The importance of learning uro-pathology
Urology is a fascinating specialty in flux with constantly new dimensions enriching the young and older urologist’s life. The collaboration and exchange with our partner specialties enrich our understanding and make us better physicians/scientists/educators. In a series of short editorials, several colleagues will try to make a compelling case for educating ourselves, and the next generations, in the urologic elements of partner specialties such as pathology, radiology, nuclear medicine, genetics, and medical oncology.
In this first short editorial, we will aim to convince you that learning uro-pathology is not only fun but will make you a better urologist.
5 seasons why every resident should learn uropathology:
1. Only by understanding uro-pathology, you will be able to deliver the right therapy for the right patient at the right time based on the tumour’s characteristics.
The complexity of modern pathology is increasing exponentially with classifications, subtypes, and histologic features, all impacting the clinical decision-making by a large degree. When you read "T1 100% neuroendocrine carcinoma" in a TURBT report, you understand that this means your patient has an aggressive tumour that is likely metastatic already, therefore needing systemic chemotherapy with etoposide and platinum. One needs to stay abreast of these changes to be able to deliver up to date management.
2. You will have better conversations with your patients.
Patients have access to their medical records, and many will read their pathology report. They will then come to you for clarifications. By being able to speak the pathologic language, you will be able to interpret for your patients the report and translate it into an understandable management plan. It is also important to know how the pathologist arrives at a diagnosis that means knowing not only about histology but also knowing about specimen processing. This is important in assessing the impact of lympho-vascular invasion versus artefacts and how the diagnosis of a positive margin on the radical prostatectomy was made and what it means. Thus, by being able to speak and understand the language of the pathologists, you will be able to understand the tumour (specifically in the age of precision/personalised medicine) and you will be able to better explain to your patients what their pathology means and how that effects their management and prognosis.
3. You will have better conversations with your pathologist.
Biopsies can miss the main lesion, margins can be unclear, knowledge of clinical factors can help the pathologist change/refine her/his diagnosis, etc. If you encounter any unclear pathologic issues that can have a significant impact on the patients care, just discuss it with your pathologist. In turn, good communication between pathologists and clinicians is also critical in assuring that the pathologists have the adequate clinical information to deliver the right diagnosis. For example, optimal patient management for high-grade non-muscle invasive bladder urothelial carcinoma can only be performed based on correct interpretation of the pathologic report within the clinical context, especially if the patient has received intravesical BCG.
4. You will understand that the field of pathology is both subjective and continuously evolving.
The classification system for urologic tumours is relentlessly changing, but, unfortunately, not all pathologists are staying up to date with the ever-increasing multiplicity/complexity. This especially applies to generalist pathologists practicing in small community settings where access to/interest of/knowledge of the current literature is limited. For example, you may get a bladder biopsy that is diagnosed as “Grad 2 TCC” or a “Gleason score 2+3=5". Moreover, you need also to know when to ask for a second opinion of the pathologic diagnosis. Alternatively, some diagnoses are neither right nor wrong but are instead subject to interpretation. Finally, going to the pathology laboratory to learn from one owns specimens will help each urologist to become a better surgeon as well as scientist.
5. You will become a better urologist.
You will understand the biologic/patho-physiologic underpinnings of the tumour. More practically, the utility of frozen sections analysis, for example, will help you deliver a tailored surgery. Frozen sections analysis shall only be done if it directly guides the intraoperative management. But to utilise this information, one needs to understand the limitations of the technique. Tissue processed on a frozen section can have artifacts such as artificial enlargement of nuclei and loss of architectural and cytologic detail, potentially leading to inaccurate diagnoses.
Conclusion
Based on the five points listed above, we strongly encourage every urologist to have a solid foundation in pathology. It will help you understand the disease and make you a better doctor as well as educator, communicator and scientist.