James Sylora, MD – Bridging Gaps for Focal Therapy in Community Urology

James Sylora, MD, stands at the forefront of community urological innovation, with a career spanning decades of dedication to advancing patient care. As a urologist based in a vibrant community outside of Chicago, Dr. Sylora’s journey began with a profound familial influence, joining his father’s esteemed practice after completing his medical education.

Dr. Sylora’s leadership extends beyond his clinical role, contributing significantly to the establishment and growth of the Associated Urological Specialists (AUS). Through his leadership and collaborative efforts, AUS has evolved into a leading institution renowned for its comprehensive approach to urological care, encompassing cutting-edge surgical techniques and treatment strategies, including focal therapy.

GU Oncology Now spoke with Dr. Sylora about his career, patient care, and vision for surgical and therapy advancements in community urology.

Could you provide a brief overview of your career timeline in urology – beginning with your medical school journey, any relevant fellowships or residencies, leading up to your current position at AUS, and any notable stops along the way?

Dr. Sylora: I am a general urologist based in the south side of Chicago, having joined my father’s practice, who was also in the same field. Our family has a background in medicine. I pursued my undergraduate studies at the University of Illinois, after which I attended Loyola University in Chicago for medical school. My interest in urology was sparked by Robert Flanigan and Bedford Waters, who were prominent urologists at Loyola during my time there.

Subsequently, I completed my residency at the University of Minnesota without opting for a fellowship. In 1995, I joined my father in practice, and since then, I have been practicing on the south side of Chicago. Over time, we formed a significant group of urologists, which eventually led to the establishment of AUS.

AUS originated from the amalgamation of 16 to 17 urologists, forming one of the Large Urology Group Practice Association (LUGPA) groups. Presently, we are part of the Solaris Consortium, extending our reach beyond our immediate locale to encompass a national network, while adhering to the same principles practiced across the country.

My focus within urology has largely been on prostate cancer, influenced by my father’s specialization in the same area. He instilled in me the importance of staying updated with the latest advancements. Throughout my career, I have maintained this philosophy, constantly seeking out new knowledge and attending numerous meetings to remain abreast of evolving practices in the field.

Under your leadership and expertise, how does a collaborative group like AUS maintain a leading edge in minimally invasive urologic techniques, such as robotic, laparoscopic, and high-intensity focused ultrasound (HIFU) procedures?

Dr. Sylora: We are fortunate to be situated near 5 universities, which compels us to stay informed and competitive. My colleagues are diligent in keeping up with advancements. Within our group, individuals specialize in various aspects of urology, whether it is prostate cancer, benign prostatic hyperplasia, stones, or female urology. Specialization allows us to excel in specific areas while still providing comprehensive care.

As for our relationship with our neighboring academic institutions, it is a blend of collaboration and friendly competition. Some of us, including myself, hold part-time appointments at institutions like Loyola University. We host residents from Cook County and the University of Illinois, fostering a collaborative environment. However, in a bustling city like Chicago, staying relevant requires offering specialized services. While we maintain cordial relations with our academic counterparts, we recognize the necessity of providing advanced care locally. Our interactions are characterized by mutual respect, and we often share insights and support each other when needed. Chicago’s medical community is more cooperative than confrontational, as evidenced by our regular gatherings and knowledge-sharing at the Chicago Urologic Society meetings.

Delving into patient care for prostate cancer, what ongoing research or developments do you see for robotic surgery?

Dr. Sylora: Robotic surgery has become the standard for prostate cancer treatment, with open surgery being rarely practiced nowadays, except by a few experienced urologists. The shift to robotics has significantly improved surgical outcomes, notably reducing complication rates and allowing for same-day discharge in some cases. A recent innovation in this realm is the emergence of single-port robotic systems, which I have embraced at Palos Hospital. While the debate continues over single-port versus multi-port approaches, I have found the single-port system beneficial in facilitating same-day discharges for patients.

Although certain aspects like morbidity, incontinence, and impotence remain unchanged, the extraperitoneal approach in single-port surgery reduces the risk of bowel injury. Dr. Crivellaro at the University of Illinois and I are among the proponents of single-port robotics in Chicago. While other institutions predominantly utilize multi-port systems, the single-port approach offers versatility, enabling various techniques like transvesical and Retzius-sparing procedures. This innovation represents the latest frontier in robotic surgery, shaping the future landscape of prostate cancer treatment.

What are some common misconceptions or concerns that patients have about robotic surgery for prostate cancer, whether single-port or multi-port, based on your experience? How do you address these concerns during consultations?

Dr. Sylora: Patients often fear the potential for incontinence and impotence associated with any surgery, and this holds true for prostate cancer treatment. When discussing treatment options like surgery or radiation versus focal therapies such as HIFU or cryoablation, the focus is on minimizing side effects. Incontinence and impotence remain significant concerns, with surgery often carrying this reputation.

During consultations, honesty is key. I explain to patients that restoring the bladder-to-urethra connection post-prostate removal is not as optimal as the original anatomy, leading to some compromise in continence. While some leakage may occur, it is important for patients to understand and accept this possibility. Similarly, while robotics may improve outcomes, I never promise better than a 50/50 chance of preserving erectile function. Despite our best efforts, erectile dysfunction can still occur post-surgery.

Managing expectations is crucial. I never oversell the procedure, preferring to provide realistic assessments. Patient satisfaction hinges on understanding the potential outcomes, even if they are not always perfect. It is about being transparent and realistic about what to expect postoperatively.

How does HIFU fit into the broader landscape of prostate cancer treatment?

Dr. Sylora: HIFU has been under investigation for quite some time. I first encountered it in 1998 during early explorations in Indiana. Essentially, HIFU involves using focused ultrasound to heat and destroy prostate cells, guided by computer-controlled precision to minimize damage to surrounding tissues. Unlike surgery or radiation, which can cause collateral damage, HIFU targets specific areas of the prostate with high-energy heat, sparing nearby structures.

Focal therapies like HIFU aim to eradicate prostate tissue or cancer while preserving vital structures like nerves and the bowel, hence the term focal. These treatments are suitable for patients with localized cancers confined to one side of the prostate. For instance, if cancer is detected only on the left side, HIFU can selectively target and treat that area, leaving the unaffected side intact.

This approach minimizes the risk of overtreatment associated with radical procedures like prostatectomy or radiation, reducing the chances of incontinence and impotence. While these risks cannot be entirely eliminated, proper execution of HIFU can significantly lower them to more acceptable levels. Furthermore, HIFU allows for same-day discharge, offering patients a less invasive treatment option with comparable benefits to traditional therapies.

Are we at a stage where most patients can access focal therapy in their community practices?

Dr. Sylora: We are just starting to see broader availability, primarily due to Medicare approval about 2 years ago. Prior to that, patients often had to seek treatment abroad due to a lack of approval and reimbursement in the United States, resulting in considerable out-of-pocket expenses. However, with recent reimbursement increases, hospitals can now offer HIFU without financial losses. Consequently, we are witnessing a surge in HIFU programs across the country, indicating a growing trend in its adoption.

Patients seem receptive, largely due to the extensive data supporting its efficacy and safety. Early concerns regarding accidental tissue damage have been addressed through improved precision. Moreover, advancements in biopsy techniques enable the detection of smaller, potentially aggressive cancers, prompting a shift toward less invasive treatments. Patients facing the dilemma of overtreatment versus active surveillance often find focal therapy a favorable middle ground, providing effective treatment without the burden of radical procedures.

How do you see the role of community urology evolving, and what opportunities do technological advancements offer for enhancing patient care and access to specialized services?

Dr. Sylora: Teleurology holds promise, especially for routine tasks like prostate-specific antigen checks, minimizing the need for in-person visits. However, for procedures requiring physical exams like focal therapies, telehealth presents challenges. Yet, recent developments allow for remote robotic surgeries, facilitated by improved internet speeds and communication satellites. This innovation enables world-class surgeons to perform procedures in rural settings, although legal and logistical issues remain.

While robotics demand specialized skills, focal therapies boast a lower learning curve and greater reproducibility, potentially standardizing care. Telehealth could facilitate knowledge transfer, ensuring consistent practices across providers. Unlike robotics, where each surgeon’s technique varies, focal therapies offer a more standardized approach. Through telehealth, expertise can be disseminated efficiently, enhancing overall care quality for prostate cancer patients.

Considering the aging population, how do you foresee the demand for urologic services evolving in community settings? Are there specific areas within urology that you expect will see increased demand or attention in the future?

Dr. Sylora: As a member of the baby boomer generation, I recognize that we are living longer, leading to a greater prevalence of urologic issues. However, there is a concerning trend of fewer urologists entering the field compared to those retiring, straining the health care system. To address this, we will rely more on physician extenders and embrace telehealth to expand our reach.

Telehealth will become integral, allowing for remote consultations and assistance with procedures like catheterization. Despite these challenges, the demand for urologic services remains high, necessitating efforts to train more urologists efficiently. The field is evolving, with advancements promising easier and more effective treatments for patients, making the future of urology both demanding and exciting.