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Editorial: Is surgery a never ending learning process?

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The concept of the learning curve is one of the most important issues in surgery and also one of the most overlooked. In the present issue of BJUI, Abboudi et al. [1] present an interesting review paper evaluating the concept of the learning curve in urological procedures. Specifically, the authors have conducted a methodologically consistent systematic review on the literature focused on the learning curve of some urological procedures, including mainly radical prostatectomy (RP), robot-assisted partial nephrectomy (RAPN) and percutaneous nephrolitotomy [1]. Surprisingly, nothing was available for BPH treatments, which are among the most prevalent urological procedures. 

Most of the studies are focused on robot-assisted RP (RARP), but the available literature is of poor methodological quality, including mainly surgical series evaluating a limited number of surgeons, with a heterogeneous selection of outcomes from which to study the learning curve and a focus on short-term outcomes. Conversely, the literature on retropubic RP or laparoscopic RP is of higher quality, including a few very large multi-institutional studies encompassing the performances of several surgeons (reference nos. 24, 26, 29 and 30 in the review) and adopting sophisticated statistical methodology; however, the current interest for these procedures is quite limited, RARP being more commonly preferred. With the above-mentioned limitations in mind, what we have learnt is that RARP operating time plateaus after 50–200 cases, positive surgical margin (PSM) rates after 50–1600 cases, and continence and potency after 200 cases [1]. Such data are only partially in line with the findings of a recent prospective Australian study [2], not included in the present systematic review, which evaluated the learning curve with RARP of a high-volume open surgeon (>3000 retropubic RPs performed before the study beginning). In that study, Thompson et al. [2] demonstrated that performances with RARP surpassed those with retropubic RP after ∼100 cases for sexual function scores and PSM rates in pT2 cancers, whereas ∼150 cases were needed to reach the same target with urinary function scores. Moreover, RARP performances kept on improving, with sexual and urinary scores plateauing after 600–700 and 700–800 cases, respectively. Similarly, with regard to PSMs, it was demonstrated that PSM rates in pT2 and pT3–4 cancers plateaued after 400–500 and 200–300 cases, respectively [2]. Although improvement is likely, it is not clear how much these performances might improve with further extension of the caseload. 

Taken together, those data suggest that even with robotic assistance, a high volume of cases is strongly associated withimproving oncological and functional outcomes after RARP. This is not an extraordinarily original concept, but implies that the daVinci platform, by itself, cannot guarantee excellent surgical quality and that the relevance of the surgeon is as high as ever. 

Limited data are available on other major robotic procedures, such as RAPN and robot-assisted radical cystectomy (RARC). Specifically, 20–75 cases are thought to be needed to observe a plateau in warm ischemia time (WIT) during RAPN, which is in line with our previous findings demonstrating a continuous decrease in WIT during the first 50 cases [3]. Similarly, 20–30 cases are supposed to be needed to achieve acceptable operating times, lymph node yields and PSM rates after RARC; however, those findings do not take in account the burden of robotic experience achieved with RARP before embarking in RARC, which is clearly a major issue [4]. 

Considering that the improvements in performances along the learning curve exceeded any effect sizes we might reasonably expect from a novel drug [5], it is clear that any attempt to centralise treatments for complex procedures in high-volume centres with high-volume surgeons should be attempted. Obviously, that is a very critical target, which is hard to achieve in many realities. In parallel, interventions to improve the performance of surgeons in order to,reduce the learning curve are mandatory. For example, fellowship-trained RARP surgeons have been shown to outperform experienced open or laparoscopic surgeons moving to RARP without specific training [6,7]. For those surgeons for whom fellowship is unfeasible or unpractical, structured courses with integration of simulation, dry laboratory, wet laboratory and da Vinci modular training, for example, using the model of the recently concluded European Robotic Urology Society Pilot Study, can significantly ease the first steps of the learning curve, reducing patients risk. In parallel, intensive courses focused on specific procedures could help those surgeons who had completed the initial steps of their learning curve to master the specific technical details necessary to improve outcomes.

Read the full article

Alexander Mottrie*† and Giacomo Novara†‡

*OLV Vattikuti Robotic Surgery Institute and † Department of Urology, OLV Hospital Aalst, Aalst, Belgium and ‡ Department of Surgery, Oncology and Gastroenterology, Urology Clinic University of Padua, Padua, Italy

References

1 Abboudi H, Khan MS, Guru KA et al. Learning curves for urological procedures: a systematic review. BJU Int 2014; 114: 617–29

2 Thompson JE, Egger S, Böhm M et al. Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective single-surgeon study of 1552 consecutive cases. Eur Urol 2014; 65: 521–31

3 Mottrie A, De Naeyer G, Schatteman P et al. Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours. Eur Urol 2010; 58: 127–32

4 Hayn MH, Hellenthal NJ, Hussain A et al. Does previous robot-assisted radical prostatectomy experience affect outcomes at robot-assisted radical cystectomy? Results from the International Robotic Cystectomy Consortium. Urology 2010; 76: 1111–6

5 Vickers AJ. What are the implications of the surgical learning curve? Eur Urol 2014; 65: 532–3

6 Kwon EO, Bautista TC, Jung H et al. Impact of robotic training onsurgical and pathologic outcomes during robot-assisted laparoscopicradical prostatectomy. Urology 2010; 76: 363–8

7 Leroy TJ, Thiel DD, Duchene DA et al. Safety and peri-operative outcomes during learning curve of robot-assisted laparoscopicprostatectomy: a multi-institutional study of fellowship-trainedrobotic surgeons versus experienced open radical prostatectomysurgeons incorporating robot-assisted laparoscopic prostatectomy. J Endourol 2010; 24: 1665–9

 

Are You Teaming Up for Movember?

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Urology, Social Media, and Prostate Cancer Controversies

The past couple of years have witnessed a rapid rise in the number of urologists engaging in conversation using social media. Urologists across the globe are now participating in the International Urology Journal Club on Twitter (#UROJC), tweeting at conferences, and using social media to build personal and professional relationships. As a result, providers with a passion for men’s health, who may never previously met in real life, are sharing ideas and experience with respect to issues in urology and patient care.

This uptick in the use of social media comes at a time when when prostate cancer screening and the optimal care of the prostate cancer patient are being hotly debated.  More research is clearly needed to settle many of the debates currently taking place both in traditional media and on social media. It, therefore, makes sense for the global urology community to partner with organizations that have a similar passion for advancing and promoting men’s health through scientific research.

Movember – Raising Awareness and Funding for Men’s Health Initiatives

Movember is a movement that began in Melbourne, Australia, in 2003. Since that time, it has spread to more than 20 other countries around the world. Each November, participants raise awareness and money for men’s health by growing a moustache. As the month goes on, and the mustache takes shape, these men become walking and talking men’s health billboards. Participants use their mustache to facilitate conversations about a wide variety of men’s health issues including prostate cancer, testicular cancer, and men’s mental health. They also actively raise money for the Movember Foundation by asking family and friends to donate to their efforts.

Movember is not just for men. Women (Mo Sistas), through encouragement, conversation, fundraising, and, in some cases, sheer tolerance, are a critical part of Movember’s success. Mo Sistas do everything Mo Bros do – they just don’t grow a moustache. Since Movember started, more than 4 million Mo Bros and Mo Sistas around the world have participated. In the process over $556 million dollars has been raised for the Movember Foundation.

Funding Cancer Research in Urology

 

Since its very inception, the Movember Foundation has supported ongoing research in men’s health. Currently the Movember Foundation is funding more than 832 men’s health programs worldwide. In 2010, Movember created a Global Action Plan to improve the clinical tests and treatments used for men with prostate and testicular cancer. Currently, Movember is funding prostate cancer research in four areas:

1. Developing more accurate blood, urine and tissue tests to differentiate between low risk and aggressive forms of prostate cancer.

2. Developing new imaging techniques that enable the earlier detection of metastatic prostate cancer.

3. Optimizing the management of men with low risk prostate cancer.

4. Understanding how increasing physical activity might improve the quality of life and survival of prostate cancer patients.

Movember’s criteria for research support encourages national and international collaboration. Working collaboratively, research groups are able to pool experience, streamline cost, and avoid duplication, in an effort to accelerate the  bench-to-bedside development of new investigations and treatments.

Disrupting the Status Quo

In the past, many different men’s health initiatives have come and gone. Movember’s innovative approach is unique in that each year, for a full month, the movement puts important men’s health issues – such as prostate cancer, testicular cancer and men’s mental health – back into the public spotlight.  The effect of the movement has been to not only energize men, but also healthcare, and even government.

One great example of this is the Prostate Cancer of Australia Specialist Nurse Program. The program, initially funded by Movember in 2011 with AU $3.6m, placed full time specialty nurses in every Australian state to help fill a gap in prostate cancer support and delivery. The pilot program was so successful that the Australian government invested AU $7.2m to allow the program to further expand. Movember has also created a variety of unexpected domino effects in the men’s health community. This year, our American colleagues, Dr. Jamin Brahmbhatt and Dr. Sijo Parekattil, inspired in part by the success of the Movember movement, started the Drive for Men’s Health. There are likely many others who, if asked, would tip their hats in the direction of Movember for their inspiration.

When Urologists Participate, Patients Benefit

Urologists by their very nature are both competitive and cooperative. The Movember movement is a unique opportunity for urologists across continents to join with other individuals and organizations that are passionate about improving the health and quality of life of men.  Movember is also an opportunity for colleagues, who may have only met via social media, to cooperate and/or compete all in an effort to raise awareness and money for men’s health research.  Last year, for example, Canadian urologist Dr. Rajiv Singal, assembled an international Movember team of Canadian and American urologists, patient advocates, and other healthcare providers to raise money and awareness for men’s health. Working together, the team raised nearly CA $50,000 dollars for the Movember Foundation.

An Invitation to Team Up

In the spirit of collaboration and friendly competition, this November we invite our urology colleagues from around the world to start their own local Movember Team, or to join our international team as we attempt to better our fundraising performance from last year.

 

Editorial: Patient-reported outcomes – a force for clinical improvement or another way for ‘big brother’ to survey clinicians?

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In the 19th century Lord Kelvin wrote, ‘If you cannot measure it, you cannot improve it’. Since then clinical improvement has often been about measuring outcomes to determine what elements of healthcare are working well and what can be improved. The early studies of antisepsis and surgical technique had endpoints, which were measured by doctors deciding whether a wound infection, cancer recurrence or even death had occurred. These outcomes were usually discrete with little room for describing states between success and failure.

In this era whether the patient perceived that the treatment had been successful or not was irrelevant to the ‘success’ of treatment providing that the medical world agreed that the treatment had been a success. As treatments have become more established and the medical and pharmaceutical world has become more patient focussed, interest has increased in how patients report the outcome of treatment, often using questionnaires.

The pioneers of this work were mainly psychiatrists concerned about patient anxiety and depression [1] and clinical oncologists, aware that multimodal chemoradiotherapy treatments, which might in many cases be offered with palliative rather than curative intent, had the potential to cause a net loss in quality of life even if patients lived a short time longer on treatment.

As these patient-reported outcome measures (PROMs) became more commonly used in clinical trials, their focus has extended to quite specific outcomes, such that in the current era it is unusual to see papers on LUTS or erectile function presented that do not use validated PROMs, such as the IPSS [2] or International Index of Erectile Function (IIEF) [3].

The current era of research is starting to make new use of the data sources that are useful both as absolute values relating to the severity of symptoms but also particularly in measuring change in level of symptoms. Hard outcomes, such as death from cancer, have been found to be related to patient reported quality of life at presentation [4].

Clinicians are now starting to develop the necessary skills to analyse PROMs. In this setting Talcott et al. [5] have used PROM data to identify unexpected variances in symptomatic outcome after prostate brachytherapy. This was an unexpected post hoc analysis of a difference in outcomes between the two control groups in a study. It found that there was a significant difference in outcome between patients who had received an implant in two centres, which might have been expected to have similar outcomes. Analysis of differences in the implant technique in the two institutions suggested that the use of a urethral catheter to clearly visualise the urethra might be the difference and modification of this part of the technique resulted in similar PROMS outcomes in both institutions.

This is a novel quality improvement approach, which may become more widespread as institutions more frequently collect, analyse and present their PROMS. The bio-informatics skills needed to analyse this type of data meaningfully may become a greater part of everyday practice in the modern era, especially for the ‘index’ most common operations in surgical specialities. It would be interesting to see what a similar approach would produce if variance in PROMs after transurethral prostate surgery were analysed between centres in the UK and USA. Organisations with a track record for effective data analysis and reporting such as Dr Foster will be watching this evolve.

Read the full article

Alastair Henderson

Maidstone and Tunbridge Wells NHS Trust, Department of Urology, Maidstone Hospital, Maidstone, Kent, UK

References

1 Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiat Scand 1983; 67: 361–70

2 Barry MJ, O’Leary MP. Advances in benign prostatic hyperplasia. The developmental and clinical utility of symptom scores. Urol Clin North Am 1995; 22: 299–307

3 Cappelleri JC, Rosen RC, Smith MD, Mishra A, Osterloh IH. Diagnostic evaluation of the erectile function domain of the International Index of Erectile Function. Urology 1999; 54: 346–51

4 Montazeri A. Quality of life data as prognostic indicators of survival in cancer patients: an overview of the literature from 1982 to 2008. Health Qual Life Outcomes 2009; 7: 102

5 Talcott JA, Manola J, Chen RC et al. Using patient-reported outcomes to assess and improve prostate cancer brachytherapy. BJU Int 2014; 114: 511–6

Editorial: Robot-assisted pyeloplasty in children

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The authors of the study on robot-assisted pyeloplasty in this issue of BJUI have carried out an excellent review of the current data on this common paediatric urology procedure [1]. Although the analysis involves small case numbers and series for meta-analysis, the data are useful for current practice. It may be worth waiting another 5 years to review the data again, by which time the learning curve for most of the surgeons will be over, and a true representation of practice and a comparison against the established standard open surgery, which has been established over decades, can be reported. The training of next-generation surgeons needs to be factored into this process, which is critically important.

With the different methods of critical evaluation presently available, we may be able to draw some conclusions from the results of robot-assisted pyeloplasty, but the problem that remains is the inconsistency of individual reports in terms of outcome and complications. We surgeons need to work on developing a consensus model for the evaluation of each procedure so that uniformity exists. The financial implications of new technology will always be higher than expected, but with a greater number of users and competitive producers the cost will be remarkably reduced. As paediatric surgeons, we do not know the unseen benefits of robot-assisted pyeloplasty, but the children’s families have a positive perception of post-surgical aesthetic appearance, and may also have some human capital gains in terms of reduced childcare expenditure. The paradigm shift to a digital era of surgery is here to stay, with safety and refinements to technology being universally available to all children.

Read the full article

Mohan S. Gundeti

BJUI Consulting Editor, Paediatrics, The Medicine University of Chicago, Chicago, IL, USA

References

1. Cundy TP, Harling L, Hughes-Hallett A et al. Meta analysis of robot-assisted vs conventional laparoscopic and open pyeloplasty in children. BJU Int 2014; 114: 582–94

Read more articles of the week

 

 

Paediatric urology in the BJUI

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The BJUI and the Editorial team are committed to the publication of high-quality and highly citable articles concerning translational science for the International Paediatric Urology Community. We encourage authors to submit original and outstanding work for publication that can influence clinical practice or introduce innovative new care methods for children across the world.
In addition to valuable contributions, the reviewers’excellent review process ensures the best publications. Although, impact factor is an important attribute for a journal; the real true value resides with its ability to make paradigm shifts and bring innovative care to children’s lives.

On this note we have included the best three articles in the ‘Paediatrics’ section in this month’s issue.

Cundy et al. [1] from London (UK), have to be commended for the thoughtful meta-analysis of robot-assisted pyeloplasty (RAP).This is an early, but, timely analysis of our current practice of different approaches to paediatric pyeloplasty. The primary outcomes were not significantly different for the open, robotic or laparoscopic approaches. This is not surprising ,as the surgeons that used these new approaches have been proficient with their traditional approaches and have embraced the newer techniques with caution. RAP had a distinct advantage of reduced analgesia and length of hospital stay compared with the traditional open approaches, and this will probably drive the adoption of the newer approaches even at the expense of increased cost. Hopefully, the cost issue will be transient; as the new technology becomes increasingly widespread the cost should level out. Randomised clinical trials may be an answer to newer treatment adoption,but this may not be possible in all scenarios – hence a prospective comparative series may answer the question, with some human factor bias [2]. The advantage of ergonomic comfort and a reduced learning curve for surgeons performing these reconstructive procedures using the robotic approach,as mentioned by the authors,has the benefit of reducing professional health hazards and saving on human capital. Unfortunately, this has never been considered or measured, although it is an important aspect.

Suer et al. [3] from Turkey, have analysed their anti-reflux surgery series in children using the open approach to predict complications in a multivariate analysis. The utmost factor is bladder dysfunction, e.g.bladder-bowel dysfunction, dysfunctional elimination syndrome or dysfunctional voiding. Over the years paediatric urologists have found this to be associated with VUR and poor outcomes after surgery. Extreme caution has to be taken when deciding to perform surgery in this group, as theVUR may be secondary and surgery may not be warranted at all.Ureteric tapering or tailoring of the dilated ureter is another factor for poor outcomes, which can be attributed to the poor vascularity of chronically dilated ureters. This practice has been based on the physics of Paquin’s law.Unfortunately, we do not have evidence of outcomes without this reduction plasty on these ureters. The authors have also emphasised the limitations of the current adult Clavien system of classification used for grading [4], which has pitfalls and does not describe the complications well either in the paediatric population. It is an appeal to the paediatric urology community for further work to be done to produce a standardised grading system for use in paediatric cases.

Dangle et al. [5] from The University of Chicago have attempted to describe extravesical robotic ureteric re-implantation for VUR in children. The technique of re-implantation has not been described well to date, although there have been a few outcome reports with variable success rates. This explains the fact there may not be uniformity in this technique and/or the learning curve. The surgery itself is challenging because of the close proximity of important anatomical structures within a confined space, and the risk of ureteric damage with improper handling is unforgiving. The video describes their current modified technique with important surgical steps for adoption. The success rate for resolution is still, not on a par with open surgery, but there were no complications. The fine balance between success and complications needs to be defined for incorporation into the paediatric urological armamentarium.

Moving forward:

‘With availability of advanced automated instruments to replace manual labour, if as a society we prefer this at an increased cost, then why not on the same philosophy adopt these new technologies in the surgical realm with proper training and safety to reduce the morbidity and achieve at par results?’.

and

‘The surgical dogma of practice needs to be challenged with evidence-based outcomes to move ahead’.

Conflict of Interest

None declared.

Mohan S. Gundeti, MD, MCh, FEBU, FRCS, FEAPU

BJUI Consulting Editor–Paediatrics, The University of Chicago Medicine, Chicago, IL, USA e-mail: [email protected]

References

1            Cundy TP, Harling L, Hughes-Hallett A et al. Meta-analysis of robot-assisted vs conventional laparoscopic and open pyeloplasty in children. BJU Int 2014; 114: 582–94

2            Orvieto MA, Large M, Gundeti MS. Robotic paediatric urology.BJU Int 2012; 110: 2–13

3            Suer E, Ozcan C, Mermerkaya M et al. Can factors affecting complication rates for ureteric re-implantation be predicted? Use of the modified Clavien classification system in a paediatric population. BJU Int 2014; 114: 595–600

4            Clavien PA, Barkun J, de Oliveira ML et al. The Clavien-Dindo classification of surgical complications: five-year experience.Ann Surg 2009; 250: 187–96

5            Dangle PP, Shah A, Gundeti MS. Robot-assisted laparoscopic ureteric reimplantation:extravesical technique. BJU Int 2014; 114: 630–2

© 2014 The Author 468 BJU International © 2014 BJU International

Highlights from the Irish Society of Urology 2014

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Failte go Cill Airne (Welcome to Killarney, Co Kerry).
The urology community of Ireland descended on the picturesque town of Killarney in the south west of Ireland for its annual scientific meeting.

Mr David Quinlan (@daithiquinlan), President of the ISU, commenced proceedings with a tribute to the late Professor John Fitzpatrick and Mr Dermot O’Flynn. It is the first ISU following the sad passing of Professor Fitzpatrick in May of this year. Professor Fitzpatrick led a distinguished career and was a respected figure in world urology. The recent BJUI blog following his death demonstrated how highly regarded he was across the globe, with many sharing personal memories of him. Outside of his undoubted ability in the operating room, he was entertaining, had a special way with words and was a great story teller. He will be missed both here and afar.

 

Dermot O’Flynn, past President of the RCSI, also passed away this year aged 93. Mr O’Flynn was an established urologist in the Meath Hospital. He played a significant role in the formalisation of urological training in Great Britain and Ireland not only to the training programme but also the specialist exit examination.

 

 

 

Academic Program

The academic program commenced on Thursday morning with front line basic science presentations. Kieran Breen (@kjkibbles – who won the ISU Registrar’s Prize winner) from the Conway Institute (scientific laboratory set up by Professor Fitzpatrick) reported tissue microarrays following radical prostatectomy regarding immunohistochemistry staining for insulin receptors, IGF-1 receptor and PTEN as markers of predicting biochemical recurrence. Early data suggest these markers could identify potential patients at risk of biochemical recurrence. Tuzova et al. presented a multi-centre study led by the St James’ group that suggested urinary profiling of DNA hypermethylation can selectively detect high-risk prostate cancers with improved specificity over the traditional PSA test.
The afternoon podium session focused on prostate cancer and resulted in an expected heated debate – Daniel Good (@willbgood1) from Edinburgh, reported the use of a novel device in prostate cancer detection. The E-finger, is a probe that fits on the tip of a finger and attempts to differentiate significant from insignificant findings based upon prostate elasticity. The debate continued regarding the use of pre biopsy MRI as well as the role of transperineal biopsies as a standard. Rick Popert advocated the use of systematic transperineal biopsy based on an anatomical map of the prostate as opposed to the traditional ‘lucky dip’ that is the transrectal ultrasound biopsy.
Friday morning focused on urological training in Ireland – Elaine Redmond outlined the lack of urological exposure among primary care physicians and suggested a urological or men’s health module be incorporated in their curriculum. Matthew Burke, highlighted the need for dedicated paediatric urological training to meet the needs of the health service going forward – this echoed the thoughts of BAUS President Mark Speakman who highlighted the impending void in paediatric urology.
Other highlights included the suggestion of a national network for the management of penile cancer in Ireland, similar to this week’s BJUI article of the week. In a country with such low volumes, a supra-regional network may improve long-term morbidity and survival.
Finally, O’Kelly et al. (@fardodokelly), demonstrated the merits and quality of national urological meetings from the smaller European countries with a favourable final publication rate of 46%. The quality of presentations, in particular basic science demonstrated this will continue.

Guest Speakers

The ISU has continued to attract significant guest speakers from the world of urology and this year we were joined by Craig Peters (‘THE’ American Paediatric Urologist), Mike Leonard (Vice-President of the Canadian Urological Association), Mark Speakman (President of BAUS) and Prokar Dasgupta (@prokarurol – Editor of the BJUI).

Guest Speakers – Mr John Thornhill (incoming ISU President), Mr Roger Plail (President of the Section on Urology, Royal Society of Medicine), Mr David Quinlan (outgoing ISU President), Professor Prokar Dasgupta (BJUI Editor), Professor Craig Peters (University of Virginia), Mr Mark Speakman (President of BAUS), Professor Mike Leonard (Vice-President Canadian Urological Association)

Professor Peters lecture on Robotic Surgery in Paediatric Urology ‘Reflections on emerging technologies’ was an eye opener in to what can be achieved if we push the boundaries. His strive for excellence and improved patient outcomes in the face of ‘robot-scepticism’ have led to advances in paediatric robotics. Outside of the robotic pyeloplasty – they have pioneered and tested the use of robotics in hypospadiology due to the undoubted improved optics as well the management of congenital abnormalities.
In one of the highlights of the meeting, Professor Peters was pitted against Professor Mike Leonard (Vice-President of the Canadian Urological Association) in a debate ‘Robotics are alien in paediatric urology’ panelled by Professor Dasgupta and Mark Speakman. ‘Robocop’ versus the sensible Canadian approach duelled in a fascinating debate – detailing clinical efficacy, cost effectiveness, quality control. Professor Peters offered Professor Leonard his card for redo pyeloplasty ‘in which the robot works quite well’.
Professor Dasgupta, (the man who still carries a diary) engaged the audience in a tour de force regarding immunotherapy in prostate cancer as well as detailing his future vision for the BJUI. This was the first year the abstracts were published in the BJUI, the Official Journal of the ISU. This is a most welcome addition and adds to the standing of our annual meeting.

Professor Prokar Dasgupta – the Editor of the ‘journal that never sleeps’ – with his pocket diary.

Mark Speakman, gave an impressive demonstration in the art of oratory at the gala dinner regarding delivering a service and the impending need to publish surgeon-specific outcomes. He continued to speak to trainees and the need to add a ‘second string to your bow’ highlighting the areas which will require urologists in the future – paediatrics, andrology and female urology – warning that we cannot all be robotic pelvic oncological urologists.

Social Media Presence

The #ISU14 hashtag gathered momentum in the past few days. Again an inaugural addition to our meeting and something we will endeavour to promote in years to come. Any attendee at the EAU, AUA, BAUS will attest to the quality of social media presence and this is something we can learn from. By the end of the meeting we had followers across the globe, in the United States and Australia.

ISU Social Media Team ( Mr Rustom Manecksha – @dr_rpm, Mr David Bouchier-Hayes – @dbh44, Mr Garrett Durkan – @gcd67, Professor Prokar Dasgupta – @prokarurol, Mr Greg Nason – @nason_greg, Mr David Quinlan – @daithiquinlan,
Mr Fardod O’Kelly – @fardodokelly)

The now standard selfie – Mr John Thornhill, Mr Roger Plail, Mr David Quinlan, Professor Prokar Dasgupta, Professor Craig Peters, Mr Mark Speakman, Professor Mike Leonard)

Symplur #ISU14 analytics

 

Moving forward

The annual meeting also ended Mr David Quinlan’s tenure as the President of the Irish Society of Urology. The ISU has moved from strength to strength under his watchful eye, incoming President John Thornhill applauded Mr Quinlan as ‘a rock who sailed a steady ship’. We look forward to welcoming all to next year in Limerick for hopefully a bigger annual conference with a wider global audience.

Mr David Quinlan (outgoing President of ISU), Professor Prokar Dasgupta (BJUI Editor), Mr John Thornhill (incoming ISU President)

 

Greg Nason is a Specialist Registrar in Urology in Ireland.
ISU Social Media Team (David Quinlan, Rustom Manecksha, David Bouchier-Hayes, Fardod O’Kelly, Greg Nason)

 

 

Editorial: A call for the international adoption of penile specialist networks

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The recent article by Tang et al. [1] from the Christie Hospital in Manchester raises an interesting question. The urological cancer plan for England and Wales specifies that review of the pathology of prostate and high-risk superficial bladder cancer should take place as part of the referral process for these cases to specialist pelvic cancer teams, but the penile pathway does not indicate that this is necessary [2]. The Royal College of Pathologists [3] also specifies the need for expert review and/or double reporting in other rare cancers and dysplasias, but does not yet specify this for penile cancers.

Penile cancers are rare, with 600 new cases diagnosed in the UK per year. They are almost invariably squamous cell carcinomas, which also occur at other sites including the lung, upper aerodigestive tract and skin. This may lead some pathologists to assume that they are similar and do not need second opinion or review; however, the subtypes of squamous cell carcinoma that occur on the penis are not common elsewhere, include basaloid, warty and verrucous carcinomas [4], and are not always recognized by general pathologists. The anatomy of the penis is challenging and the identification of invasion of urethra, corpus spongiosum and corpus cavernosum is important in accurate staging. Penile cancers have their own TNM system. TNM7, published in 2010 [5], recognises the importance of grading and different stage groups on prognosis.

Our own experience at St George’s Hospital in South London mirrors that of the Christie Hospital in North West England. Our practice from the outset of the establishment of our supra-regional penile centre was to review outside pathology in the setting of our specialist multidisciplinary meeting to devise a management plan for each patient. We also found that our reviewed cases were more likely to be under-graded and that staging was frequently inaccurate if it was attempted at all. Our original audit was presented at the BAUS annual meeting in 2005. We repeated the audit in 2008 after the publication of the Royal College of Pathologists guidelines on the reporting of penile cancer and found no improvement (unpublished data).

An average urological pathologist in a non-specialist centre in the UK will only see 1–3 cases of penile cancer per year and will have little opportunity or incentive to gain expertise in this area. Although second opinion services through the supra-networks are freely available, these are not always sought, perhaps because of time pressures and the mistaken impression that penile cancers are like those of other sites. There is also a lack of awareness of new entities, for example, differentiated penile intraepithelial neoplasia (PeIN) and subtypes of undifferentiated PeIN. There has been a recent change in nomenclature, whereby all morphological types of squamous carcinoma in situ and dysplasias are now classified within PeIN [6].

The supra-network of penile centres in the UK has allowed a small group of pathologists to gain expertise in the reporting of penile cancer in a specialist clinical setting, and has produced a group of pathologists with a special interest in this type of tumour, all of whom are seeing at least 25 new cases per year. Many centres are seeing more, with our own centre managing 126 new cases in 2012.

In 2008 we formed a UK-wide group of specialist penile pathologists (the Hobnobs) which meets annually to exchange both clinical and research information and to discuss individual cases. Members of this group are currently updating the Royal College of Pathologists penile guidelines [3]. These will advise central review, but we recognize we are writing them mainly for specialist pathologists to ensure consistent and high-quality assessment of penile cancer to inform the penile cancer team.

In the UK, expert pathological review of penile cancer is already the norm for the penile supra-networks, but it would be difficult to make this the global standard for several reasons. Sub-specialization in penile cancer management is not widely practised outside Britain and there are few specialist high-volume centres, with some notable exceptions in Europe and the USA. Without clinical sub-specialization it is difficult for pathologists to develop an interest and sufficient expertise to offer an expert second opinion because the numbers seen by any individual pathologist will be too small.

The UK penile supra-network system works well and has led to a group of pathologists developing an interest in this area simply because they are seeing a large number of such cases and working with dedicated clinical teams. Penile supra-networks should be adopted worldwide. Following this, a group of expert and experienced pathologists will ultimately be developed, who can offer a central review and expert second opinion service, as has happened over the last 10 years in the UK.

Read the full article

Catherine M. Corbishley
Department of Cellular Pathology, St George’s Healthcare NHS
Trust, London, UK

References

1. Tang V, Clarke L, Gall Z et al. Should centralised histopathological review in penile cancer be the global standard? BJU Int 2014;114: 340–343

2. Manual for Cancer services. Urology measures Version 2.1. NHS National Cancer Peer Review Programme 2011 and Evidence guide for Urology Supraregional Penile MDT NHS National Cancer Peer Review Programme 2010.

3. Royal College of Pathologists. Cancer Datasets and Tissue Pathways. Available at: https://www.rcpath.org/publications-media/publications/datasets.

4. Epstein JI, Cubilla AL, Humphrey PA. Tumours of the Prostate Gland, Seminal Vesicles, Penis and Scrotum. American Registry of Pathology, Washington DC published in collaboration with the Armed Forces Institute of Pathology, 2011, 405–612

5. Gospodarowicz MK (section editor, Genitourinary Tumours). TNM classification of malignant tumours (7th edition) penis. In Edge SB,Byrd DR, Compton CC Fritz AG, Greene FL, Trotti A eds, AJCC Cancer Staging Manual, 7th edn. New York: Springer, 2010:447–455

6. Velazquez EF, Chaux A, Cubilla AL. Histologic classification of penile intraepithelial neoplasia. Semin Diagn Pathol 2012; 29: 96–102

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sLND for Prostate Cancer Nodal Recurrence: #urojc September 2014 summary

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The September 2014 edition of the International Urology Journal Club (#urojc) returned to familiar territory – prostate cancer. In particular, the discussion focused on salvage lymph node dissection following radical prostatectomy. For the second time (first in July 2014), two journal articles were selected. Both were kindly made available to open access by The Journal of Urology (@JUrology).

The first paper from the Mayo Clinic by Karnes et al., titled ‘Salvage Lymph Node Dissection (sLND) for Prostate Cancer Nodal Recurrence Detected by 11C-Choline Positron Emission Tomography/Computed Tomography (PET/CT)’, reported on a retrospective single-surgeon series of 52 men who underwent salvage lymph node dissection for nodal recurrence post radical prostatectomy. Median follow-up was 20 months. Three-year Biochemical recurrence (BCR)-free survival rate was 45.5% (PSA <0.2). Metastatic/systemic progression-free and cancer-specific survival rates were 46.9% and 92.5% respectively. They concluded that sLND may delay further progression of disease but highlighted the need for randomised controlled trials.

The second paper from German group Tilki et al., titled ‘Salvage Lymph Node Dissection for nodal recurrence of prostate cancer after Radical Prostatectomy’, also reported on a retrospective series of 58 patients who underwent sLND for nodal recurrence on PET/CT post radical prostatectomy. Median follow-up was 39 months. All but 1 patient had BCR. Five-year clinical recurrence-free and cancer-specific survival rates were 35.9% and 71% respectively.  Tilki et al. concluded that while most patients had BCR, sLND may delay ADT and clinical recurrence in selected cases.

A common sentiment shared during the discussion related to the lack of randomised evidence for sLND:

There were some serious concerns about the methodology and results from the two articles:

Discussions quickly shifted away from the two articles to the actual clinical question of sLND in oligometastatic disease and delay to ADT. Matthew Katz provided useful links to the use of stereotactic radiation therapy.

Issues surrounding sLND training and the paradigm shift in recent years were also highlighted:

Opinions were divided on the question of surgical morbidity versus the potential increase in time to ADT:

Pop culture references were in vogue this month. An article by the Mayo Clinic on the 11C-Choline PET scan sparked the linked exchange:

Some take home messages pertained to the uncertainty regarding patient selection and the role of sLND in the broader multidisciplinary arena of prostate cancer treatment:

The winner of the Best Tweet Prize is Brian Chapin (@ChapinMD) for his tweet above.  We thank the Journal of Clinical Urology for supporting this month’s prize by way of a one year electronic subscription to their journal.  We also thank the Journal of Urology for supporting this month’s discussion by way of allowing time limited open access of both articles.

Staying true to form, this month’s edition of #urojc provided a forum for lively international discussion. We look forward to next month’s installment and especially encourage trainees to make use of this excellent educational opportunity.

 

Isaac Thangasamy is a second year Urology Trainee currently working at the Royal Brisbane and Women’s Hospital, Brisbane, Australia. He is passionate about education and social media. Follow him on Twitter @iThangasamy

 

Editorial: Perioperative aspirin: To give or not to give?

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As the population ages and life expectancy increases, one may safely assume that more men will be diagnosed with diseases of the elderly such as prostate cancer. In the USA, it is estimated that the number of older adults (≥65 years old) will double between 2010 and 2030, contributing to a 45% increase in cancer incidence [1]. Also, it is likely that these older patients will present with multiple comorbidities, commonly described as ‘multimorbidity’ in the contemporary medical literature, including chronic cardiac and pulmonary conditions requiring multidisciplinary medical management.

Hence, the present study by Leyh-Bannurah et al. [2] examining the peri-operative use of aspirin in patients undergoing radical prostatectomy (RP) is a timely and important contribution, and may very well influence our clinical decision-making regarding the perioperative management of the anti-coagulated patient. Their results show that perioperative continuation of aspirin made no difference in peri and postoperative outcomes following RP. Previous studies have assessed the effect of aspirin continuation in patients undergoing minimally invasive RP, but the present study is the first to evaluate the effect of aspirin continuation in patients undergoing minimally invasive and open RP at a high-volume tertiary centre. Studies from other surgical specialties evaluating the role of anti-platelet therapy and its timing before surgery have shown conflicting results. The study by Park et al. [3], looking at discontinuation of aspirin for ≥7 days vs <7 days before surgery in patients undergoing lumbar spinal fusion, found that aspirin discontinued only 3–7 days before surgery significantly increased the risk of intraoperative bleeding. Alghamdi et al. [4] found similar results in patients undergoing coronary artery bypass grafting. In contrast, the study by Wolf et al. [5] showed that continuation of aspirin up to the day of the surgery did not increase the risk of bleeding, transfusion or other adverse outcomes in patients undergoing pancreatectomy. Similarly, Khudairy et al. [6] assessed the use of clopidogrel and its discontinuation time in hip fracture repair, and found that whether it was stopped ≥1 week or <1 week before surgery did not make any difference to the risk of bleeding or peri-operative complications. Nonetheless, the evidence provided by the present study by Leyh-Bannurah et al. is important, as the risk of bleeding seems to be procedure-specific, depending on the nature and source of potential bleeding (primarily arterial vs primarily venous). The lack of information, however, regarding cardiovascular morbidities in their patient population is an important limitation of their study; as such factors may influence perioperative decision-making, including the threshold for transfusion.

Read the full article

Akshay Sood and Quoc-Dien Trinh*
VUI Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, and *Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA

References

  1. Lamb A. Fast Facts: prostate cancer, seventh edition. BJU Int 2012; 110: E157
  3. Park JH, Ahn Y, Choi BS et al. Antithrombotic effects of aspirin on 1- or 2-level lumbar spinal fusion surgery: a comparison between 2 groups discontinuing aspirin use before and after 7 days prior to surgery. Spine 2013; 38: 1561–1565
  4. Alghamdi AA, Moussa F, Fremes SE. Does the use of preoperative aspirin increase the risk of bleeding in patients undergoing coronary artery bypass grafting surgery? Systematic review and meta-analysis. J Cardiac Surg 2007; 22: 247–256
  5. Wolf AM, Pucci MJ, Gabale SD et al. Safety of perioperative aspirin therapy in pancreatic operations. Surgery 2014; 155: 39–46
  6. Al Khudairy A, Al-Hadeedi O, Sayana MK, Galvin R, Quinlan JF. Withholding clopidogrel for 3 to 6 versus 7 days or more before surgery in hip fracture patients. J Orthop Surg 2013; 21: 146–150
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15th Asia-Pacific Prostate Cancer Conference 2014

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Blog author Dr Sarah Wilkinson enjoys lunchtime entertainment at APCC in Melbourne.

The 15th Asia-Pacific Prostate Cancer Conference 2014 (#apcc14; prostatecancerconference.org.au/) is the largest prostate cancer educational event in the region and attracts over 800 multidisciplinary delegates every year. The world’s leading experts in prostate cancer have featured on the Faculty at this conference in recent year’s and this year’s Faculty was again a great team-sheet for leaders in this field:

The Confernece kicked off on Sun 31st August with a series of Masterclasses including the very popular da Vinci© Prostatectomy Masterclass (featuring Dr Henk Van Der Poel, Dr John Davis, Dr Markus Graefen and Dr Paul Cathcart), along with new master classes focusing on Prostate MRI scanning (led by Dr Jelle Barentsz), and LDR Brachytherapy (led by Dr Juanita Crook).

MRI Prostate Masterclass led by Jelle Barentsz was a sell-out

The Nursing & Allied Health streams also opened their plenary sessions to a busy auditorium. The official Poster and Welcome Session was held on Sunday evening on what was an unseasonally warm and to Winter in Australia. Whilst enjoying the range of lovely canapés and beverages on offer via Melbourne’s premier conference and catering venue (https://mcec.com.au/), delegates caught up with their long lost urology colleagues and perused the high quality posters on display. Poster prizes were awarded for each of the three conference streams; Clinical Urology, Nursing & Allied Health, and Translational Science, as judged by experts in the respective fields. The task of picking just one winner for the Clinical Urology category proved too difficult for judges A/Prof Henry Woo (@DrHWoo) and Dr Phil Dundee (@phildundee), so a dual prize was awarded to both Dr Fairleigh Reeves (@DrFairleighR) and A/Prof Jeremy Millar (@jeremymillar). Rob McDowell took out the poster prize for the Nursing & Allied Health stream with his poster on baseline characteristics of participants in a telephone-delivered mindfulness intervention for men with advanced prostate cancer. The Translational Science winner was Saeid Alinezhad, who presented; ACSM1, CACNA1D and LMNB1 as three novel prostate cancer biomarker candidates.

Monday morning saw the Official Conference Opening given by conference President Prof Tony Costello (@proftcostello) who announced the opening of a new Royal Men’s Hospital to specifically address the needs of men’s health in Australia. The life expectancy of Australian males is currently 5 yrs less than women, and cancer mortality is a third higher for prostate cancer compared to breast. Rates of alcohol, tobacco and drug abuse, as well as suicide, are all 4x higher in men compared to women. 66% Australian men are overweight or obese, and men are also far less likely to visit their GP for a check-up. Next we were lucky enough to have Federal Minister for Health and Sport, the Hon. Peter Dutton MP (@PeterDutton_MP), take leave from Parliament to give the Ministerial Address. Mr Dutton expressed his support for the conference and the forthcoming opening of the new “Royal Men’s Hospital”, a clinic focussed on Men’s Health in Australia’s premier health science precinct, and spoke of how he hopes the recently proposed $20 billion Medical Research Future Fund will further help advances in this area.

Conference President Prof Tony Costello with Australia’s Minister for Health, Hon Peter Dutton MP

The 2nd Patrick C Walsh Lecture was given by Dr Peter Carroll from the Department of Urology, UCSF, USA. Dr Carroll discussed how we can refine current risk assessments for patients with prostate cancer, and in the process give them refined treatment options. Dr Caroll and his team (including Dr Matthew Cooperberg who was also present), have led the way in risk stratification for men with localised prostate cancer and continue to find ways to best select men at higher risk of adverse outcomes.

This year’s point-counter point debate focused on the preferred method of prostate cancer biopsy. In the left side of the ring we had Mr Jeremy Grummet (@jgrummet) who argued the case for a transperineal biopsy due to multi-drug resistant rectal flora. On the right side we had Mr Shomik Sengupta (@shomik_s) who was in favour of sticking with the well-established TRUS. Following a very close audience vote, session chair A/Prof Nathan Lawrentschuk (@lawrentschuk) declared the winner, “Close, but transfecal by an organism.”

The Conference dinner was held on Monday evening at the Mural Hall, Myer Building. 18th century style mirrored commodes and Parisian inspired parquet flooring transported guests to another world, whilst some fine whisky and entertainment was enjoyed.

And for those who hadn’t partied too hard, the Clinical Urology and Translational Science Breakfast sessions were back by popular demand beginning promptly at 6:45 am the next morning. Both sessions focused on genomics and its implications in diagnosis and treatment planning in what is now coined ‘The Genomic Era’.

Later in the morning we remembered renowned British urologist Prof John Fitzpatrick, who sadly passed away aged 65 on May 14th 2014, suffering from a massive subarachnoid haemorrhage. His close colleague and friend, Prof Roger Kirby, delivered the remembrance speech “Life in the Fast Lane”, along with a musically accompanied slide show. Prof Kirby’s tribute can also be read here at Blogs@BJUI (https://www.bjuinternational.com/bjui-blog/professor-john-fitzpatrick-1948-2014/).

The urology Twitterati were again out in full force at #apcc14. During peri-conference period (including the 5 day lead up period, the actual conference dates, and 2 days post-conference), almost 400,000 impressions were generated in cyperspace from 424 tweets, by 111 participants. There was an average of 2 tweets per hr over the peri-conference period and each participant averaged 4 tweets each.

The conference ended with the exciting news of a 2nd Prostate Cancer World Congress, to be held August 18-21st 2015 in beautiful Cairns, Queensland Australia. See you there!

 

 

 

Sarah Wilkinson completed her PhD in prostate cancer research and is now working as a Medical Science Liaison for Oncology and Haematology at GSK. Twitter: @wilko3040

 

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