Category: BJUI Blog

TUF Cycle India

September 17, 2015/88 Comments/by Roger Kirby

The Urology Foundation Cycle Challenge in Rajasthan

19 – 28 November 2015

In memory of Professor John Fitzpatrick

After the gruelling cycling challenges in Sicily, Malawi, Madagascar, Patagonia, and most recently South Africa, which together have raised many hundreds of thousands of pounds for The Urology Foundation (TUF), our next Challenge is a 500 Km ride through Rajasthan, India. We now have 50 intrepid cyclists signed up and ready to participate in this exciting, but very demanding, ride. Some grizzled veterans, such as Roger Plail and Andrew Etherington (80 years old next year!) will be joining us again. Peter Rimington, who led the South African challenge, will be there, but is replaced as “local knowledge team captain” by Abhay Rane, who has done a great job in recruiting and motivating participants this year. Our wonderful CEO Louise de Winter will be bravely accompanying us on the ride, as she did in Africa.

The ride commences in Bharatpur – the eastern gateway to Rajasthan. It is most famous for the Keoladeo Ghana National Park, a world heritage site and one of the finest water-bird sanctuaries in the world. On the first morning we will have a chance to visit the specacular Taj Mahal in Agra, one of the true wonders of the world.

From there, we start our adventure by cycling through the National Park. Our first day’s cycling takes us to the Bhanwar Vilas Palace in Karauli. The following day we will ride to the famous Ranthambore National Park, which is famous for its tigers; the conservation project there is popular with wildlife buffs and professional photographers from right across the world. With luck we may encounter some of the animals to be found in the park including sambar, cheetah, wild boar, leopard, jackal and hyena. We will overnight at the famous “Tiger Den”.

From here on it is just toil, sweat and tears, together with the ever-present risk of “Delhi Belly”! We will no doubt, just as we did before before, rise to the challenge and press on relentlessly to our final destination, the famous “pink city” Jaipur. Here the “Amber Fort” and a well-earned celebration awaits us.

I am very much hoping that many of you will support our endeavours with a donation, and participants themselves will add their own comments, stories and photographs to this blog. TUF is such a worthy cause, and really does an amazing job in supporting and promoting urology, not only throughout the British Isles, but in Africa and beyond. Do watch (and especially contribute to) this space! We will be posting updates to let you know how we get on.

Click here to see a short video on the challenges the TUF cyclists faced https://trendsinmenshealth.com/video/tuf-cycle-india-2016/

Roger Kirby, The Prostate Centre, London

Functional urology is coming to you!

September 11, 2015/by Dirk De Ridder

This month’s edition features three interesting papers in the field of functional urology. Overactive bladder (OAB) syndrome has a prevalence of 14%, prostatitis symptoms have a prevalence in the male population of 8.2% and a substantial number of all men undergoing radical prostatectomy will remain incontinent. These are clinical entities that every urologist encounters in his daily practice.

The treatment of refractory OAB symptoms with anticholinergics, can be optimized by adding mirabegron in a flexible dose scheme. This has been nicely shown in a Japanese population by Yamaguchi et al. [1]. Despite the fact that Japanese health authorities recommend starting with a lower dose of 2.5 mg of solifenacin or 25 mg of mirabegron, these data can be extrapolated to other populations as well, where 5 mg of solifenacin and 50 mg of mirabegron are used as standard doses.

Chronic bacterial prostatitis and chronic pelvic pain syndrome are difficult to deal with. As there is a lack of well-designed prospective randomized controlled studies in this field, Rees et al. [2] used the Delphi consensus methodology to draw up experience- and science-based consensus guidelines. Their Delphi panel included 58 participants consisting of GPs, urologists, pain specialists, nurse specialists, physiotherapists, cognitive behavioural specialists and sexual health specialists. The guidelines give a well-structured overview of the diagnostic and therapeutic possibilities for chronic bacterial prostatitis and chronic pelvic pain syndrome.

Post-radical prostatectomy incontinence varies widely from 3 to 87%. Artificial sphincters are still the main treatment for this complication. While the results in non-irradiated patients might be good in the long term, it remains unclear how external beam radiotherapy would affect the outcome of artificial sphincters in post-radical prostatectomy incontinence. Bates et al. [3] performed a meta-analysis on the complications occurring after the implantation of an artificial sphincter after radical prostatectomy and radiotherapy. The combination of radical prostatectomy and external beam radiotherapy increases the risk of infection and erosion and urethral atrophy and results in a greater risk of surgical revision compared with radical prostatectomy alone. Also persistent urinary incontinence is more common in this population.

These three papers highlight important and relevant problems in urology. It is clear from these papers that we need more insight and more research into the underlying mechanisms of these highly prevalent entities. With an ageing population that wants to remain active as long as possible, we need to invest more time, people and money in this field to improve the quality of life of these patients. Basic science and clinical science need to work together to improve our knowledge and understanding.

Functional urology is coming to you! You will not escape from this growing population.

References

1 Yamaguchi O, Kakizaki H, Homma Y et al. Safety and efﬁcacy of mirabegron as ‘add-on’ therapy in patients with overactive bladder treated with solifenacin: a post-marketing, open-label study in Japan (MILAI study). BJU Int 2015; 116: 612–22

2 Rees J, Abrahams M, Doble A, Cooper A. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int 2015; 116: 509–25

3 Bates AS, Martin RM, Terry TR. Complications following artiﬁcial urinary sphincter placement after radical prostatectomy and radiotherapy: a meta-analysis. BJU Int 2015; 116: 623–33

Dirk De Ridder

Department of Urology, University Hospitals KU Leuven, Leuven, Belgium

The Urological Ten Commandments

September 7, 2015/3 Comments/by Jonathan Glass

“It is my ambition to say in ten sentences what others say in a whole book.” – Friedrich Nietzsche

The EAU guidelines on lower urinary tract symptoms have been published recently. These contain 36,000 words. It was pointed out to me that the American declaration of independence contained 1300 words and The Ten Commandments just 179 words.

The challenge was therefore to write ten commandments for urology in 179 words. The rules I set were that I should write them whilst keeping the spirit of the structure of the decalogue as closely as possible. (It may be worth rereading the original before reading on). So here goes.

1) I am a logical specialty. Thou shall investigate thoroughly prior to undertaking intervention for I am a specialty that avoids surprises.
2) Though interested in the whole of medicine thou will perform no other procedures other than urological.
3) Thou shalt not base intervention on old imaging for the clinical situation could have changed.
4) Remember that 80% of diagnoses can be made with history alone. Thou shalt listen carefully to your patient to this end.
5) Honour sound surgical principles. Urological tissue is forgiving but anastamoses under tension will not heal.
6) Thou shall not ignore haematuria.
7) Thou shall not leave a stent and forget it has been placed.
8) Thou shall not adopt new technology without proper clinical evaluation unless it is part of a trial.
9) Thou shall not fail to see the images yourself in assessing the patient before you.
10) Thou shall not fail to assess the potential for harm before embarking on a surgical procedure. If you would not do it to your family, your neighbour or friends, you will not do it to the patient who is in your clinic.

I put these out for discussion. Other offerings please.

Jonathan M. Glass @jonathanmglass1

The Urology Centre, Guy’s Hospital, London, UK.

[email protected]

The Urology Tag Ontology Project

September 1, 2015/by Alexander Kutikov

This blog was first posted at https://www.symplur.com/blog/the-urology-tag-ontology-project/

Urologists have been on the forefront of harnessing Social Media for professional use. Urological Organizations and Journals have used Social Media to lower barriers for information dissemination [1,2] [3] [4]. Meanwhile, Social Media engagement at Urological meetings has been used to augment the experience of attendees and allow remote “attendance” for those not able to physically be present at the meetings [5,6] [7]. Academic exchange through a formal Twitter-based Journal Club on the #urojc hashtag has enjoyed international participation [8]. Social Media has also been employed to assess the Media’s and the Public’s responses to news events in the Urologic clinical space [9], and guidelines for responsible and effective Social Media use now have been developed [10] [11]. Moreover, an extremely active patient advocacy voice has been growing louder on a number of the Social Media channels.

The Urology Tag Ontology Project aims to align hashtag use for this burgeoning Urological Social Media community. Utilizing this standardized list of Social Media communication descriptors, the project hopes to facilitate communication and promote collaboration in the healthcare provider and patient communities.

In creating the list, we crowd-sourced the Urologic Social Media community at large and were fortunate to receive buy-in from key stakeholders (Table 1).

Effective and standardized hashtag use remains an organic process that clearly cannot be dictated by a simple creation of a list. Indeed, the current list attempts to strike a balance between existing hashtags that enjoy heavy use and those descriptors that key opinion leaders in a particular urologic sub-specialty would like to see gain traction. As such, we hope for the Urology Tag Ontology Project to remain a “living document,” which is reassessed and updated on a regular basis.

Alexander Kutikov, MD, FACS @uretericbud
Associate Professor of Urologic Oncology
Fox Chase Cancer Center, Philadelphia, USA @FoxChaseCancer
Associate Editor for Digital Media
European Urology @EUPlatinum

Henry Woo, MD @DrHWoo
Associate Professor of Surgery
University of Sydney, Sydney, Australia
Founder and Manager
International Urology Journal Club #urojc @iurojc

James Catto MB, ChB, PhD, FRCS @JimCatto
Professor in Urological Surgery
University of Sheffield
Editor-in-Chief
European Urology @EUPlatinum

Table 1: Urological Social Media Stakeholders Supporting Urology Tag Ontology Project

Organization	Hashtag / Twitter Handle
European Association of Urology (EAU)	@UroWeb
American Urological Association	@AmerUrological
EAU Guidelines Committee	#EAUGuidelines
AUA Social Media Committee	N/A
Society of Urologic Oncology / Young Urologic Oncology Committee	@SUO_YUO
Urological Society of Australia and New Zealand	@USANZurology
British Association of Urological Surgeons	@BAUSurology
Endourological Society	@EndourolSoc
European Urology Journal	@EUPlatinum
Journal of Urology	@JUrology
BJUI	@BJUIjournal
Urology Gold Journal	@UroGoldJournal
Nature Reviews in Urology Journal	@NatRevUrol
Prostate Cancer and Prostatic Diseases Journal	@PCAN_Journal
Journal of Sexual Medicine	@JSexMed
Bladder Cancer Journal	@BladderCaJrnl
Journal of Clinical Urology	@JCUrology

References

[1] Loeb S, Catto J, Kutikov A. Social media offers unprecedented opportunities for vibrant exchange of professional ideas across continents. European Urology 2014;66:118–9. doi:10.1016/j.eururo.2014.02.048.

[2] Cress PE. Using Altmetrics and Social Media to Supplement Impact Factor: Maximizing Your Article’s Academic and Societal Impact. Aesthetic Surgery Journal 2014;34:1123–6. doi:10.1177/1090820X14542973.

[3] Nason GJ, O’Kelly F, Kelly ME, Phelan N, Manecksha RP, Lawrentschuk N, et al. The emerging use of Twitter by urological journals. BJU Int 2014:n/a–n/a. doi:10.1111/bju.12840.

[4] Loeb S, Bayne CE, Frey C, Davies BJ, Averch TD, Woo HH, et al. Use of social media in urology: data from the American Urological Association (AUA). BJU Int 2014;113:993–8. doi:10.1111/bju.12586.

[5] Matta R, Doiron C, Leveridge MJ. The dramatic increase in social media in urology. The Journal of Urology 2014;192:494–8. doi:10.1016/j.juro.2014.02.043.

[6] Canvasser NE, Ramo C, Morgan TM, Zheng K, Hollenbeck BK, Ghani KR. The Use Of Social Media in Endourology: An Analysis of the 2013 World Congress of Endourology Meeting. J Endourol 2014:140715142757008. doi:10.1089/end.2014.0329.

[7] Wilkinson SE, Basto MY, Perovic G, Lawrentschuk N, Murphy DG. The social media revolution is changing the conference experience: analytics and trends from eight international meetings. BJU Int 2015;115:839–46. doi:10.1111/bju.12910.

[8] Thangasamy IA, Leveridge M, Davies BJ, Finelli A, Stork B, Woo HH. International Urology Journal Club via Twitter: 12-Month Experience. European Urology 2014;66:112–7. doi:10.1016/j.eururo.2014.01.034.

[9] Prabhu V, Lee T, Loeb S, Holmes JH, Gold HT, Lepor H, et al. Twitter Response to the United States Preventive Services Task Force Recommendations against Screening with Prostate Specific Antigen. BJU Int 2014;116:65–71. doi:10.1111/bju.12748.

[10] Rouprêt M, Morgan TM, Bostrom PJ, Cooperberg MR, Kutikov A, Linton KD, et al. European Association of Urology (@Uroweb) recommendations on the appropriate use of social media. European Urology 2014;66:628–32. doi:10.1016/j.eururo.2014.06.046.

[11] Murphy DG, Loeb S, Basto MY, Challacombe B, Trinh Q-D, Leveridge M, et al. Engaging responsibly with social media: the BJUI guidelines. BJU Int 2014;114:9–11. doi:10.1111/bju.12788.

Clever surgeons and challenging study endpoints

August 18, 2015/by John Davis

Intraoperative in vivo tracking of a periprostatic nerve with multiphoton microscopy in rat model.

In the last 6 months, the BJUI editorial team has evaluated an average of 59 urological oncology papers per month with an average acceptance rate of 16%. We receive additional papers for our ‘Translational Science’ section. Studies with high-quality methods are given the highest priority. Other papers compete well if they are highly applicable to clinical practice (i.e. comparative, multicentre, multi-surgeon design) and/or show us new ideas in surgical technique, re-designed study endpoints, or explore new sources of data. For translational science, the best candidates are studies that look at new diagnostic tests in humans and beyond simple immunostaining techniques. We want to evaluate biomarkers likely to be validated and translated into a clinical test. Clinical impact will be even higher if a biomarker is linked to a therapy outcome rather than just a risk estimate. We want our papers to guide us to better outcomes for our patients, hopefully control healthcare costs, and, yes, be well-cited in the literature.

Our review process is tough but fair, and we congratulate and highlight three authorship groups for acceptance into this month’s issue of BJUI. The theme of ‘clever surgeons and challenging study endpoints’ is well illustrated by all three groups. Zargar et al. [1] report on an exclusive database of high-volume minimally invasive surgeons who have tackled the partial nephrectomy option for small renal masses. The comparison is simple in concept and retrospective in design, but what they have done is to significantly increase the outcome measures into a ‘trifecta’ concept in perioperative outcomes (previously reported) with an even more stringent ‘optimal outcome’ endpoint that includes renal function preservation. With a database of 1185 robotic and 646 laparoscopic cases, the robotic procedures showed superior trifecta results (70% vs 33%), complication rates (14.8% vs 20.9%), positive surgical margin rates (3.2% vs 9.7%), and warm ischaemia time (18 vs 26 min). The optimal outcome endpoint included a minimum 90% estimated GFR (eGFR) preservation and no chronic kidney disease upstaging. Only the robotic cohort had sufficient data available and the rate was 38.5%. The latter figure is an interesting challenge, as defining such a high threshold for success challenges surgical technique and allows more room to identify incremental advancement. This may be the largest study of its kind, but non-randomised and with limitations discussed in peer review such as the learning curve influence, use of eGFR as an endpoint with two kidneys, and incomplete data. The definitions used are of interest and the field could use some uniformity moving forward in measuring perioperative and long-term benchmarks of quality.

Durand et al. [2] give us a glimpse into the future of surgery, a science fiction world of prostate surgery where nerves and prostatic glands can be colour coded and seen at a microscopic level in real time. The pictures stand for themselves, especially Fig. 1. If such imaging can be integrated into technique decisions, and perhaps future instrument designs, then perhaps we will have a whole new wave of studies possible on linking surgical technique to improved functional and oncological outcomes after radical prostatectomy. The paper has a nice depth in detail, methods, results, as well as narratives in solving technical problems with novel technology.

This issue’s ‘Article of the Month’ by Gavin et al. [3] is a different look at the question of morbidity after localised prostate cancer treatments, specific to long-term care at >2 years from treatment. The database is from a cancer registry and they have an impressive 54% response rate from a population that is 2–18 years from diagnosis. Rather than Likert-like scales of symptom severity, they simply look at ‘current’ vs ‘ever had’ symptoms and look at the total burden including multiple/overlapping symptoms. Although this may not be as robust and validated as the Expanded Prostate Cancer Index Composite (EPIC) instrument, the simple phrasing of ‘current’ vs ‘ever had’ is probably capturing a very high proportion of symptoms rather than dismissing them if minor or in the past. Again, we see more erectile dysfunction after radical prostatectomy and radiation with hormonal therapy, and more bowel symptoms after radiation therapy. Hormone therapy patients have hot flashes and fatigue, and watchful-waiting patients have some advantages but are certainly not free of symptoms. The burden of symptoms is interesting, nine of 10 reported at least one of seven key symptoms at some point and three of four are current. Therefore, as the authors indicate, ≈75% of prostate cancer survivors will have ongoing symptoms needing follow-up care. This is a significant database resource adding to our understanding of long-term outcomes of patients with prostate cancer and supporting the significance of the Durand et al. [2] study that may show the way forward towards reducing such burdens of disease treatment.

References

1 Zargar H, Al laf ME, Bhayani S et al. Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study. BJU Int 2015; 407–14

2 Durand M, Jain M, Aggarwal A et al. Real-time in vivo periprostatic nerve tracking using multiphoton microscopy in a rat survival surgery model: a promising pre-clinical study for enhanced nerve-sparing surgery. BJU Int 2015; 478–86

3 Gavin AT, Drummond FJ, Donnelly C, O’Leary E, Sharp L, Kinnear HR. Patient-reported ‘ever had’ and ‘current’ long-term physical symptoms after prostate cancer treatments. BJU Int 2015; 397–406

John W. Davis, MD
Associate Editor, BJUI

#pass4prostate gears up for Rugby World Cup

August 17, 2015/by Declan Murphy

Here is a fun campaign which should appeal to anyone interested in rugby or prostate cancer for that matter. The 2015 Rugby World Cup kicks off in England and Wales next month and as part of their warm up schedule, Australia are playing USA Rugby in a friendly match at Soldier Field in Chicago on the 5th of September. As part of their sponsorship of this fixture, Astellas are supporting a social media campaign called #pass4prostate which will directly raise funds for prostate cancer research in both the USA and Australia.

As part of their support, Astellas will donate $5 to prostate cancer research and advocacy organizations for every qualifying #pass4prostate submission posted to Twitter, Facebook, or Instagram, up to a maximum contribution of $125,000 in the USA and a further $40,000 in Australia. At socialboost you will get the best review of the instagram traffic boosting tools. Therefore to make sure we maximize this commitment, we need to drive lots of traffic using the #pass4prostate hashtag! You can see examples of Australian and US rugby players supporting the campaign below by throwing around special blue rugby balls, but the campaign is encouraging people to make videos supporting the campaign and throwing anything blue around (in a rugby style of course!).

The campaign will run up to the match on 5^th September, and there be lots of activity at the 2^nd Prostate Cancer World Congress which takes place in sunny Far North Queensland, Australia, from 17-21^st August 2015. Follow #pcwc15 or #pass4prostate to get involved!

For full details, please visit the pass4prostate website.

Declan Murphy

Melbourne, Australia

@declangmurphy

That’s what’s wrong with you and your ‘Star Wars’ generation

August 10, 2015/2 Comments/by Nathan Lawrentschuk

Just a few years ago whilst operating, I was curious to find out about one of our unit’s patients on the ward. We still had a bit of time to go in the current case, a retroperitoneal lymph node dissection. There was a chance the patient on the ward would require surgery and being at that time of the day an earlier ‘heads up’ is always best. One of the theatre staff kindly paged our resident. It was 5.05pm. No response. The other resident who was scrubbed directed them to get the resident’s mobile phone and call direct. This did not seem unreasonable – perhaps they were tied up. Maybe the phone could rouse him? Ring ring… Finally an answer. It’s the urology team wanting an update from the ward. “Sorry I’m in the car”. Have you rounded yet? Sort of. Is there a handover? Silence. We’ll call you back later!’

I was astounded at two things – the resident having clearly left without giving a handover in person (or verbally) and the fact that they appeared to have left without the customary afternoon ward round being conducted. I grumbled and sent the other resident up to check on the patient. Was I becoming one of those ‘grumpy old surgeons ‘ whining at the ‘youth of today’? I didn’t think so as what was expected was probably the minimum expected.

Fast forward two weeks. Same time being 5.05pm and the same resident actually appears in person to give handover (were they learning?) I couldn’t miss the chance to poke at him “What a surprise – you’re still here and it’s after 5pm!” The scrub nurse and registrar and Anaesthetist all laughed having been there when he was in the car on the prior occasion. Clearly smarting he quipped “That’s what’s wrong with you and your ‘Star Wars’ generation”… “What do you mean? what’s wrong?” I quizzed. He thought… then responded: “You all think you are the only ones who have worked hard and that all Gen Y doctors are lazy… You guys shoe-box all of us… .”. I pointed out I was miffed that he had left without handover. He claimed all was fine with the ward and had no real excuse for not giving handover but no ill effects happened and the patient in question avoided theatre. “Only just” I added.

All the while the ‘Star Wars’ jibe had gotten under my skin. His blatant and underhand use of the name of a movie that was perhaps the “God amongst Gods” being a classic tale of good and evil that had delivered many new words and ideas and music to at least one generation…

I took my time. So wanting to get it out of my system I chose my words carefully: “So you say ‘I’m part of the ‘Star Wars’ generation’ so that must make you… part of the ‘Avatar’ generation?” He paused… “That’s right – you are exactly right”. This was potentially going to be fun.

OK. “So remind me, who were the lead characters on Avatar? The female lead Avatar?” Deafening silence…. “What about the actors’ names?” … Silence…… I then pointed out it was embarrassing given one was Australian and I couldn’t help but point out the other I quickly recalled being Sigourney Weaver!

Maybe I was being a bit hard – “OK, what was the mineral they were mining on their planet?” Silence …….”unobtainium!” I yelped… “Who could forget that? Alright give me a line from the movie, any line?” Silence …. “Alright hum me the ‘Theme to Avatar'”… Again, silence.

I paused, then in a friendly way with a wry smile, I stated: “May the force be with you!” and gleefully hummed the well known Star Wars theme… as he ducked off….

So was this reinforcing the stereotypes that Gen Y is all flash and glamour with No Substance?

Probably not, but it teaches us that one generation is not that far from the next (the other resident a Gen Y knew more about Star Wars than I did!!). And subsequently I have had some of the best residents ever. So it is all about attitude and understanding what is required. The resident really lifted their game after this, which was excellent and they ended up with a great report – having taken on board the veiled but constructive “criticism”.

Honesty and communication is the best policy, sometimes laced with humour and by doing this “Help them, you will”.

Nathan Lawrentschuk @lawrentschuk

University of Melbourne, Department of Surgery and Ludwig Institute for Cancer Research, Austin Hospital and Peter MacCallum Cancer Centre, Department of Surgical Oncology, Melbourne, VIC, Australia

Sailing into “UnCHAARTED” waters

August 5, 2015/4 Comments/by Simon Chowdhury

Chemotherapy comes alive for prostate cancer!

Systemic therapy for metastatic prostate cancer has radically changed in the last 10 years with the introduction of several novel agents that have shown significant improvements in progression free and overall survival. These have all been studied in metastatic castrate refractory prostate cancer (mCRPC) and have improved overall survival but in each case by less than 6 months. (The latest major breakthrough is the introduction of a relatively old drug, docetaxel chemotherapy, earlier in the disease for hormone sensitive patients).

In this week’s New England Journal of Medicine we see the eagerly awaited results from the CHAARTED study from Christopher Sweeney and colleagues. This novel study aimed to improve treatment for men with newly diagnosed hormone sensitive metastatic prostate cancer by adding docetaxel chemotherapy to androgen deprivation therapy (ADT).

790 men with newly diagnosed metastatic prostate cancer were randomised to ADT plus docetaxel (6 cycles at 75mg/m2) or ADT alone. The addition of docetaxel to ADT was shown to significantly improve overall survival by 13.6 months (57.6 months vs. 44.0 months; p<0.001). The clinical benefit was greatest in the subgroup with high volume disease where the improvement in overall survival was 17 months (49.2 months versus 32.2 months). High volume disease was defined as the presence of visceral metastases and/or 4 or more bone metastases with at least one beyond the vertebral bodies or pelvis. The combination was well tolerated with approximately 6% of patients having neutropenic fever and one death possibly related to docetaxel.

The results from this study are truly practice changing. Supporting evidence from the UK STAMPEDE study (Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy) was presented at this year’s American Society of Clinical Oncology (ASCO) meeting. STAMPEDE showed that for men with metastatic hormone sensitive prostate cancer 6 cycles of docetaxel in addition to ADT improved median overall survival by 22 months (43 versus 65 months).

Chemotherapy for metastatic prostate cancer has had a checkered past with a lack of enthusiasm and nihilism from clinicians and patients. The results from CHAARTED and STAMPEDE are already changing those views. The prostate cancer community needs to react to these results and look to make this treatment available to all suitable men. There are issues with regards to costs of chemotherapy (although docetaxel is now generic), workload, sequence, patient selection, toxicity management, etc. The CHAARTED and STAMPEDE investigators must also use this opportunity to interrogate the tumour samples from these studies to see if they can identify biomarkers that predict docetaxel activity. We will not get this opportunity again as docetaxel + ADT will be be standard of care for future studies.

The clinical benefit from the addition of docetaxel to ADT is one of the largest seen in any oncology study. All men presenting with newly diagnosed metastatic prostate cancer should be considered for 6 cycles of docetaxel in addition to ADT.

Simon Chowdhury is a Consultant Medical Oncologist at Guy’s, King’s and St Thomas’ Hospitals, London. He is actively involved in clinical trial research into urological cancers.

Could Urolift stand the test of time for LUTS management?

August 4, 2015/by admin Z.9

Several new surgical technologies have been assessed during the last decades in order to improve the management of LUTS (Lower Urinary Tract Symptoms): HoLEP (Holmium laser enucleation of the prostate), HoLAP (Holmium laser ablation of the prostate), TUMT (transurethral microwave therapy), TUNA (transurethral needle ablation), HIFU (high-intensity frequency ultrasound) and more recently Greenlight laser vaporization. All these techniques have been compared to TURP (transurethral resection of the prostate), which it is currently considered as the surgical standard procedure for men with mid-size prostate gland associated with moderate-severe LUTS and obstruction.
This month, the #urojc tribe discussed a multicentric randomized trial of a new surgical treatment option for LUTS caused by prostate enlargement: the Prostatic Urethral Lift (PUL), which supposedly reduces the negative effects of other surgical therapies on sexual function. One important controversy of the article is the use of a composite end-point, the BPH6 that includes the assessment of 1) LUTS relief, 2) postoperative recovery experience, 3) erectile function, 4) ejaculatory function, 5) urinary continence preservation and 6) safety, a concept that may resemble the Pentafecta from the surgical treatment of prostate cancer.
The PUL vs TURP – BPH6 study seems to be a well done RCT that accurately follows the CONSORT
statement.

Despite of this, #urojc participants showed reluctance to accept the main outcomes of the study. Interestingly, comments about COI (conflict of interest) and the impact of the industry in manuscripts were mentioned…

People were not completely convinced about using a novel endpoint to compare TURP and PUL… the BPH6 seems to balance the impact of the 6 elements… or perhaps it gave more magnitude to the sexual side effects…

As usual in this #urojc, urologists mentioned specific details about the design and methods of the study…

And participants questioned about why authors emphasized in the manuscript specific points that may favor PUL over TURP…

Good discussion went throughout the 48 hours session, constructive comments about the study, and some other tweets revealed skepticism at this new technique….

And then, @sivanrij evoked the truth about LUTS (by the way, one of the most retweeted/favorited comments)…

Despite being something completely related to the type of health care system, and the specific conditions of each continent or region, costs were compared…

Some experts in PUL shared their thoughts…
Final thoughts were mentioned…

Only time will determine the real success of this novel therapy…

But some questions remain unanswered…

… And helpful references were mentioned…

https://www.bmj.com/content/326/7400/1167

#urojc Commentary on #BPH endpoints “Patients not p-values” by Rees @MattBultitude @CanesDavid @antnoah @soph_cash https://t.co/IMVK6DbAvL — Stacy Loeb, MD (@LoebStacy) July 6, 2015

https://www.ncbi.nlm.nih.gov/pubmed/?term=25885560

Classic Barry paper-BPH minimum clinically important difference #urojc @MattBultitude @CanesDavid @antnoah @soph_cash https://t.co/KDdzc0uZpy

— Stacy Loeb, MD (@LoebStacy) July 6, 2015

https://www.ncbi.nlm.nih.gov/pubmed/7563343

At this time we do not have any treatment options for LUTS/BPO that preserves the ejaculatory function, and PUL may be an option in selected cases; we should accept that it is another option to increase our therapeutic armamentarium…
#urojc demonstrates that Twitter is a powerful tool to share our scientific thoughts all over the world. #urojc gives the opportunity to discuss articles with world-wide experts and authors of the published articles. Following and participating in these discussing definitely opens our minds, expands our medical knowledge and contributes to offer better health care to our patients.

Daniel Olvera-Posada (@OlveraPosada) is a Mexican Urologist, trained at @incmnszmx, currently in his second year of the Endourology Fellowship (@EndourolSoc) at @westernu, in London Ontario, Canada.

Here comes the sun

July 29, 2015/by Ben Challacombe

Sun, sea, sand and stones: BJUI on the beach.

Welcome to this month’s BJUI and whether you are relaxing on a sun-drenched beach or villa somewhere having a hard-earned break, or back at your hospital covering for everyone else having their time off, we hope you will enjoy another fantastic issue. After an action packed BAUS meeting with important trial results, innovation, social media and the BJUI fully to the fore, this is a great moment to update yourself on what is hot in urology. This is probably the time of year when most urologists have a little extra time to take the BJUI out of its cover or open up the iPad and dig a little deeper into the articles, and we do not think you will be disappointed with this issue, which certainly has something for everyone.

In the ‘Article of the Month’, we feature an important paper from Egypt [1] examining factors associated with effective delayed primary repair of pelvic fractures that are associated with a urethral injury. Do be careful whilst you are travelling around the world, as most of the injuries in this paper were due to road traffic accidents. They reported 76/86 successful outcomes over a 7-year period. When a range of preoperative variables was assessed, four had particular significance for successful treatment outcomes. The paper really highlights that in the current urological world of robotics, laparoscopy and endourology, in some conditions traditional open surgery with delicate and precise tissue handling and real attention to surgical detail are the key components of a successful outcome.

Whilst you are eating and drinking more than usual over the summer, we have some food for thought on surgery and metabolic syndrome with one of our ‘Articles of the Week’. This paper contains an important message for all those performing bladder outflow surgery. This paper by Gacci et al. [2] from an international group of consecutive patients clearly shows that men with a waist circumference of >102 cm had a far higher risk of persistent symptoms after TURP or open prostatectomy. This was particularly true for storage symptoms in this group of men and should influence the consenting practice of all urologists carrying out this common surgery.

Make sure you drink plenty of Drink HRW to stay well hydrated on your beach this August, as the summer months often lead to increased numbers of patients presenting to emergency departments with acute ureteric colic, so it seems timely to focus on this area.To this end I would like to highlight one of our important ‘Guideline of Guidelines’ series featuring kidney stones [3] to add to the earlier ones on prostate cancer screening [4]and prostate cancer imaging [5]. This series serve to assimilate all of the major national and international guidelines into one easily digestible format with specific reference to the strength of evidence for each recommendation. Specifically, we look at the initial evaluation, diagnostic imaging selection, symptomatic management, surgical treatment, medical therapy, and prevention of recurrence for both ureteric and renal stones. Quite how the recent surprising results of the SUSPEND (Spontaneous Urinary Stone Passage ENabled by Drugs) trial will impact on the use of medical expulsive therapy remains to be seen [6].

So whether you are sitting watching the sunset with a drink in your hand or quietly working in your home at night, please dig a little deeper into this month’s BJUI on paper, online or on tablet. It will not disappoint and might just change your future practice.

References

1 Koraitim MM, Kamel MI. Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome. BJU Int 2015; 116: 265–70

2 Gacci M, Sebastianelli A, Salvi M et al. Central obesity is predictive of persistent storage lower urinary tract symptoms (LUTS) after surgery for benign prostatic enlargement: results of a multicentre prospective study. BJU Int 2015;116:271–7

3 Ziemba JB, Matlaga BR. Guideline of guidelines: kidney stones. BJU Int 2015; 116: 184–9

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

5 Wollin DA, Makarov DV. Guideline of guidelines: prostate cancer imaging. BJU Int 2015; [Epub ahead of print]. DOI: 10.1111/bju.13104

6 McClinton S, Starr K, Thomas R et al. Use of drug therapy in the management of symptomatic ureteric stones in hospitalized adults (SUSPEND), a multicentre, placebo controlled, randomized trial of a calcium-channel blocker (nifedipine) and an a-blocker (tamsulosin): study protocol for a randomized controlled trial. Trials 2014; 15: 238

Ben Challacombe
Associate Editor, BJUI