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For higher grade cancers, I don't care if they do seem to be focal on imaging and by biopsy, I don't think those patients are candidates for focal therapy. For some low risk or intermediate risk cancers, maybe even some of the higher risk intermediate cancers that seem to be limited in scope or in size, I think focal therapy could have a role. But I do worry that most of the people getting focal therapy are those who really don't need treatment in the first place, but they like the idea of doing the treatment or having the treatment because the morbidity is so low.It is something we should continue to pursue, but with great caution.
T.S.: You have a particular interest in neobladder reconstruction. Based on your experience, which form of urinary diversion offers the best balance of quality of life and oncologic outcomes?
Prof. Joseph A. Smith: Well, you know, the diversion doesn't have anything to do with oncologic outcomes. Presumably they're going to be the same despite the type of diversion. The quality of life that the patient experiences is going to depend upon their type of diversion. We did a lot of studies where we tried to compare, using validated quality of life measures, people who had an ileal conduit versus a neobladder. But those studies are all very flawed, because by definition the patient had either chosen that method or had that recommended to them. So, they want to believe that what they have is the right one for them and it's hard to really make comparisons. For the right candidates,
I think neobladder is a good procedure. The morbidity is not increased compared to abdominal diversions. Patients just have to be willing to accept some of the consequences, perhaps a need to catheterize. But those are some of my happiest patients, because it meant that they had a very low pressure neobladder, which meant they never leaked. They catheterized 4 times a day and they were dry. That wasn't really a very bad outcome. I don't consider the need for self-catheterization to be a huge drawback. The bigger drawback of course is the risk of incontinence, especially nocturnal incontinence, and I was never able to reduce that risk. Most patients would do good at night, but most patients would have to wear protection at night. I personally was never able to overcome that barrier.
T.S.: As Vice President of the American Association of Genitourinary Surgeons (AAGUS), what are your primary responsibilities, and how does the organization contribute to the advancement of the field?
Prof. Joseph A. Smith: Well, that’s one of the most prestigious, perhaps the most prestigious organization in our specialty and we’ve expanded the number of international members including individuals from Greece who attended our meeting. So, it’s highly prestigious for the individual, but it really is an organization with a meeting once a year. I guess the biggest benefit scientifically is that many people choose that as a place to present their most innovative work, and they get a lot of feedback from other experts about that. But it’s not an organization that develops its own protocols or its own research. It’s really more of a prestigious organization to honor the contributions and the ongoing commitment of most of the experts in our field.
F.N.: You have dedicated a significant part
of your career to improving surgical care in developing countries, like Africa. Could you share more about what initially motivated you to take on this initiative?
Prof. Joseph A. Smith: That has been an important part throughout my career and now it's just the primary focus of my career. I've been motivated towards humanitarian work. My thinking has matured in a sense. Going to places where there is a dearth of surgeons or no surgeons at all and operating as much as you can, and then come home, that's beneficial. Because you've helped those people on whom you've operated, but you've left no legacy on the ground. So, in more recent years and decades, the entire focus has been to train the local surgeons, and to help them develop their own training programs. We've done that worldwide. But my own personal primary interest has been in Africa. You remember some of our discussion earlier about robotic surgery and how at least in America a lot of urologists are not that good at open surgery for urological cancer anymore, because they've learned that all robotically. That means that the number of people that I can have to Africa with me and help train the African surgeons is limited, because they're not very good in some of the open
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