Dr. Sami Majdalany '17 on urology residency at UC Davis in CA

Dr. Sami Majdalany, a 2017 graduate of the University of Medicine and Health Sciences (UMHS), is currently a preliminary urology resident at Anschutz Hospital, part of the University of Colorado in Aurora. He became interested in urology late in his fourth year at UMHS, after completing a urology elective. In June, he will join the urology program at UC Davis as a PGY-2 resident, as the program has expanded to include three residents per year.

Dr. Majdalany advises those interested in pursuing urology, especially as international medical graduates (IMGs), to focus on strong Step exam scores, pursue research fellowships to network with program directors, and put in the necessary time and effort to stand out in the highly competitive field. He highlights the benefits of his experience at UMHS, including the opportunity to study on the beach, the supportive group of classmates, and the school's assistance in finding him a urology elective.

Dr. Majdalany grew up in Ottawa, Canada and always had an interest in medicine, frequently visiting his grandparents' doctor and getting stitches as a child. He majored in biology at Carleton University before deciding to pursue a medical degree at UMHS in St. Kitts, attracted by the school's faculty, facilities, and support for international students.

After graduating, Dr. Majdalany completed research fellowships at the University of Michigan and Henry Ford Hospital, focusing on urology. Despite facing challenges as an international medical graduate, his passion and perseverance allowed him to eventually match into a urology residency program at UC Davis in California. He starts his new residency this coming June.

Urology is a diverse field that treats patients of all ages and genders, managing issues ranging from prostate problems and kidney stones to bladder cancer and erectile dysfunction. Dr. Majdalany emphasizes the importance of compassion and clear communication when working with patients on these sensitive topics. He is excited about advancements in urology, such as new minimally invasive procedures and imaging techniques for prostate biopsies.

Prestigious residency at UC Davis

UMHS Endeavour: Thanks for speaking to us, Dr. Majdalany. Could you just please talk about what you're doing right now and in your upcoming urology position at UC Davis in California?

Dr. Sami Majdalany: Good afternoon, Scott. It's nice to chat with you today. Right now, I'm a preliminary urology resident at the University of Colorado. It's similar to a preliminary surgery residency where the preliminary surgery resident will follow the path of general surgery for the year. So, my year is following the path of the categorical urology interns, for me that’s completing eight months of urology and four months of general surgery.

Tell us a little bit about how you first became interested in urology and what are some of your goals for your upcoming position at UC Davis?

I became interested in urology very late in my fourth year at UMHS. I was initially interested in OB-GYN when a previous graduate suggested that I do a urology elective. And once I did, I got hooked and wanted to pursue it as my specialty. My upcoming position at UC Davis in California is a PGY-2 urology position. The urology program there received a compliment expansion to their resident roster. So, they're going to have three residents per year now. And I was given the opportunity to join as a second-year urology resident and I'm very happy not to be an intern again.

Urology is a very hard specialty to get into. And for our current and prospective students out there or even some of our alumni, what would you say is a good career path for a urologist?

So just to clarify, career path after residency or to pursue urology residency?

Just pursuing urology in general. Maybe for people that are in med school now or they're thinking of going to med school and they think they want to go into urology, is there any kind of special background or anything that they need to do education wise or volunteering that would be helpful?

It's a long path, especially for IMGs. I think our match rate for the 380 positions that are offered per year is less than five percent. So, you really need to stand out. Step scores are important to get your application looked at so it’s important to do well but remember they don’t define you as a doctor. If you end up doing a research year, it would be helpful to complete Step 3 as well, before applying. As an IMG, I would say you need to pursue a research fellowship, which there are many across the States, not just for performing research because you can have a magnitude of research on your CV, but a research fellowship is mainly for networking. If you are doing the correct research fellowship at a teaching institution, then you should be meeting the right people, doing research with program directors. I think that should be the path of an IMG who would like to pursue urology residency. Meet the right people, do the research, do the time.

UMHS graduate Dr. Sami Majadalny & attending urologist Dr. Steven Steinberg perform a hydrocelectomy, a surgical procedure to remove a hydrocele, a fluid-filled pouch in the scrotum. Photo: Courtesy of Dr. Majdalany.

Can you tell us about one or two things that you really liked about UMHS as a med school that helped you become the doctor that you are today?

Of course. A lot of good things to mention actually. Can't beat studying on the beach; that was a highlight of when I first got there from the cold winters in Canada.

Of course.

Good group of classmates I had the opportunity to get to know. We’re still friends today and they’re an excellent group of doctors in their fields. The best thing from being at UMHS—that's where I met my wife. So that's the top of the list right there. Also, UMHS—they worked hard and found me urology electives, so I don't think I would have had the opportunity to find urology if it wasn't for them finding me the electives.

Is there anything else that you would like to add to people out there about UMHS or urology in general that we haven't covered?

I feel incredibly fortunate to have attended UMHS because it led me to the path that I’m currently on. And then about urology in general, if you have your heart set on something, do everything you can to pursue it. There will be ups and downs when you're trying to pursue something difficult, but if you really want something, persevere.

You're one of the very first UMHS grads to go into urology, so I know it's a very competitive specialty, and you've worked really hard and I think that you would be an inspiration to a lot of people out there.

Thank you. And if there's any prospective students who would like more detailed information or advice, I'm happy to chat anytime.

Growing up in Ottawa, Canada

Dr. Majdalany, would you mind talking about your formative years? Where did you grow up in Canada? And did you always want to be a doctor?

I grew up in Ottawa, Canada. Did I always want to be a doctor? I think I did as a child. I was frequent flyer for stitches in the emergency room as a kid, something that just stuck with me. Of course, I didn't know what it involved at the time, but I was always interested in sciences, so by the time I went to university I knew I wanted to be a doctor. So that's how I started to pursue the right courses I needed to take in order to get there.

What appealed to you about UMHS and what specifically did you like about studying in St. Kitts?

I did the EBS program, so it was 16 months in St Kitts. The good Caribbean weather, the nice hikes and sightseeing are things you could do if you have family or friends that come to visit. But still conducive to studying. Transportation between where the students lived and the school was easy. I was drawn to the roster of faculty that had a great medical backgrounds and wanted to learn from them. The ratio of med students to anatomy cadavers was a good highlight. The administration were really passionate about the school, specifically President Ross was heavily involved during our orientation which showed his dedication to the students.

Why cadavers are important for med schools

Let’s switch gears and talk about the state-of-the-art facilities at UMHS. I was in St. Kitts last year and I remember going into the anatomy lab. I didn't know that there were cadavers there. It's so clean; there's no smell. I remember one of the staff members coming in and talking about how they treat the cadavers with respect and later all the cadavers are eventually given a dignified burial. Very few med schools now have cadavers. If they do have cadavers, they don't have very many. I think having real cadavers is so important for medical education. Do you want to talk a little bit about that as well—about the importance of having cadavers for med students as opposed to digital cadavers, which a lot of med schools are using now?

I didn't know they had digital cadavers. I think it's important to have an anatomy lab with cadavers. Not just for learning anatomy, but for medical students themselves who don't know what they want to do. They know they want to be a physician, but they don't know what type of physician they want to be, and it's okay because my opinion changed so many times. I originally went to medical school thinking I wanted to be a pediatrician, but then when I started in the anatomy lab, I thought, oh, the human body is cool. Is there something I could do like that?

But there was also, I had fellow classmates who didn't want anything to do with the cadavers, and they're not in the surgical field, so that's okay. I think cadaver labs aren't just there to help you understand anatomy. Cadavers also help each student learn—do I like doing this? Having a live anatomy lab is worth it.

When you're doing your rotations, because every student will have to do a surgical rotation, your patient is not on the screen, they are right in front of you in clinic or on the operating table.

I think that you need that experience of actually working on a human being and also whatever disease that they may have passed away from, you can learn from it. I don't think you can do that digitally or from an android or whatever they're using in some of these schools.

It also gives you that dissection experience, there were points during the cadaver lab where we did have to make an incision or we did have to move a piece of the human body, and it's going to make you feel comfortable doing so.

Research fellow position at the University of Michigan

After graduation you started a research fellow position at University of Michigan Endourology Lab. Endourology is a subspecialty within urology that utilizes minimally invasive techniques to view and perform surgery within the urinary tract, right? You also did research at Henry Ford Hospital, Vattikuti Urology Institute. Can you tell us about those experiences?

When I knew I wanted to pursue urology, I was originally in the Match for OB-GYN, but I exited the match and started to look for urology research positions. They call them research fellowships after graduation. So the Endourology Translational Lab at the University of Michigan was interviewing for the position. I applied for it and was honored to receive that spot. I was there for two and a half years. High volume of research, both clinical and bench work, even creating guidelines and practice suggestions for the American Urological Association.

We tested thermal temperatures during laser lithotripsy for kidney stones treatment. Creating parameters on how hot the laser can fire without damaging the kidney and ureter.

As part of the lab there, we'd host device companies to come in and test medical devices. Urology is an innovative field; there are many devices that are constantly produced.

During that time, the idea of innovation sparked me become more engaged and I pursued a PhD in device innovation/medical technology. With that, I was able to continue tinkering around on my own, creating a patent for my own medical device.

At the two-and-a half-year mark at University of Michigan, I was looking into applying to residency and I was trying to figure out where which were the urology IMG-friendly schools. Some of the bigger institutions, you’ll see one IMG every five years. I knew Henry Ford is known to be an IMG friendly school. I started looking for a research fellowship in the urology department there.

I applied for it and I initially started, as their outcomes research fellow, focusing on prostate cancer outcomes. However, in that time I started making my own little niche of research, video research. The emerging trend is learning from video research. People want to see a video; they're called “how-to videos”. I became so proficient with video research the entire department had me leading their research projects from the oncology section, to men's health, reconstruction, and also the minimally invasive techniques.

Urology for IMG grads

Earlier you said that some people think that urology as a specialty is really too hard to get into as an IMG. What would you say to those people now that you're going into it. Any words of advice?

During my fourth year of medical school, I also pursued volunteer research at Augusta University, exploring various areas urology biomarkers. Along the way, I heard many program directors, very kindly say: “Don’t apply to urology”, even hearing from people I know saying "Why are you doing this? It's going to take you forever." Many people questioned my path, asking why I was pursuing something so competitive. But to me, true passion is worth the effort. If you're committed and persistent—especially when others doubt you or urge you to give up—I believe that's when your dedication truly shows.

I think it just comes down to passion and perseverance. There was actually something I wanted to mention. It’s not about just doing the research. During the fourth year into research, I had over 32 publications and one of the associates, the co-chair at Henry Ford told me, "You'd be promoted to professor at this point with your CV." But still, I wasn't matching at that time. I didn't Match on three occasions and I kept going. Despite the exponential growth of my CV, and hearing during interviews "This is the biggest CV I've ever seen," it really doesn't matter. It comes down to your passion, doing well, being a good person and meeting the right people. When I started my current preliminary urology position, I asked our program director, “Why did you choose me, I’ve been at this so long”.

He said, "It looked like from your application, you are extremely passionate about urology and you haven't stopped over these five years, and I wanted to give you that chance to show us clinically.”

Why urologists treat men & women

Let’s change course and discuss urology as a specialty. Many are not that familiar with exactly what a urologist does. Can you discuss some of the main areas of urology that affects patients such as enlarged prostates, screening for prostate and bladder cancer, treating and preventing kidney stones, urinary incontinence, and also erectile dysfunction just in general?

Definitely, everyone can see a urologist. There's pediatric urologists because there's congenital issues that affect the penis, urethras, ureters, and kidneys. There's so many congenital issues that a pediatric urologist needs to address.

Women also go to urologists. Would a woman normally go to a urologist for kidney stones? I'm just curious because we often think of urologists as being a male specialty.

Anyone with a kidney stone will see urologist. Whether we treat it with medical expulsion trial or surgically intervene with any multitude of stone treatments we offer.

And actually, specifically for women, one of my most proud research accomplishments was about females with bladder cancer. Bladder cancer is a urological issue, of course.

Since I brought it up, we can chat a little bit about bladder cancer, it all starts with screening. People usually get screened for bladder cancer if they have blood in their urine at any point in time because blood in urine is never normal.

For muscle-invasive bladder cancer or high-risk non–muscle-invasive bladder cancer that does not respond to other treatments, a urologist will perform a robot-assisted cystectomy (removing the bladder), and divert the urine through a stoma (pouch) called a urostomy.

However, new techniques are creating what's called a neo-bladder. A completely new bladder is created using parts of your small intestine, without the need for a pouch outside. My research in that area involved robotic surgery to perform the cystectomy in females, while preserving all the female genital organs inside, as the previous way this was performed was to remove the ovaries, the uterus. This research “how to” video I created with our team, was published in the Urology Gold Journal, and won third prize at the World Congress of Robotic Surgeons. It highlighted a complete genital sparing robotic cystectomy for females with prevention of vaginal prolapse afterwards by doing a vaginal repair on the inside. So, urology is definitely for all genders.

PSA test to screen for prostate issues

At what age do you normally advise male patients to start doing the PSA blood test to check for prostate cancer?

Usually 50, but if they have a family history of prostate cancer, we'd say 10 years earlier than that.

 Besides prostate cancer, what are other things a PSA test screens for?

The PSA may also be elevated in benign prosthetic hypertrophy. Some men just have enlarging prostates without cancer, but the prostate grows in men, and there's a multitude of treatments for enlarged prostates.

Everything has its own risk. Whether someone wants to just do a trial of medications first, a urologist will do that as well. Depending how bothersome a patient’s symptoms are its an open discuss between patient and provider on recommendations and patient preference

Treating BPH & erectile dysfunction

If you have BPH, do men with enlarged prostates at some point have to have that surgery?

Not all the time. Sometimes, the prostate will just stop growing. Also, urology, like I was saying, we manage things medically, so there's things to help shrink the prostate, like finasteride, things to help open the channels, Tamsulosin [generic form of Flomax]. But as urology too, we also recommend diet changes. So there's a lot of prosthetic health diets that men could go on to help shrink the prostate, to a degree. I think there's a big push for pumpkin seed oil, which is shown to help with prostate or even the lycopenes that are found in processed tomatoes. So, there are diets that we also recommend, but if it comes to the point where a man can’t urinate, or also having erectile dysfunction because of the enlarged prostate, people say it’s time for the "roto rooter" or what urologists call transurethral resection of the prostate. We peel the prostatic tissue away with cautery

The new big thing now that people are getting trained on for BPH is Holmium Laser Enucleation of the Prostate (HoLEP). That’s where a patient under anesthesia in the OR, will have a cystoscope placed through the urethra and using a special holmium laser connection, to chip off prostate tissue.

I knew somebody that that had the UroLift, and that was really big a few years ago. Are you familiar with that procedure?

It is another type of BPH procedure; however, it doesn't work for everyone, and it has a maximum capacity if your prostate is a certain weight.

You mentioned the diet. I have read that saw palmetto and other natural supplements can help. Do they?

I have seen that palmetto supplements help with prostate growth and shrinkage.

So, the natural supplements actually work to some degree?

Yes—saw palmetto, lycopene, pumpkin seed oils. I know there's a whole list actually. I can look through our guidelines, but obviously there are no [FDA] regulations with how much people can say on a box. We do have our AUA guidelines so if a patients telling us they're taking a supplement, we don’t discourage or encourage but we can offer some insight. And based on symptoms on how bothersome their BPH is to them we can offer them a procedure.

I think some of the issues that people have, not only with the prostate drugs, but the surgery, they're worried about, especially men are worried about urinary incontinence or sexual issues not being able to ejaculate or developing erectile dysfunction. How do you address that?

Yes, so from prostate issues to erectile dysfunction on its own, to even men who have Peyronie's disease, which are calcifications in the penis that cause curvature. All these can be erectile dysfunction issues. Of course, there are steps to take before we get to the last step. There's a trial of erectile dysfunction medications. If those don't work, then we move on to, well, in conjunction to those, sometimes the urologist will recommend the penis vacuum. That's still as part of our recommendations in conjunction with the medications.

Is that like a penis pump? I've seen that at my urologist, like the implant or whatever.

Oh, no. So the implant is the last phase after all ED medications have been trialed. The implant is called Inflatable Penile Prosthesis (IPP). It’s the last phase because once there is an implant the patient will no longer have erections on their own, they will need to manually pump the implanted inflation devices to achieve an erection.

The surgery involves two silicon malleable implants that go inside the penis. A small cut is made and they're implanted inside, a reservoir of saline is implanted into the abdomen, and then a manual pump is implanted in the scrotum in the back so it's not visible for aesthetic purposes. Whenever an erection is desired, they pump it, it gets erect, and when they don't want it, they hold the button down and it deflates. This IPP was actually one of my research areas, publishing on same-day discharge and opioid-free pathway for IPP.

I'm just curious because I know an older gentleman—an acquaintance that I know had that done. And are you still able to ejaculate when you do that or is it just strictly to be able to get an erection if you can't get in any other way?

There may be some, not actually ejaculate, but a discharge. But it's mainly to get the erections.

A lot of men who go to urologists are always worried about the side effects, the sexual side effects. And I know some medications cause more side effects than others. You mentioned Flomax. I have read that Flomax can cause sexual side effects.

It can cause retrograde ejaculation. So sometimes the sperm, instead of going forward, it'll shoot back up into the bladder and then you'll end up urinating out semen.

Do you ever have patients that are afraid to talk about sensitive issues regarding their urological health? Such as problems with urination, ejaculation or erectile dysfunction?

Lots of patients are embarrassed or especially the older patients, they're embarrassed because it wasn't a thing to talk about back in their day. So, that's why we provide our patients with our AUA symptom score to fill out in the waiting room, not just for urination, but it's a sexual symptom score to see if they're satisfied with all aspects of their erections. It's a way of starting the conversation that might be difficult for someone to start on their own.

New treatments, medications & breakthroughs

What are some of the new treatments, medications, and technological breakthroughs in urology? You were mentioning that laser procedure for enlarged prostate, that's better than that old-fashioned "roto rooter." But what are some of the new meds or new procedures that you can talk about?

Starting at the prostate, I'm not sure if you're familiar or if you've done it before, but prostate biopsies have come a long way.

So, they're not really painful anymore?

No. I mean, they're uncomfortable, but most of them are done in just the clinic setting. Some of them are done in the OR but the newest thing right now is the MRI ultrasound fusion biopsies. A patient will get an MRI, they'll come to their biopsy day, the ultrasound probe will go inside the patient and then the MRI images will overlap on the ultrasound screen, being fused with the live ultrasound biopsy. Allowing us a more precise targeting of lesions of interest in the biopsy. We'll have that precise biopsy target as well as specific other regions of the biopsy tissue to compare.

You don't have to go in with the needle and do the old-fashioned biopsy in that case? Because I think that's what freaks out a lot of people.

 It’s still a large needle whether it’s a transrectal or transperineal biopsy, but the way I've seen it done most of the time is in the OR, patient's asleep, prostate probe is in the rectum, a little square grid is at the perineum, and we're visualizing the prostate live and using the really thin needle.

The risks for prostate biopsies are infection [because a] needle is going in and out. Also, blood in the urine, blood in the semen because there's the risk of the needle poking the seminal vesicles. But I think the trans perineal biopsy, so going through the perineum is the exciting new way of doing the biopsies. The older way of doing it, the transrectal biopsy was just the ultrasound probe in the rectum and a needle going through that rectal probe. Many urologists are picking up the newer transperitoneal way.

So, is it less invasive for the patient?

They still have an ultrasound probe in the rectum, but the main argument for the transperitoneal biopsy is there's been less infection rate afterwards since the needle is not going through the rectum. It's going through the perineum.

Urological procedures & surgery

What has your experience been with urological procedures or surgery? Are you going to be primarily doing that when you go to UC Davis?

One of the strengths of the program I’m currently in is the emphasis on hands-on experience, tailored to my comfort level, and allowing me to gain more independence. In the clinical setting, I’ve had the opportunity to independently perform procedures such as prostate biopsies, bladder BOTOX injections and cystoscopies for bladder cancer detection. In the operating room, I’ve assisted with and performed bladder and urethral biopsies, as well as several transurethral resections of the prostate (TURPs), all under the supervision of attending physicians and senior residents.

You mentioned the UroLift, too.

Yes, the UroLift is a minimally invasive procedure (one of many) for benign prostatic hypertrophy (BPH), that uses small implants to hold the enlarged prostate tissue away from the urethra, improving urine flow. I’ve performed 2 of these procedures as an intern, under guidance of course, as my current program really wants me to shine next year.

At UC Davis, the primary focus for PGY-2 residents is operating room experience, with approximately 90–95% of time spent in surgery. This emphasis is particularly strong due to the central role of robotic surgery in urology. The program prioritizes early exposure to the robotic platform to build proficiency. 

Oh, that's amazing. And we probably already talked about this, but what do you think are some of the common misconceptions about urology? Again, I think a lot of people, even med students, don't really know what a urologist does.

That’s completely fair—I didn’t fully understand it myself until I completed the elective. A common misconception is that urology is not a surgical specialty, but in reality, we are a surgical residency that provides comprehensive care. We see patients in clinic, manage conditions medically when appropriate, and operate when necessary. For instance, with kidney stones, we often attempt medical expulsion therapy before considering surgery. In cases of low-risk prostate cancer, we may opt for active surveillance instead of immediate intervention. Urology requires a careful balance of medicine and surgery, knowing when each is appropriate. Another misconception is that urology only involves older men, but it spans all age groups. Transitional urology, for example, focuses on patients with congenital urologic conditions as they transition into adulthood

Urologists are doctors that specialize in dealing with private areas of the body—I can't speak for women—but with men, it's very sensitive areas. I’d imagine you must be compassionate and cognizant of that since some patients might feel awkward seeing a urologist for the first time. Do you agree?

Yes, exactly. The most important aspect is not rushing a patient. I know medicine is rush, rush, rush these days. You have to take the time and understand their worries, their concerns, and that's going to make a trusting relationship. A patient won’t feel comfortable discussing their urological needs if you’re not present in the conversation and just moving the appointment along.

When a doctor asks a patient to go urinate and they're measuring your flow or doing the prostate ultrasound—that must be tough for some. Prostate MRI scans must be terrifying for some men.

Performing the Urodynamic study, like you mentioned to measure flow rates while a patient wears various electrodes to measure their detrusor muscle and abdominal wall pressure, can be uncomfortable or maybe even embarrassing for patient’s. Or even performing a prostate biopsy is a very sensitive interaction. It's like the old saying that everyone says, “Treat your patients like you want your family to be treated.” That's how I see it every day, If this was my dad, I’d want someone to be patient with him.

Especially if they're older or whatever age, it's not a type of medicine that people are used to, it's definitely a specialty. Just one thing I wanted to touch on is I know we are slowly but surely getting more and more people out in California, and that was always a coup for us to get California and when we started getting residencies in 2020. So how did it feel to be going to California and actually getting a position out there as an IMG from UMHS?

I was relieved we had California because I was always seeing positions out there, but previously never applied. I don't know how many people have gone to California from UMHS so far, but it feels good to match there and represent UMHS. And like you said, I think I’m the first urology resident from our school, so it's a lot of firsts for our school, which makes me proud. I'm happy to answer questions or if someone's genuinely interested and wants advice on pursuing urology, I'm always happy to teach and help out.

Email Dr. Sami Majdalany at samimajdalany@gmail.com

Top photo: Dr. Sami Majdalany '17.  Photo courtesy of Dr. Majdelany.