD Associate Professor of Clinical Urology Chief of Urology, FF Thompson and Clifton Springs Hospitals

Alexandra Karnyski, FNP-C Maureen Kiernan, NP Victoria Mesko, FNP-C Robyn Reis, NP Parker Remelt, PA Claire Smith, PA Kristin Smith, RPA-C

Mahmoud Khalil, MD, Fellow Jacob Gantz, MD, PGY6 Michael Witthaus, MD, PGY6 Thomas Osinski, MD, PGY5 Alexander Cranwell, MD, PGY4 Alexis Steinmetz, MD, PGY4 Kit Yuen, MD, PGY4 Karen Doersch, MD, PGY3

Elizabeth Ellis, MD, PGY3 Austin Lee, MD, PGY2 Aaron Saxton, MD, PGY2 Christopher Wanderling, MD, PGY2 Timothy Campbell, PGY1 Stephen Hassig, PGY1 Laena Hines, PGY1