Category: Article of the Week

Video: Prostatic urethral lift for the treatment of LUTS

April 23, 2014/by admin Z.9

Multicentre prospective crossover study of the ‘prostatic urethral lift’ for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia

Anthony L. Cantwell, William K. Bogache*, Steven F. Richardson^†, Ronald F. Tutrone^‡, Jack Barkin^§, James E. Fagelson^¶, Peter T. Chin^†† and Henry H. Woo

^‡‡Atlantic Urological Associates, Daytona Beach, FL, *Carolina Urological Research Center, Myrtle Beach, SC, ^†Western Urological Clinic, Salt Lake City, UT, ^‡Chesapeake Urology, Baltimore, MD, USA, ^§University of Toronto, Toronto, ON, Canada, ^¶Urology Associates of Denver, Denver, CO, USA, ^††Figtree Private Hospital, Figtree, and ^‡‡Sydney Adventist Hospital Clinical School, University of Sydney, Sydney, NSW, Australia

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OBJECTIVE

• To assess the clinical effect of the ‘prostatic urethral lift’ (PUL) on lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) through a crossover design study.

PATIENTS AND METHODS

• Men aged ≥50 years with an International Prostate Symptom Score of ≥13, a maximum urinary flow rate (Q_max) of ≤12 mL/s, and a prostate of 30–80 mL were enrolled into a crossover study after completing a prospective, randomised, controlled, ‘blinded’ pivotal study in which they were control subjects receiving a sham procedure.

• Patients were followed for 1 year after crossover PUL at 19 centres in the USA, Canada and Australia. The sham procedure involved rigid cystoscopy with simulated active treatment sounds.

• PUL involved placing permanent UroLift^® (NeoTract, Inc., Pleasanton, CA, USA) implants into the lateral lobes of the prostate to enlarge the urethral lumen.

• Urinary symptom relief, health-related quality of life (HRQL) impact, urinary flow parameters, sexual function, and adverse events were assessed and compared between the sham and PUL using paired statistical analysis.

RESULTS

• Symptom, flow, HRQL and sexual function assessments showed response improvements from baseline results, similar to results from other published studies, and most parameters were markedly improved after PUL vs the sham procedure in the same patients.

• Symptom, flow, and HRQL improvements were durable over the 12 months of the study.

• Adverse events associated with the procedure were typically transient and mild to moderate; one patient (2%) required re-intervention with transurethral resection of the prostate in the first year.

• There were no occurrences of de novo, sustained ejaculatory or erectile dysfunction.

CONCLUSION

• The PUL can be performed under local anaesthesia, causes minimal associated perioperative complications, allows patients to quickly return to normal activity, provides rapid and durable improvement in symptoms, and preserves sexual function.

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Article of the week: Stent QOL comes with strings attached

April 16, 2014/by admin Z.9

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Barnes and colleagues summarising their paper on stent extraction strings.

If you only have time to read one article this week, it should be this one

Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial

Kerri T. Barnes, Megan T. Bing and Chad R. Tracy

Department of Urology, University of Iowa, Iowa City, IA, USA

Read the full article

OBJECTIVE

• To determine whether ureteric stent extraction strings affect stent-related quality of life (QoL) or increase complications after ureteroscopy (URS) for stone disease.

PATIENTS AND METHODS

• In all, 68 patients undergoing URS (October 2011 to May 2013) for stone disease were randomised to receive a ureteric stent with or without an extraction string.

• Patients completed the Ureteric Stent Symptom Questionnaire (USSQ) on postoperative days 1 and 6, and 6 weeks after stent removal.

• Pain was assessed at stent removal.

• Adverse events, including early stent removal, stent migration, retained stent, urinary tract infection (UTI), emergency room (ER) visits and postoperative phone calls were monitored.

RESULTS

• There was no difference in stent-related QoL as measured by the USSQ between those with and without a stent extraction string, pain at stent removal between those who pulled their stent independently vs those who underwent cystoscopy for stent removal, or in the rate of UTIs, ER visits or phone calls between groups.

• Five patients (four female, one male) removed their stent early by inadvertently pulling the string; none required replacement.

• Patients without a string had a significantly longer period with the postoperative ureteric stent (10.6 vs 6.3 days, P < 0.001).

• One patient without a stent string retained her ureteric stent for 6 months, which was removed by cystoscopy without incident.

CONCLUSION

• Ureteric stent extraction strings may offer several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.

Read more articles of the week

Editorial: Tether your stents!

April 16, 2014/by Archana Fernando

Ureteric stents are commonly placed after ureteroscopy to protect the ureter and to facilitate subsequent stone fragment passage. They are known to be a cause of significant morbidity as judged by standardised validated questionnaires [1]. Whether placement of a stent is required at all is debatable, with randomised studies suggesting they are unnecessary after routine ureteroscopy [2]. The European Association of Urology (EAU) guidelines recommend stent insertion only ‘in patients who are at increased risk of complications’ and ‘in all doubtful cases to avoid stressful emergency situations’. Despite this, available evidence would suggest that we continue to commonly place stents [3].

If a stent is placed, the principal means of reducing morbidity is by minimising the stent dwell-time. One of the ways of doing this is to leave a stent with extraction strings/tether. This obviates the delay associated with scheduling cystoscopic extraction, the morbidity of cystoscopy and potentially reduces additional hospital visits if the patient is able to remove the stent at home.

Tethered stents are not widely used due to preconceptions about their tolerability, increased risk of complications (e.g. infection, migration) and accidental removal. Perhaps for this reason there have been few studies into the effectiveness of tethered stents in minimising stent-related morbidity to date, with only a handful in the past 30 years that have specifically addressed this issue.

In this issue of BJUI, Barnes et al. [4] report on the results of a prospective randomised trial analysing stented patients with or without the extraction strings attached, for both quality of life and postoperative complications after ureteroscopy for stone disease. This follows on from a retrospective series previously reported by the same group [5]. It is pleasing to see the authors, who originally concluded that randomised trials are needed in this area, actually get on and do the trial!

Two aspects of the trial methodology are worth highlighting: (i) the surgeons were not told that the patient was part of the study until they had made the decision to stent to minimise selection bias; (ii) patients completed the Ureteric Stent Symptom Questionnaire (USSQ) 6 weeks after stent removal as a control for their USSQ scores at postoperative days 1 and 6.

The headline results showed that there was no difference in quality of life and stent-related symptoms between patients with and without the extraction strings. There was also no difference in postoperative complications, emergency room visits or phone calls between the groups. What is surprising is that they found no difference in pain scores between self-removal and cystoscopic removal. This has not been our experience with tethered stents and may be due to the few men in the study. However, stent dwell-time was significantly less for patients with tethers compared with those without (10.6 vs 6.3 days, P < 0.001).

For urologists planning on using this technique it should be noted that the authors removed the original knot and shortened the string considerably to reduce the risk of accidental removal. For this reason the string was not attached to the patient’s skin.

This trial addresses many of the reservations urologists have about the use of tethered stents. Furthermore, reducing accidental removal and encouraging self-removal should be possible with improved patient education and selection. This was addressed by a study in New Zealand [6], which showed the feasibility of self-removal of stents.

The authors also acknowledged weaknesses in their study, which included failure to reach target enrolment, a 68% completion of trial surveys and a larger proportion of women in the study group due to male anxiety about self-removal of stents. In all, 15% of stents were inadvertently removed early and thus this technique should be used with caution in patients where early removal may be detrimental, e.g. in single kidneys. This does of course prompt the question: ‘If you are going to place a stent, how long does the stent need to stay for?’ and hopefully future trials may address this unanswered question.

Archana Fernando and Matthew Bultitude

Urology Department, Guy’s and St Thomas’ NHS Trust, London, UK

References

Joshi HB, Newns N, Stainthorpe A et al. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol 2003; 169: 1060–1064
Song T, Liao B, Zheng S, Wei Q. Meta-analysis of postoperatively stenting or not in patients underwent ureteroscopic lithotripsy. Urol Res 2012; 40: 67–77
Mangera A, Parys B. BAUS Section of Endourology national ureteroscopy audit: setting the standards for revalidation. J Clin Urol 2012; 6: 45–49
Barnes KT, Bing MT, Tracy CR. Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial. BJU Int 2014; 113: 605–609
Bockholt N, Wild T, Gupta A et al. Ureteric stent placement with extraction strings: no strings attached? BJU Int 2012; 110: 1069–1073
York N, English S. Self-removal of ureteric JJ stents: analysis of patient experience. Presented at AUA 2013, May 7; San Diego, CA, USA. Abstract no. 1979. J Urol 2013; 189 (Suppl. 4): e812

Video: Stent extraction strings after ureteroscopy

April 16, 2014/by admin Z.9

Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial

Kerri T. Barnes, Megan T. Bing and Chad R. Tracy

Department of Urology, University of Iowa, Iowa City, IA, USA

Read the full article

OBJECTIVE

• To determine whether ureteric stent extraction strings affect stent-related quality of life (QoL) or increase complications after ureteroscopy (URS) for stone disease.

PATIENTS AND METHODS

• In all, 68 patients undergoing URS (October 2011 to May 2013) for stone disease were randomised to receive a ureteric stent with or without an extraction string.

• Patients completed the Ureteric Stent Symptom Questionnaire (USSQ) on postoperative days 1 and 6, and 6 weeks after stent removal.

• Pain was assessed at stent removal.

• Adverse events, including early stent removal, stent migration, retained stent, urinary tract infection (UTI), emergency room (ER) visits and postoperative phone calls were monitored.

RESULTS

• There was no difference in stent-related QoL as measured by the USSQ between those with and without a stent extraction string, pain at stent removal between those who pulled their stent independently vs those who underwent cystoscopy for stent removal, or in the rate of UTIs, ER visits or phone calls between groups.

• Five patients (four female, one male) removed their stent early by inadvertently pulling the string; none required replacement.

• Patients without a string had a significantly longer period with the postoperative ureteric stent (10.6 vs 6.3 days, P < 0.001).

• One patient without a stent string retained her ureteric stent for 6 months, which was removed by cystoscopy without incident.

CONCLUSION

• Ureteric stent extraction strings may offer several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.

Read more articles of the week

Article of the week: Survival and causes of death after RP

April 9, 2014/by admin Z.9

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Røder discussing his paper.

If you only have time to read one article this week, it should be this one

Survival after radical prostatectomy for clinically localised prostate cancer: a population-based study

Martin Andreas Røder¹, Klaus Brasso¹, Ib Jarle Christensen², Jørgen Johansen³, Niels Christian Langkilde⁴, Helle Hvarness¹, Steen Carlsson⁵, Henrik Jakobsen⁶, Michael Borre⁷ and Peter Iversen¹

¹Copenhagen Prostate Cancer Center and Department of Urology, ²The Finsen Laboratory, Copenhagen Biotech Research and Innovation Centre (BRIC), Rigshospitalet Copenhagen University Hospital, Faculty of Health and Medical Sciences, Copenhagen, ³Department of Urology, Regional Hospital West Jutland, Holstebro, ⁴Department of Urology, Aalborg University Hospital, Faculty of Medicine, Aalborg, ⁵Department of Urology, Odense University Hospital, Faculty of Health Sciences, Odense, ⁶Department of Urology, Herlev Hospital, Copenhagen University Hospital, Faculty of Health and Medical Sciences, Herlev and ⁷Department of Urology, Skejby, Aarhus University Hospital, Department of Clinical Medicine, Aarhus, Denmark

Read the full article

OBJECTIVES

• To describe survival and cause of death in a nationwide cohort of Danish patients with prostate cancer undergoing radical prostatectomy (RP).

• To describe risk factors associated with prostate cancer mortality.

PATIENTS AND METHODS

• Observational study of 6489 men with localised prostate cancer treated with RP at six different hospitals in Denmark between 1995 and 2011.

• Survival was described using Kaplan–Meier estimates. Causes of death were obtained from the national registry and cross-checked with patient files.

• Cumulative incidence of death, any cause and prostate cancer-specific, was described using Nelson–Aalen estimates.

• Risk for prostate cancer death was analysed in a Cox multivariate regression model using the covariates: age, cT-category, PSA level and biopsy Gleason score.

RESULTS

• The median follow-up was 4 years. During follow-up, 328 patients died, 109 (33.2%) from prostate cancer and 219 (66.8%) from other causes. Six patients (0.09%) died ≤30 days of RP.

• In multivariate analysis, cT-category was a predictor of prostate cancer death (P < 0.001). Compared with T1 disease, both cT2c (hazard ratio [HR] 2.2) and cT3 (HR 7.2) significantly increased the risk of prostate cancer death. For every doubling of PSA level the risk of prostate cancer death was increased by 34.8% (P < 0.001). Biopsy Gleason score 4 + 3 and ≥8 were associated with an increased risk of prostate cancer death compared with biopsy Gleason score ≤ 6 of 2.3 and 2.7 (P = 0.003), respectively.

• The cumulative hazard of all-cause and prostate cancer-specific mortality after 10 years was 15.4% (95% confidence interval [CI] 13.2–17.7) and 6.6% (95% CI 4.9–8.2) respectively.

CONCLUSIONS

• We present the first survival analysis of a complete, nationwide cohort of men undergoing RP for localised prostate cancer.

• The main limitation of the study was the relatively short follow-up.

• Interestingly, our national results are comparable to high-volume, single institution, single surgeon series.

Read more articles of the week

Editorial: Nationwide prostatectomy practice

April 9, 2014/1 Comment/by Henk G. van der Poel

Surgical management of prostate cancer is one of the most frequently performed urological procedures [1]. Available data suggests that surgeons’ experience is correlated with both oncological and functional outcome [2]. These initial observations stress the importance of concentration of prostatectomy in high-volume institutes. This centralisation could improve documentation and monitoring of outcome. The data presented by Røder et al. [1] from Denmark show a rapid increase in registered prostatectomy procedures in recent years in six institutes. It remains to be studied whether this is caused by centralisation and better registration or the results of an increased overtreatment. For that, data on the incidence of low-risk disease over time in their series needs analysis.

At least one-third of the population was treated since 2008. The relatively short follow-up and associated few events, and high number of low-risk patients (47% had biopsy Gleason ≤6) make outcome analysis of less value. It is therefore not surprising that in their analysis low- and intermediate-risk tumors had similar outcome. On the other hand, despite prostatectomy, one-third of deaths during follow-up were prostate cancer related in their population. Consistent with reported data at 15 years after prostatectomy more patients died from prostate cancer than from other causes [3]. But still a considerable number of men died from prostate cancer. This also seems the case in the group of men often soothed for having indolent, low-risk disease. At 15 years Røder et al., reported 8.9% of these men with low-risk disease still dying from prostate cancer in Denmark, despite prostatectomy. And although this percentage was lower than that of the prostatectomy group in the Scandinavian Prostate Cancer Group Study Number 4 (SCPG-4) study (14.6%) [4], most men will still find it disturbingly high and it is three-times higher than the 3% life-time risk of dying from prostate cancer for all men. In other words, it may be perceived that prostatectomy does only partly reverse the risk of dying from prostate cancer, even in men with low-risk disease.

The data from Røder et al. [1] can, with longer follow-up, set the standard for oncological outcome on a national level. Of interest is the observation that, although not significant in the multivariate analysis, variation among institutes for outcome seems to exist but not clearly dependent on institutes volume. Variations of case-mix and patient selection could be topics of further study. With the short follow-up available we are also looking forward to data on functional outcome and perioperative complications that may be more mature. Comparison with now also available registries in Belgium and the Netherlands would be of interest.

It always strikes me that prostate cancer seems to be a systemic disease from the start even in assumed ‘low-risk’ disease, yet surgical management is only focused at loco-regional control. Perhaps the mortality improvement shown in the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) trial by prostatectomy is merely caused by disease delay provided by local control even in the presence of systemic disease. Initial encouraging data from an ongoing study evaluating the role of radiotherapy to the prostate in the presence of bone metastases seem supportive of this notion. Is prostatectomy a debulking management of a systemic disease at most, and an unneeded cure for many, or is there this sub-sub group of men that is eventually fully benefiting from the intervention reversing not only death but also the debilitating effects of androgen ablation.

Henk G. van der Poel

Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands

Read the full article

References

Røder MA, Brasso K, Christensen IB et al. Survival after radical prostatectomy for clinically localised prostate cancer: a population-based study. BJU Int 2014; 113: 541–547
Vickers A, Savage C, Bianco F et al. Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center. Eur Urol 2011; 59: 317–322
Shikanov S, Kocherginsky M, Shalhav AL, Eggener SE. Cause-specific mortality following radical prostatectomy. Prostate Cancer Prostatic Dis 2012; 15: 106–110
Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2011; 364: 1708–1717

Video: Survival after RP for clinically localised prostate cancer

April 9, 2014/by admin Z.9

Survival after radical prostatectomy for clinically localised prostate cancer: a population-based study

Martin Andreas Røder¹, Klaus Brasso¹, Ib Jarle Christensen², Jørgen Johansen³, Niels Christian Langkilde⁴, Helle Hvarness¹, Steen Carlsson⁵, Henrik Jakobsen⁶, Michael Borre⁷ and Peter Iversen¹

¹Copenhagen Prostate Cancer Center and Department of Urology, ²The Finsen Laboratory, Copenhagen Biotech Research and Innovation Centre (BRIC), Rigshospitalet Copenhagen University Hospital, Faculty of Health and Medical Sciences, Copenhagen, ³Department of Urology, Regional Hospital West Jutland, Holstebro, ⁴Department of Urology, Aalborg University Hospital, Faculty of Medicine, Aalborg, ⁵Department of Urology, Odense University Hospital, Faculty of Health Sciences, Odense, ⁶Department of Urology, Herlev Hospital, Copenhagen University Hospital, Faculty of Health and Medical Sciences, Herlev and ⁷Department of Urology, Skejby, Aarhus University Hospital, Department of Clinical Medicine, Aarhus, Denmark

Read the full article

OBJECTIVES

• To describe survival and cause of death in a nationwide cohort of Danish patients with prostate cancer undergoing radical prostatectomy (RP).

• To describe risk factors associated with prostate cancer mortality.

PATIENTS AND METHODS

• Observational study of 6489 men with localised prostate cancer treated with RP at six different hospitals in Denmark between 1995 and 2011.

• Survival was described using Kaplan–Meier estimates. Causes of death were obtained from the national registry and cross-checked with patient files.

• Cumulative incidence of death, any cause and prostate cancer-specific, was described using Nelson–Aalen estimates.

• Risk for prostate cancer death was analysed in a Cox multivariate regression model using the covariates: age, cT-category, PSA level and biopsy Gleason score.

RESULTS

• The median follow-up was 4 years. During follow-up, 328 patients died, 109 (33.2%) from prostate cancer and 219 (66.8%) from other causes. Six patients (0.09%) died ≤30 days of RP.

• In multivariate analysis, cT-category was a predictor of prostate cancer death (P < 0.001). Compared with T1 disease, both cT2c (hazard ratio [HR] 2.2) and cT3 (HR 7.2) significantly increased the risk of prostate cancer death. For every doubling of PSA level the risk of prostate cancer death was increased by 34.8% (P < 0.001). Biopsy Gleason score 4 + 3 and ≥8 were associated with an increased risk of prostate cancer death compared with biopsy Gleason score ≤ 6 of 2.3 and 2.7 (P = 0.003), respectively.

• The cumulative hazard of all-cause and prostate cancer-specific mortality after 10 years was 15.4% (95% confidence interval [CI] 13.2–17.7) and 6.6% (95% CI 4.9–8.2) respectively.

CONCLUSIONS

• We present the first survival analysis of a complete, nationwide cohort of men undergoing RP for localised prostate cancer.

• The main limitation of the study was the relatively short follow-up.

• Interestingly, our national results are comparable to high-volume, single institution, single surgeon series.

Read more articles of the week

Article of the month: The surgical spectacle

April 2, 2014/2 Comments/by admin Z.9

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

The surgical spectacle: a survey of urologists viewing live case demonstrations

Sammy E. Elsamra, Mathew Fakhoury, Hector Motato, Justin I. Friedlander, Daniel M. Moreira, Joel Hillelsohn, Brian Duty, Zeph Okeke and Arthur D. Smith

The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA

Read the full article

OBJECTIVE

• To evaluate perspectives of urologists viewing live case demonstrations (LCD) and taped case demonstrations (TCD).

METHOD

• A 15-question anonymous survey was distributed to attendees of the live surgery session at the American Urological Association 2012 national meeting (Atlanta) and the second International Challenges in Endourology meeting (Paris).

RESULTS

• Of 1000 surveys distributed, 253 were returned completed (response rate 25%). Nearly half of respondents were in the academic practice setting and nearly 75% were beyond training.

• Just over 30% had performed a LCD previously. The perceived benefit of an LCD was greater than unedited and edited videos (chi-squared P = 0.014 and P < 0.001, respectively). Nearly no one selected ‘not helpful’ and a few selected ‘minimally helpful’ for any of the three forms of demonstration.

• Most respondents identified that opportunity to ask questions (61%) and having access to the full unedited version (72%), two features inherent to LCD, improved upon the educational benefit of edited videos.

• Most (78%) identified LCD as ethical. However, those that did not perceived lower educational benefit from LCD (P = 0.019).

• A slim majority (58%) would allow themselves or a family member to be a patient of a LCD and the vast majority (86%) plan to transfer knowledge gained at the LCD session into their practice.

CONCLUSIONS

• Urologists who attended these LCD sessions identified LCDs as beneficial and applicable to their practice.

• LCDs are preferred over videos. The large majority considers LCD ethical, although not as many would volunteer themselves for LCD.

• Further studies are necessary to determine if there is actual benefit from LCD over TCD to patient care.

Read more articles of the week

Editorial: Do live case demonstrations have a future in surgical education?

April 2, 2014/by Walter Artibani

The ever increasing desire for instant access to information is a reflection of our times facilitated by social networks and by video and information technology. Nowadays, sport events are dissected and quantified from every possible perspective. We know almost real-time any detail of a soccer match: how many miles each player runs, how many good or bad passages of play, how many faults and so on, including if needed the details of heart rate and weight loss. The same and even more is available for example in formula one racing. Theoretically the same could easily be applied to surgical performance and it is foreseeable it will be applied, as a self-performance improvement method and as a development of one of the most popular ‘scientific and educational’ activities during surgical meetings, live case demonstrations (LCDs). All this, together with simulation, could in the near future have a tremendous impact on surgical performance and training. Twitter and Instagram show the power of the immediate real-time diffusion of events, as condensed as possible, so that the tweet or the instantaneous image can be visible and digested without losing time. Video clips follow the same concept and certainly BJUI is pioneering the use of short surgical video clips that are easily accessible and usable at any spare time of a busy day.

The core issue about LCDs is that at present there is no solid scientific evidence of their educational value, and this is outlined in the paper by Elsamra et al. [1] published in this issue of BJUI, which commendably attempts to evaluate the educational benefit of LCDs in terms of perception, clearly not a very strong criterion.

Data about the outcomes of live surgery operations are scant. Clearly patient’s safety is the first goal of any surgical activity, and this applies to LCDs. As mentioned in the paper, the European Association of Urology (EAU) Executive felt the urgent need to establish procedures and regulations in order to endorse live surgery events. The reader can find all related information on the EAU website. These regulations are meant to be in the best interest of patients, surgeons and organisers. Among others, one important innovation is the requisite of a ‘patient advocate’ present during the LCD, being an experienced medical doctor, independent from the organising committee of the educational event, in charge of advising in case of unexpected events, which can endanger patient’s safety.

Moreover, the EAU has established a prospective database of all endorsed live surgery events. This will hopefully allow in a few years an answer, with solid data, to the question of whether an intervention performed during a live surgery event has the same outcome compared with the same intervention executed by the same surgeon in his usual environment. The more challenging goal is to quantify the educational value of a live surgical event and the jump from perception to scientific evidence is far from being an easy task.

Walter Artibani
Urologia – Azienda Ospedaliero Universitaria Integrata di Verona, Verona, Italy

Read the full article

Reference

Elsamra SE, Fakhoury M, Motato H et al. The surgical spectacle: a survey of urologists viewing live case demonstrations. BJU Int 2014; 113: 674–678

Article of the week: Impact of blood transfusion during radical cystectomy

March 26, 2014/by admin Z.9

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Kluth discussing his paper.

If you only have time to read one article this week, it should be this one.

Impact of peri-operative blood transfusion on the outcomes of patients undergoing radical cystectomy for urothelial carcinoma of the bladder

Luis A. Kluth^1,3, Evanguelos Xylinas^1,4, Malte Rieken^1,5, Maya El Ghouayel¹, Maxine Sun¹, Pierre I. Karakiewicz⁶, Yair Lotan⁷, Felix K.-H. Chun³, Stephen A. Boorjian⁸, Richard K. Lee¹, Alberto Briganti⁹ , Morgan Rouprêt¹⁰, Margit Fisch³, Douglas S. Scherr¹ and Shahrokh F. Shariat^1,2,11

¹Department of Urology and ²Division of Medical Oncology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA, ³Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany, ⁴Department of Urology, Cochin Hospital, Assistance Publique-Hopitaux de Paris, Paris Descartes University, Paris, France, ⁵Department of Urology, University Hospital of Basel, Basel, Switzerland, ⁶Department of Urology, University of Montreal, Montreal, QC, Canada, ⁷Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA, ⁸Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA, ⁹Department of Urology, Vita-Salute University, Milan, Italy, ¹⁰Department of Urology of la Pitié-Salpétrière, Assistance Publique-Hôpitaux de Paris, University Paris VI, Faculté de Médicine Pierre et Marie Curie, Paris, France, and ¹¹Department of Urology, Medical University of Vienna, Vienna, Austria

L.A.K. and E.X. contributed equally to this work

Read the full article

OBJECTIVE

• To determine the association between peri-operative blood transfusion (PBT) and oncological outcomes in a large multi-institutional cohort of patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).

PATIENTS AND METHODS

• We conducted a retrospective analysis of 2895 patients treated with RC for UCB.

• Univariable and multivariable Cox regression models were used to analyse the effect of PBT administration on disease recurrence, cancer-specific mortality, and any-cause mortality.

RESULTS

• Patients’ median (interquartile range [IQR]) age was 67 (60, 73) years and the median (IQR) follow-up was 36.1 (15, 84) months.

• Patients who received PBT were more likely to have advanced disease (P < 0.001), high grade tumours (P = 0.047) and nodal metastasis (P = 0.004).

• PBT was associated with a higher risk of disease recurrence (P = 0.003), cancer-specific mortality (P = 0.017), and any-cause mortality (P = 0.010) in univariable, but not multivariable, analyses (P > 0.05).

• In multivariable analyses, pathological tumour stage, pathological nodal stage, soft tissue surgical margin, lymphovascular invasion and administration of adjuvant chemotherapy were independent predictors of disease recurrence, cancer-specific mortality and any-cause mortality (all P values <0.002).

CONCLUSIONS

• Patients with UCB who underwent RC and received PBT had a greater risk of disease recurrence, cancer-specific mortality and any-cause mortality in univariable, but not multivariable, analysis.

• Although the greater need for PBT with more advanced disease is probably caused by a number of factors, including surgical and cancer-related factors, the present analysis showed that the disease characteristics rather than need for PBT led to worse outcomes.

Read more articles of the week