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E. David Crawford: Hello everyone. My name is E. David Crawford. I'm a professor of urology at the University of California in San Diego. Just over a year ago, I heard this term "functional urology" from one of my good friends, Brian Flynn. We've invited Brian aboard here to discuss this whole concept that he is interested in, and others call functional urology and reconstructive urology.

Brian graduated from medical school at Temple, did his residency at Geisinger, and a fellowship at Duke University in reconstructive and female urology. He has been on the faculty of the University of Colorado, and I've had the great honor of working with Brian over the years. Brian is a superstar. He's been president of the Rocky Mountain Urological Association and probably one of the youngest presidents of the South Central Section.

So Brian, let's talk a little bit about this. When I got into urology, there was urology and a subspecialty in pediatric urology. Now we have cancer, urologic oncology, endourology, reconstructive urology. We still have peds, we have female, we have andrology, we have stones. Why do we need this functional urology, and what does it mean? And thanks for joining us.

Brian Flynn: Yeah. Thank you so much, David, for this opportunity. It's been great talking to you about this subject. And I know you and I have talked a lot online and offline about this specialty and where it's going. And the question is, is this even new? You asked me, why do we need a new specialty? I think it's always been there. We're just really starting to bring everything together and codify what we've been doing for a very long time in urology.

Probably the simplest definition of functional urology is it's dressed-up general urology, and it's a deeper understanding of the functional problems that really bother people outside of cancer, stone, and peds. It's everything else really in urology dealing with the pelvic floor and issues that people deal with every day in their lives.

E. David Crawford: Yeah. When I hear the word "functional," it has a connotation with me as something like alternative medicine or things like that. How is that resonating with people?

Brian Flynn: Well, I think "functional" is a word that's been rebranded. If you think about this term, it's gone from way back when people looked at Eastern medicine as quackery to something that was considered alternative, to integrative, to now functional. So that word has changed also. And if you look at functional medicine, our goal is to really get people functional again. I see people all the time. I tell them, "I can't cure you of your BPH. I can't cure you of your incontinence any more than we can cure hypertension, but we can make you functional again."

And functional is a positive word. Think about functional urology, David, compared to dysfunctional urology, right? This specialty at one point was called voiding dysfunction. Who wants to be an expert in something that's dysfunctional, right? This is a much more positive term, and it's a term that patients embrace and understand quite well. They really do.

E. David Crawford: So Brian, I know you have sort of an overview slide of this, and you showed that during our meeting last year, and this one right here. It seems to me it's pretty complicated right now. And so how does this solve this? What does it do to help us really?

Brian Flynn: I think this sort of sits in the middle of a lot of specialties. This is the bridge. This is the communication. If you look at reconstructive surgeons, they're really great technical surgeons. They're great at building things and doing robotic surgery and extremely complicated surgery. And then you look at people that maybe work more in the functional world, they have a much deeper understanding. From the original teaching of Alan Wein, failure to store, failure to empty, and Chris Chapple, Sender Herschorn, and others who have come before me, who have really helped us understand how the physiology, how the brain and bladder connect.

I think the reason why functional and reconstructive urology is important and having a deep understanding of both is if you really want to be great at taking care of people in this space, you need to be at least good at both functional urology and reconstructive urology. So you have to understand the technical aspects of surgery, but you also have to understand the physiology and the urology on the functional side. And if you can be really good at both of those things, then you can be really great at taking care of patients in this space.

I think it is the bridge between reconstructive surgeons and functional surgeons. And I think you could be someone who practices in both circles and maybe have at least a decent understanding of both sides. So we're trying to fill a gap that has been created. And I think, as you know, specialties change over time, titles change, and if you just look in this box here, andrology—that's a term that's not used commonly anymore. Stone urology became endourology, and so on and so forth. So I think this is the time, this is the right opportunity.

E. David Crawford: This data, out of curiosity, what percentage of the practicing urologists that are listening to this practice is actually functional urology?

Brian Flynn: I would say anybody who's in a non-specialized practice, general urology practice, is in fact in this space. Let me make an example, Dave. Think about general surgery, right? General surgery, at least at academic medical centers, no longer exists. There's a department of surgery. Within the department of surgery, you have CT, you have transplant, you have oncology. And the people that used to be general surgery are now trauma and acute care surgeons.

So that general space eventually coalesces within any specialty to then gobble up everything else that's left. So in urology, there'll be no general urology left. Anybody who is a non-specialist will fall into this box because this is where the overwhelming part of urology exists. You know from running meetings for 30 years, your audience is often general urologists, and they come out and they want to learn and they want to understand, and to some extent, many of them develop expertise in that space just as much as people do in oncology and pediatrics, and this gives them some recognition.

Think about you as a specialist oncologist. I'm going to go send you to this general urologist. How does that resonate with your patient? Compare it to, "I'm going to send you to Brian Flynn. He's an expert in functional urologic disorders. He's going to get you functional again. He's going to get you back out on that golf course." And I think that helps people understand.

So I think the LUGPA groups have done a really good job understanding this. They haven't codified it yet, but they're getting there just like they have their men's health clinics and other clinics within a clinic. Think about this as a clinic within those big urology centers.

E. David Crawford: Well, I really think you're right on when you mentioned general surgery. I grew up with my early training in general surgery, and they lost it. They lost the GI and other things. Same thing with cardiac surgery. They lost a lot of that to interventional radiology. And what you're talking about here is a way to recapture, and as you say, codify and have a group that is doing this and interacting with patients, and it's much needed.

How is this interacting with societies? There are so many societies out there right now and so many meetings, and I know that you have a slide on that that you were going to share with us. Yeah, that one. Thank you.

Brian Flynn: Yeah. And I think anytime there's a new kid on the block and there's a new interest, we have a meeting coming up on the International Functional and Reconstructive Urology Update. And it makes societies look and see, "What are we doing well? What are we not doing well?" If you go to the GRS meeting, this is some of the best surgeons in the world. And if you want to learn how to do surgery, go to that meeting, and you'll hear amazing talks on reconstructive surgery of the upper and lower urinary tract.

You go to SUFU, you'll get a deep dive and understanding of the neurourology and the functional part of it. If you look at AUGS and IUGA, those are societies that are only female-focused, right? A hundred percent. And I think the EAU, I put that in the middle along with the ICS because I think those two societies have done the best at focusing on the disease, not on the gender.

Incontinence is incontinence, whether it's a man or a woman. Why are we breaking it down between specialists that only see men or specialists that only see women? People ask me, "What do you do? What is functional urology?" I take care of urinary problems, failure to store, failure to empty, in men and women. That's what I do 90% of the time. And you can't really separate those things arbitrarily.

I think patients and providers get frustrated. If someone refers me a patient with a lower urinary tract problem, I'm going to take care of 100% of it. I'm not going to send it to the next person because now it's not incontinence, now it's obstruction, right? So what we're trying to do here, Dr. Crawford, is really sit in the middle of all these societies, work collaboratively with the societies, help educate their fellows. This meeting we have coming up, we have 30 fellows attending from around the country, and those 30 fellows come from all six of these boxes, seven of these boxes, and so they're all coming into this space because they're identifying maybe gaps in their training that we're trying to fill.

E. David Crawford: Your meeting is going to be phenomenal, and I hope some of our listeners have a chance to take a look at it. It's coming up very soon. You have over 50 faculty and all those fellows and residents. Unbelievable. And congratulations on doing that. And I think as we go on, thank you, we really are going to see the value of this. As I said when I heard about this at our meeting last year, and Ryan Terlecki and you and Fernando Kim all pushing this, I think it's in the right direction.

Brian, I hope that we can, in the future, have you record your talk that you've given and a deeper dive into this, and we'll contact you about that so people who want more information can get it. Really, I want to thank you for your time. I know you're busy with this meeting coming up, and I think this is one of the most important things going on in urology right now. As you said in the past, things like urogynecology, all these other terms are falling by the wayside. Really, there's a new branding of what the word "functional" means, and we're finding out that we can intervene in a lot of things. So thank you. And any last parting comments you want to make?

Brian Flynn: Yeah. Thank you, David, and thank you UroToday. I mean, I've been pitching this thing for 10 years and you were the first person to listen and the first person to give me 10 minutes, and that happened at your meeting in Charlottesville two years ago, and then a year ago. We had a whole session. We had a half day on functional urology, and then Ryan Terlecki started listening, Fernando Kim after that, and here we are now. Only two years later, after that 10-minute talk at FUDS, we now have an entire two and a half day meeting. So thanks for that opportunity. Thanks for giving us a chance. And I'm excited to see where this can go.

E. David Crawford: Thank you. And we look forward to all the folks coming to Denver. Take care.

Brian Flynn: All right, thank you.