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Dr. Jeff Campsen: You've had kidney pain. You don't know what to do. You're at the end of your rope. There may be a procedure that can help you. We'll talk about that next on The Scope.

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Dr. Jeff Campsen: I'm Dr. Jeffrey Campsen, and I'm here today with Dr. Blake Hamilton. We're going to talk about kidney disease, kidney pain, and techniques to help kidney pain. It's a specific type of pain that we'll talk about today that may be helped by a procedure called autotransplantation of the kidney. So there's all types of kidney pain. Is there a specific type of pain or a scenario that a patient comes to you and ultimately gets to this point?

Dr. Hamilton: Yeah. Well, first let's make it clear. We're talking about very unusual, extreme pain after other things have failed. We're not talking about your basic first time kidney stone episode. Kidney stone pain is very severe. It's some of the worst pain you can have. Most of the time, this pain goes away. The kidney stone passes. You have surgery. It gets better. But sometimes people who have had previous episodes will end up with this recurrent, chronic, refractory pain that doesn't seem to respond to anything. We can take out all the stones. We can make sure the kidney's not obstructed. Everything looks fine, and the patient still has debilitating pain. And then the question is, "What do you do? How do you help them?"

Many things have been tried. Obviously, one of the things that people do is they simply take the kidney out. Well, that's a problem because you lose a kidney. So this idea of autotransplantation is an extension of kidney transplant, which is what you've built your career on and is an expert at. The typical transplant of a kidney is a kidney that's donated by somebody else and goes into the patient. Autotransplant means it's the patient's own kidney that's taken out and then transplanted into a different part of the body. In this case, it goes down into the pelvis, adjacent to the bladder. The idea of this is that when you take the kidney out, you sever the nerve supply from the kidney, and so you stop that pain. But by transplanting it, you preserve the function of the kidney.

Dr. Jeff Campsen: So from what you've said, I've got a couple of questions. At the beginning, when you're trying to diagnose this, is there a scenario or a type of pain that really moves you in the direction that this may help them?

Dr. Hamilton: The character of the pain may range from dull and aching to severe flank pain. So it's not the quality of the pain as much. The location has to be fairly typical, but it's really the duration, the chronic nature of it, and the fact that we tried everything else to make it go away and cannot. The next step is to say, "Can we predict if an autotransplant will work?" So we've been working with our radiology colleagues, and what we have them do is under radiology guidance, they'll put a needle right by the hilum of the kidney and they'll inject some anesthetic right where those nerves run. If that makes the pain go away, then we can predict that this operation is going to be helpful for them. We're early in our series, but so far, we've got a pretty good track record. We think this is an excellent technique for predicting success.

Dr. Jeff Campsen: Now, this is something that you've developed over your career to try to figure out whether or not this will work. It's not something that's written about a lot, and it's a procedure that you've had success with recently?

Dr. Hamilton: Yeah. Autotransplant has been around for a while. It was originally described for something called Loin Pain Hematuria Syndrome, which in Layman's term means, you've got flank and and you've got blood in your urine, and nobody knows why. This is more focused on the pain aspect of it. They may or may not have blood in the urine. The success rate is somewhere between 60 and 70 percent, but by comparison with other things like chronic pharmacologic management of the pain, which is not very good and leaves people somewhat functionally debilitated because of the medications, this is an excellent opportunity to improve people's quality of life.

Dr. Jeff Campsen: In your understanding of this, why do you think this works?

Dr. Hamilton: The nerves are sending a message to the brain that something's wrong when there is no longer something wrong. So what we're trying to do is interrupt that message by severing the nerves. These are sensory nerves to the kidney, so after you sever the nerves to the kidney, the kidney functions just fine. We know that, again, from the long history of kidney transplant experience. We also know that people with kidney transplants don't really experience pain in their kidney. For example, if they get a kidney stone, they don't get that same kind of pain. That's why we suspected that this would work.

Dr. Jeff Campsen: Importantly, I think, by the time they get to this point to where you're going to offer them this procedure, they're ready to literally get rid of their kidney?

Dr. Hamilton: Most people say, "Do anything you want. Take the kidney out. Stomp on it. Get rid of it. Throw it away." But that's a little short-sighted because we have two kidneys, and there is some reserve for sure. But if you're 30 years old and you've got another 50 or 60 years to live, that second kidney may prove to be very useful down the road. So we do everything we can to save kidneys, and this is yet one more way to do that without sacrificing a good functioning kidney.

Dr. Jeff Campsen: As people are listening to this and they say, "Well, I've got pain that I think is from my kidney," how should they go about seeing a urologist or a primary provider to start thinking about this?

Dr. Hamilton: The first step is to do an evaluation of the kidney. So imaging, like, a CAT scan, looking for stones, looking for common things. Often, there may be some little stones if they have a history of stones. So, we'll usually go in and do an endoscopic surgery where we remove all of the stone pieces, all of the fragments, really clean out the kidney, and then let a little time go by and reevaluate. If the pain goes away, that's great. If there's any blockage, if it's relieved by some kind of a drain, great. But if you do several things and the pain persists, then we start talking about what we might do next. Often, these patients have had all of this done by other physicians and they come to me looking grasping for straws, looking for any hope, any sliver of a chance that they might get better. At that point, they're ready to have their kidney removed. In fact, curiously, they often ask if they can donate their kidney. I have to tell them, "No, I don't think anyone wants your kidney."

Dr. Jeff Campsen: That's a good point. I think the piece to pull away from this is that this is not the first line therapy. This is way down the road after multiple attempts to take care of the pain and the primary disease have not necessarily been completely successful.

Dr. Hamilton: That's right. This is in-stage treatment. I mean, I would guess something, like, 1 out of 10 or 1 out of 20 patients in these extreme conditions actually progress to this point.

Dr. Jeff Campsen: So someone's at the end of their rope. They've had a lot of procedures with their urologist. What do they do?

Dr. Hamilton: Most of the time, these patients are referred by their urologist who send them to me because we're a University center, and I have some experience in this. The urologist often doesn't really know what more to do either. So that's where we get started. This is not the kind of thing that's done around the community. I mean, this is a very specialized procedure. Even among academic medical centers, not everybody is offering this to patients. So, I think it will grow in popularity as we and others demonstrate good success with this.

Dr. Jeff Campsen: I think the University of Utah really provides a multidisciplinary group that can handle the care of this difficult patient.

Dr. Hamilton: Right. This goes beyond my own expertise. I mean, I need people who are good at image-guided needle placement. I need somebody who can do the transplant surgery. We need post-op management. We need pre-op evaluations. So it really is a team approach here.

Dr. Jeff Campsen: So what do you think? Does it work?

Dr. Hamilton: Well, I think our success rate is around 75 percent. It's not perfect, but I think in this patient population where there are not a lot of options, this is a very good approach. I think it's showing great promise.

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Dr. Tom Miller: Screening for prostate cancer.

Dr. Blake Hamilton: Oh my.

Dr. Tom Miller: Why the oh my?

Dr. Blake Hamilton: This is a very controversial subject.

Dr. Tom Miller: This is Dr. Tom Miller. We are going to be talking about prostate cancer screening next on The Scope.

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Dr. Tom Miller: Hi, I'm here with Dr. Blake Hamilton. He's the medical director for the urology clinic, and he's also associate director for the division of urology. Let's talk about it. Is prostate cancer screening with P.S.A. testing something that's time has come and gone?

Dr. Blake Hamilton: No, I don't think so. It's a shifting environment to be sure, but I think it still has relevance.

Dr. Tom Miller: You know, the national guidelines, or a couple of the guidelines out there now say that you really don't need to screen men for prostate cancer using the blood test, the P.S.A., prostate specific antigen test. That's based on a couple of large studies, I believe. The outcomes of those studies, one in Europe, one in the United States, didn't back up the idea that using this test could save lives best that the studies showed.

Dr. Blake Hamilton: We have to go back and understand the history of P.S.A. P.S.A. is a protein that's produced by the prostate. It has a role. It has a function. We learned many years ago, three decades ago, that it goes up in prostate cancer, and when you treat prostate cancer it goes down. It became used as a marker for recurrence of treated prostate cancer. It continues to be very reliable. It's one of the best blood markers that we have for cancer.

Dr. Tom Miller: No question. I think we all know that we find more prostate cancer using this test. The question is does it save lives in the long run.

Dr. Blake Hamilton: The two studies that you refer to, depending on how you interpret them, show that there was not enough difference between the group that was screened and the group that was not screened. There are several problems with those studies. One is that they may not be mature enough. They had an average follow up of eight, nine, ten years, and the arms are separating. If we get to 15 years I think we'll see a difference. I think we'll see a clear separation between those two arms. The other problem is there are some methodological problems in how the patients were accrued. It's complicated. I think the real issue is that some people with prostate cancer will suffer immensely and die, and many will not. What we really need to do is do a better job of trying to predict who needs treatment and who doesn't. I think that what's happened over the last couple of decades is when men are diagnosed with prostate cancer based on P.S.A. screening they automatically have gotten treatment. So, in a sense as a community we've over-treated men with prostate cancer.

Dr. Tom Miller: I think part of the concern is also the potential complications of the surgery or the other treatments available for prostate cancer. I mean it's not a benign procedure, and there are outcomes that are difficult for the patient. I think that is coloring the judgment of some of the task force groups that are looking at screening guidelines currently.

Dr. Blake Hamilton: The problem is you still have some 250,000 men who will be diagnosed with prostate cancer this year in the United States. There will be some 35,000 of those who will die from prostate cancer. To say that prostate cancer screening with P.S.A. has come and gone would be throwing the baby out with the bathwater. What we need to do is keep the screening but make better decisions about when to biopsy and when to treat prostate cancer. Already we're seeing a significant decline in the number of men who are being treated, and that's appropriate. But, we've got to keep looking for the ones that are going to be lethal cancers, because they're real.

Dr. Tom Miller: Let's talk practicalities. Are you saying that we should continue to follow the past guidelines which say begin screening in men at the age of 50, and then continue screening every year with P.S.A. testing?

Dr. Blake Hamilton: There are now many alternatives to that.

Dr. Tom Miller: Right.

Dr. Blake Hamilton: One alternative, which comes from the U.S. preventive services task force, is to not screen at all. The American Urological Association has modified their guidelines to suggest that we screen maybe not every year but every two years in men between the ages of 55 and 70 where we think that we'll find the highest yield in the patients for whom it will really matter. Screening in 80 year olds, not important. Screening in the younger generation, not enough data to show evidence that it helps or makes a difference.

Dr. Tom Miller: Younger generation meaning 50 years old and above?

Dr. Blake Hamilton: Less than 55.

Dr. Tom Miller: Less than 55.

Dr. Blake Hamilton: Although there are many researchers who would argue that between 45 and 55 should be included. The guidelines as we have them now would be that those men in that 15 year window, and screening not as intensely as we have in the past, but not to give it up.

Dr. Tom Miller: Let's say that your P.S.A. is elevated. What should the patient do? Should they go then to a urologist who specializes in prostate cancer? A lot of this, as you say, is going to depend on the expertise of the specialist taking care of this type of problem.

Dr. Blake Hamilton: I think most urologists have the ability to evaluate an elevated P.S.A. and make a decision on a biopsy. There continue to be a variety of opinions out there. If you have a single elevation in the P.S.A. I think it's reasonable to wait some time and repeat it and think about what that means.

Dr. Tom Miller: So, screening is something that you believe we should continue. You think it's a good idea.

Dr. Blake Hamilton: Yes, I think we should continue screening but do it judiciously and appropriately, and then think carefully without automatic treatment of those who are diagnosed with prostate cancer.

Dr. Tom Miller: A final thought. What about that time honored rectal exam? Do we still have to do that on patients? It's the brunt of so many jokes.

Dr. Blake Hamilton: Yes, it is. Unfortunately, there are some bad prostate cancers that have low P.S.A.s and are only found on physical examination, so we're going to continue doing that exam, Tom.

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Tom Miller: Red urine. What should you do? This is Tom Miller on The Scope, and we're going to talk about that next.

Man: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Tom Miller: I'm here with Dr. Blake Hamilton, who is the Medical Director for the Urology Clinic and the Associate Director of the Division of Urology in the Department of Surgery. Blake, what should someone do if they notice the color of their urine changing from clear or yellow to red? This is something I see in my practice, questions I get not infrequently.

Dr. Hamilton: Well, the obvious assumption when you see red urine is that it's blood and it's bad. So the first question is, 'Is it really blood?' There are some unusual things that will cause red urine. Probably the most notorious is eating fresh beets.

Tom Miller: You know, this is great because two weeks ago, I had a patient who called me. She was frantic, and everyone thinks they will have cancer if they have blood in the urine. So she had red-colored urine. I said, 'Just take a deep breath.' I brought her in, and she did a urine sample. It was totally normal. She was very reassured by that. But 24 hours later, she called me back and she said, 'You know, I just ate a ton of beets the day before that happened. Now I know.'

Dr. Hamilton: Right. A urinalysis is a very simple test that will quickly screen for that and let you know if there's actual blood or if the color is due to something else. There are some other food products, some dyes, some fresh berries, but beets is the main culprit. If you get a urinalysis and there actually is blood, then you've got to have a different conversation. Again, not all of it is cancer, so there's no need to panic right away.

Tom Miller: Is there some difference between the age of the person that might have blood in the urine?

Dr. Hamilton: Yes, certainly.

Tom Miller: And whether that's just short-term, like, one episode or whether it's prolonged?

Dr. Hamilton: As with many cancers, it's more prevalent in the older population. So if you have a young person in their 20's, cancer is very unlikely. In fact, in young women, a urinary tract infection or a bladder infection would be far and away the most common explanation.

Tom Miller: Right. And that would probably turn up on the urinalysis?

Dr. Hamilton: Yes. It would look like an infection, and often it would have symptoms. So when you ask the right questions and you get this information, then you treat them with antibiotics, and it goes away. It's pretty straightforward.

Tom Miller: I understand that in young people, blood in the urine could be due to excessive exercise or vigorous exercise. Is that true?

Dr. Hamilton: That's correct. That is correct. There's something called Jogger's Hematuria where after physical exercise like running you can have blood in your urine. It's thought to simply be some mechanical friction between the walls of the bladder that irritates it and causes a small amount of bleeding.

Tom Miller: So it's like a nosebleed of the bladder?

Dr. Hamilton: Well, a little bit.

Tom Miller: Yeah. A little bit.

Dr. Hamilton: Runners have discovered that if they actually run with their bladder just very slightly full, not completely full but not completely empty, they can avoid this.

Tom Miller: So in older folks, there's a higher risk of blood in the urine being a sign post for cancer, but not always. Not the majority of the time. Is that right?

Dr. Hamilton: Yeah, that's right. Men, for example, get enlarged prostates, and that's a common cause of visible blood in the urine. Again, not related to prostate cancer, but it's just the process of growth and some inflammation. You have to look for some other things in that age group to make sure you're not missing something more important.

Tom Miller: What about kidney stones? Usually when a person has blood in their urine due to kidney stones, it's painful.

Dr. Hamilton: Yeah, that's right.

Tom Miller: But not always. Is that right?

Dr. Hamilton: Kidneys stones that have been around for a while, the patient may have had a painful episode in the past. And then the pain resolves, but they could have new or ongoing bleeding. Certainly, the blood caused by a rigid stone rubbing against delicate tissue could result in blood in the urine.

Tom Miller: So for patients who notice red urine, what would you say to that? For our audience, a lot of them are pretty worried. Should they go immediately to the physician? Should they go to the ED? What would you recommend? What do you think they ought to do?

Dr. Hamilton: I think they ought to have it investigated fairly soon with a simple urine test. If there's no blood, then you can dismiss it, and if there is blood, then I think you go onto some additional testing.

Tom Miller: What if they're less than 35 years old? Would you say that you could watch it if it was just one episode and they were athletes?

Dr. Hamilton: I think you could just watch it. I think that's a pretty safe course of action.

Tom Miller: When would you say that a young person would need to have that investigated?

Dr. Hamilton: Well, for a young person, if it happens one time, it probably is not anything terrible. But if it happens over and over, I think it really needs to be investigated because it could be something much worse.

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