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Richard Turner-Warwick

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Richard Turner-Warwick CBE MSc, MCh (Oxon), DM.(Oxon), DSc.(Hon NY), FRCP, FRCS, FRCOG, FACS, FRACS (Hon), FACS (Hon)

Richard Turner-Warwick, now retired, but in good health, was one of the giants of British urology and is, quite literally, the Father of reconstructive urology, both nationally and internationally. A brilliant surgeon, teacher and writer, he managed to inspire a great many urologists around the world. He also restored quality of life to countless patients from many continents who had suffered traumatic or neoplastic injury to their genitals or lower urinary tract. In his honour we have organized a meeting on reconstructive urology, kindly supported by The Urology Foundation (TUF), in Glasgow on Saturday 12th October 2014, immediately in advance of the SIU meeting in the same city. This blog is designed to publicise this meeting, and also provide an opportunity for those that worked with and for Richard to post their memories and reminiscences of the great man. Please do post a comment, and also join us in Glasgow at what will certainly be an exceptional day.

LINK TO REGISTER: https://tinyurl.com/RTWmeeting

 

Biography

Born in 1925, Richard Turner-Warwick was educated at Bedales School – at Oxford University and at The Middlesex Hospital Medical School in London. At Oxford he took an honours degree in Natural Science.

He was captain of the Oriel College Boat Club, rowed in the 1944, 1945 Oxford Crews and won the Oxford and Cambridge Boat Race in 1946 when he was President of the OUBC. His MSc thesis was on Neuro-Anatomy.

During his pre-clinical training at The Middlesex Hospital he obtained the Senior Broderip Scholarship and a number of other Medals and Prizes – qualifying in 1949. From 1949 until 1960, mostly at The Middlesex Hospital, he had an unusually extensive specialist training in internal medicine and pathology – and then in abdominal, thoracic, gynecological, and plastic surgery. He trained in urological surgery with Sir Eric Riches and with Sir David Innes Williams at the Institute of Urology in London.

He obtained his FRCS in 1954, his MRCP in 1955, his Oxford Doctorate of Medicine in 1957 and his Oxford Mastership of Surgery in 1962. He was able to visit many urological centres in America as the Comyns Berkley Travelling Fellow – becoming a Senior Resident in Urology at the Columbia-Presbyterian Medical Centre in New York. He was appointed a Consultant General Surgeon to The Middlesex Hospital in 1960 – one of six, with additional charge of the Thyroid Clinic. His outpatient assistant at this time was Deborah Doniach, the pioneer of clinical auto-immunity – her treatment of Hashimoto’s lymphadenoid goitre with thyroxine led to its shrinkage so that decompression-thyroidectomy no longer provided the control histological material she needed – it was for this purpose that he developed his trephine biopsy instrument.

He took over the Urological Department at The Middlesex Hospital when Sir Eric retired in 1963. He created a pioneering urodynamic unit as an integral part of his routine clinical service – synchonously combining video-cysto-urethrography with measurement of pressure and flow voiding dynamics.

Since about 1975 he confined his personal surgical interest and practise to Functional Reconstruction – he was additionally appointed to the staff of St Peter’s Urological Hospitals in London and also an Honorary Visiting Urological Surgeon to the Royal Prince Alfred Hospital in Sydney in 1978 where he operated for three weeks each year until 1987. His main interest and reputation at that time was in reconstruction of the male urethra.

He was elected a Hunterian Professor of the Royal College of Surgeons in 1977, later serving on the Council of this and also that of the Royal College of Obstetricians and Gynaecologists. He was President of the British Association of Urological Surgeons 1982-1984. Among his many distinctions he was given the Victor Bonney prize of the RCOG; in 1987, the Valentine Gold Medal of the New York Academy of Medicine in 1991, the Gordon Watson Medal of the RCS in 1992, the Spence Medal of the American Association of Genito-Urinary Surgeons in 1997 and the William Didusch award of the for medical art in 2002.

He was elected to FACS (Hon). in 1997, to FRACS (Hon) in 1981, to elite Fellowship of the Urological Society of Australia in 1988 the Honorary Fellowship of the American Association of Genito-Urinary Surgeons in 2002. He was awarded an Honorary Doctorate of Science in New York in 1988. During the 40 years between 1965 and 2005 he undertook more than 300 operating surgical teaching visits – mostly in America, Australia, New Zealand but also in Europe and the UK.

 

The Genesis of Urethral Reconstructive Surgery over the Last 50 Years

In Honour of Richard Turner-Warwick

 Friday 10th – Saturday 11th October 2014
Royal College of Physicians and Surgeons, Glasgow

LINK TO REGISTER: https://tinyurl.com/RTWmeeting

 

Friday 10th October

Afternoon      Arrival

19:00             Dinner – with reflections by attendees

Royal College of Surgeons & Physicians, Glasgow

 

Saturday 11th October

09:00             Welcome and Introduction

Christopher Chapple & Roger Kirby

 

09.05              A Lifetime’s Experience of Urethral Surgery

Richard Turner-Warwick

 

09:15              Genesis of Anterior Urethral Surgery: From Scrotum to Oral Mucosa

Jack McAninch

(15 minutes talk, with 5 minutes questions and discussion)

 

09:35              Developments in Bladder Reconstruction

Anthony Stone

(15 minutes talk, with 5 minutes questions and discussion)

 

09:55              Anastomotic Urethroplasty: To Transect The Urethra Or Not? The Heineke Mikulicz Approach

Julian Shah

(15 minutes talk, with 5 minutes questions and discussion)

 

10:15              Oral Mucosa and Beyond

Richard Inman

(15 minutes talk, with 5 minutes questions and discussion)

 

10:35              Effective Management of Lichen Sclerosis

Sanjay Kulkarni

(15 minutes talk, with 5 minutes questions and discussion)

 

10:55              Break for Morning Coffee

 

11:15              Reflections on a Lifetime’s Practice

James Wong

(15 minutes talk, with 5 minutes questions and discussion)

 

11:35              Lessons Learned From the Use of Stents

Christopher Chapple

(15 minutes talk, with 5 minutes questions and discussion)

 

11:55              Penile Surgery

Culley Carson

(15 minutes talk, with 5 minutes questions and discussion)

 

12:15              Hypospadias

Patrick Duffy

(15 minutes talk, with 5 minutes questions and discussion)

 

12:35              Break for Lunch

 

13:30              Difficult Retrieval Surgery

Tony Mundy

(15 minutes talk, with 5 minutes questions and discussion)

 

13:50              Colonic Mucosal Graft Ventral Onlays Utilizing the TEM Transanal Approach

Leonard Zinman

(15 minutes talk, with 5 minutes questions and discussion)

 

14:10              Development of Contemporary Management of Pelvic Fracture Urethral Distraction   Injury

George Webster

(15 minutes talk, with 5 minutes questions and discussion)

 

14:30              Posterior Urethral Reconstruction Following Radical Prostate Surgery: Minimally Invasive Approaches to the Posterior Urethra

Roger Kirby

(15 minutes talk, with 5 minutes questions and discussion)

14:50              Round Table Discussion

All speakers

What do we do well? What don’t we do so well?  What needs to be developed for the future?  Who should carry out surgery?  How should they be trained?  Is there a minimum number of procedures somebody should do per year?  How should we assess outcomes? (45 minutes)

 

15:35              Summary of meeting (10 minutes)

 

15:45              Meeting Closes

 

Best of China 2014

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Introduction

Recent years have witnessed the boom of Chinese urology. An increasing amount of high-quality research is carried out in China, which is reflected in increasing numbers of articles being accepted by prestigious journals like BJUI. As the president of the Chinese Urological Association, I believe that it is necessary to select provocative articles – focusing on better solutions to widely discussed clinical issues as well as latest achievements from Chinese laboratories – for readers in China and abroad. This BJUI Virtual Issue – Best of China 2014 includes 12 studies from Chinese urologists, covering a wide range from basic research, translational medicine to clinical concerns. Many of the selected studies are aimed to assess the safety and efficacy of a certain urological surgery, such as remote ischaemic preconditioning during laparoscopic partial nephrectomy (by Prof. Yiran Huang), tubeless percutaneous nephrolithotomy (by Prof. Qing Jiang) and photoselective vaporization of the prostate (by Prof. Danfeng Xu), which are hot issues in the clinic. Also, the articles on functional molecules in the progress of urinary disorders (by Prof. Benkang Shi) and urological pathology and epidemiology (by Prof. Liqun Zhou) are well worth reading. I hope that this collection can provide interest and value, and that this Virtual Issue can help to build a solid connection between Chinese urologists and the peers of the world. Many thanks to all of those who contribute to the development of Chinese urology as a cause.

引言

近年来，中国泌尿外科事业发展迅猛，涌现出越来越多高质量的科研成果。在BJUI等权威杂志上中国学者的文章日益增多就是很好的说明。作为CUA的主任委 员，我认为将那些具有启发性的中国泌尿外科学者的文章加以整理，以飨读者是很有意义的。这些文章或是有关临床问题的解决方案，或是有关实验室的最新进展。 这部精选合集就选择了12篇中国泌尿外科学者近期在BJUI发表的文章，内容涵盖基础医学、转化医学和临床医学。有些文章侧重评估当前热议的一些泌尿外科 术式的安全性和有效性，比如肾部分切中远端缺血预处理技术（黄翼然） 、无造瘘管的经皮肾镜术（重医二附院 姜庆）和绿激光前列腺汽化术(徐丹枫)。另外，有关功能性分子在泌尿外科疾病进展中的作用（史本康）及泌尿外科病理学和流行病学的文章（周利群）也值得一 读。我希望这本合集能为读者带来兴趣和启发，希望这本精选集有助于建立中国泌尿外科学者和其他国家的同道之间紧密的联系。感谢那些为中国泌尿外科事业做出 贡献的人们！

Yinghao Sun MD, PhD
President, Second Military Medical University (SMMU)
Director & Professor, Department of Urology, Shanghai Hospital, SMMU
President, Chinese Urological Association (CUA)

Click here for the list of free articles

 

Editorial: Neutrophil-to-lymphocyte ratio as a prognostic factor in upper tract urothelial cancer

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The immune system response is critical to cancer development, treatment and progression. Dalpiaz et al. [1]. show that patients with a higher neutrophil-to-lymphocyte ratio (NLR) have a higher cancer-specific and overall mortality when undergoing radical nephroureterectomy for upper tract urothelial cell cancer (UTUC). The study is the first and largest one to evaluate the impact of preoperative NLR on UTUC and proposes its incorporation into our risk assessment tools as an independent predictor of survival.

Pathological prognostic factors such as tumour stage and grade have established importance in UTUC [2]. Additionally, lymphovascular invasion and tumour necrosis have been shown to be independent predictors of survival [3]. Preoperative markers have the advantage of prospective planning and counselling for treatment. The NLR has been studied in various cancers, including renal and gastric, and was recently incorporated into a risk stratification scheme for radical cystectomy patients as an independent prognostic factor for survival [4].

Dalpiaz et al. retrospectively reviewed 202 patients with UTUC who underwent radical nephroureterectomy. A threshold NLR value of 2.7 was used to discriminate between patients. NLR was significantly associated with lymphovascular invasion, but not with age, gender, tumour site, vascular invasion, tumour grade, pathological T-stage, tumour site, tumour location or presence of tumour necrosis. The mean follow-up was 45 months. The median survival was 44.5 months in the low-NLR group and 27 months in the high-NLR group. Multivariate analysis showed that T-stage and NLR were predictors of cancer-specific survival. High NLR and muscle invasion were shown to be independent predictors of overall survival.

Although interesting, these results should be interpreted cautiously as it is very difficult to control all confounders in a retrospective study. The authors did try to address aspects of the inflammatory response by incorporating Eastern Cooperative Oncology Group Performance Status and Charlson Comorbidity Index into their analysis. They found no statistically significant association between NLR and Eastern Cooperative Oncology Group Performance Status or Charlson Comorbidity Index. When adjusting for these variables, the relationships between NLR and cancer-specific survival and between NLR and overall survival were maintained. Although helpful in supporting the conclusions, using the Eastern Cooperative Oncology Group Performance Status and Charlson Comorbidity Index as markers of the inflammatory response should be approached carefully, as many other factors, such as hydronephrosis, tumour invasion, and pre-procedure treatments, which were not evaluated could have a more significant effect on the NLR than general measures of chronic conditions.

The threshold value of the NLR (2.7) was obtained by testing all possible thresholds and choosing a value based on its ability to predict survival and mathematical convenience. Thus the threshold value is self-serving to the conclusion. The statistical analysis suffers due to the dichotomous discrimination as opposed to further divisions like quartiles, but nonetheless shows the value of NLR as an important predictor, the threshold value of which might differ from cohort to cohort.

The present study shows that NLR as an important predictor of survival in UTUC. NLR is easy to perform, relatively inexpensive and is probably already available as part of the standard evaluation of patients with UTUC. It is therefore easy to assess. How should it change our practices? For example, should we be considering neoadjuvant chemotherapy, lymph node dissections or earlier radical surgery in patients with high NLR? The present study develops the hypothesis that can serve as the basis of future validation in a larger cohort or in a prospective fashion.

Read the full article

Moben Mirza
Department of Urology, University of Kansas, Kansas City, KS, USA

References
  2. Rouprêt M, Hupertan V, Seisen T et al.; French National Database on Upper Tract Tumors; Upper Tract Urothelial Carcinoma Collaboration. Prediction of cancer specific survival after radical nephroureterectomy for upper tract urothelial carcinoma: development of an optimized postoperative nomogram using decision curve analysis. J Urol 2013; 189: 1662–1669
  3. Zigeuner R, Shariat SF, Margulis V et al. Tumour necrosis is an indicator of aggressive biology in patients with urothelial carcinoma of the upper urinary tract. Eur Urol 2010; 57: 575
  4. Gondo T, Nakashima J, Ohno Y et al. Prognostic value of neutrophil-to-lymphocyte ratio and establishment of novel preoperative risk stratification model in bladder cancer patients treated with radical cystectomy. Urology 2012; 79: 1085

 

Guideline of Guidelines

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Many of us have developed an addiction to sports this summer. The World Cup football in Brazil with its continuous party spirit, the lush green lawns of Wimbledon and then the Test series between India and England. Our Web Editor could not contain himself:

Amidst all the fun and excitement, three important pieces of news are highlighted here:
  1. I requested our Associate Editor Stacy Loeb, who has a strong background in statistical methodology and health services research, to launch a series entitled ‘Guideline of Guidelines’. Most busy urologists tell me that they often find the many different society guidelines confusing. So we decided to publish a critical summary, finishing up with a set of ‘key points’ that our readers can use in their day-to-day practices. And what better way to kick off than with our biggest controversy – screening for prostate cancer [1].
  1. At #BAUS14 we conducted a live audience poll on when (and if) we should go completely digital. Here are the results:
  1. Inflammatory responses to tumours are recognised as being as important as stage and grade in predicting outcomes of treatment. Our ‘Article of the Month’ is a large 12-year European series of radical surgery for upper tract TCC. Neutrophil–lymphocyte ratio appears to be an important biomarker, as values of >2.7 confer worse cancer-specific and overall survivals [2]. The ratio of total neutrophils:total lymphocytes is easy to calculate from a routine preoperative blood test. I hope that many of you will be able to counsel your patients with this clinically useful biomarker.

Prokar Dasgupta
Editor-in-Chief, BJUI
Guy’s Hospital, King’s College London, London, UK

References

Editorial: The importance of knowing testosterone levels in patients with prostate cancer

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The paper by San Francisco et al. [1] in this issue of BJUI, reviews 154 patients with prostate cancer who were included in an active surveillance cohort. In all, 54 (35%) progressed to active treatment. Men who had disease reclassification had significantly lower free testosterone than those who were not reclassified. They concluded that on multivariate analysis, free testosterone and a family history of prostate cancer were independent predictors of disease reclassification. The authors acknowledge that this was a retrospective study of small size and the data was missing in some of the men, sex hormone-binding globulin (SHBG), luteinizing hormone and oestradiol were not measured. Nevertheless, this review adds to the increasing evidence that it is important to measure testosterone levels in men with prostate cancer.

Previous studies have indicated that a low testosterone level before treatment for prostate cancer is an independent predictor of a more aggressive high-grade cancer [2]. In addition to this, there appears to be an increased likelihood of extraprostatic disease at the time of diagnosis [3] and an unfavourable response to treatment [4].

Garcia-Cruz et al. [5] in 2012 reported that low testosterone bioavailability is related to a positive prostate cancer diagnosis in patients submitted for prostate biopsy. In a further study, he showed that low testosterone levels were related to poor prognosis factors in men with prostate cancer prior to treatment. Testosterone was inversely related to prostate cancer bilaterally and percentage of tumour in the biopsy. Higher testosterone levels were found in patients allocated to the low-risk progression group. In the multivariate analysis, older age and lower testosterone levels were related to a higher D’Amico risk of progression [5]. The researchers went on to show that higher SHBG and lower bioavailable testosterone are related to prostate cancer detection on biopsy. The study was a prospective analysis of 279 patients referred for prostate biopsy. Low bioavailable testosterone and high SHBG levels were related to a 4.9- and 3.2-fold increased risk of detection of prostate cancer on prostate biopsy taken due to an abnormal PSA result or an abnormal DRE [6].

Free testosterone accounts for about 1–2% of total testosterone and hence most circulating testosterone is bound to SHBG and as such, is inactive. Yamamoto et al. [7] had previously shown that men with a low free testosterone (<1.5 ng/dL) had an increased risk of a high Gleason score (>8) compared with men with higher free testosterone (8% vs 2%; P = 0.04). Additionally, a free testosterone level of <1.5 ng/dL was associated with increased risk of biochemical recurrence of tumour.

Morgentaler et al. [8] have been turning conventional wisdom upside down. They report on 13 symptomatic testosterone deficient men who also had untreated prostate cancer. The men received testosterone therapy while undergoing active surveillance for a median of 2.5 years. None of the men had aggressive or advanced prostate cancer and they were rigorously followed up. Despite effective treatment, neither the PSA level nor prostate volume showed any change. Follow-up biopsies were taken in all of the men at yearly intervals and none developed cancer progression.

It is intriguing to think that the decline in testosterone with age and comorbidities may contribute to tumorigenesis in the prostate. Clearly this study needs to be replicated with much larger numbers. But it seems reasonable to suggest that we ought to know about the hormonal environment existing in our patients with prostate cancer. This will of course, raise the even more controversial area of what to do about men with symptomatic hypogonadism with treated and untreated prostate cancer. There is limited data available on this issue.

Before considering testosterone therapy, the first step should be intensive lifestyle intervention; this is not only known to improve cancer survival, but raises total and free testosterone. Weight loss inhibits aromatase, and other complex cytokines, this reduces the suppression of the pituitary gonadal axis and conversion of testosterone to oestrogen, raising testosterone levels.

Read the full article

Michael Kirby*,†
*The Prostate Centre, London, and †Institute of Diabetes for Older People (IDOP), Beds & Herts Postgraduate Medical School, Puckeridge Bury Campus, Luton, UK

References

  1. San Francisco I, Rojas P, Dewolf W, Morgentaler A. Low free testosterone predicts disease reclassification in men with prostate cancer undergoing active surveillance. BJU Int 2014; 114: 229–235
  2. Massengill JC, Sun L, Moul JW et al. Pretreatment total testosterone level predicts pathological stage in patients with localized prostate cancer treated with radical prostatectomy. J Urol 2003; 169: 1670–1675
  3. Chen SS, Chen KK, Lin AT, Chang YH, Wu HH, Chang LS. The correlation between pretreatment serum hormone levels and treatment outcome for patients with prostatic cancer and bony metastasis. BJU Int 2002; 89: 710–713
  4. Ribeiro M, Ruff P, Falkson G. Low serum testosterone and a younger age predict for a poor outcome in metastatic prostate cancer. Am J Clin Oncol 1997; 20: 605–608
  5. Garcia-Cruz E, Piqueras M, Huguet J et al. Low testosterone levels are related to poor prognosis factors in men with prostate cancer prior to treatment. BJU Int 2012; 110: E541–546
  6. Garcia-Cruz E, Carrión Puig A, Garcia-Larrosa A et al. Higher sex hormone-binding globulin and lower bioavailable testosterone. Scand J Urol 2013; 47: 282–289
  7. Yamamoto S, Yonese J, Kawakame S et al. Preoperative serum testosterone level as an independent predictor of treatment failure following radical prostatectomy. Eur Urol 2007; 52: 696–701
  8. Morgentaler A, Liphultz LI, Bennett R, Sweeney M, Avila D Jr, Khera M. Testosterone therapy in men with untreated prostate cancer. J Urol 2011; 185: 1256–1260
Read more articles of the week

SoMe Guidelines in Urology: #urojc August 2014 summary

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The August 2014 twitter-based international urology journal club (#urojc) took an introspective look at the newly published European Association of Urology recommendations on the appropriate use of social media.

This month’s article hit close to home as a panel of international urologists (many who are active on Twitter and #urojc) attempted to bring social media (SoMe) to the general public of urologists with some basic guidelines on effective, safe and honest communication. The article described the various social networks frequently used by physicians, highlighted some benefits of SoMe involvement, and pointed out the possible risks of SoMe. Recommendation statements emphasized clear, confidentiality, refraining from self-promotion, limits on patient-physician interaction and caution in engaging in SoMe.

From the start, it was evident that this was not a fluff piece and there was discussion to be had:

 

@CBayneMD started it off with concern about the recommendation to keep personal and professional content separate. Many argued that adding something personal kept the communication more interesting and reminded readers that behind the online persona is a person.

 

Good arguments were made on both sides. Using different SoMe outlets for personal and professional posts may make it easier to keep it appropriate.

 

The guideline section on refraining from self-promotion was generally well accepted, though some clarification was called for.

 

Another criticism was of the group of EAU panelists chosen to write the guideline. An excellent choice was made to include the twitter handles of the guidelines authors in the byline.

 

Several of the authors are undoubtedly SoMe experts.

 

@wandering_gu, one of the authors, defended the decision to include authors with varied levels of SoMe experience.

A common twitter disclaimer, amongst physicians, “RT (retweets) are not E (endorsements)” may or may not be worth much.

…but may be necessary, nonetheless.

@Dr_RPM summarizes the message of this guideline document.

Whether or not you agree with the EAU SoMe guidelines or the previously published BJUI SoMe Guidelines, it’s clear that SoMe in medicine, and especially urology, is an important part of the future. We should all continue to be thoughtful in our involvement with SoMe and encourage our friends and colleagues to participate. Thank you all for another exciting discussion. Make sure to keep an eye on @iurojc and #urojc for next month’s International Urology Journal Club!

 

Parth K. Modi is a PGY-4 urology resident at Rutgers-RWJMS in New Brunswick, NJ. He has an interest in urologic oncology, robotics and bioethics and tweets @marthpodi.

 

Editorial: Unveiling the surgical risk associated with neoadjuvant chemotherapy in bladder cancer

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In this issue of BJU International, Johnson et al. [1] examine the association between neoadjuvant chemotherapy (NAC) for bladder cancer and 30-day morbidity related to radical cystectomy (RC). Level 1 evidence supports use of cisplatin-based NAC for bladder cancer; a meta-analysis of 11 randomised trials including 3005 patients who received NAC found a 5% absolute increase in 5-year overall survival and a 9% absolute increase in 5-year disease-free survival compared with RC alone [2]. Despite this, recent studies have reported underutilisation of NAC at ≈20% [3], with several reasons proposed for this ‘non-compliance’ to guidelines. A 2013 National Cancer Data Base (NCDB) analysis found that increasing age, lower patient income, and treatment at a non-academic institution (P < 0.01) negatively influenced the receipt of NAC, while higher clinical stage and fewer comorbid conditions were associated with higher likelihood of receiving NAC (P < 0.01) [3].

Another relevant concern is that NAC may increase perioperative complications for RC given the toxicities associated with chemotherapy, advanced age and often high rates of renal and cardiac comorbidities among potential candidates [4]. Credit should be given to Millikan et al. [5] for first negating this fear in 2001 with a randomised trial comparing NAC vs adjuvant chemotherapy in patients with bladder cancer; this study did not find any increase in perioperative morbidity.

The present analysis by Johnson et al. [1] further debunks this misconception in contemporary practice (2005–2011), drawing on the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), which prospectively collects a sample of risk-adjusted validated surgical patient data from >450 participating USA hospitals. The authors show that NAC was not an independent predictor of complications, reoperation, wound infection or dehiscence. The robustness of these findings is reinforced by the shorter adjusted length of stay among patients receiving NAC. Given that scant data exists on this topic, the authors contribute a valuable paper that substantially adds to the literature.

Despite its strengths, the study should be interpreted in light of notable limitations that the authors acknowledge. Many crucial variables are not tracked by the NSQIP and therefore cannot be accounted for, including type of chemotherapy regimen, delay between chemotherapy and surgery, surgical technique (open, laparoscopic, robotic), surgical quality (margins, extent of lymphadenectomy), clinical/pathological stage of bladder cancer, and hospital/surgeon volume. Besides, because RC is a morbid procedure with a mean length of stay of 11 days, 30-day complication rates do not capture its true morbidity as well as 90-day rates. In particular, several common complications, such as postoperative ileus or small bowel obstruction, tend to occur later during the postoperative recovery period. As such, chances are that the event rate is biased downward by the short-term duration of data capture by the NSQIP. This study also cannot fully examine the association of NAC with certain subtypes of complications, including gastrointestinal or bleeding complications, especially when other investigators examining robotic RC have reported a conflicting increase in perioperative complications associated with NAC [6] driven by a 27% rate of gastrointestinal complications, which are not tracked by the NSQIP. Of note, unadjusted rates of transfusion and bleeding events were both higher in the NAC group in the present study.

One of the relevant and heartening observations of the report is the gradual increase in the use of NAC over the study period from 4% of eligible patients to 11%, close to the NCDB estimates of 7.6% in 2006 to 20.9% in 2010 (P < 0.01) [3]. Interestingly, there was an increased probability of any complication in the most recent time period (odds ratio 0.47 for 2005–2009 relative to 2010–2011 in the primary multivariate model, P < 0.001). A plausible explanation is that as physicians have heeded the message to increase usage of NAC, treatment has expanded into a wider population with more comorbidities and therefore a greater propensity for complications. It would have been of interest to address this point by restricting the analyses to the most recent data to see if NAC does indeed predict perioperative complications in the most recent period from 2010 to 2011.

Finally, given the lack of detail available in the NSQIP, other relevant questions could not be addressed. Among them it would be relevant to know if complication rates vary between standard MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) and newer chemotherapy regimens such as dose dense MVAC (DD-MVAC) or gemcitabine plus cisplatin (GC). Similarly, the role of the delay or the elapsed time between chemotherapy and surgery on complications might be helpful in future trial planning.

Additional work still needs to be done to identify prognostic factors for both perioperative complications and long-term outcomes after NAC, so that this valuable therapy can be appropriately provided to the correct patients. Indeed, given the lack of randomised controlled trial data investigating less toxic regimens than MVAC, perhaps NAC is underused because clinicians and patients are underserved by the available data. The authors should be commended for their efforts in deconstructing possible barriers to increased uptake of NAC, a therapy known to confer survival benefits for our patients with bladder cancer.

Joaquim Bellmunt,*† Jeffrey J.Leow‡ and William Martin-Doyle§
*Bladder Cancer Center, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, USA; †University Hospital Del Mar-IMIM, Barcelona, Spain; ‡Brigham and Women’s Hospital, Division of Urology and Center for Surgery and Public Health, Boston, MA, USA; §University of Massachusetts Medical School, Worcester, MA, USA

Read the full article

References

  1. Johnson DC, Nielsen ME, Matthews J et al. Neoadjuvant chemotherapy for bladder cancer does not increase risk of perioperative morbidity. BJU Int 2014; 114: 221–228
  2. Bellmunt J, Orsola A, Wiegel T et al. Bladder cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. ESMO Guidelines Working Group. Ann Oncol 2011; 22 (Suppl. 6): 45–49
  3. Zaid HB, Patel SG, Stimson CJ et al. Trends in the utilization of neoadjuvant chemotherapy in muscle-invasive bladder cancer: results from the National Cancer Database. Urology 2014; 83: 75–80
  4. Meeks JJ, Bellmunt J, Bochner BH et al. A systematic review of neoadjuvant and adjuvant chemotherapy for muscle-invasive bladder cancer. Eur Urol 2012; 62: 523–533
  5. Millikan R, Dinney C, Swanson D et al. Integrated therapy for locally advanced bladder cancer: final report of a randomized trial of cystectomy plus adjuvant M-VAC versus cystectomy with both preoperative and postoperative M-VAC. J Clin Oncol 2001; 19: 4005–4013
  6. Johar RS, Hayn MH, Stegemann AP et al. Complications after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 2013; 64: 52–57
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Social Media and Twitter from a Resident’s Perspective

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“Happy Twitterversary! You’ve just turned 1”

Really? As I stared bleary eyed, post-call at the email in my inbox I couldn’t believe what an ingenious idea such an email was (how many of us remember the day we started using Twitter?) and that another year as a resident (albeit on Twitter) was behind me.

No question I was a “slow adapter” to social media, in particular Twitter – it was too reactionary, I was too busy, it would take up too much time. I can’t remember how or why I was persuaded, but curiosity led to me to create a Twitter account in the middle of the night while waiting to put up a ureteral stent. Immediately my perception and the time frame in which I obtained information completely changed. I started adding accounts for sports and news outlets and…..urologists and urology journals. Who knew?!

Over the past year, I’ve become more comfortable and engaged with Twitter. As a resident, there are a number of opportunities and a few challenges associated with navigating and managing a successful and educational Twitter experience.

Opportunities:

1) World-wide collaborations with leaders in the field who may otherwise be “less accessible” – as a resident, this may be THE most important aspect of Twitter. For those of us pursuing fellowship, building research connections, etc., being able to have access to and follow program directors and leaders in urology is invaluable.

2) Centralization for notifications of publications that are recently in press – as an aspiring urologic oncologist and academician, this is very helpful. BJU International (@BJUIjournal), the Journal of Urology (@JUrology), European Urology (@EUplatinum), Urology Match (@UrologyMatch) and UroToday.com (@urotoday) are personally a few of the most active and informative accounts I follow.

3) Connected at meetings – the ability to be “everywhere”! Getting updates from multiple concurrent sessions has changed the way I attend meetings. AUA 2014 this past year in Orlando was my first meeting on Twitter – to be able to keep up to date on concurrent sessions while contributing to the session I was attending, enhanced and broadened my learning experience.

Drs. Tim Averch, Benjamin Davies, Stacy Loeb, Brian Stork , Henry Woo, Matt Cooperberg, Declan Murphy (Not pictured, Dr. Christopher Bayne). American Urological Association Social Media Committee – See more at: https://www.drbrianstork.com/blog/medical-student-perspective-aua14/

 

 

4) Quick hit knowledge “tidbits” – what immediately comes to mind is the evolution of the International Urology Journal Club. This has been very useful and has changed the social media landscape for international, real-time, educational discussions.

Like everything with being a resident, Twitter takes time. However, whether we are walking to a meeting, waiting in the OR, riding the elevator, there are opportunities throughout the day to stay involved and engaged. While I may occasionally miss out on discussions, such as the 48 hours of Urology Journal Club (which may just happen to correspond with a call week), one can always use hashtags (ie. #urojc) to go back and catch up on the banter and knowledge shared.

Personally, I have yet to encounter my attendings expressing concern about what I’m Tweeting or how I’m engaging in social media. To my knowledge, residents are not receiving any formal training or best practice training in social media during residency.  As Twitter continues to evolve and the field of Urology continues to lead the medical foray into Twitter, a resident “social media ethics seminar” may be something the AUA considers during the national meeting. Perhaps this may be held in conjunction with the Twitter training sessions at the AUA Resource Center and may take into consideration the recent Engaging Responsibly with Social Media: the BJUI Guidelines and the EAU Recommendations. As importantly, medical students interested in Urology should be aware of their online profiles displayed on social networking websites, considering that program directors are increasingly utilizing this avenue to further evaluate residency applicants.

Until then, we may all consider sticking to the advice of ESPN Radio personality Colin Cowherd “Social media: Don’t do it after a cocktail or in your underwear.”

 

Zach Klaassen is a Resident in the Department of Surgery, Section of Urology Georgia Regents University – Medical College of Georgia Augusta, USA. @zklaassen_md

 

Editorial: Pushing the robot-assisted prostatectomy envelope – to the safety limits? Better outcomes

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The present article by Lim et al. [1] describing the new technique for robot-assisted radical prostatectomy is provocative. It really does highlight the dramatic improvement in outcomes of prostate cancer surgery for men over the last 25 years. What used to be a 3-week hospital stay with a 50% incontinence rate and a 100% impotence rate [2, 3] now becomes a day case with a high likelihood of excellent urinary control early after surgery and a fair potential for potency preservation. Twenty-five years ago men who underwent radical prostatectomy were truly brave patients.

Lim et al. report a single series by the senior author of 50 cases performed using the so-called Retzius preservation technique. Their cohort of 50 patients treated this way was compared with a retrospective cohort of the surgeon’s patients. The patients had lower-risk disease and patients who had seminal vesicle invasion or extracapsular extension noted preoperatively, presumably on MRI, were excluded from the series. The authors report a shorter operating time and an earlier return to urinary continence in the first 6 months after surgery.

I guess where surgeons are now taking us is to an attempt to remove the prostate from the hammock of neurovascular, muscular and fascial tissue surrounding it, without disturbing the anatomy [4]. If this can be achieved then radical prostatectomy with minimal morbidity is a very compelling choice for the primary treatment of prostate cancer.

The authors’ hypothesis is that preservation of the levator fascia, puboprostatic ligaments and detrusor apron will fix the bladder somewhat like a sling would, with support at the bladder neck during increased intra-abdominal pressure.

It should be noted, however, that the present paper represents a single series of patients selected after a long learning curve by a very experienced surgeon. These excellent outcomes may simply reflect the fact that the surgeon is now extremely technically capable. It is contentious to assume that a propensity score matching of a retrospective cohort would represent a true comparator to contemporary outcomes. These excellent outcomes probably reflect technical improvements achievable with more risky and innovative surgery – after many cases. The authors should be congratulated on pushing the envelope to achieve even better outcomes for patients undergoing this operation, but the exclusion of patients with high-risk disease is probably the major negative aspect of their report. It has become increasingly obvious that patients with high-risk disease are those who benefit most from radical prostatectomy surgery. Surgery for patients with very-low-risk disease (Gleason 6) is probably unnecessary. Nevertheless, with continued insights such as those provided by these surgeons, we may be able to increase the range of patients to whom Retzius-sparing surgery in higher risk cohorts can be offered.

Read the full article

Anthony J. Costello
Department of Urology, Royal Melbourne Hospital, Parkville, Victoria, Australia

References

  1. Lim SK, Kim KH, Shin T-Y et al. Retzius-sparing Robot-assisted Laparoscopic Radical Prostatectomy – combining the best of retropubic and perineal approaches. BJU Int 2014; 114: 236–244
  2. Wein AJ, Kavousi LR, Novick AC, Partin AW, Peters CA. Campbell-Walsh Urology, 10th edn. Saint Louis, MO: Saunders, 2011: 5688
  3. Catalona WJ, Carvalhal GF, Mager DE, Smith DS. Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol 1999; 162: 433–438
  4. Costello AJ, Brooks M, Cole OJ. Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU Int 2004; 94: 1071–1076
Read more articles of the week

Do we really need to show a survival benefit to justify ePLND in prostate cancer?

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Whilst extended pelvic lymphadenectomy has become part of standard care in select patients undergoing radical prostatectomy at some centres, it is not universally accepted or performed and remains controversial, so why is this? The most common reasons cited for not performing a node dissection, or at least an extended node dissection, include lack of proven therapeutic benefit and the increased operative time and risk of complications. But do we really need to show a survival benefit to accept the role of extended pelvic lymphadenectomy for patients undergoing radical prostatectomy? It would take a randomised trial run over at least a decade, thousands of patients and untold cost to prove or disprove. Although randomised trials can be invaluable in assessing some aspects of medical or surgical care, they are not always appropriate or even desirable for surgical outcomes as O’Brien et al eloquently illustrated. What’s more, results from RCTs in surgery can be misleading – consider the Prostate Cancer Intervention Versus Observation Trial, in which overall survival at a median follow-up of 10 years was approximately 50% in both arms. This is equivalent to the overall survival in the observation arm of Messing’s trial, in which virtually no patients died of non-prostate cancer causes and contrasts starkly with the current life expectancy of 65 year old males in Australia of 20 years. Patients in PIVOT weren’t living long enough to die from prostate cancer!

There is no doubt that for accurate nodal staging, an extended lymphadenectomy is currently the gold standard, as reflected in the EAU guidelines on prostate cancer. Two very elegant trials in recent years assessed the performance of similar templates in terms of staging accuracy and concluded that a modified extended template struck the right balance between accuracy and risk of complications. Joniau et al, showed in a prospective cohort of 74 patients, around half of whom were lymph node positive, a modified extended template including the pre-sacral nodes had a staging accuracy of 97% and removed 88% of positive nodes. Omitting the pre-sacral nodes accurately staged 94% of patients and removed 76% of positive nodes. Mattei et al concluded that their modified ePLND removed approximately 75% of “sentinel” nodes in a prospective series of 34 node negative patients. Whether a “modified” ePLND or “plain” ePLND is performed, the staging accuracy is significantly better than a “standard” PLND, which omits the nodes around the internal iliac vessels and according to Joniau et al would accurately stage 76% of patients and remove only 29% of positive nodes. A “limited” node dissection, removing only the tissue within the obturator fossa performed even worse, staging 47% and removing just 15% of positive nodes.

 From Mattei et al European Urology 2008, 53:118-125

But what is the real value in accurate nodal staging? Does it change patient management? The Messing trial showed that node positive patients who received adjuvant hormone therapy had improved CSS and OS compared to node positive patients observed until clinical progression. The study, however, has limited application to current real life patient management. Whilst patients with high volume nodal disease are likely to benefit from adjuvant hormone therapy, some patients with node positive disease, particularly those with micro-metastatic disease, will not suffer biochemical progression let alone clinical progression and therefore may not warrant ADT. Furthermore, most patients will be commenced on hormone therapy according to specific PSA criteria long before clinical progression. Despite these apparent weaknesses, the CSS and OS are remarkably similar to many retrospective series of node positive patients outside trials and managed in “real life”. Bader and Schumacher presented series of 92 and 122 node positive patients respectively, none of who received adjuvant hormone therapy. Ten year CSS for both of these series was approximately 60% and 10-yr OS in the Schumacher cohort was 53%, almost identical to the 10-yr OS in the Messing trial. Conversely, a number of retrospective series of node positive patients in which all, or almost all patients received AHT, 10-yr CSS ranged between 74-86% and 10-yr OS was 60 – 67%. These outcomes are similar to the AHT arm in Messing’s trial, in which 10-yr CSS was 85% and 10-yr OS was 75%. This is far from compelling evidence in favour of AHT in node positive patients, but it is certainly food for thought.

Rather than treat all node positive patients equally, however, we should be more sophisticated in our approach. Briganti and Schumacher have shown that patients with 1 or 2 positive lymph nodes have better 10-yr CSS than patients with 3 or more positive nodes whether they receive adjuvant hormone therapy or not. In Schumacher’s series, 10-yr CSS was 72-79% for patients with 1 and 2 positive nodes, versus 33% for patients with 3 or more positive nodes, without AHT. In Briganti’s series, 10-yr CSS for patients with 3 or more positive nodes was 73% and they were almost twice as likely to die from prostate cancer than those with fewer than 3 nodes positive. All patients received AHT. Perhaps then, we should consider patients with higher volume nodal disease on extended pelvic lymphadenectomy for immediate adjuvant hormone therapy, whilst those with micro-metastatic disease may be suitable for observation until predetermined PSA criteria are reached.

Beyond the staging benefit, Jindong et al recently published a prospective, randomised trial showing a BCR free survival benefit for patients undergoing extended versus standard pelvic lymphadenectomy. With a median follow-up of just over 6 years, intermediate risk patients undergoing ePLND had a 12% absolute reduction in biochemical recurrence (73.1% v 85.7%) and high risk patients more than 20% (51.1% v 71.4%) compared to those undergoing a standard node dissection. This may eventually translate into a survival benefit, or at least a clinical progression benefit, but in this cohort of patients, a reduction in biochemical recurrence means a reduction in the numbers requiring salvage radiation therapy and salvage androgen deprivation and the consequent side-effects and complications of these treatments.

It is clear the complication rate following ePLND is higher than with sPLND or no node dissection, but a recent review revealed the difference is accounted for by an increase in the incidence of symptomatic lymphoceles, most of which resolve with conservative management. Ureteric, nerve and major vascular injuries are rare. This would appear to be a much more acceptable complication profile than that following salvage radiotherapy, or androgen deprivation. Although uncommon, membranous urethral stricture following salvage radiation often confers debilitating and enduring morbidity. Continence and potency rates also suffer, not to mention bowel toxicity. A 20% absolute reduction in biochemical recurrence may also swing the pendulum away from adjuvant radiation in high risk disease, benefiting even more patients.

Proving a survival benefit with level 1 evidence is the holy grail of medical and surgical trials, but it is not the only outcome to consider. Biochemical recurrence following radical prostatectomy carries significant psychological burden and salvage therapies can carry significant morbidity. Disease recurrence is most common in the high risk population and there is now level 1 evidence of a real benefit to these patients when ePLND is included as part of their surgical care.

 

Dr Philip E Dundee

Epworth Prostate Centre and The Royal Melbourne Hospital

T: @phildundee

 

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