Stone disease is a highly prevalent condition that unites all countries around the world, although surgical management will depend on many factors including availability of different technologies. However, percutaneous nephrolithotomy (PCNL) remains the cornerstone for the management of larger renal stones in all parts of the world, and Rizvi et al. [1] report on a huge cohort of PCNL procedures – 3 402 to be precise from Karachi. This is a single-centre series, over an 18-year period, reporting real-life data and showing a stone clearance rate of ~80%, as assessed by plain abdominal radiograph of the kidneys, ureters and bladder, and ultrasonography (US). Whilst the definition of stone-free and imaging modality used to judge it remains a contentious issue, this paper reflects the excellence of high-volume surgery in specialist centres.
Recently, the BJUI became the affiliated journal for the International Alliance of Urolithiasis (IAU), whose annual meeting takes place in Shaoxing this month. To celebrate this, we are proud to publish a ‘Best of Urolithiasis’ issue, which features some of the top stone papers published in the BJUI over the last few years [2]. Choosing articles for this was quite a task given the quality and whilst we have attempted to recognise submissions that potentially change practice, the geographical diversity of the work shows not only the global nature of stone disease but also the excellent research that is being done worldwide and in different healthcare systems to improve care and outcomes. Of particular importance are randomised trials that are often lacking in surgical areas. One such paper from China addressed the question of US vs fluoroscopy for PCNL access during mini-PCNL [3]. Whilst the truth is that surgeons should use whatever gives the best outcomes, the authors in a very high-volume centre were able to demonstrate the effectiveness of US-only punctures, although a combination may be better in complex stone burdens. Another randomised controlled trial (RCT) of clinical importance was from the USA, where the authors conducted a good quality double-blind RCT of NSAID use before ureteric stent removal under local anaesthesia [4]. Whilst a small study, the incidence of severe pain in the 24 h after stent removal was 55% in the placebo group vs 0% in the NSAID group – as such this simple study should have changed practice for all who perform this procedure.
I hope you take the time to check out the virtual issue on urolithiasis and read the other papers I could not mention here. Please continue to send your high-quality stone papers to the BJUI and maybe your submission will feature in our next ‘Best of Urolithiasis’ issue.
Last year I introduced Publons via a BJUI Blog . It is pleasing that Wiley, the publishers of the BJUI, have now partnered with Publons to make digital archiving and verification of reviewer (and editorial) work easily accessible with a mouse click once a review is completed.
So, what is Publons again? Perhaps a brief reminder: Just as PubMed collates publications, Publons collates peer reviews you have performed and verifies you did them. With one hyperlink you may go to all of your reviews listed by date and under sections of journals. In addition, Publons also allows you to showcase to what editorial boards you belong. It also now allows editorial board work to be collated and rewarded.
I can do this all myself, can’t I? Well yes you can but this service is free and offers third party verification of peer reviews. This is important in the era of fake news. You also find out when an article you reviewed is published.
Publons is important because until now it has been difficult to track and quantify the hard work done by reviewers that is all pro bono. Getting credit for reviews is important and this website finally acknowledges that fact. Finally you can compete with other colleagues (all friendly of course). For those with editorial roles for journals the handling of manuscripts can also be collated to again get credit. A final side point is that making your reviews public is possible should you choose to do so (and gets your more points) but that is an individual (and sometimes journal) decision.
Reminder how to access and use Publons:
1) The journal may be aligned with Publons (as BJUI now is) so just click the box at time of review (see example here):
2) Simply forward your official thank-you receipt email as below to [email protected] and they will do the rest (example here):
3) I can’t find the emails- is there any way of back tracking to reviews done over the years? Yes- take screen shots of your “Official Journal Dashboard “like this de-identified one below and send to reviews@publons (I have done this and it works quite well but you may need to take more than one screen shot per page to make it more easily digestible)
4) You can ask a journal to email you a summary and provided they send enough detail Publons will look at it and probably accept it (I have not done this but heard it may work)
So there you have it. The variety of methods is straightforward. A new Publons dashboard will be created and is easy and documents well which journals you have reviewed for and when.
What are the Publons awards? We can see here in the example of Prof Henry Woo (urologist, Australia) whom has reviewed many papers (see his total score and review numbers). Publons also ranks overall reviewer status and within different reviewers topic sections. It also gives “awards” each quarter to the best reviewer overall, best from your university etc. The value of such awards is likely to rise each year as more people use the Publons platform.
Are there other benefits? Well for Editors and Publishers to be able to tap into key reviewers will be extraordinary moving forward.
So its easy and free to join and benefit from Publons and the earlier you start the easier it is to track your digital online CV. Get credit and build your online presence (it allows a photo and short biography and links to your ORCID identification) and gain a sense of accomplishment by being a peer reviewer- without whom journals would not exist. It is also quite fun to see how your colleagues are ranked (or others from your country, specialty and university) and also the ridiculous number of reviews people from different fields has done.
Nathan Lawrentschuk PhD MBBS FRACS
Associate Editor BJU International/Editor USANZ BJU International Supplement
Since 2008 we have cycled in Sicily, Malawi, Madagascar, Patagonia, South Africa and Rajasthan raising more than three quarter of a million pounds for The Urology Foundation. The seventh and latest instalment of the TUF cycling series is an amazing 450km cycle challenge through two of South East Asia’s most fascinating countries. The challenge starts in Vietnam’s Ho Chi Minh City and finishes at the world heritage site of Angkor Wat in Cambodia. En route we will shed a lot of sweat, but also experience breathtaking scenery, ancient temples and the warmth of the local people.
The cycling will be tough but we are going to be using bikes from ecosmobike.com to make it less harder, it will be in hot and humid conditions, but the camaraderie along the way will be very special as doctors, patients and supporters team up to raise much needed funds for The Urology Foundation (TUF).
Funds raised by Cycle Vietnam to Cambodia will enable The Urology Foundation to help improve the management and treatment of urological diseases through the development and support of medical education and sponsorship of research – training healthcare professionals specialising in urology and supporting basic and clinical research by funding scholarships in the UK and abroad.
Day One (Fri 10 November 2017) – Depart UK
Overnight flights from London to Ho Chi Minh City, Vietnam
Day Two (Sat 11 Nov) – Arrive Ho Chi Minh City – Transfer Ben Treh
On arrival in Ho Chi Minh City we are met at the airport by our support team where buses will be waiting for us to transfer, approximately two hours, to our hotel in the town of Ben Treh. In the afternoon we will have the bike fitting. Dinner will be at the hotel and will be followed by a briefing about the challenge ahead.
Day Three (Sun 12 Nov) – Ben Tre – Tra Vinh 50kms (approx. 31 miles)
Today we will have a warm-up day with the cycling being relatively easy and the distance not too challenging. After breakfast we cycle out of the hotel along lovely country roads with very little traffic. We then follow a traffic free route through villages that give us an insight into Vietnamese rural life. After crossing a number of river tributaries by bridge we reach one that requires a short ferry crossing. About an hour later we reach the main Mekong River where we re-group for a longer ferry crossing.
Day Four (Mon 13 Nov) – Tra Vinh – Can Tho 104kms (approx. 64 miles)
The cycling today is fairly flat and takes us through rural communities and a number of small towns. Interest today is provided by the many Pagodas that we pass, some of which we will use for rest stops.
Day Five (Tues 14 Nov) – Can Tho – Chau Doc 70kms (approx. 43 miles)
We leave our hotel early this morning with a road transfer of approximately 2.5 hours. We start cycling from the town of Am Cham. We stop at a local restaurant in the small town of Triton for lunch before continuing through scenic agricultural land. This afternoon we encounter our first major climb. Further, smaller climbs take us into the town of Chau Doc where we find our overnight hotel. On arrival we will de-fit the bikes in preparation for our crossing into Cambodia.
Day Six (Wed 15 Nov) – Chau Doc – Phnom Penh
Today we enjoy a day off the bikes and a fascinating journey by boat from Vietnam to Cambodia. After breakfast we have a short transfer to the harbour where we embark on the boats that will take us along the historic Mekong River to the border.
We will see many boats along the way and experience life on the river which supports many thousands of Vietnamese. After crossing the border we continue our journey up-river to the city of Phnom Penh where we have lunch in a restaurant overlooking the busy harbour.
We will visit the Royal Palace which is described as an impressive Khmer style Palace. We overnight at a hotel in Phnom Penh where we will be briefed by our Cambodian support team.
Day Seven (Thurs 16 Nov) – Phnom Penh – Kampong Cham 60kms (approx. 37miles)
Today we have our first day of cycling in Cambodia. Following an early breakfast we will have a short transfer to take us out of the city to the surrounding countryside where quiet roads await us. After about 35kms we reach the end of the tarmac road and continue the rest of today on dirt roads. We overnight in the town of Kampong Cham.
Day Eight (Fri 17 Nov) – Kampong Cham – Kompong Thom 107kms (approx. 66 miles)
This is probably our most demanding day of cycling. After breakfast we leave town on an undulating road that passes many Temples and Pagodas and leads us into a forest of rubber trees. We will have lunch today in a large Pagoda complex before continuing our ride into the town of Kampong Thom.
Day Nine (Sat 18 Nov) – Kompong Thom – Siem Reap 60kms (approx. 37 miles)
This morning after an early breakfast we have a transfer of approximately 1 hour to our start point at Kampong Kdei. Our route today takes us through the Cambodian countryside until we reach the outskirts of Siem Reap. Our finish line will be at the entrance to the ancient city of Angkor where we will enjoy a celebratory drink and have a photo opportunity. This evening we will have our celebration dinner at a nearby hotel; this will be followed by a cultural show.
Day Ten (Sun 19 Nov) – Siem Reap – Visit Angkor Wat / Free Day
Today is a free day to explore the areas ancient ruins and temples, or relax by the pool, or do a spot of shopping. Why not re-visit the Angkor Wat temple, take a walking tour of the overgrown ruins of Ta Prohm which is entwined with tree roots and gigantic creepers, visit the tranquil Bayon with its multitude of serene stone faces, or see the impressive 350m long Terrace of the stone Elephants.
Day Eleven (Mon 20 Nov) – Depart Siem Reap
We depart for the airport at Siem Reap to begin our journey home.
Day Twelve (Tues 21 Nov) – Arrive UK
Altogether we will have cycled 450 Km in extremely hot and humid conditions. Do support us with a donation to a great cause by sponsoring Louise de Winter our CEO’s fundraising page here: https://cyclevietcam2017.everydayhero.com/uk/louise-de-winter All donations made will go towards funding the vital research, training and education in urology diseases so badly needed.
This issue’s Article of the Month comes from Karachi, Pakistan. The cover features The Great Bath, one of the best-known structures among the ruins of the ancient Indus Valley Civilization at Mohenjo-daro, in the province of Sindh, which was built over 4500 years ago.
John Wickham BSc, MB BS, MD, FRCS(Eng), FRCP(Hon), FRCR(Hon), FRSM(Hon)
1927 – 2017
The news of the passing of the legendary John Wickham on 26 Oct 2017 will sadden many. Here is a celebration of the life of a visionary thinker, innovator and pioneering surgeon.
Born in Chichester, John moved with his mother to Littlehampton and spent many happy years in rural Sussex. This year he published his book “An Open and Shut case – The story of Keyhole or Minimally Invasive Surgery” which describes his unique journey through life and his passion for reducing the trauma of surgery for the benefit of his patients. A couple of years before this, he sent me the “raw” version to read and comment on. This will forever remain a treasured possession along with a first signed copy of the final version which arrived on my desk in May 2017. A brilliant exercise in honest writing combined with his wry humour.
There were a number of exciting events in his childhood. He describes “epilation radiotherapy” to his scalp to eradicate ringworm which he provides as the explanation for the lack of hair in later life. Such personal touches keep the reader engaged as do his daily travels from Littlehampton to Bart’s (St. Bartholomew’s Hospital), costing £16 per quarter. He was interviewed by Sir William Girling-Ball for his entry into medical school and subsequently worked for Sir Ronald Bodley-Scott, physician to HM the Queen. Time spent in the Royal Air Force (RAF) toughened him up for the complexities of life as a surgeon.
He was trained in urology by Mr A W Badenoch, another legend in his own right. John describes his first inguinal hernia repair, during which his chief had to leave to take a phone call and he was saved by guidance from the anaesthetist. In his days the pass rate for the FRCS was around 10% and he was one of the lucky ones! He subsequently worked with Prof. Ian Aird of the textbook fame. He met his wife Ann, during a below knee amputation from behind a surgical mask. He was awarded a Fullbright scholarship to Lexington, USA which he thoroughly enjoyed. Despite the offer of a job to stay back, the family decided to return to the UK, where he became a Bart’s man, going on to lead the Department of Urology as its head with Bill Hendry as his colleague.
He was also the Director of the Academic Unit at the Institute of Urology at the then 3Ps (Peter, Paul and Phillips) Hospitals and after the move of St. Peter’s to the Middlesex Hospital. He was also Consultant Urological Surgeon to the King Edward VII Hospital and The London Clinic.
He is credited with a number of pioneering achievements. His device for renal cooling with coils was published in the BJU in 1967. He worked with the famous Sir David Innes Williams and was awarded the Hunterian Professorship. He also published a seminal paper on urethral pressure profile.
Very few will know that he was sidelined with an attack of acute pancreatitis and needed a cholecystectomy for gall stones.
He developed PCNL with Mike Kellett and then the Society and Journal for Minimally Invasive Therapy (SMIT) as well as the Intrarenal Society. He inspired the future generation of great innovators like Graham Watson, Ron Miller and Malcolm Coptcoat, to name a few. With the help of the Kuwait Health Office he managed to instal a Dornier lithotripter in Welbeck street which was revolutionary in those days.
John developed the PROBOT, the first autonomous surgical robot with Prof. Brian Davies at Imperial College. Initially tested in potatoes, it was then refined with the addition of a mapping ultrasound and a vaportome, leading to a world first clinical trial at Guy’s, where he had moved to with the support of Lord Ian McColl. In this project, he was ably helped by Malcolm Coptcoat, Anthony Timoney, Senthil Nathan and Bibhas Kundu. Many years later this device was displayed at a public exhibition at the Royal College of Surgeons of England. It is curious how autonomy is again being discussed amongst roboticists after some 30 years.
Following retirement from the NHS he continued to innovate by establishing a company called Syclix which allowed him to design laparoscopic instruments with pen like grips rather than the traditional handles. He arrived at Guy’s one summers morning to show me these instruments to try on one of my laparoscopic nephrectomy patients. At my request, he examined Ben Challacombe’s thesis on the first ever randomised trial of telerobotics and was then guest of honour at our first robotics symposium in 2004 and the inauguration of the King’s-Vattikuti Institute of Robotic Surgery in 2014.
While clinically active he did his best to spread his philosophy about Minimally Invasive Surgery throughout the world by lecturing and publishing articles in the BMJ, amongst other journals. Many did not believe in him, but he was clearly light years ahead of his time. He received numerous honours, which included the Cheselden Medal and the Galen Medal of the Society of Apothecaries.
It was a privilege to know him and he will remain a lasting inspiration to many.
To provide objective criteria for preoperative staging chest computed tomography (CT) in patients diagnosed with renal cell carcinoma (RCC) because, in the absence of established indications, the decision for preoperative chest CT remains subjective.
Patients and Methods
A total of 1 946 patients undergoing surgical treatment of RCC, whose data were collected in a prospective institutional database, were assessed. The outcome of the study was presence of pulmonary metastases at staging chest CT. A multivariable logistic regression model predicting positive chest CT was fitted. Predictors consisted of preoperative clinical tumour (cT) and nodal (cN) stage, presence of systemic symptoms and platelet count (PLT)/haemoglobin (Hb) ratio.
Results
The rate of positive chest CT was 6% (n = 119). At multivariable logistic regression, ≥cT1b, cN1, systemic symptoms and Hb/PLT ratio were all associated with higher risk of positive chest CT (all P < 0.001). After 2000-sample bootstrap validation, the concordance index was found to be 0.88. At decision-curve analysis, the net benefit of the proposed strategy was superior to the select-all and select-none strategies. Accordingly, if chest CT had been performed when the risk of a positive result was >1%, a negative chest CT would have been spared in 37% of the population and a positive chest CT would have been missed in 0.2% of the population only.
Conclusions
The proposed strategy estimates the risk of positive chest CT at RCC staging with optimum accuracy and the results were statistically and clinically relevant. The findings of the present study support a recommendation for chest CT in patients with ≥cT1b, cN1, systemic symptoms or anaemia and thrombocythemia. Conversely, in patients with cT1a, cN0 without systemic symptoms, anaemia and thrombocythemia, chest CT could be omitted.
Olá! The 37th Congress of the Société d’Urologie (SIU) was held in Lisbon, a beautiful, historic city (19th-22nd October 2017). It is the first time the congress has been held here. We were told by the co-hosts during the opening ceremony that Portugal has a history of finding new routes and building bridges to other cultures, which they hoped to emulate at the Congress. The iconic 24 de Abril Bridge, the largest in Europe, was visible from the Congress Centre serving as a visual reminder of bridges being made during this congress.
The SIU is unique as it is a truly international association with no country or continent affiliation; it has 7000 members from 130 countries and 24 directors from every continent. Therefore the congress brings urologists from all over the world together. The words “Together, United, Stronger” said during the opening ceremony resonated as the ethos of the conference; and is especially pertinent in the current worldwide political climate. Furthermore, that the educational, global and philanthropic aspects of being part of such a society was highlighted as ways we can all help each other.
SIU 2017 had an engaging scientific programme providing a valuable educational experience to attendees over the four days. It covered the breadth of urology and we were honoured to listen to such notable speakers. The navigable congress centre (as well as the congress being a smaller meeting, as compared to EAU, AUA) meant delegates could easily attend whatever took their interest. The Scientific Programme included Plenary sessions, Master Classes, debates, ‘controversies’ sessions, instructional courses, poster presentations, the SIU Nurses’ Symposium and hosted urological organisation meetings. There were also Industry supported sessions and an Exhibition Hall.
The social programme allowed relaxation and networking amongst colleagues; plus sampling local Portuguese wines, food and an insight into Portuguese culture. The opening ceremony included a Fado performance. The SIU night held at Pátio da Galé in the PraÇa do Comércio was the pinnacle of the social aspect of the conference. The refreshments were plentiful and delicious, there were gelato stands as well as enough Pastel de Nata to feed a small army! A typical brass band, ceramic station, football net and DJ kept people entertained until we were told to leave. The SIU President’s Dinner held in the Queluz Palace was an amazing night in impressive surroundings for invited guests.
The fully attended WUOF session on the first day brought experts in the field of Urological cancers to provide their views on the changing paradigms and new treatments. All talks provided succinct, expert opinion. The presentation by Marc Dall’Era on the genetics of prostate cancer and link with the BRACA gene was particularly informative; especially as these men get worse cancer: pictured. Genetic counselling of patients diagnosed with prostate cancer may need to increase in the future. Genomics was discussed in other cancer sessions too; it’s growing availability, reducing costs and correlation with difference in outcomes between patients must surely strengthen the argument for more personalised medicine.
I also particularly enjoyed the presentation by Tony Finelli who unraveled the notion of ‘surgical outcome’ which is often used to analyse the quality of surgery; this is then used in arguments for high volume centres. He suggested instead that assessing quality needs Quality Indicators and one alone isn’t sufficient. His group in Canada used their national database to propose 32 Quality Indicators, which are valid, reliable, feasible and useable; they found that higher quality had lower mortality and morbidity. Patient centred care, patient selection, high quality surgery and recovery was a common theme in other sessions too.
The SIU Innovators Symposium didn’t disappoint; highlights included Dr Sotelo’s presentation of ‘sticky situations’ in robotic surgery. His operative videos showed all the things you really don’t want to see whilst operating, however he and the panel provided tips in order to avoid or correct these operative mistakes. Dr Sotelo’s advice regarding having a ‘haemorrhage tray’ present was ingenious and useful: pictured. Thank you to Dr Sotelo and Dr Knudsen who shared their operative videos with us in order to provide this learning; mistakes in surgery should be shared to avoid others making the same mistakes. The symposium also invited two influential leaders, Professor Prokar Dasgupta, editor BJUI, and Professor Arnulf Stenzl to give their approach on leadership. Prof Stenzl suggested it was easier to explain how not to be a bad leader as he has learnt more from his mistakes than from successes. Prof Dasgupta suggested his leadership style was to be collaborative, trusting team members to deliver, democratic and transformative; also that he, as a leader, wanted to “help other people do well”.
SIU had a strong presence of trainees; many attending to present their academic work during the moderated poster sessions, listen to worldwide experts and of course network with others from around the world and generating future collaborations. One session ‘Sage Advice from the Wise’ was particularly aimed at trainees’ where Urological trainees met 10 experts (all wise, but certainly not old!). We were able to discuss career plans, ask questions about fellowships and talk about the advantages of academia alongside clinical practice. There was also a Residents Rapid Fire Q&A which was won by Dr Avinash Odugoudar: pictured.
Urological cancer treatment featured heavily on the programme. One particularly inspiring talk on advanced testicular cancer by one of the leading surgeons in Europe, Axel Heidenreich, really expanded our horizons of just what can be achieved operatively for patients with metastatic disease, including aortic resection and Whipple’s procedure. It proves that big, open surgery does exist in urology for the right patients; requiring expertise and courageous surgical skills but offering patients treatment despite disseminated disease. One session included debating the use of routine radiation for positive surgical margins in prostate cancer. The presentations by Dr Dall’Ezra and Dr Briganti actually came to very similar conclusions. Both wanted to avoid over treatment and championed a risk stratified approach with emphasis on patient selection; as not all those with positive margins recur. It was suggested that choosing those at greatest risk of recurrence for example the site(s) of positive margin, high Gleason score, early rise in PSA (even if remains less than 0.5) and ultra-sensitive PSA can help to stratify need for adjuvant radiotherapy; or alternatively monitor with option for salvage treatment.
Robotic assisted surgery for prostatectomy, cystectomy and nephrectomy was debated freely throughout the congress. Most quoted recent evidence that there is no clear advantage with regards to blood loss, LOS, long term outcomes and survival; but very different costs. Dr Mihir Desai argued that if you already had the robot you should encourage high volume surgery, but that departments have a responsibility to put the robot to good use; not for simple cases, but rather be reserved for difficult operations so the real advantages of robotic assisted surgery will be better appreciated. Criticism was made of RCTs not being the right research method for comparing surgical techniques as it leads to comparison of individuals not techniques. We eagerly anticipate the iROC study. An important point made regarding robotic cystectomy was that it must include intra-corporeal bladder formation, otherwise many of the advantages of the minimally invasive part are lost. Laparoscopic surgery was argued as not old fashioned; but rather an efficient and cost effective method of minimal access surgery without compromising on outcomes. However open surgery is still an option in many hospitals worldwide; a question from the audience included the dilemma faced by departments whose similar outcomes between open and laparoscopic procedures do not justify the switch to laparoscopy.
Prof Catto, editor of European Journal of urology delivered a compelling presentation of the advantages of radical cystectomy over radiotherapy for locally advanced bladder cancer. He also mentioned the importance of surgical planning and management intent: pictured. In some cases he does pre-operative MRI, however a PET scan when organised, doesn’t necessarily change his management. He also presented a plenary lecture on risk factors for upper tract TCC which confirmed smoking as the number one risk as well as occupation. However combustion occupations and amine-relate occupations show a difference in cancer aggression suggesting the biology of the cancer is different. Like others, he wanted to aim for personalised treatment of cancer with specific treatments according to genotype.
Debating the merits of surgery was a common theme in several sessions, perhaps unsurprisingly. However a particular highlight was the debate of medical vs surgical theory for lichen sclerosis (LS). The clear and compelling argument by Bradley Erickson for medical treatment rested on 10 points, which included: that LS is an inflammatory condition and these are not necessarily managed by surgery, the dermatologist and gynaecologist manage LS without surgery, LS in the urethra demonstrates squamous change which is reversible and lastly that we don’t really fully understand this disease yet.
Female urology was the first plenary session of the congress and the use of mesh unsurprisingly featured in other sessions, included one entitled ‘controversies in urology’. The clear message from Dr Badlani was to know the anatomy and not to ‘have a go’ at continence surgery, it needs expertise. He and his panel presented difficult cases including mesh seen at cystoscopy, operative video of hydro-dissection and an image of compete extrusion which led the audience to wonder if it had even been placed correctly in the first place!?
In the joint SIU-GURS meeting panel members each presented a challenging case from their experience of reconstructive surgery and ileal conduit formation; then this was discussed amongst the panel. There was an amazing X-ray of a huge stone in an ileal conduit due to stasis of urine, confirming the need to avoid long conduits. A fear held by many was early failure of the anastomosis; when debating when to re-operate, I particularly liked the phrase “three months to let the belly cool down” said with an American drawl. Margit Fisch shared her top tips of surgery: pictured. An insight into managing continence in patients with Spina Bifida was succinctly presented by Sean P. Elliot; he advised that the patients needed to be ‘proud of their stoma’ and that each needed an individual surgical plan but holistic approach.
Endourology and stone sessions were well attended and each explored different treatment modalities for stone management. Plus the congress offered masterclasses for ureteroscopic techniques, the joint SIU-Endourology session, poster sessions and a ‘controversies session’ debating URS vs Mini-perc. There was also an instructional course on lasers and flexible ureteroscopic technique. Experienced surgeons from across the globe argued for and against the role of ESWL vs RIRS vs PCNL in modern practice. Aside from patient and stone factors there was an appreciable point made of the importance of surgeon experience and available resources of the institution. Non-surgical aspects of stones were also presented, such as diet and hydration in stone disease. Advances in stone surgery, including a robotic assisted ureteroscope was particular enlightening and futuristic; however brought up the inevitable dilemma of clinical need for such technology at a time of financial restraint facing many healthcare systems.
Andrology sessions included a joint SIU-ISSM session, a master class on urethral stricture disease, video session on male reconstruction and poster session on sexual function and dysfunction. There was a debate on the role of the urologist in the management of male infertility and improving sperm. The (interesting) use of an acronym F.A.S.T was described by host urologist from Portugal Dr Pedro Vendeira: pictured. This is in relation to the follow up of non-responders to PDE-5 inhibitors, of which non responders were those who had tried these medications more than eight times. He described a 50% drop out of the use of these drugs due to cost, side effects and co-morbidities. The difficulty of treating Peyronies was discussed by Dr Moncada who confirmed the absence of the role for medical therapies, except use of PDE-5 inhibitors to strengthen erections. There was a role for ‘ penile rehabilitation’ which included a (peculiar) traction device. He presented his and the EAU indications for surgery and he stressed the importance of managing patient expectation and informed consent.
In conclusion, the SIU Congress was both informative and enjoyable. Our co-hosts promises: of warmth, friendship and the Portuguese tradition of sharing wine were delivered alongside a beneficial education programme. Those that did not attend can access abstracts and lectures online via the SIU@U platform.
SIU are also increasing their activities with the following initiatives: ‘B2B’ bench to bedside, ‘Uro-Technology’ training and ‘U-care’ a global urological research collaboration. SIU also wants to build on the opportunities for global education and global health; plus help colleagues without same level of resources.
Thank you to the SIU organisers for a successful congress! Thank you to the presenters and speakers for their expertise and dedication to academia in urology; and congratulations to all the prize winners. I’m sure the next SIU Congress 2018 in South Korea will be equally successful.
The RSM section of Urology #RSMUrology hosted a day on the Key issues in Endourology on 20th October. This was the first meeting of the academic year under President Roland Morley. Sri Sriprisad put together a complete endourology day with key subject areas of “PCNL and stones”, “upper tract TCC” and “BPH and retention”. Speakers from India, America and Spain provided expert opinions from around the globe.
The day started with the evolution of stone and urological laparoscopic surgery. Showing an insight into the challenges with the initial introduction of laparoscopic urological surgery. In order to allow surgeons the chance to discuss their experiences and troubleshoot and develop surgical techniques the SLUG forum (southern laparoscopic urology group) was created, which is still running today in the annual AUA meeting.
PCNL techniques were the subject for several debate lectures. Access for PCNL tracts was debated by Dr Janak Desai, visiting from Samved Urology hospitalin India, arguing for fluoroscopic puncture with over 10,000 cases to date! Jonathan Glass, from Guy’s and St. Thomas’ Hospital, spoke for the prone position for the majority of PCNL, but selecting the supine position in 5-10% of cases depending on the anatomy and stone position. Dr Desai also spoke on ultra-mini PCNL, which he advocates using to treat solitary kidney stones under 2 cm in preference to flexible ureteroscopy.
The future of ESWL was debated and the audience voted that it is still “alive and clicking” by a narrow margin. However, although up to 80% clearance rates are quoted for upper pole stones less than 2 cm, the problem is that results of treatment are varied and unpredictable, and real-life success rates are far inferior. The variation in results may in part be due to the fact that there are no formal training courses for specialist radiographers nor SAC requirements for specialist registrars. Professor Sam McClinton presented on clinical research in stone disease with results from the TISU trial on primary ESWL vs. ureteroscopy for ureteric stones due out next year. The results will be fascinating and may help to decide if ESWL has a future in the UK.
Professor Margaret Pearle, visiting from the University of Texas Southwestern Medical Centre, explained the importance of treating residual fragments. With data showing that 20 – 36% of >2 mm residual stones after ureteroscopy required repeat surgery within 1 year. In a thought provoking lecture, she presented data showing that ureteroscopy may not be as good as we think and when critically examined, true stone-free rates maybe no better than ESWL. Maybe miniaturised PCNL is the way forward after all?
The follow up of small kidney stones is an uncertain area with very little written in either the EAU or AUA guidelines. Data from a meta-analysis by Ghani et al. shows that for every year of follow up on small kidney stones 7% may pass, 14% grow and 7% will require intervention. However, it is not possible in most health systems to follow everyone up forever and Mr Bultitude advocated increasing discharge rates from stone clinics to primary care after an agreed time of stability, allowing more on the complex and metabolic stone formers.Figure 1- Stone follow up algorithm
The expert stone panel then debated several challenging cases including “the encrusted stent”, stones in a pelvic kidney or calyceal diverticulum. These cases certainly are a challenge and require an individualized approach usually with multi-modality treatments.
Figure 2 – Stone expert panel
Upper tract urological biopsies are notoriously inaccurate, with only 15% of standard biopsies quantifiable histologically. Low grade tumours, are potentially suitable for endoscopic management with laser ablation. Dr Alberto Breda, from the urology department of Fundacio Puigvert Hospital in Spain, presented a novel solution for the future. This promising new technology uses confocal endomicroscopy to grade upper tract urological cancer. Initial results show 90% accuracy in diagnosing low grade tumours, which could then be safely managed endoscopically avoiding nephron-ureterectomy for some patients.
Figure 3 – Confocal endomicroscopy for upper tract malignancy
In the final session, a debate on BPH treatment, the audience preferred the bipolar resection technique for treating “the 60 year old with retention, with a 90 gram prostate and on rivaroxaban”, although HOLEP came a close second, with that talk giving the quote of the day “I spend more time with the morcellator than the wife.”
Like most journals, BJUI relies on the hard work and dedication of its peer reviewers and we are grateful to them all. This month, BJUI introduces the Four Seasons Peer Reviewer Award – each quarter the Editor and Editorial Team will select an individual peer reviewer whose reviews over the last 3 months have stood out for their quality and timeliness.
The Autumn Crown goes to Gianluca Giannarini.
Gianluca is Staff Member at the Urology Unit of the Academic Medical Centre “Santa Maria della Misericordia” in Udine, Italy.
He qualified from Udine University and trained in Florence, Pisa and Leuven, Belgium, before a 2-year clinical research fellowship at the Department of Urology of the University of Bern, Switzerland.
His clinical and research interests focus on urologic oncology, reconstructive surgery and prostate MRI.
