This month, the Article of the Month comes from the Sunnybrook Health Sciences Centre, Toronto, and the University of Toronto,
The cover image shows that city’s skyline including the famous CN Tower, the third tallest tower in the world.
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Department of Urology, Dalhousie University
Halifax, NS, Canada
To describe the technique of robot-assisted high-extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for ‘node-only’ recurrent prostate cancer.
In all, 10 patients underwent robot-assisted sRPLND+PLND (09/2015–03/2016) for ‘node-only’ recurrent prostate cancer, as identified by 11C-acetate positron emission tomography/computed tomography imaging. Our anatomical template extends from bilateral renal artery/vein cranially up to Cloquet’s node caudally, completely excising lymphatic-fatty tissue from aorto-caval and iliac vascular trees; RPLND precedes PLND. Meticulous node-mapping assessed nodes at four prospectively assigned anatomical zones.
The median operative time was 4.8 h, estimated blood loss 100 mL and hospital stay 1 day. No patient had an intraoperative complication, open conversion or blood transfusion. Three patients had spontaneously resolving Clavien–Dindo grade II postoperative complications. The mean (range) number of nodes excised per patient was 83 (41–132) and mean (range) number of positive nodes per patient was 23 (0–109). Seven patients (70%) had positive nodes on final pathology. Node-positive rates per anatomical level I, II, III and IV were 28%, 32%, 33% and 33%, respectively. In patients with positive nodes, the median PSA level had decreased by 83% at the 2-month follow-up.
The initial series of robot-assisted sRPLND+PLND is presented, wherein we duplicate open surgery with superior nodal counts and decreased morbidity. Robot-assisted technical details for an anatomical LND template up to the renal vessels are presented. Longer follow-up is necessary to assess oncological outcomes.
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The recent paper by Koo et al. [1] on ‘unprofessional’ online content amongst American urology residency graduates has received attention in the lay press and social media outlets. The paper has an Altmetric Attention score of 341 [2] – good for the fifth most online-cited paper the BJUI has ever published. Seventeen news outlets have reported the study, including MSN, Medscape, and US News & World Report.
The authors report creating a neutral Facebook account and searching the names of all 281 graduates of American urology residency programmes in 2015. They perused 201 accounts presumably belonging to graduates. Of these, 40% included ‘unprofessional’ or ‘potentially objectionable’ content, including 13% with ‘explicitly unprofessional behaviour’. On the surface, we agree these findings make compelling headlines. Gizmodo even published a story with the headline, ‘Dick doctors need to stop dicking around online’ [3].
The focus of the paper on trainees, not faculty, is also a flaw. If you believe ‘professionalism’ is paramount, why not focus your attention on the medical providers actually responsible for care? Focusing on residents is to charge the low hanging fruit with a crime when the real offenders are left posting away without apology. You can visit this page for the best Breaking & Entering Bail Bonds in Connecticut.
Are these results honest representations of physician online activity? Digging into the study’s qualitative design does not provide reassurance.
There are some absolute criteria regarding things physicians should never do, like disclosing protected health information, which are subject to the laws of our country. Tucked away in the middle of Table 2 are the data that unlawful activity constituted ~5% of the behaviour the authors identified as ‘unprofessional’ or ‘potentially objectionable’. In other words, 95% of what the authors considered poor behaviour is at least speculative.
Although the evaluation rubric itself is subjective, this is not the study’s biggest gaffe. Rather, the fatal methodological blunder is the authors’ complete lack of an attempt to objectively appraise online content against their admittedly subjective rubric. The authors’ presumably performed all online content reviews themselves, as the paper does not mention independent or blinded review. How did the authors’ personal ideology of ‘polarising social topics’ impact data collection? Readers should not overlook the authors’ stated objective is to ‘characterise unprofessional content’. Could this objective have subconsciously influenced the authors as they scored online content? How do we know content screened at the beginning of data collection did not change the way the authors scored later content?
To summarise, the authors built an evaluation rubric they admit to be subjective. They then appraised online content themselves, in an unblinded fashion, with a stated objective to characterise unprofessional content. Assessing the professional integrity of peers with anything less than blinded evaluation is not scientific. Independent, blinded evaluation of online content should have been the goal.
Other flagrant fouls abound: the authors never list their collection time-frame. Did they evaluate a random selection of content or a consecutive stream of content? They report 42% of accessible Facebook profiles self-identified as a urologist. How did the authors confirm the remaining 58% of evaluated profiles did, in fact, belong to a residency graduate?
The authors reviewed Facebook profiles in July 2015. Since the authors flagged any photograph, text, or link pertaining to politics, religion, or any polarising social topics it is worth considering a small sample of the events in the USA during June 2015:
Good luck finding something ‘non-polarising’ in the news. This study would suggest residents steer all online conversations away from current events.
This study [1] is, to borrow a new hackneyed American aphorism, fake news. BJUI promotes intellectual discourse through responsible use of social media, yet this study muzzles free speech by stigmatising expression. Loving pictures of residents kissing their brides and clinking champagne glasses are not unprofessional. Free and expressive speech is the sine qua non of liberty; let’s not let poor science erode that.
Cite this article: Bayne, C. E. and Davies, B. J. (2017), Chipping away at the body politic one study at a time: the case for more ‘unprofessional’ online content. BJU Int. doi:10.1111/bju.13986
This issue’s Article of the Month comes from The James Buchanan Brady Urological Institute, Baltimore, MD, established over 100 years ago by “Diamond Jim” Brady.
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Having trained and worked in London throughout my urology career, I have recently relocated and joined the exciting, dynamic urology community of my birthplace, Hong Kong. Coincidentally, it so happens to be this year’s host of the Urological Association of Asia (UAA) annual congress #UAA2017.
The beautiful and mesmerising night view of the Victoria Harbour of Hong Kong.
Established in 1990 in Fukuoka, Japan, the #UAA currently has 25 urological associations as members or affiliated members across Asia and Australasia with and over 25,000 members. This was my attendance at the #UAA and it most certainly did not disappoint. What made the conference even more special was the chance to meet up with my good friend and ex-colleague from Guy’s Hospital @nairajesh – both of us were honoured to speak at the meeting. With over 1600 delegates attending the meeting and over 500 scientific abstracts presented, the congress served as an excellent platform for knowledge exchange and the establishment of professional links with many urological greats in Asia and beyond.
Pre #UAA2017 Congress Activities
#UAA2017 started off with a pre-congress ‘wet-lab’ 3D laparoscopic skills and endourology workshop hosted by @HKUniversity and the European School of Urology @UrowebESU. Both transperitoneal laparoscopic and retroperitoneoscopic techniques were taught by eminent leaders and pioneers in minimally invasive urological surgery by faculties from Europe, India and China, including Professor Jens Rassweiller, Professor Christian Schwentner (@Schwenti1977), Dr Domenico Veneziano (@d_veneziano), Professor Janak Desai (@drjanajddesai), and Professor Zhang Shudong.
Joint UAA-ESU 3D laparoscopic and endourological skills course faculties. Left to right: Dr Ada Ng (Hong Kong), Dr Wayne Lam @WayneLam_Urol (Hong Kong), Professor Janek Desai @drjanajddesai (India), Professor Jens Rassweiller (Germany), Professor MK Yiu (Hong Kong), Dr James Tsu (Hong Kong), Dr WK Ma (Hong Kong).
Joint UAA-ESU 3D Laparoscopic skills workshop – Above: Professor Rassweiller (Germany) supervising overseas delegates. Below: Professor MK Yiu (Hong Kong) demonstrating techniques of laparoscopic suturing to delegates from China.
The renal cell carcinoma #RCC masterclass was a particular highlight. A whole day of excellent lectures and speakers entertained both local and international delegates, and was particularly popular with trainees. There were talks examining the role of percutaneous biopsy of renal tumours presented by Alessandro Volpe (@foxal72), an update of current trends and techniques in robotic and laparoscopic partial nephrectomy by Dr. Joseph Wong (Hong Kong) and Dr. Shuo Wang (China) and a fantastic discussion examining the role of non-clamping partial nephrectomy by Dr. Ringo Chu (Hong Kong). The afternoon session kicked off with @nairajesh giving a comprehensive review on the surgical management of advanced #RCC. Professor Axel Bex (Netherlands) continued with an examination of neoadjuvant and adjuvant systemic therapy in #RCC and the emerging role of #immunotherapy. Professor Alessandro Volpe (@foxal72) discussed the current #EAU guidelines and recent updates.
Masterclass in #RCC: @foxal72 , @nairajesh , Professor Axel Bex (Netherlands), with moderators Dr Ringo Chu (Hong Kong) and Dr Joseph Wong (Hong Kong).
Day 1 of #UAA2017
The plenary session on day 1 of #UAA started off with Professor Zengnan Mo from China on the epidemiology of prostate cancer in Asia. There is, not surprisingly, a very diverse range of incidence of #prostatecancer rate across the largest continent in the world, inevitably effected by the presence of #PSA screening in countries such as Japan and Korea, ethnicity (East Asia vs Middle East), genetics (Israeli Jewish population), and their local healthcare system and policies. Arguably the currently available #prostatecancer screening trials may not be applicable to the Asian populations, and various on-going studies in Japan and China are going to address these issues. One in particular is an ongoing population-based study funded by the Chinese Ministry of Science and Technology, in which over 50,000 men will be recruited into the screening, early detection, localised, and advanced #prostatecancer cohorts and to be followed up with time. Obviously, we will not expect to see the results of the trial anytime soon, but will surely answers to address the behaviour of prostate cancer in the Asian population in the future.
Professor Sam Cheng (@UroCancerMD) from Vanderbilt University then gave a comprehensive review on the current status of #cystectomy. Robotic cystectomy appears to have the benefit of reduced blood loss and length of stay. However, long-term oncological outcome still remains uncertain, and certainly, patient reported outcome measures (PROMs) is lacking.
Day 2 of #UAA2017
After early showers on day 2 of UAA, Hong Kong was heating up with temperatures over 33 degrees Celsius. So were the discussions in the plenary session in the morning. Professor Freddie Hamdy (@Freddie_Hamdy) gave the #EAU lecture on #activesurveillance for #prostatecancer. This was followed on nicely with the current status of #prostatecancer management in Hong Kong by Dr. Yau-Tung Chan and Dr. Gerhardt Attard (UK) enlightened the audience with a concise update in the management of hormone sensitive prostate cancer, an area where the landscape is ever-changing.
The advanced oncology session started off with a heated debate in the use of mass clamping (Dr Ringo Chu, Hong Kong) versus selective artery clamping in partial nephrectomy (Dr Tae-Gyun Kwon, Korea). Both speakers presented with very valid arguments and perhaps it was fair to say it ended up with all square. Professor Krishna Sethia (UK) gave a fascinating summary of the current local management of #penilecancer at centralised penile cancer centres in the UK, after which I was honoured to provide an update on current nodal management in #penilecancer from my recent experience at St George’s University Hospitals @StGeorgesTrust in the UK. It was exciting to see the centralisation of services in #penilecancer in the UK has given great opportunities to understand and optimise management of patients with such rare disease.
The Semi-live sessions entertained the audience on both days of the conference. Excellent videos were presented throughout. Professor Koon Rha of Yonsei University in South Korea gave a fantastic semi-live talk on his tricks and techniques of Retzius-space sparing Robot-assisted radical prostatectomy. Perhaps what’s even more exciting to know is that a Korean company has produced a new robot for surgery which has been well tested by Professor Rha’s group, which has just literally been licenced and approved in Korea just days before #UAA2017. Will this finally drive the cost of robotic surgery down? Time will tell.
Associate Professor Declan Murphy (@declanmurphy) and Mr. Rajesh Nair (@nairajesh) both contributed with a beautiful video showcasing techniques in total pelvic exenteration and long-term outcomes of urinary diversion and reconstruction in this cohort of patients.
The Gala dinner in the evening was full of fun and entertainment. Following the performance of a soprano quartet formed by local Hong Kong urologists (who sang the classic My Way with a twist on prostate examination!), the rock stars of urology – Professor Jens Rassweiller, Dr Samuel Yee from Hong Kong, and Dr Domenico Veneziano (@d_veneziano) provided an energetic and electrifying live performance of some rock classics!
Urology Rock N’ Roll! Left to right: Professor Jens Rassweiller (Germany), Dr Domenico Veneziano (Italy), Dr Samuel Yee (Hong Kong).
However, perhaps the highlight and the most touching moment of the evening the performance of a song written and sung by a young local former patient with a history of #ketaminebladder , who was successfully treated by the urology team lead by Professor Anthony Ng at the Prince of Wales Hospital in Hong Kong. His surgery and treatment has transformed his life – he is now enjoying a career as both a singer-songwriter of a rock band and as a footballer!
Day 3 of #UAA2017
The morning plenary session also saw the evergreen Dr Peggy Chu of Hong Kong, renown for her discovery of ketamine-associated uropathy and pioneered the management of this challenging 21st century urological disease.
Left to right: Dr CW Man (Hong Kong), Congress President of #UAA2017, and Dr Peggy Chu (Hong Kong).
She delivered a very interesting talk on revisiting the role of #gastrocystoplasty. Interestingly, the operation was first described and carried out in human by the honourable Professor CH Leong at my current institution, Queen Mary Hospital @HKUniversity , in the 1970s following a successful animal study at the same institution. Its use has been limited due to its associated metabolic disturbances, but arguably it is still a weapon that can be used when tackling patients with tuberculosis-associated severely contracted bladder, in particular those who have already been rendered to have a single solitary kidney due to the disease. Another situation when #gastrocystoplasty can still be considered are those patients with #ketamine uropathy. Although patients are usually required to be completely abstinence from #ketamine abuse for a certain lengthy period of time before they are eligible for surgical treatment, many fear the avalanche effect of ileal re-absorption of the drug if an ileo-cystoplasty has been carried out in these patients, if they happen to resume ketamine use in the future. Hence, #gastrocystoplasty may be a better substitution tissue for cystoplasty in the management of such patients.
The meeting also provided an opportunity to catch up with fellow Guy’s Hospital urology graduates @nairajesh and @declanmurphy over a cold pint of Hong Kong locally made #MoonzenBeer, when the temperature outside the conference centre was hitting 34 degrees Celsius!
Left to right: Dr Wayne Lam (Hong Kong), Mr Rajesh Nair (Australia/United Kingdom), A/Prof Declan Murphy (Australia).
All credits to #UAA and the local organisers’ immense effort and hard work, making this congress a valuable learning experience for everyone who participated. We very much look forward to #UAA2018. Bring on Kyoto, Japan!
Wayne Lam
Assistant Professor in Urology, Queen Mary Hospital, University of Hong Kong
Twitter: @WayneLam_Urol
Rajesh Nair
Fellow in Robotic Surgery and Uro-Oncology
Department of Urology, Dalhousie University
Halifax, NS, Canada
To evaluate the association between stent dwelling time and sepsis after ureteroscopy, and identify risk factors for sepsis in this setting.
The prospectively collected database of a single institution was queried for all patients who underwent ureteroscopy for stone extraction between 2010 and 2016. Demographic, clinical, preoperative and operative data were collected. The primary study endpoint was sepsis within 48 h of ureteroscopy. Logistic regressions were performed to identify predictors of post-ureteroscopy sepsis in the ureteroscopy cohort and specifically in patients with prior stent insertion.
Between October 2010 and April 2016, 1 256 patients underwent ureteroscopy for stone extraction. Risk factors for sepsis included prior stent placement, female gender and Charlson comorbidity index. A total of 601 patients had a ureteric stent inserted before the operation and were included in the study cohort, in which the median age was 56 years, 90 patients were women (30%), and 97 patients were treated for positive preoperative urine cultures (16.1%). Postoperative sepsis, <48 h after surgery, occurred in eight (1.2%) non-stented patients and in 28 patients (4.7%) with prior stent insertion. Sepsis rates after stent dwelling times of 1, 2, 3 and >3 months were 1, 4.9, 5.5 and 9.2%, respectively. On multivariate analysis, stent dwelling time, stent insertion because of sepsis, and female gender were significantly associated with post-ureteroscopy sepsis in patients with prior stent placement.
Patients who undergo ureteroscopy after ureteric stent insertion have a higher risk of postoperative sepsis. Prolonged stent dwelling time, sepsis as an indication for stent insertion, and female gender are independent risk factors. Stent placement should be considered cautiously, and if inserted, ureteroscopy should be performed within 1 month.
The authors of this issue’s Article of the Month are primarily based in Nara, Japan. The cover shows the Tōdai-ji Temple in Nara, houses the world’s largest bronze statue of the Buddha, and one of the many sika deer that roam through the city.
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Many of the authors of this issue’s Article of the Month are based in Boston, MA and the cover image shows the statue of Paul Revere, one of Boston’s most famous landmarks
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Department of Urology, Dalhousie University
Halifax, NS, Canada
To study a novel penile reinnervation technique using four sural nerve grafts and end-to-side neurorraphies connecting bilaterally the femoral nerve and the cavernous corpus and the femoral nerve and the dorsal penile nerves.
Ten patients (mean [± sd; range] age 60.3 [± 4.8; 54–68] years), who had undergone radical prostatectomy (RP) at least 2 years previously, underwent penile reinnervation in the present study. Four patients had undergone radiotherapy after RP. All patients reported satisfactory sexual activity prior to RP. The surgery involved bridging of the femoral nerve to the dorsal nerve of the penis and the inner part of the corpus cavernosum with sural nerve grafts and end-to-side neurorraphies. Patients were evaluated using the International Index of Erectile Function (IIEF) questionnaire and pharmaco-penile Doppler ultrasonography (PPDU) preoperatively and at 6, 12 and 18 months postoperatively, and using a Clinical Evolution of Erectile Function (CEEF) questionnaire, administered after 36 months.
The IIEF scores showed improvements with regard to erectile dysfunction (ED), satisfaction with intercourse and general satisfaction. Evaluation of PPDU velocities did not reveal any difference between the right and left sides or among the different time points. The introduction of nerve grafts neither caused fibrosis of the corpus cavernosum, nor reduced penile vascular flow. CEEF results showed that sexual intercourse began after a mean of 13.7 months with frequency of sexual intercourse varying from once daily to once monthly. Acute complications were minimal. The study was limited by the small number of cases.
A total of 60% of patients were able to achieve full penetration, on average, 13 months after reinnervation surgery. Patients previously submitted to radiotherapy had slower return of erectile function. We conclude that penile reinnervation surgery is a viable technique, with effective results, and could offer a new treatment method for ED after RP.
The much awaited results of the STAMPEDE study of abiraterone for hormone naive prostate cancer was simultataneously presented at #ASCO17 and published ‘on line ahead of print’ in the NEJM. The formal title of the study was “Abiraterone for Prostate Cancer Not Previously Treated with Hormone Therapy”.
Briefly, the study randomised 1917 men with locally advanced or metastatic hormone naive prostate cancer to receive either ADT alone or ADT in combination with abiraterone and prednisolone. significantly higher rates of overall and failure-free survival than ADT alone.We were privileged to have the lead author Professor Nick James join us for the June #urojc. He posted the following video which is a lovely summary about STAMPEDE. All of us could benefit from watching this and it is a useful link for our patients.
— Nick James (@Prof_Nick_James) June 5, 2017
The data from the study is clear and it was not surprising that the majority of the discussion surrounding this paper was not going to be a dissection of the methodology or dataset and its analysis but rather how these results might impact upon urological practice.
There was a somewhat provocative start to the discussion with:-
Are urologists prepared to prescribe abiraterone/prednisone?
Or do they wait & quietly hope that enza studies show as good efficacy?#urojc— Urology JC #urojc (@iurojc) June 4, 2017
Prepared and willing but will insurance pay for AA-P (in absence of CRPC)? #urojc— cp (@hosewater2) June 4, 2017
Need to monitor BP, LFTs etc makes prescribing AA impractical in urology clinic. Currently I leave it to Med Onc in chemoRx day ward— Garrett Durkan (@GCD67) June 4, 2017
#urojc Agreed, how could we not? But insurance coverage will be an issue in US until they accept STAMPEDE data.— Alan Hay (@alanhaymd) June 4, 2017
To turn the question around, we saw the following tweet:-
Why would we not prescribe abi? #urojc— Michael Douglas (@mddo5) June 4, 2017
Hmm….A couple of controversial excuses:-
1. Discomfort/lack of familiarity with prescribing Abi + P.
2. Obsession with robotics?#urojchttps://t.co/rlehsQDCzu— Henry Woo (@DrHWoo) June 4, 2017
But @urogeek came out swinging
I have been prescribing abi, enza and xofigo for years now. All are easier to give than BCG. Don’t understand why urologists are afraid— Dave Penson (@urogeek) June 4, 2017
Yes but it’s not hard to learn and it’s important urologists learn it. Believe me, learning robotics mid-career was a lot tougher— Dave Penson (@urogeek) June 5, 2017
But he was not alone in these thoughts.
In Germany those treatments are prescribed and monitored by urologist – works perfect @BertrandTOMBAL@urogeek@martin_schostak#ASC017— Axel Merseburger (@amerseburger) June 5, 2017
I agree with Dave, but it does take interest to learn the nuance. It would be like taking up robotics “just because” without real interest— David Morris (@DavidMorrismd) June 5, 2017
yes- we should use ABI-Both are great drugs for urologists to use but why wait! https://t.co/XnYX36VA3W— Judd Moul (@JuddMoul) June 4, 2017
But lets be fair, these responses are from urologists immersed in clinical trials experience and highly academic centers. The following tweet perhaps brought out what many were thinking.
With respect to Dr. Woo, it is a med outside our wheelhouse and @urogeek is uro onc trained. But that said, I’m going to have to learn it…— Michael Douglas (@mddo5) June 4, 2017
But perhaps the onus is upon us to make that extra effort to learn. As has been mentioned, we manage one of the most toxic agents competently in the form of intravesical BCG for bladder cancer.
That’s an important point & all the more important that urologists learn all about abiraterone https://t.co/ADvz4bHZrD#urojchttps://t.co/uaKP9mfhi3— Henry Woo (@DrHWoo) June 4, 2017
Naturally, there was bound to be some discussion about cost of treatment.
Not really news, but here’s the way to save $ on abi #urojchttps://t.co/X4TvfYS7r0— Nick Brook (@nickbrookMD) June 5, 2017
In the UK’s NHS, where abi is saved for castrate-resistant met prostate ca, can we afford the average of 33 months pts were on it? #urojc— Su-Min Lee (@leeurol) June 4, 2017
Typical duration 18m in CRPC and gain 3m OS. Duration 33m in HNPC so you buy 15m extra Abi and gain ~36 m OS. Probably cost effective— Nick James (@Prof_Nick_James) June 4, 2017
Magnitude of effect on OS probably similar and is cheaper! Q is would both be even better?— Nick James (@Prof_Nick_James) June 4, 2017
For a bit of light hearted banter, there was the following exchange which we hope nobody took too seriously.
— Urology JC #urojc (@iurojc) June 5, 2017
The twitter account of the journal Prostate Cancer and Prostatic Diseases posted a poll which was responded to by 117 participants with only 10% choosing the ADT alone option. Whilst far from scientific, does this represent a significant change in thinking? It was not long ago where we could have predicted that almost all respondents would have chosen the ADT alone option.
What would you now offer your hormone naive metastatic prostate putting aside cost/access/AE issues?#ASCO17#urojc— PCAN (@pcan_journal) June 3, 2017
And to finish up, a question answered by Nick James as follows:-
— Urology JC #urojc (@iurojc) June 5, 2017
A big thanks to all who participated in the June #urojc discussion. A special thanks to lead author Nick James for his insightful comments that really added to the discussion. We will be back for another installment of the #urojc in July. See you then.
Henry Woo (@drhwoo) is the Director of Uro-Oncology and Professor of Robotic Cancer Surgery at the Chris O’Brien Lifehouse in Sydney, Australia. He is also Professor Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney.