Category: BJUI Blog

The British Association of Urological Surgeons nephrectomy audit for T1 renal tumours

December 18, 2015/2 Comments/by Prokar Dasgupta

It is hard to believe that 3 years have elapsed since my new team took over publishing the BJUI, aiming to make it ‘the most read surgical journal on the web’. Many of our readers believe that we have achieved that and a number of web statistics indicate that we are not far away. Complacency is not in our DNA and this year you will notice a number of subtle changes to www.bjui.org to make it even more attractive and user friendly. Of course we rely heavily on feedback from o ur authors and readers. The January 2016 issue includes our ‘Thank you to reviewers’ online, listing all 785 people who have reviewed for us in 2015. We just cannot achieve our high standards without you. Each reviewer is entitled to Continuing Professional Development (CPD) points as a recompense for the time they spend helping us select only the very best papers.

Last year, we published a fantastic selection of ‘Articles of the Month’. If you missed any, you can ﬁnd them collected together in our free online virtual issue (https://bit.ly/ZrWA6q). The end of 2015 was dominated by falling PSA testing and prostate cancer detection rates, as highlighted in David Penson’s editorial in JAMA [1]. In the UK and many other parts of the world we have already been through this. I remember during my training years that the majority of men presented with locally advanced or metastatic disease. And while we look towards ‘smart’ screening of high-risk groups, particularly those with a relevant family history of prostate and breast cancer, I urge you again to look at the summary table of our ‘Guideline of Guidelines’ by Loeb [2] on this thorny subject.

The BAUS has taken the lead on public reporting of surgical outcomes. The BJUI is proud to publish our nephrectomy audit [3], which has >6000 patients. Radical nephrectomy (RN) was performed mostly for T1b and partial nephrectomy (PN) for T1a tumours. Over 90% of RNs were minimally invasive – an established standard of care. Only 43% of PNs were minimally invasive of which one-third were robotic, with no obvious difference between the robotic and laparoscopic arms. As expected, the complication rates of PN were higher than RN. All of us as surgeons can learn a lot from large national datasets such as this and, more importantly, strive to improve continuously. I hope you enjoy reading this important paper and look forward to interacting with many of you in 2016.

References

1 Penson DF. The pendulum of prostate cancer screening. JAMA 2015; 314: 2031–3

2 Loeb S. Guideline of guidelines: prostate cancer screening. BJU Int 2014; 114: 323–5

3 Hadjipavlou M, Khan F, Fowler S et al. Partial vs radical nephrectomy for T1 renal tumours: an analysis from the British Association of Urological Surgeons Nephrectomy Audit. BJU Int 2015; 117: 62–71

Prokar Dasgupta, Editor-in-Chief, BJUI

King’s College London, Guy’s Hospital, London, UK

Should radiotherapy be a routine added-treatment for patients with N0,N+ non-metastatic prostate cancer on hormonal therapy?

December 14, 2015/by Irela Soto Troya

Once again we are approaching the end of another productive year in urological research. The final meeting of the year of the International Urology Journal Club #urojc was held from Monday December 7th to Wednesday December 8th AEDT. This month’s topic was a recent paper published in @JAMAOnc by the well-known STAMPEDE group.

In this new analysis of the STAMPEDE trial, the subject was the control arm. The trial’s definitive primary outcome was to evaluate the overall survival when adding radiotherapy (RT) to the cohort of N0 and N+ M0 high risk prostate cancer patients receiving hormonal therapy. The intermediate primary outcome was the failure-free survival (FFS), which was defined as biochemical failure, progression (locally, lymph nodes, or distant metastases) or death from prostate cancer.

The first comments of the discussion were about the satisfaction of a new study evaluating the beneficial effect of RT in addition to ADT in N+M0 disease. For the N0M0 Sub-cohort, 2 year survival was 97% (95% CI, 93%-99%), and 84% (95% CI, 74%-91%) were still alive after 5 years. On the other hand, for the N+M0 sub-cohort, 2 year survival was 93% (95% CI, 88%-96%), and 71% (95% CI, 56%-82%) were still alive after 5 years.

FFS was better with received RT in both groups: In the N0M0 sub-cohort the adjusted HR was 0.25 (95% CI, 0.13-0.49) with 2 year FFS of 96% (95% CI, 90%-98%) in patients receiving RT compared with 73% (95% CI, 57%-84%) in those not reporting RT (Figure). In the N+M0 the results were similar, with an adjusted HR of 0.35 (95% CI, 0.19-0.65), and a 2-year FFS of 89% (95% CI, 77%-94%) and 64% (95% CI, 51%-75%), respectively.

Since this approach to high-risk N0,+ M0 disease is not a standard of treatment, there were some concerns about urologist opinions, and mainly, about the side-effects of pelvic radiation.

This trial showed the adverse effects associated with RT, split by N0M0 and N+M0. The majority (78%) of N+M0 received conventionally fractionated RT to prostate and pelvis, and of the N0M0, 46% received it only to prostate and 42% to prostate and pelvis. The reported adverse effects were similar for patients with and without nodal involvement, with no grade 4 or 5 adverse effects reported.

Another question during the discussion was about the control group and the different baseline characteristics of the patients if comparing to other countries (mainly previous surgery).

Most urologists conclude that this information contributes to the growing evidence of the different modalities of treatment that should be offered to patients with prostate cancer. Every urologist focused on the importance of determining the risk and stage of the patient to give an appropriate treatment. They also mentioned how these results correlate with other treatment outcomes.

The previous published trials about the subject conclude that this combination reduces the risk of prostate cancer death; however, the population of those studies varies. Most patients were low-risk N0M0 prostate cancer and none were N+M0.

Other thoughts were shared, such as the usefulness of ADT for high-risk M0 prostate cancer, the prostate cancer stage and its relation to treatment response, and the needed collaboration of other specialties for study trials.

We still have to remember that the study has some limitations, though: The study population is drawn from a control arm of a clinical trial. There is no randomization of patients, and those planned for radiotherapy were the ones considered fit for it, so there might be an overestimated benefit biased by a better prognosis.

Indeed this is not the last of the STAMPEDE trials. One of the authors, @Prof_Nick_James mentioned redoing analysis of all the arms to evaluate more parameters about the outcomes of the different treatments.

This topic raises many questions about the treatment approaches to high-risk prostate cancer. As the authors expressed “There is a need for randomized clinical trials within the N+M0 population to address questions prospectively”. So far the results shown seem to be of benefit, and support the routine use of radiotherapy in patients with N+M0 prostate cancer. But as usual, we always need more proof.

This is the last meeting of 2015, so I have to finish this summary with a “Merry Christmas and Happy New Year 2016” to all the Urological twitter family!

Irela Soto Troya is a urologist born and trained in the Republic of Panama, and is a Fellow at Severance Hospital/Yonsei Medical Health System, Seoul, South Korea.
Twitter @irela_soto

Scientific impact and beyond

December 1, 2015/1 Comment/by Prokar Dasgupta

After a constant upward trajectory for 3 years, in 2015 the BJUI achieved an impact factor (IF) of 3.53, the highest ever in its history. Complacency is not in our DNA and we hope to achieve much more. We set out to become the most read surgical journal on the web and as part of that initiative have just launched our Android app in addition to the existing iPhone and iPad app. But our true impact beyond the IF, lies perhaps in the Altmetric score.

Altmetric is a score of the impact of (or perhaps better, the attention attained by) articles, based on mentions over a period of time in online channels such as news outlets, science blogs, Twitter, Facebook, Sina Weibo and Wikipedia, amongst others. The automated algorithm’s calculation of an article’s score applies weighting to the sources, such that a mention on a news outlet is weighted 8, or in a science blog 5, whereas a Twitter mention is only weighted 1, and a Facebook mention 0.25. News outlet scores are also tiered by their reach, re-tweets score less than original tweets, and bias is accounted for, e.g. tweets by independent researchers count more than a tweet by the journal that published the article.

The results are visualized as the ‘Altmetric donut’ with the calculated score in the centre. In the donut the different colours represent the different channels; so, for example Twitter is cyan, Facebook is dark blue, Blogs (including Weibo) are orange, News outlets red, Google+ is magenta, Video is pale green, Reddit is pale blue and Wikipedia is dark grey. The proportion of the donut that is shown in each colour generally reflects how much of the score was contributed to by that channel, but when many channels need to be represented then each is given a segment as is seen in the rainbow donut for our ‘Am I Normal’ article [Veale et al].

To give some context to the phenomenal level of interest in the ‘Am I Normal’ article, which at the time of writing boasts a score of 1034, most articles attain a score of 3 or under, and a score of 9 is sufficient to put an article in the top 10% of all 4,386,073 that Altmetric has scored. ‘Am I Normal’ is, perhaps unsurprisingly, in the top 1% of all articles scored.

Our other highly citable innovation is the BJUI Guideline of Guidelines (GOGs), which have made access to, and the understanding of, often conflicting urological guidelines a lot easier. Along with our other guidelines on chronic prostatitis [Rees et al] and continence [Tse et al], they will all be available in early 2016 as a virtual issue of GOGs [Loeb; Ziemba & Matlaga; Wollin & Makarov; Syan & Brucker] in a single repository on our web journal. Completely free, of course!

Prokar Dasgupta, Editor-in-Chief, BJUI
Scott Millar, Managing Editor, BJUI
Jo Wixon, Publisher, John Wiley and Sons Ltd

The professional benefits of USANZ trainee week 2015

November 30, 2015/by Sanchia Goonewardene

I landed on a bright sunny Brisbane morning for the Urological Society of Australia and New Zealand (USANZ) Trainee Week 2015 – an annual, 5 day, comprehensive, bi-national conference specifically for trainees. I have much to be grateful for including sponsorship from BAUS, TUF, USANZ and SURG. All these organisations had realised international organisation inter-working is required to foster a higher level of teaching for trainees.

Later that day, I had opportunities to meet trainees from all over Australia and New Zealand (ANZ). The quality of training given is truly remarkable. When looked at in detail, the ANZ system focuses on general surgery training initially, prior to moving to urology as a separate speciality. The result of this are that they are superb open surgeons. This is often a dying art and difficult to gain.

Our first day started with a chance to observe mock FRACS stations. The standard of the candidates was incredibly high, despite it being a mock exam. As part of this, an overview of the FRACS exam was given by one of the FRACS senior examiners, Mr. Neil Smith. The day concluded with meetings of trainees for each region within ANZ – again another fantastic way to support the trainees. I have never seen anything quite like this. This also ensures trainees are receiving adequate training as concerns and issues are relayed directly to the training board chair. The evening concluded with a Welcome reception and barbeque at Brisbane Surf club.

The next day started with a series of lectures on bladder cancer, led by Mr Shomik Sengupta (Melbourne) and Mr. Roger Watson (Brisbane). There were many learning points for trainees to take away, including case based management discussions, role of cystoprostatectomy and role of bladder preservation (Dr Tanya Holt, Brisbane).

Also covered were the roles of neoadjuvant vs adjuvant chemotherapy, (Dr. Niara Oliveira, Brisbane), the pros and cons of urinary diversion (Dr. Sarah Azer), and LND (Dr. Jonathan Chambers, Brisbane). After lunch the most amazing teaching was given on uro radiology, with a focus on nuclear medicine and also on pathology. The FRACS exam is very different from any other end of training exam, as there will be both radiology and pathology stations.

The next day dawned bright and early, with a whole morning of paediatric urology. I can think of many registrars, who would love a whole morning of teaching on this subject- it is not often easy to get access to paediatric urology. Testicular embryology and maldescent were very nicely covered by Mr. Peter Borzi, (Brisbane). Both normal and abnormal conditions were discussed including reasons for orchidopexy with maldescent. Former USANZ President, David Winkle then spoke on translation care. Mr Pete McTaggart, then covered Adolescent voiding dysfunction, a profoundly difficult subject to manage, given the age of the patient and the disease involved.

The next focus was on the adrenal including functions of the adrenal, management of the adrenal mass and investigations and phaeochromocytoma. This again, is another area, which is not often covered or encountered in clinical practice.

The morning concluded with a Board of Urology update addressed by Mr Richard Grills, Board Chair, covering the training programme for urologists. Also covered were training policies and involvement of RACS in governing this. Most impressively, USANZ has negotiated membership for all of its’ trainees with EAU, SIU and AUA. A good step forward regarding international working and fellowship.

The next day started with a breakfast meeting, on how to pass the FRACS exam. This session was chaired by Dr. Matt Winter. Big congratulations also went out to Dr. Tim Smith, who had had a baby the day before and still attended to teach. Topics covered were perspectives of preparing emotionally, physically, and psychologically. This recognised how difficult it can be to prepare. All tips and tricks were given by former trainees, who had passed the exam. Further mock practice also occurred, being taken through a pathology exam.

A whole session was dedicated to renal cancer covering topics such as active surveillance, partial and radical nephrectomy, RFA and cryotherapy. A really fantastic lecture was given by Mr. Simon Wood on management of RCC and cyotreductive nephrectomy, followed by oncological management of metastatic RCC. This is an area, which unless you are in a renal fellowship, may not see.

The next session involved teaching on upper tract and transplant. This was absolutely brilliant at covering donor assessment, management of transplant ureter and assessment of renal function and prognosis. Unless a transplant job were done, this knowledge would not be gained. All of this contributes to making a far better surgeon.

The afternoon focused on mastering difficult interactions with colleagues. Lastly, the day ended, with case based discussions, focused on FRACS viva practice. After having gone through that, I have a greater respect for all candidates going through post graduate exams. The evening was completed by a lovely boat ride through Brisbane and farewell dinner.

The next day, started with a bang, with Prof Samaratunga (Brisbane) talking on prostate grading. It is wonderful to have a lady professor. It shows the forward thinking of the Australia medical field, clearly ahead of others. Next, very valuable teaching was received from Dr. Peter Swindle (Brisbane). This was followed by teaching on PSA screening by Dr John Yaxley (Brisbane). PSMA PET was then covered by Dr. Rob Clarke (Brisbane), and its role in detection of prostate cancer. A fantastic presentation on management of elevated PSA was covered via a balloon debate- much loved by all and a different way of learning.

The conference ended with a quiz- Masters of the Uroverse. Teams from different regions of Australia battled it out for the title. It ended the conference is a very fun and unusual way. After having been to this meeting, my knowledge base has grown.

Our thanks go to Ms. Deborah Klein, the star organiser who is Education and Training Manager of USANZ, the Convener Mr. Stuart Philip and Mr. Richard Grills Chair, Board of Urology for hosting a thoroughly enjoyable event. Also to all the trainees and consultants who made us incredibly welcome.

Sanchia Goonewardene, University of Warwick, UK. @survivorshipuk

The second joint academic meeting of the Sri Lankan and British Associations of Urological Surgery (SLAUS & BAUS)

November 17, 2015/by Mark Speakman

The inaugural international joint meeting of BAUS and SLAUS was held two years ago. The second joint meeting has just finished in Colombo, bringing together British and Sri Lankan urologists. We were also joined by excellent Chinese and Indian colleagues.

The meeting commenced on Monday 2^nd November with a series of urological workshops. These started with an excellent laparoscopic workshop at Colombo South Teaching Hospital, led by Gordon Kooiman (King’s, UK), Wei Wang, Zhu Gang (Bejing) and Srinath Chandrasekera (Sri Lanka).

The College of Surgeons of Sri Lanka was the chosen venue for the second day of the pre-congressional sessions. This kicked off with a trans-world MDT, with John Kelleher (UK), Gordon Kooiman (UK), Mark Speakman (President of BAUS), Archana Fernando (Guy’s and St Thomas’ Hospitals, London), Sanchia Goonewardene (University of Warwick), Ranga Wickramarachi (National Hospital of Sri Lanka) and Niroshen Seneviratne, (Sri Jayawardenapura, Sri Lanka). Fifteen complex cancer cases were presented, ranging from prostate and bladder cancer to complex renal cases. The intellectual sparks flew as each side vigorously debated their management of each patient, with input from Chinese Professors Zhu Gang and Wei Wang. The MDT was wonderfully organised by Dr Ranga Wickramarachi, who brought together both faculties, with solid science and learning on both sides.

The afternoon was led by Mr Julian Shah (University College London), who presented on medico-legal issues and communication skills, with input from Sri Lankan doctors. There are an ever increasing number of medico-legal situations clinicians may find themselves in, and this workshop provided the tools for how to manage them. Also noteworthy were the acting skills of Dr Manjula Herath (Kandy Hospital, Sri Lanka) and his colleagues, who deserved an Oscar for the excellent case scenarios they enacted as a background for a critique of their communication skills. On a more serious note, these clearly highlighted issues that are becoming more and more significant in today’s practice.

The third day of the pre-congressional sessions was a trip to Galle in the south of the island for a joint meeting with the Galle Medical Association. A 6am start was complemented by teaching on the neuropathic bladder by Ms Jean Macdonald and Mr Julian Shah, as well as a workshop on penile diseases from Mr Suks Minas at the Jetwing Lighthouse hotel. There was also teaching from Galle medical personnel, notably Kareen Hareen on haematuria. Additionally, there was a lecture on LUTS/BOO from Mr Speakman, and wise lessons to all trainees present on the validity of BPH treatment. A wonderful lunch was served, with chances to interact with Sri Lankan trainees and to clearly see differences in training in both countries – although we are not that dissimilar. A relaxed afternoon beckoned, including a wonderful tour of the ancient Portuguese Galle fort and its scenery. This was followed by afternoon tea at the Closernberg Hotel, Galle.

The next day brought live surgery at Lanka Hospital, conducted by Julian Shah, and Suks Minhas (University College London), with a focus on female and functional urology. A complicated ureteric strictures managed by pyeloplasty and a complex female urethral stricture were demonstrated with live surgery. Additionally, there were video operative lectures by EAU Secretary General Professor Chris Chapple (Royal Hallamshire Hospital, Sheffield), on urethroplasty; valuable lessons for all trainees.

There was also a visit to Sri Jayawardenapura hospital from the Faculty. It was brilliant to see Sri Lankan medicine in practice, with lessons to be learnt by all BAUS faculty members. Afterwards a workshop on trauma occurred at the Faculty of Medicine, University of Sri Jayardenapura, composed of all Faculty members. The best lesson learnt was how to manage renal trauma. This was followed by a hands-on skills for ureteric reconstruction. The course, run by Peter Thompson, had been started 20 years before by Prof. Harold Ellis at RCS England. This was run by Mr Thompson, Ms Goonewardene and Prof. Wang (China). It was considered a fantastic opportunity for all trainees, with hands-on experience of anastomoses of the pig urinary system. Its success was justified the next day when, in practice, a trainee was called upon to manage a ureteric injury.

A beautiful inauguration ceremony in front of 200 people was conducted that evening at Kings Court, Cinnamon Lakeside Hotel, with traditional Kandian dancing and lighting of the oil lamp. This was followed by inauguration speeches, given by Prof. Satish Goonesinghe (Colombo), Prof. Chris Chapple (EAU), and Mr Mark Speakman (BAUS). The evening ended with entertainment from Kandian dancers, and singing from Prof. J. Shah, Prof. S. Fonseka and Mr J. Kelleher– the rock band was aptly named ‘The Professors.’

The next day, the full congress kicked off, with a presentation from Mr Thompson on the history of British urology. The audience learned about great legends, including Malcolm Coptcoat, pioneer of laparoscopic surgery at King’s College London. The next section was on urolithiasis, started by Ms S. Goonewardene on metabolic stone analysis, Ms J. Macdonald (North Middlesex Hospital) on PCNL, and finally from Dr Ranga Wickramararchi on open stone surgery. The learning outcomes demonstrated to trainees the importance of being a well-trained general urologist prior to sub speciality training.

The next section was brightened by Mark Speakman, President of BAUS, talking on surgeons’ outcome data — a really valid subject as this can greatly impact surgical practice. Training issues as part of this were also highlighted. At the end of the day, this can also be used as a continuous assessment tool to improve practice. This was followed by Prof. C. Chapple talking on OAB, a complex subject to manage. There was great interaction between trainees and Faculty, a wonderful learning experience.

Mark Speakman, Chris Chapple, Satish Goonesinghe and Majula Herath at the Inuguration ceremony

This was followed, after a lovely tea, by Julian Shah speaking on female voiding difficulties. This was very important to all present, as it clearly highlighted other factors that can affect bladder function. After that, Prof. Chapple spoke on advances in pharmacotherapeutic management of LUTS; valuable lessons for all present. Also presented were the potential complications or failures of TURP prostatectomy, highlighting the importance of good case selection. To complete this section, the sensitive bladder was reviewed by Dr Sanjay Pandey, (India).

After lunch there were registrar presentations, varying from renal cell carcinoma to paediatric urethral valves. The afternoon was completed by a detailed uro-oncology session, with presentations from Gordon Kooiman, Mark Speakman, Suks Minhas and John Kelleher, covering a range of oncological subjects.

Each speaker was presented with a beautiful silver plaque for their involvement. The ceremony concluded with an evening dinner aboard an arc in the Colombo wetlands. The meeting closed, and was clearly one of the most successful there had ever been, with the promise of returning in years to come with further joint BAUS/SLAUS meetings.

–Mark Speakman and Sanchia Goonewardene

Mark J Speakman

Consultant Urologist, Taunton & Somerset FNHST and President BAUS
Twitter: @Parabolics

Does presentation with metastatic prostate cancer matter?

November 16, 2015/by Anthony Noah

November saw the return of the International Urology Journal Club #urojc on Twitter. The annual meetings of the World Congress for Endourology (#WCE2015) and Société Internationale D’Urologie (#SIU15) led to an October break for #urojc. This month’s discussion was based around a recent editorial in the New England Journal of Medicine by Welch et al on the effects of screening on the incidences of metastatic-at-diagnosis prostate and breast cancers. In the three days prior to the start of the discussion the editorial and it’s now well-known graph had been trending amongst medical Twitter users.

The issue of PSA screening for prostate cancer has been a topic of debate amongst urologists for a number of years. PSA and DRE are first line for early detection of prostate cancer. Supporters of PSA screening argue that it leads to a significant fall in prostate cancer specific mortality. Many others believe there is insufficient evidence to support universal PSA screening given the risks of prostate biopsy and potential overtreatment of low risk prostate cancer.

The editorial presented data showing a significant fall in the number of patients first presenting with metastatic prostate cancer (advanced stage incidence) following the introduction of universal screening. However no effect was shown on similar data for breast cancer. Variations in disease dynamics were suggested to play a role.

The conversation started on Sunday 1st November at 20:00 (GMT), marking the beginning of the fourth year of #urojc. The first questions centred around the reasons behind the trends seen in the graph. Being a urology journal club the conversation was based almost exclusively on the prostate cancer aspect of the editorial.

One suggestion for the discrepancy between the two cancers is that PSA is a better detector of metastatic disease, whilst mammography can only detect localised disease.

Based on incidence of metastatic prostate cancer, the article makes a convincing statement in support of universal PSA screening. However, a successful screening programme should result in a reduction in the incidence of advanced cancers, decreased advanced-stage incidence and reduced mortality. Leading to the question of whether looking solely at advanced-stage incidence is useful.

The importance of responsible treatment and active surveillance was mentioned early on.

One of the most important questions of the discussion: What impact and relevance does the image have? Views were polarised. Some contributors were cautious about drawing conclusions from the graph whilst others were satisfied that it justified PSA screening.

The article drew comparison between Halsted’s and Fisher’s descriptions of cancer progression. Halsted suggested cancer originates from a single site and spreads, whereas Fisher’s paradigm proposed that breast cancer is a systemic disease by the time it is detectable.

The United States Preventive Services Task Force (USPSTF) has recommended against universal screening of prostate cancer, suggesting the risks of testing outweighed the benefits. However, many believe this to be based on outdated evidence.

The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial results showed a 12% higher incidence of prostate in the screening arm versus control, with no difference in mortality. Yet, the European Randomized Study of Screening for Prostate Cancer (ERSPC) has shown screening to result in a 1.6 fold increase in prostate cancer with a 21% reduction in mortality.

The debate briefly discussed the morbidity and cost of metastatic disease.

The editorial certainly raised a number of interesting points. It seems the topic of universal PSA screening will continue to be debated. There is a significant benefit to screening in the prevention of metastatic prostate cancer. Whether this is due to differing disease dynamics or PSA being a better screening tool than mammography is as yet unclear.

One point we can all agree on is that increasing utilisation of active surveillance with timely biopsies is important in preventing overtreatment of low risk disease and identifying those at risk of disease progression for curative treatment.

Anthony Noah Urology Speciality Trainee, West Midlands, UK
Twitter: @antnoah

Abandoning PSA screening: What is an acceptable price to pay?

October 27, 2015/by Daniel Moon

The PSA screening debate continues to rage with conflicting advice from various bodies as to appropriate guidelines for men considering prostate cancer screening. In Australia the Urological Society of Australia and New Zealand (USANZ) has supported offering screening to men aged 55-69 [Urological Society of Australia and New Zealand Position Statement on PSA testing 2009], as has the Royal Australasian College of Pathologists [Royal College of Pathologists Australia Position Statement on PSA testing 2014], however the guidelines for General Practitioners is yet to endorse this approach. A consensus group gathered by the Cancer Council of Australia, including Urologists, Oncologists, Epidemiologists and consumer advocates have recently put together proposals being considered by the NHMRC that recommend screening in men of an appropriate age with >7 year life expectancy, as long as active surveillance is offered to those diagnosed with low risk disease [Cancer Council Australia: Draft Clinical Practice Guideline PSA Testing and Early Management of Test-Detected Prostate Cancer]. The US Preventative Service Task Force Grade D recommendation against screening has been well documented, yet widely criticized for failing to include Urologists in its deliberations – the very specialists tasked with evaluating and treating localized prostate cancer.

Screening trials have reported conflicting results [Schroder et al, Pinsky et al], however with longer follow-up it becomes easier to demonstrate a survival advantage in men who are screened, and this does not even directly take into account the reduction in morbidity from advanced disease in populations as a result of early detection.

The issue at hand seems inherently very simple – that mass PSA screening will inevitably lead to overdiagnosis and, if a conservative approach is not adopted in low-risk disease or men with significant co-morbidities, overtreatment. Since PSA testing was introduced, the natural history of prostate cancer has become better understood [Albertsen], along with the understanding that many men with prostate cancer harbor “clinically insignificant” disease. Urologists have recognized this internationally and developed active surveillance protocols in response [Kates et al, Klotz]. Here in Australia the Victorian prostate cancer registry now confirms a significant number of men with low-risk disease being managed conservatively [Evans].

In the meantime, however, the pendulum is swinging the other way, and on the back of the USPSTF recommendations we are now seeing evidence of a drop in PSA screening. Confusing the debate is the extrapolation of negative studies to men of an entirely different population (e.g. using the Prostate Cancer Intervention vs Observation Trial [PIVOT], which comprised an average age of 67 to conclude that men in their 50s will not benefit from screening), poor design of the reported screening trials (e.g. the PLCO trial, which formed the backbone of USPSTF recommendations but due to compliance/contamination compared a population of 52% screened vs 85% screened), and the accusations of vested interests, particularly when Urologists take a pro-screening position (just read comment section on BJUI 2013 report of “Melbourne consensus statement on prostate cancer testing”)

What is the end result at a population level? In Victoria, Cancer Council data confirm a drop in prostate cancer screening and diagnosis [FIGURE]. There is no reason to believe that true prostate cancer incidence has suddenly declined, and we can conclude therefore that the negative publicity surrounding PSA screening is having an impact and less men are undertaking screening and diagnosis; a reversal of the jump in incidence that occurred when PSA testing was first introduced. Is this a bad thing though? Could this just be that we are finally reducing the diagnosis of clinically irrelevant cancers that are the bane of a PSA screening programme?

Trends in prostate cancer incidence and PSA testing rates, 2001-2014
Source: Cancer in Victoria: Statistics and Trends 2014. Cancer Council Victoria

My disclosure is that as a Urologist with a subspecialty practice in prostate cancer management, I deal at a personal level with patients, rather than population statistics, and in the last few months alone, multiple patients have highlighted for me the sacrifice we must admit to making if we are to abandon or even discourage PSA testing. A few specific cases are worth sharing as scenarios that GPs could consider including in the risk/benefit discussion required before ordering a PSA test.

Case 1:
64-year-old, well man with no relevant past/family history was referred with a rising PSA from 3.9μg/L in 2010 to 6.6μg/L in 2011. No abnormality was found on rectal examination and a biopsy was advised but refused given contemporary publicity in the lay press outlining the risk of biopsy and harms of overdiagnosis/overtreatment. Over the next 5 years the patient undertook various natural remedies and in 2014 when the PSA was 13.3μg/L, an MRI was performed that demonstrated a PIRADS 4 lesion. It was only until 2015 when the PSA had reached 21.9μg/L that a biopsy demonstrated a significant volume of Gleason 9 adenocarcinoma, with pelvic lymphadenopathy on staging.

Case 2:
A 57-year-old man requested PSA screening in 2013; however, he was advised by his local doctor that this was unnecessary based on current guidelines. In 2015 the patient’s brother was diagnosed elsewhere with prostate cancer and underwent radical prostatectomy. The patient then demanded a PSA, which was performed and found to be 40μg/L. Rectal examination revealed a firm, clinical stage T3 malignancy and biopsy demonstrated extensive Gleason 4+4 prostate cancer.

Case 3:
A 51-year-old man was found in 2010 to have a mildly elevated screening PSA of 4.5μg/L. Despite repeated recalls from the GP to have this repeated and further investigated the patient refused until in 2015 he presented with obstructive voiding symptoms and was found on examination to have a diffusely firm, clinical stage T3 malignant prostate. Repeat PSA was 39μg/L and subsequent investigation confirmed extensive Gleason 9 prostate cancer with positive pelvic lymph nodes.

For these men curative treatment is probably no longer an option. Whilst a small anecdotal group, these are real men seen at a community level who demonstrate the power of PSA screening to identify aggressive, clinically significant disease, at an early, curable stage. This is the coalface that General Practitioners and Urologists work at. When the USPSTF ratifies the Grade D recommendations on the basis of flawed and often misinterpreted trials in the absence of specialists who treat such patients, when Epidemiologists and well-meaning Oncologists who never see or evaluate localized prostate cancer lobby against the harms of overdiagnosis and overtreatment, they are condemning these men, and many others, to suffer and die from a preventable disease.

This risk of increased advanced cancer in a non-screened population has already been foreseen and reported [Scosyrev]. How many such men is it acceptable to sacrifice in the name of preventing overdiagnosis and overtreatment?

Rather than the knee-jerk response to abandon PSA testing, the answer, which is increasingly accepted by Urologists, is clearly to unlink prostate cancer diagnosis from treatment. It is to improve diagnostics as we are seeing with development of multiparametric MRI and molecular/genetic markers to make screening and treatment selection smarter. I fear that if this is not more widely accepted and the current situation continues, it is helpful that so much research is being conducted in the management of men with high-risk, oligometastatic and advanced disease, because it will be more and more of these cancers that we will be treating.

Dr Daniel Moon is Director of Robotic Surgery at the Epworth Healthcare, and a Urologist at the Peter MacCallum Cancer Institute, Melbourne
@drdanielmoon

Worldwide Live Robotic Surgery 24-Hour Event 2015

October 15, 2015/4 Comments/by admin Z.9

For the first WRSE24 we had over 2500 unique viewers registered from 61 countries (58 on the day).

This time we want you the global audience to get involved and participate online

In the Worldwide Robotic Surgery Event

Register now for free

In February 2015, with EAU approval, ten robotic centers from 4 continents planned to stream live surgery continuously for 24hrs.

Viewing of live surgery was limited to medical professionals using password protection, following registration. LiveArena ™ provided the infrastructure and technological support. All surgeries were completed without incident and we have submitted our outcome data to the EAU live surgery committee, who are supporting our next planned event. Further details can be found at www.wrse24.org

Following previously published EAU Policy on Live Surgery Events (LSE’s), whilst ongoing live surgery at conferences is assured, there remains debate as to how best we can optimise this form of training. The EAU panel reached >80% consensus view that performing live surgery from home institutions may be safer, identifying several issues with a ‘‘travelling surgeon’’. A BJUI poll related to the first WRSE24 found that 76% of respondents would ‘attend’ a streamed virtual surgical conference rather than travel if accreditation were the same, further indicating the potential for uptake into training and education events.

The outcome from the first event surpassed many of our expectations. Registrants came from 61 countries. 1390 unique viewers visited the www.WRSE24.org website during the live 24 hours and this number increased to 2277 over the next 6 days.

The event was well received by industry and the project was a finalist in the category of “Innovative Technology for Good Citizenship” at the prestigious Microsoft Partnership awards held in July 2015, which received over 2,300 nominations from 108 different countries.

We are also delighted to announce that the forthcoming WRSE24 will involve surgeons from 2 more continents making it the first live urological conference to have contributors from 6 continents.

As well as all the surgeons previously involved we will be joined by 5 new surgeons including 2 additional robotic centres: Clinique St Augustin (Dr Richard Gaston and Professor Thierry Piechaud) and Sao Paulo University Hospital (Dr Rafael Coelho). Benjamin Challacombe will be operating from Guys Hospital, London and Ketan Badani will be operating from Mount Sinai, New York. Our aim is to stream live surgery from 12 leading robotic centres, a list of whom can be seen below. Finally we will have a live teleconference link via Skype between Professor Hassan Abol-Enien from the world famous Mansoura University Hospital and Professor Peter Wiklund at Karolinska.

The second event will also see the 24hour studio sessions split into six 4hour sessions. The contributing centres are Karolinska Stockholm, OLV Aalst, Guys London, Mt Sinai New York and Keck USC, Los Angeles.

The first event was primarily focused on providing access to live streamed HD video of world leading surgeons operating in their normal working day, with their expert teams. The second event plans to build on this format with more audience participation utilizing social media. We are working with LiveArena™ and Microsoft™ to optomise this aspect. There will be improved opportunities to ask questions to the surgeons utilizing a Microsoft Yammer ™ app that will be integrated into the WRSE24 site or via twitter using #wrse24. Although the concept of a Twitter backchannel at educational events has become familiar, future approaches may be able to improve on ways of communicating within a global audience. Our aim for the 2^nd WRSE24 is to enliven virtual participation, widening access to a fuller, interactive, experience for the online audience, with an emphasis on conversation, connection and crowd sourcing of opinions. To highlight the benefits of crowd sourcing of opinions we are planning an ambitious project to have an interactive live debate between Mansoura University Hospital and Karolinska University Hospital. This will include polling technologies available via Yammer™, so that the second part of this planned live discussion will potentially be guided by the opinions of the global audience. A research-group at Stockholm University, with a specialist interest in Social Media are also working closely with WRSE24 to help interpret this data, so that we can learn from this event.

For more details on this worldwide event and the complimentary activities that are planned please visit www.wrse24.org

Controversies in management of high-risk prostate and bladder cancer

October 12, 2015/by Stacy Loeb

Recently, there has been substantial progress in our understanding of many key issues in urological oncology, which is the focus of this month’s BJUI. One of the most substantial paradigm shifts over the past few years has been the increasing use of radical prostatectomy (RP) for high-risk prostate cancer and increasing use of active surveillance for low-risk disease [1,2].

Consistent with these trends, this month’s BJUI features several useful articles on the management of high-risk prostate cancer. The ﬁrst article by Abdollah et al. [3] reports on a large series of 810 men with D’Amico high-risk prostate cancer (PSA level >20 ng/mL, Gleason score 8–10, and/or clinical stage ≥T2c) undergoing robot-assisted RP (RARP). Despite high-risk characteristics preoperatively, 55% had specimen-conﬁned disease at RARP, which was associated with higher 8-year biochemical recurrence-free (72.7% vs 31.7%, P < 0.001) and prostate cancer-speciﬁc survival rates (100% vs 86.9%, P < 0.001). The authors therefore designed a nomogram to predict specimen-conﬁned disease at RARP for D’Amico high-risk prostate cancer. Using PSA level, clinical stage, maximum tumour percentage quartile, primary and secondary biopsy Gleason score, the nomogram had 76% predictive accuracy. Once externally validated, this could provide a useful tool for pre-treatment assessment of men with high-risk prostate cancer.

Another major controversy in prostate cancer management is the optimal timing of postoperative radiation therapy (RT) for patients with high-risk features at RP. In this month’s BJUI, Hsu et al. [4] compare the results of adjuvant (≤6 months after RP with an undetectable PSA level), early salvage (administered while PSA levels at ≤1 ng/mL) and late salvage RT (administered at PSA levels of >1 ng/mL) in 305 men with adverse RP pathology from the USA Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry. At 6.2 years median follow-up, late salvage RT was associated with signiﬁcantly higher rates of metastasis and/or prostate cancer-death. By contrast, there was no difference in prostate cancer mortality and/or metastasis between early salvage vs adjuvant RT. A recent study from the USA National Cancer Data Base reported infrequent and declining use of postoperative RT within 6 months for men with adverse RP pathology, from 9.1% in 2005 to 7.3% in 2011 [5]. As we await data from prospective studies comparing adjuvant vs early salvage RT, the results of Hsu et al. [4] are encouraging, suggesting similar disease-speciﬁc outcomes if salvage therapy is administered at PSA levels of <1 ng/mL.

Finally, this issue’s ‘Article of the Month’ by Baltaci et al. [6] examines the timing of second transurethral resection of the bladder (re-TURB) for high-risk non-muscle-invasive bladder cancer (NMIBC). The management ofbladder cancer at this stage is a key point to improve the overall survival of bladder cancer. Re-TURB is already recommended in the European Association of Urology guidelines [7], but it remains controversial as to whether all patients require re-TURB and what timing is optimal. The range of 2–6 weeks after primary TURB was established based on a randomised trial assessing the effect of re-TURB on recurrence in patients treated with intravesical chemotherapy [8], but it has not been subsequently tested in a randomised trial. Baltaci et al. [6], in a multi-institutional retrospective review of 242 patients, report that patients with high-risk NMIBC undergoing early re-TURB (14–42 days) have better recurrence-free survival vs later re-TURB (73.6% vs 46.2%, P < 0.01). Although prospective studies are warranted to conﬁrm their results, these novel data suggest that early re-TURB is signiﬁcantly associated with lower rates of recurrence and progression.

References

1 Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA 2015; 314: 80–2

2 Loeb S, Berglund A, Stattin P. Population based study of use and determinants of active surveillance and watchful waiting for low and intermediate risk prostate cancer. J Urol 2013; 190: 1742–9

3 Abdollah F, Klett DE, Sood A et al. Predicting pathological outcomes in patients undergoing robot-assisted radical prostatectomy for high- risk prostate cancer: a preoperative nomogram. BJU Int 2015; 116: 703–12

4 Hsu CC , Paciorek AT, Cooperberg MR, Roach M 3rd, Hsu IC, Carroll PR. Postoperative radiation therapy for patients at high-risk of recurrence after radical prostat ectomy: does timing matter? BJU Int 2015; 116: 713–20

5 Sineshaw HM, Gray PJ, Efstathiou JA, Jemal A. Declining use of radiotherapy for adverse features after radical prostatectomy: results from the National Cancer Data Base. Eur Urol 2015; [Epub ahead of print]. DOI: 10.1016/ j.eururo.2015.04.003

6 Baltacı S, Bozlu M, Yıldırım A et al. Signiﬁcance of the interval between ﬁrst and second transurethral resection on recurrence and progression rates in patients with high-ris k non-muscle-invasive bladder cancer treated with maintenance intravesical Bacillus Calmette-Guerin. BJU Int 2015; 116: 721–6

7 Babjuk M, Bohle A, Burger M et al. European Association of Urology Guidelines on Non-Muscle-Invasive Bladder Cancer (Ta, T1, and CIS). Available at: https://uroweb.org/wp-content/uploads/EAU-Guidelines- Non-muscle-invasive-Bladder-Cancer-2015-v1.pdf. Accessed September 2015

8 Divrik RT, Yildirim U, Zorlu F, Ozen H. The effect of repeat transurethral resection on recurrence and progression rates in patients with T1 tumors of the bladder who received intravesical mitomycin: a prospective, randomized clinical trial. J Urol 2006; 175: 1641–4

Stacy Loeb – Department of Urology, Population Health, and the Laura and Isaac Perlmutter Cancer Center, New York University, New York City, NY, USA

Maria J. Ribal – Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain

A Medical Voyage of Discovery

October 9, 2015/by Jim Duthie

I am still getting used to being able to stretch out in bed. For the last two weeks my nights were spent in a wooden bunk designed for trainee Japanese fishermen, none of who apparently exceeded 175cm in height. Or 50cm in width during any point in their nocturnal contortions. Combined with a roaring generator, constant motion, four roommates, and another person in the same situation on the other side of the thin plywood wall from me getting up for their daily four o’clock watch, nights were not a highlight on the ship. The ship was the Pacific Hope, a (mostly) refurbished training trawler with a new career in humanitarian outreach.

My day job as a Urological Surgeon mostly involves lasers and robots, but for this two-week period the peak technology available was a blood pressure cuff. I had not looked in an ear since I was an undifferentiated junior doctor, or taken anyone’s blood pressure, or diagnosed knee arthritis. One thing that I was confident of, was that I was better than no doctor at all for the inhabitants of Ambrym Island, Vanuatu. In the event I enjoyed the collegiality of an Irish Junior doctor who was hard working, quick to learn, and most importantly hilarious company. Between us we solved most problems, and had the bail out option of referral to Port Vila hospital for blood tests or imaging if we were completely baffled. As well as tuberculosis, a yaws, and an elephantiasis, we were saddened by how widespread hypertension was becoming, thanks to the introduction of low quality, high-salt canned beef to the islands. I managed to rescue a man with a rotten diabetic leg, sepsis, and uncontrolled blood glucose (no insulin) with a bedside debridement and urgent transfer to the mainland. We followed up a week later and surprisingly, it looked like he wouldn’t need an amputation. I couldn’t do anything for a woman with early Parkinson’s disease, as medication would never be reliably available for her. I even saw one case of BPH, but didn’t have any alpha-blockers.

It was a cheerful, positive environment, with grateful patients and hard working team mates. There were no managerial reviews, waiting lists, or funding approval involved in treating the patients. We didn’t order unnecessary tests to rule out the miniscule possibility of an alternative pathology, as we knew no one would sue us for trying to help them.

I swam a lot, ate coconuts, had no phone or internet access on ship, and the world still turned. I won’t get any publications out the trip, and had to pay for the privilege of working, but it was actually a privilege to do the work.

I climbed a mountain and looked into a lava lake, watched dolphins play and flying fish fly, swung off a 10 metre high crane into the ocean, and walked an hour through jungle to do a house call. I don’t usually get to do these things as part of my job.

The Pacific is an area of high medical need that is comparatively safe and accessible for a third world region. Most of us train to be doctors because we want to make people better, and volunteering is a way of really feeling like you are achieving this. Taking two weeks off work will make little difference to my career development, was good for my mental health, and allowed me to stare at the horizon more than I otherwise would have. As doctors, we have portable skills; our tools are our hands and brains, and they work well in remote areas. Have you been finding work a bit “samey” lately?

I’m going back next year.

Jim Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Tauranga, New Zealand. @Jamesduthie1