Amanda Wilde (Host): A look at urologic services and
prostate cancer on this episode of Curating Care, a podcast brought to you by
St. Clair Health, expert care from people who care. I'm Amanda Wilde. And
joining me is Dr. Shailen Sehgal, urologic surgeon here at St. Clair Health.
Dr. Sehgal, great to have you here.

Dr Shailen Sehgal: Thanks so much for having me. It's a
pleasure to be here.

Host: Now urology, it requires a broad range of
competencies to treat a variety of conditions. Can you explain the services a
urologist provides and why someone might seek your expertise?

Dr Shailen Sehgal: Yeah, and I think that's a great
question. And a lot of people don't know the answer to that, Amanda, but
urology has a huge breadth. I mean, on a daily basis, I see urologic cancers,
specifically prostate cancer, kidney cancer, bladder cancer, testicular cancer,
cancers of the upper urinary tract. And it runs the gamut to erectile
dysfunction, men's health issues, testosterone deficiencies, infertility. A lot
of quality of life aspects of care we administer, for instance, helping people
attain, continence, helping with urinary frequency, et cetera. We also do
elective procedures, vasectomies. So, there's a huge breadth to the field. We
always say at some point somebody's going to need to see us, whether it's when
they're 15, 50 or 95.

Host: I was going to say, you must see most of the adult
population.

Dr Shailen Sehgal: Right. For sure.

Host: Now, you're board-certified in urology, completed
your residency and fellowship at the University of Pennsylvania in
Philadelphia. Can you talk a little bit about your own experiences and why you
chose this field?

Dr Shailen Sehgal: That's exactly right. So, I finished
my training at the University of Pennsylvania. And my wife's from around the
Pittsburgh area, and you always go where your wife's from as a rule. So, I
chose urology because I think in medical school, you have to make a decision as
to whether you want to be a primary medical doctor or a surgeon, and I was
pretty sure after doing my clinical rotations that I wanted to do surgery. And
most of the urology and urologic surgeons that I met were happy surgeons. They
were able to fix their patient's problems pretty readily, whether it was a
cancer issue or if it was a urinating issue or infertility issue or a simple
procedure like a vasectomy. So, a lot of the surgeries are successful. There's
a huge breadth to the field like we talked about. So if you get very interested
in one aspect of urology and urologic care, you're able to specialize with that.
You can do very, very big surgeries. So, you can take bladders out and form new
bladders with intestines, and you can do very small procedures, like doing
scope-based procedures. So, it gives you that ability.

In addition, a huge part of what we do is in office-based
practice, right? So, we're kind of the medical doctors of the urinary tract to
treat urologic conditions with medications, behavioral modifications, et
cetera. So, I think the breadth of the field is very attractive, the fact that
the therapies we administer tend to be very successful. And that's what drew me
to the field.

Host: Yeah. Success is a good thing. You also were
working in a large urban health system in Philadelphia and then moved to a
community-based health system. What are the differences there, or what was that
like for you?

Dr Shailen Sehgal: It carries a lot of similarities and
differences. I think one of the similarities is that, and I feel blessed to be
part of St. Clair Health and the entire system here, because we administer
pretty sophisticated care for urology here. I mean, we have five very talented
urologists. We have the ability to consult with tertiary care centers, and
execute that care plan. So I think in that regard, what I was doing in
Philadelphia at the University of Pennsylvania is similar, meaning providing a
high level of care to individuals tackling tough urologic problems, and
tackling them in a sophisticated way. I think one of the differences and one of
the things that's gratifying is that we're able to administer that care to the
community that we live in. You know, when you're in an urban setting like
Philadelphia, you'll see people that travel in from hour, two hours away,
people that are down the street. But at St. Clair, it's neat because I'm truly practicing
in the community that I live in. I live just minutes from the hospital. So,
that's one of the most gratifying things for me and probably one of the biggest
differences between an urban center like the University of Pennsylvanians and
St. Clair Urology.

Host: Now, we are going to talk about prostate cancer
specifically, focusing on this because it's pretty common. One in seven men are
diagnosed with prostate cancer and it is the most common type of cancer for men
in the us. When should men start to consider seeing a urologist just to start
screening?

Dr Shailen Sehgal: it's actually one of the more
controversial topics in all of urology and primary care, because preventative
medicine's important and it's been a topic of conversation for probably the last
10 or 15 years in urology. But we tend to practice by the American Urological
Association guidelines. And what they say is that men aged less than 40,
typically we don't do prostate cancer screening, because it's not considered to
render a health benefit to them. And then, you have the next age group, which
are men aged 40 to 54. Those individuals routinely, the American Urological
Association says, do not need to get screened for prostate cancer.

Having said that, there are some caveats, right? So if
individuals in that age group have a family history of prostate cancer, and
certainly if they have a family history of significant or lethal prostate
cancer or an African-American race, then we should strongly consider doing
prostate cancer screening in those aged 40 to 54.

The biggest group where we do prostate cancer screening are men
aged 54 to 69. By the guidelines, that's the group where you should have a
rational conversation with them and discuss kind of the merits of prostate
cancer screening. And typically, what that involves is checking a PSA, which is
a blood test, Amanda, and then doing a prostate exam, a rectal exam. And as a
blanket statement in general, men aged 70 and above or with a more limited life
expectancy, we don't do prostate cancer screening. Having said that, I think
all of this has to be a good rational conversation between the urologist and
the patient to determine what's best for them.

Host: So, the screening process is a physical exam and a
blood test.

Dr Shailen Sehgal: That's correct.

Host: And if prostate cancer is detected, then what?
What are the treatment options?

Dr Shailen Sehgal: One of the great things about
prostate cancer, not that you want to say any cancer is a great thing, but when
it comes to prostate cancer, there's a whole slew of different treatment
options. In actuality, a lot of the low-risk, low-grade prostate cancers we are
watching and we are watching in a careful way. We're watching them with exams
over time; PSA checks, which are blood tests; MRIs of the prostate, biopsies
over time. Some low-risk prostate cancers, we're starting to see more in the
realm of chronic diseases such as high blood pressure, diabetes, high lipids
where it's something that we should monitor and take further action if it
changes over time.

Having said that, there are clinically significant prostate
cancers and we have a whole algorithm with which we use to try to figure that
out. And if the prostate cancer does fall into a category that deserves
treatment, the two biggest categories of treatment are surgery and radiation.
So, we have a rational conversation with the patient about what might be best
for them. In addition, there are other treatments for prostate cancer,
including radiation seeds, freezing the prostate, high-intensity frequency
ultrasound. So, there are a number of different choices. I always tell people,
I want patients when they hear that diagnosis, because when they hear the C
word, obviously they get very concerned, but I want them to know that there's
many things that we can do to try to fix it. And frankly, we usually can fix
it.

Host: What are the statistics on that?

Dr Shailen Sehgal: So, it certainly depends on the kinds
of prostate cancer that's discovered. For low-risk prostate cancer, I would say
it has an excellent prognosis. Intermediate and even high-risk prostate cancer
has an excellent prognosis. I think that one of the questions that we have is
how can we fix this in one fell swoop, right? How can we fix this with just
surgery or just radiation or one therapy rather than resorting to multiple
therapies? So for all but the very high risk, high volume diseases, it tends to
have an excellent prognosis.

Host: On the subject of surgery, St. Clair Health
invested in the newest model of the da Vinci Surgical System. And in the US,
75% of prostate surgeries are performed using the da Vinci System. Tell our
listeners what robotic-assisted surgery means and the benefits of using this
method.

Dr Shailen Sehgal: It's funny because there's a whole
generation of urologists that consider themselves to be robotic
prostatectomists, meaning that the primary way where they learn to take the
prostate out is with a robotic technique. And I'm no exception to that. But I
think the benefits are the visualization is better, the blood loss is less, the
recovery is better. Individuals oftentimes don't need a narcotic medication
after surgery. I just did a robotic prostatectomy yesterday and I spoke to the
guy and he said it just felt like he did a bunch of sit ups, which is pretty darn
good when you compare it to the old-fashioned way that we used to do it with a
big incision. Patients required narcotic medications for a number of days
afterwards, et cetera. I think that the kind of the trifecta of outcomes, which
we use to determine a patient's success after surgery, whether it's cancer
outcomes, potency and continence are similar between an open technique and a
robotic technique, but the recovery itself tends to be better with a robotic
technique.

Host: Yeah. It sounds like it can be dramatically
better. One of the tools you mentioned was tertiary care centers, and St. Clair
is a member of the Mayo Clinic Care Network, which allows for second opinions
from a Mayo Clinic specialist or subspecialist. What does that mean for you and
for your patients to have access to that kind of clinical collaboration?

Dr Shailen Sehgal: I think it's a real privilege for us
and for the patients. Because oftentimes, we can administer the care, right? We
have the medications to do it. We have the surgical expertise to do it. But the
problem is complex. If an individual has multiple urologic cancers or they have
a unique urologic cancer, we can certainly do the surgery. We have the ability
to do that. We have five great surgeons in our group. But the real question is,
is that the right next step? And so, being able to use the Mayo Clinic to
determine whether this is a rational next step.

So first of all, it's a great resource for our practice to know
that it's there, to know that you have kind of this backup opinion that you can
get in a pretty expedient way. When we submit a request to the Mayo Clinic to
see what their opinion is, they usually get back to us within a week or so. And
to have that as a second opinion and have a group of five urologic surgeons
that are doing surgery at a high level, is remarkable that St. Clair has that.

Host: It's one of your many effective options that
you've described today. Dr. Sehgal, thank you so much for sharing your
expertise in unpacking that wide, wide world of urology with us today.

Dr Shailen Sehgal: Oh, it's been my pleasure. And thanks
for having me, Amanda.

Host: That was Dr. Shailen Sehgal, urologic surgeon at
St. Clair Health. To contact Dr. Sehgal, please call 412-942-4100 or visit
stclair.org. Please rate and review this episode and check out all podcast
episodes at stclair.org/curatingcare. Thanks for listening to Curating Care,
brought to you by St. Clair Health.