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Staring Into The Abyss

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I was surprised at the referral in the first place, but baffled after seeing the patient in the flesh. It was someone else’s clinic, and the note read that this 94 year-old man on androgen deprivation for asymptomatic low volume metastatic prostate cancer for many years had a climbing PSA. About 8. Please discuss combined androgen blockade with him. I began the talk about how combined blockade has a pretty weak benefit at the best of times, and that in a 94 year-old it almost certainly would not make him live any longer. He was asymptomatic, so he would not feel any better, and he may have a worsening of his side effects. I wrapped it up by telling him he was old enough to make his own decisions about his treatment, and if he didn’t want another pill to take, he could certainly say no. He said yes. I clarified the points about limited or no benefit, and possible exacerbation of side effects. He said if it would give him a few more years, he’d take it. I told him it wouldn’t. He wanted it anyway. I could not promise the treatment would not make him live any longer, and that was good enough for him. At the end of the consultation he was well counseled, and had made his decision. You might think of an 80 year-old you have seen who seemed more like a 60-year old, and think I was being unfair to the man, but I can confirm he was a 94 year-old who seemed very much to be 94.

I tend to assume that when people get to a certain age, they have come to terms with a few things, including death. This is not always the case, and I think running from death is becoming more popular. While research confirms that doctors have few illusions about treatment leading up to their own demise, and plan to refuse much of it, laypeople are hungry for all the invasive treatment they can get. As doctors, we don’t always help with this. We have pills and procedures that make statistically significant improvements in cancer specific survival, and what cancer sufferer would say no to that? We spend a lot more time studying how to hold failing anatomy together than we do learning to let entropy take its course. We have treatments that hint at immortality, nobody needs to die of Condition X anymore, now that we have Drug Y. What if this patient in front of us is the one in a hundred that has a durable remission? What if we kill them through inaction? What about the guilt-ridden estranged son who wants “Everything Done”?

Popular media have kept up a sustained and determined campaign for cardiovascular resuscitation in particular. Having an intelligent, sensitive, pragmatic talk to a family about not resuscitating the palliative patient due to the invasive, undignified nature of resuscitation for a virtually negligible chance of durable success is not as convincing as James Bond being defibrillated in his Aston Martin.

 

What is the definition of “good survivor” if not continuing to drink, gamble, and assassinate day zero post-resuscitation? Sadly, days or weeks of vegetative decline is much more common.

So what of the 94 year-old, who has already outlasted his cohort’s life expectancy by over 20 years? Who lived through two world wars, the rise and fall of the Soviet Communist state, the invention of Rock ‘n’ Roll, space flight, and electric foot spas? Objectively, he made an informed decision about his health care, prioritizing his values and concluding that the chance of increased quantity, however tiny, trumped quality. I can’t help think that in reality he kidded himself that he was beating death once again. He had evaded those cruel icy fingers, and secretly maybe thought he could live to a hundred and fifty. If he was my Grandpa, maybe I could have talked to him about embracing the end as a part of the natural cycle; not fearing, but accepting. But then, I was just his doctor.

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

 

Vasectomy causes aggressive prostate cancer – HELP!!!

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How many of you have already had a patient get in touch about this latest scare? As one expects nowadays, I first heard about this paper on Twitter within a few minutes of it being published, but it wasn’t long after that a recent patient of mine rang my rooms to challenge me about the reassurance I had given him only last week about the lack of increased risk of prostate cancer, which he had specifically asked me about. And of course since then, we have had headlines in the mass media all over the world alerting us to the results of this 24-year study that suggests that vasectomy confers an increased risk of not just prostate cancer, but high-grade prostate cancer in men undergoing vasectomy. Here are just some of the headlines:

 

So what are we to make of all this? The private vasectomy counselling has always been a challenging area due to the well documented possibilities of early and late failure, and also of the ever present issue of chronic scrotal pain. And while the area of prostate cancer risk has been raised previously, I must say I have always felt comfortable saying that on balance, the increased risk of developing significant prostate cancer following vasectomy proved to be minimal. “Don’t worry about it” was my typical blithe reassurance. Do I have cause to change my advice now?

Let’s look at this paper from Siddiqui et al. The data is taken from the well-known Health Professionals Follow-up Study (HPFUS), which originally enrolled almost 50,000 men aged between 40 and 75 back in 1986. Of these, about 12,000 (25%) underwent vasectomy and 6000 of these (12.2% of population) were subsequently diagnosed with prostate cancer over the 24-year follow-up period. Of these, 811 (1.6%) died of prostate cancer. The authors calculate that vasectomy was associated with a small overall increase in the risk of prostate cancer (RR = 1.10). However the headlines are coming from the higher relative risk of 1.22 among men subsequently diagnosed with high-grade prostate cancer (Gleason 8 to 10). Also, vasectomy appeared to confer a higher relative risk (1.19) of actually dying of prostate cancer or developing distant metastases compared to men who did not undergo vasectomy. It is these findings that vasectomy appears to confer not just an increased risk of prostate cancer, but an increased risk of developing aggressive or a lethal prostate cancer, which has provoked some concern.

This topic is not new and other studies have shown that this risk does not exist or at best, the risk is minimal and the quality of evidence not good enough to change practice. Does this current paper change all that? It will certainly change the nature of counselling for men considering vasectomy as there may well be a case to consider. As the population of men presenting for vasectomy are not a typical population who would be counselled about the early detection of prostate cancer, perhaps this other difficult counselling area also needs to be broached.

HELP!!!!

 

Declan Murphy is a urologist at Peter MacCallum Cancer Centre in Melbourne, Australia, and Associate Editor at BJUI. Twitter @declangmurphy

 

 

#UroJC July 2014 – Is there a place for laser techniques in our current schema of bladder cancer diagnosis and management?

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This month’s International Urology Journal Club (@iurojc) truly engaged a global audience with participants from ten countries including author Thomas Herrman (@trwhermann) from Hannover, Germany.  A landmark 2000 followers was reached during July, nearly two years since @iurojc’s conception in late 2012. In fact, since this time nearly 1100 people have participated in the journal club from around the world.

Bladder cancer was up for debate for the first time this year and @iurojc trialled the discussion of two complementary articles recently published online ahead of print in the World Journal of Urology.  The first article provided an update of the current evidence for transurethral Ho:YAG and Tm:YAG in the endoscopic treatment of bladder cancer, and the second was a randomised controlled trial (RCT) comparing laser to the gold standard transurethral resection of bladder tumour (TURBT).  Authorship groups were from Germany and China respectively; our Chinese authors unfortunately unable to join the dialogue due to restriction on all twitter activity in the country.

Initial conversation focussed on the methodology, results and limitations of the RCT, however this soon extended to a more general discussion around the current difficulties with the diagnosis and management of bladder cancer and the pros and cons of using laser for this purpose.  Key themes debated over the 48-hour period included the importance of accurate staging, current standards of TURBT, advantages of en bloc resection and the learning curve, cost and usefulness of laser technology.

Both studies reiterated one of the major goals outlined in the EAU guidelines for non-muscle invasive bladder cancer (NMIBC), to achieve correct staging with inclusion of detrusor muscle and complete resection of tumours.  This is important in limiting second resection and consequently has a resulting cost offset.  In the review article, only 3 studies commented on staging quality and another two commented that laser was suitable for staging but did not specify if detrusor muscle was identified.

@ChrisFilson and @CBayneMD expressed their concern over the RCT by Chen and Colleagues

@linton_kate astutely pointed out another limitation

and author of the review article @trwherrmann summed this up nicely

In the RCT by Chen et al. there was a significantly greater number of pT1 tumours detected with laser than TURBT, the authors suggested this might be due to better sampling.  It remains unclear if this would impact on management and this did not enter the arena for discussion during this @iurojc.

Many argued that TURBT techniques and practices should be optimised before newer techniques are introduced.

‘En bloc’ was touted as the new trendy word in endourology.  EAU guidelines recommend en bloc resection for smaller tumours.  The articles suggested that en bloc resection of bladder tumours should provide more accurate staging however conclusive data is missing to substantiate this in the current literature. 

@DrHWoo discussed potential advantages of the laser technique

@linton_kate pointed out that en bloc resection is not limited to the laser technique

Further to this, the lack of obturator nerve reflection with laser was emphasised in the RCT.  Obturator kick was noted during TURBT in 18 patients and none during laser resection, however none of these patients suffered bladder perforation.  The significance of this was debated and usefulness of obturator block in this context discussed.

The pendulum seemed to the swing out of favour of laser during the discussion, with several limitations outlined including reduced ability for re-resection, cost and the presence of a learning curve.

Regarding additional cost, the host rebutted

The flow of academic dialogue was interrupted midstream (pardon the pun) by a light-hearted discussion around the ergonomics of TURBT.

Below are some of the key take home messages that arose from the usual culprits in this month’s @iruojc discussion

Kindly author @trwherrmann invited us to his upcoming en bloc resection workshop.  Keep an eye out for this.

@iurojc would like to thank Prostate Cancer Prostatic Diseases who have kindly provided the prize for this month which is a 12 month on line subscription to the journal. @nickbrookMD’s made efforts to sway the vote his way.

Whilst usually the Best Tweet Prize is reserved for some incisive comment, the repeated complaints from @nickbrookMD for his failure to ever win the Best Tweet prize has seen for the first and final time that the @iurojc has bowed to pressure. Congratulations to @nickbrookMD for finally having made it with the above tweet.

If you haven’t tuned into @iurojc, follow future journal club discussions via the hashtag #urojc, on the first Sunday/Monday of each month. 

 

Dr Marnique Basto (@DrMarniqueB) is a USANZ trainee from Victoria who recently completed a Masters of Surgery in the health economics of robotic surgery and has an interest in SoMe in Urology.

 

 

 

 

Canadian Urological Association 69th Annual Meeting on the Rock

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June 27 to July 1, 2014 saw close to 900 Canadian urologists & associates come together in the country’s most easterly city – St John’s, Newfoundland – for the 69th annual Canadian Urological Association meeting (https://www.cua.org/). As ‘Newfies’ have a well-established reputation in our country for their extreme friendliness, unique traditions and ability to throw one hell of a party, it was a highly anticipated four days!

The meeting kicked off on Friday with various pre-CUA affiliated meetings, such as the Executive Committee Meeting, CAGMO and CUOG meetings. An optional Advanced Laparoscopic and Robotic Urology Skills Course was held over two days on Thursday & Friday. Also on Friday, the incoming final-year residents from across Canada began the annual senior resident retreat (CSUR), which included excellent sessions with Dr Gerald Brock on resident involvement with the CUA and Dr Robert Siemens on critically reviewing the literature. We residents were also lucky enough to be invited to enjoy a lobster dinner and beer tasting at YellowBelly Brewery & Public House – one of the oldest structures in North America dating back to 1725. Sitting at the intersection of Water St & George St, this impressive stone gastropub is the location where the ‘Great Fire of 1892’ was finally extinguished. The evening, for most, carried on to George St – the street with the most bars & pubs per square foot of any street in North America!

The CSUR course finished on Saturday after a great half-day review of urodynamics with Drs Greg Bailly and Jerzy Gajewski. Further affiliated meetings were held including the 2nd CUA Multidisciplinary Meeting for members of CAGMO, CUOG, GUROC and CNUP. An instructional course entitled Better Botox – from patient prep to injection protocols, was also offered to attendees. The major part of the CUA meeting (https://cuameeting.org/index.php/en/) began officially on Saturday afternoon with the first two Educational Forums – both on the topic of Castrate Resistant Prostate Cancer with tips and tools for the Canadian urologist to improve care of patients with CRPC. This included presentations from Drs Neil Fleshner, Ricardo Rendon, Alan So, Lorne Aaron, and Geoff Gotto. Here it was stressed that urologists should be comfortable as the primary physician giving medical treatment for CRPC. Saturday evening held the conference welcome reception – always a fantastic reunion – and unmoderated poster session.

Sunday morning started with a Welcome Address from CUA President Dr Peter Anderson, followed by the first State-of-the-Art Lecture on the role of medical management of nephrolithiasis in the age of lithotripsy with a focus on AUA Guidelines – an excellent overview presented by Dr Glenn Preminger of Durham, NC. A similarly themed Educational Forum covering medical management of stones in a case-based approach followed this; faculty included Dr Preminger as well as Drs Sero Andonian, John Dushinski and Jason Lee. The second State-of-the-Art Lecture saw Dr Surena Matin from Houston, TX present on neoadjuvant chemotherapy for UTUC, where he discussed benefits such as taking advantage of pre-op renal function and results showing both down-staging and a survival advantage. An Educational Forum followed on strategies for upper tract surveillance in urothelial carcinoma, management of post-op urinary diversion complications and contemporary use of biomarkers by Drs Matin, Adrian Fairey and Alan So. In the afternoon, Dr Eric Rovner from Charleston, SC gave a State-of-the-Art Lecture on SUI and slings. He presented an algorithm using the best available evidence on appropriate selection of sling type and reiterated that urodynamic studies are not necessary pre-operatively in the ideal index SUI patient. A forum entitled ‘Innovations in Functional Urology’ had Dr Catherine Dubeau from Worcester, MA joining Drs Sender Herschorn and Eric Rovner to discuss female SUI, post-prostatectomy incontinence and management of elderly patients with OAB. Dr William Gee from Lexington, KY then gave the address of the AUA President-elect, which was followed by the CUASF lecture by Dr Ron Kodama who discussed education & evaluation of residents. The late afternoon took a pediatric turn including a lecture by Dr Anthony Caldamone from Providence, RI on ‘Putting the Undescended Testicle in its Place!’ A point/counterpoint followed between Dr Caldamone and Dr Martin Koyle on the ideal surgical management for congenital duplication anomalies. The day wrapped up with podium sessions on pediatric urology, endourology and surgical education.

The annual CUA ‘fun night’ took place Sunday evening and was entitled Rally in the Alley. This was a very well-organized pub crawl that saw roughly 500 people split into 5 groups, each with a signature scarf colour and a different instrument to follow. For example, if you were in the blue bagpipe group, you put on your blue scarf and followed the bagpiper who would lead from pub to pub on George St (https://www.georgestreetlive.ca/). With one minute left before switching locations, you’d hear the bagpiper start up again – the signal to down your drink and move on! The five groups each did the pubs in a different order so that there was no overlap until everyone convened at the same final destination. In addition, each pub had a very ‘Newfie’ activity for everyone to try – including Irish Dancing, singing Newfie songs (‘we’ll rant and we’ll roar like true Newfoundlanders!’), and of course getting ‘Screeched in’ – a Newfoundland tradition involving reciting a poem, downing a shot of the cheap high alcohol spirit and kissing a freshly caught cod! It was an awesome night that truly gave all the ‘come from away’ folks a glimpse of life in Newfoundland (and perhaps a hangover to boot).

Monday was another full day, starting with moderated poster sessions on prostate cancer, pediatrics and sexual health and infertility. Next, Drs Paul Johnston and Stephen Steele gave a brief overview of clinical pearls that could change your practice. A State-of-the-Art Lecture by Dr Daniel Lin from Seattle, WA followed; he discussed selection of patients and outcomes in active surveillance. An Educational Forum came after this with Drs Laurence Klotz, Daniel Lin, and Chris Morash covering prostate biopsy and active surveillance.

The afternoon kicked off with the EAU Address from Dr Andrzej Borkowski of Warsaw, Polland, followed by a State-of-the-Art Lecture from Dr Mark Speakman of Somerset, UK on LUTS/BPH. Dr Speakman’s lecture was both highly entertaining and informative, and he stressed the importance of exercise and a healthy lifestyle in preventing LUTS progression. Drs Speakman, Gerald Brock, Sender Herschorn, and David Staskin of Boston, MA then gave an educational forum on prevention and management of LUTS/BPH. Dr Laurence Levine then discussed treatment of Peyronie’s Disease in the seventh State-of-the-Art Lecture, giving a useful summary on which type of surgery to choose depending on patient factors such as penile length and erectile function. An Educational Forum finished off the afternoon and covered the often-dreaded topic of Management of Scrotal Pain. Drs Keith Jarvi, Jay Lee, and Laurence Levine emphasized the importance of a multi-disciplinary approach in dealing with this type of chronic pain, and created a systematic approach that most urologists could utilize to avoid feeling helpless in dealing with this disorder. Dr Levine also showed promising results of micro-denervation of the spermatic cord for patients with refractory scrotal pain and good response to a cord block.

Monday evening held the annual President’s Reception. At the back of the room was a bar made entirely from carved ice – proving that Newfies really do love their icebergs. You can even drink beer made using 25,000-year-old iceberg water harvested from a Newfoundland ‘berg! These huge ice formations can be seen, along with whales, from the very picturesque, well-worth-the-climb, Signal Hill in St John’s. The reception also saw Dr Peter Anderson present Dr Jerzy Gajewski with the CUA Lifetime Achievement Award; clearly a surprise to Dr Gajewski but a well-deserved honour. Dr Anderson then handed over the reigns as CUA president to Dr Stuart Oake, who gave a sneak preview of what to expect in Ottawa for the annual meeting in June of 2015.

The final day of the conference started with a smorgasbord of topics in six different moderated poster sessions. Drs Bobby Shayegan and Keith Rourke covered ‘clinical pearls that could change your practice’ – a collection of useful tidbits collected during the various lectures and forums throughout the 4-day conference. Dr Derek Puddester gave a State-of-the-Art Lecture on physician health & wellness, reminding us all to practice mindfulness often. The final State-of-the-Art Lecture was by Dr Axel Heidenreich from Aachen, Germany, who covered the role of radial prostatectomy in the management of locally advance and metastatic prostate cancer. The last educational forum was on optimizing patient outcomes in kidney cancer – a session given by Drs Heidenreich, Rodney Breau, Steven Pauler and Simon Tanguay.

As the conference came to a close, staff and residents from across the country sat in the St John’s airport and reminisced about the week’s events. It was not only a great educational opportunity that many took advantage of; it was also a relaxing reunion for the relatively small group of urologists that are spread out across this vast country. Kudos to Dr Anderson and the Local Organizing Committee lead by Chair Dr Chris French, for putting on a meeting to remember. Newfoundland is certainly a beautiful and unique corner of our great country, and anyone would be wise to pay ‘the Rock’ a visit (https://www.newfoundlandlabrador.com/). Finally, if there is anywhere better to spend Canada Day than the charming easterly city of St John’s Newfoundland, it’s Ottawa, Ontario. So mark your calendars, as everyone is invited to the CUA meeting in Ottawa, June 27-30 2015! See you there!

 

Ellen Forbes is a Urology Resident at the University of Alberta. Twitter: @DrElForbes

 

Editorial: Is zero sepsis alone enough to justify transperineal prostate biopsy?

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The landscape of infectious complications after TRUS-guided biopsy of the prostate has changed dramatically. While sepsis after TRUS-guided prostate biopsy has always been a concern for urologists performing this very common procedure, in the past couple of years a number of factors have added to these pre-existing concerns for urologists and patients alike.

First, key papers have reported the true incidence of sepsis and hospital re-admission after TRUS biopsy and have shown that these rates are increasing. Loeb et al. [1] reported that the 30-day re-admission rate in a Surveillance, Epidemiology and End Results (SEER)-Medicare population was 6.9% and that this rate is increasing. Nam et al. [2] similarly reported a 3.5-fold increase in hospital admissions after prostate biopsy in the previous 10 years, principally attributable to infection-related complications. These reports have been replicated around the world and there is consensus that this is a growing problem.

Second, there are increasing concerns about the emergence of resistant organisms, in particular, extended spectrum beta lactamase (ESBL), in regions where antibiotic use has contributed to the emergence of these strains [3]. Media attention has focused on this issue and has led to increased concerns among urologists and patients alike. It has also led to a requirement for extra precautions when assessing patients for prostate biopsy such that in some regions, rectal swabs are being taken to identify ESBL-carriers ahead of time. In a contemporary series, Taylor et al. [4] report that 19% of men undergoing transrectal prostate biopsy in Canada carry ciprofloxacin-resistant coliforms in rectal swabs. The thought of passing a needle through this flora into the prostate is somewhat disturbing; rectal swabs may become mandatory when offering a TRUS-guided biopsy to any patient and should absolutely be taken if planning a TRUS biopsy in someone who has travelled to South-East Asia in the preceding 6 months.

The Bloomberg News, in a well-researched report into antibiotic use in India and the emergence of resistant strains of Escherichia coli, reported some startling statistics about the overuse of antibiotics in that country, and described how the ‘perfect storm’ of antibiotic overuse, poverty and poor sanitation (half of the country’s 1.2 billion residents defaecate in the open), is contributing to the emergence of superbugs colonizing the gut of dwellers and visitors to India [5]. It is clear that even walking through a puddle in New Delhi puts a visitor at high risk of harbouring ESBL organisms in the rectum for many months after.

In this month’s BJUI, Vyas et al. [6] describe a consecutive series of 634 patients undergoing prostate biopsy at Guy’s Hospital in London using a transperineal template-guided approach, and report a sepsis rate of zero. They also report other notable factors including a 36% cancer detection rate in men who had previously undergone transrectal prostate biopsy with no evidence of malignancy and, in men on active surveillance for Gleason 6 prostate cancer, they observed upgrading to Gleason ≥7 cancer in 29% of cases after immediate re-staging biopsy using a transperineal approach. An even larger contemporary study from Pepe et al. [7] reports zero sepsis in a consecutive series of 3000 men undergoing transperineal prostate biopsy.

It is quite impossible to imagine such large series of prostate biopsies with no episodes of sepsis if performed using a transrectal approach. The documented increasing levels of ESBL and high levels of asymptomatic gut colonization, especially for those resident or travelling through South-East Asia, mean that adequate risk assessment and counselling of patients before TRUS biopsy is more important than ever before. A careful history regarding recent antibiotic use is also essential as previous recent use of quinolones is also a risk factor for infection after a transrectal biopsy [8].

While widespread adoption of a transperineal approach to prostate biopsy would have considerable resource and logistic issues, and inevitably would not be accepted by all urologists, the rising rate of infectious complications and of resistant organisms colonizing the rectum may mean that continuing with a transrectal approach becomes too risky and therefore unacceptable to patients and clinicians alike. While a transperineal approach also appears to add value in terms of more accurate staging and also facilitates the emerging interest in MRI fusion-guided biopsies and focal therapy, zero sepsis alone may be enough to convince many that a transrectal approach should no longer be preferred.

Read the full article

Declan G. Murphy*†, Mahesha Weerakoon† and Jeremy Grummet‡

*Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, †Australian Prostate Cancer Research Centre, Epworth Richmond Hospital, and ‡Department of Urology, The Alfred Hospital, Melbourne, VIC, Australia

References

  1. Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Complications after prostate biopsy: data from SEER-Medicare. J Urol 2011; 186: 1830–1834
  2. Nam RK, Saskin R, Lee Y et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2010; 183: 963–968
  3. Williamson DA, Masters J, Freeman J, Roberts S. Travel-associated extended-spectrum beta-lactamase-producing Escherichia coli bloodstream infection following transrectal ultrasound-guided prostate biopsy. BJU Int 2012; 109: E21–22
  4. Taylor S, Margolick J, Abughosh Z et al. Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int 2013; 111: 946–953
  5. Gale JN, Narayan A. Drug-defying germs from India speed post-antibiotic era. 2012; Available at: https://www.bloomberg.com/news/2012-05-07/drug-defying-germs-from-india-speed-post-antibiotic-era.html. Accessed June 2014
  7. Pepe PA, Aragona F. Morbidity after transperineal prostate biopsy in 3000 patients undergoing 12 vs 18 vs more than 24 needle cores. Urology 2013; 81: 1142–1146
  8. Patel U, Dasgupta P, Amoroso P, Challacombe B, Pilcher J, Kirby R. Infection after transrectal ultrasonography-guided prostate biopsy: increased relative risks after recent international travel or antibiotic use. BJU Int 2012; 109: 1781–1785

 

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Consultant on call: incorporating lean thinking or Chaos theory?

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The RCS report on ‘the implementation of the working time (EWTD) directive’ has recently been submitted. Recommendations include the need to rethink teams and services working patterns.

In urology a combination of the EWTD, depleted middle grade numbers and political will, have necessitated that consultants increasingly deliver out of hours service. There are theoretical advantages to a consultant being first point of call: the most experienced clinician physically present on the ‘shop floor’, delivering expertise at the point of contact with the patient, identifying and treating conditions more quickly than a more junior doctor. These views were supported by a major impact paper published in the BMJ that highlighted increased death rates for elective cases operated on Fridays and at the weekend. The conclusion from this paper and popularised in the press was that patients are more susceptible when senior doctors are not on the ‘shop-floor’. However there are recognised confounding variables to the papers findings. Friday operating lists have often been allocated to the most junior surgeons and post-operative complications are primarily related to co-morbidities and what occurs on the operating table, rather than the variability and quality of decisions made in post-operative care. Incomplete data was excluded and there may be a weekend effect for routine coding. The study itself highlighted the weaknesses of using administrative data and selection biases that exist for elective procedures scheduled on weekends.

The downside of frontline consultants is underutilization. The need to maximize utilization of staff-skills is not unique to healthcare and whole support industries have developed to optimise this most precious of resources. One of the most successful approaches has been lean thinking, which originated in the Japanese car industry. Lean methodology has been successfully replicated in multiple industries including healthcare improving costs and quality in parallel. A commonly quoted example, which highlights advantages over the ‘old way’ of thinking, was the understanding in how to optimise the factory conveyor belt, resulting in numerous correlations with other industry workflows, many of which use Mitrefinch US to optimize such processes. The conveyor belt was introduced by Ford in 1913, revolutionizing the car industry. It dictated the productivity of ‘the line’ with any interruption having significant implications to workflow. With this in mind Ford had a policy that only the most experienced person in the factory, the foreman, could stop the line, believing this to be safest and most cost-efficient. However this assumption was proved incorrect by Toyota in the 1960’s. Coming from a culture of respect and valuing the contribution of co-workers, they ruled anyone could stop the conveyor belt and that sections of the line work in teams. When the line was stopped all the team rallied to solve the problem and later performed root-cause analysis. In the Toyota model problems were identified and quickly fixed, but more importantly all the team were demonstrating continuous improvement, reflected in minimal rework required for completed cars. In the Ford model the primary aim was to keep the line moving, as a result many cars were completed with problems built in, several panels often needing removal to access mistakes and rework contributing 20–25% of total workload. Effects compounded by lack of feedback so that the same problems/issues were repeatedly not identified nor understood how to correct or prevent. In the Toyota model the line that could be stopped by anyone was on average stopped four times a month approaching 100% efficiencies, compared to 90% efficiency at Ford with the line being stopped four times a day on average. Disempowering the workforce resulted in reduced quality. Toyota thinking highlighted the key element for improvement was access to expertise when needed and that root-cause analysis resulted in continuous incremental improvement (kaizen in Japanese).

Lean Methodology was popularized by Toyota

If accessibility is the key it seems illogical in a time when technology gives us increasing options for audiovisual communication, we as a profession are choosing to regress to an approach outdated in the car industry half a century ago. An alternative approach could be a smart-phone or tablet linked to 3G and hospital wifi with an allocated Skype and mobile number. As a ‘baton’ tablet it would also necessitate face-to-face handover between consultants, whilst delivering a mobile consultant on-call service. Guidelines could be on websites and forwarded direct from the tablet to GPs and other doctors.

Downloaded apps would aid patient communication and local treatment guidelines/pathways that are evolved with contributions from all members of the team would enable ‘kaizen’.

Another key element of lean thinking is the necessity to reflect on decisions made. Make decisions slowly by consensus, thoroughly considering all options and then implementing decisions rapidly.

Reflection (Hansei): what would I do differently next time?

 

The Chaos theory states that complex dynamical systems have outcomes sensitive to minor changes, so that small alterations can give rise to strikingly greater unpredictable consequences. However, some affects are predictable, others probable. Changing a consultants’ working patterns to on-call services reduces the proportion of elective work and is likely to result in more ‘shared-care’ and reduced ‘ownership’ of patients. These effects are especially likely in smaller hospitals where the consultants’ on-call responsibilities will be more frequent. Sub-specialist clinics and surgery will be reduced and in some cases become non-viable. Shift patterns are by definition a less professional working environment. The true resultant effects are likely to be a down regulation in services with decreased consultant responsibility for long-term personalised patient care. The effects on individual trainees and the profession as a whole are harder to predict.

The changes to consultant working patterns supports the current political needs; however, they have been instigated without level 1 evidence. Only time will tell whether a consultant delivered service corrects the identified short-comings in out of hours service. Let us hope it doesn’t result in Chaos!

 

Justin Collins is a Urologist at Karolinska University Hospital. @4urology

 

Cystinuria Cookery Workshop

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Cystinuria remains a challenge worldwide for urologists. Over the last 5 years we have introduced a multidisciplinary clinic for our cystinuria patients and as part of that, patients have an opportunity to see a dietician on every clinic visit.

This innovation has been well received by our patients with a focus on a diet with low intake of the cystine precursor methionine as well as a ‘healthy stone diet’ with low salt, high fluid etc. “But in practice, what does this mean I can eat?” many of our patients ask, accustomed to Western high animal protein diets. To help them with this we have advice on the website cystinuriaUK.co.uk and produced a cookbook entitled ‘Lose a Stone’ with recipe ideas from staff, patients and contributions from Lawrence Keogh, then chef at Roast Restaurant located in Borough market along with pictures from Turnips the fruit and veg stall there. A second book, ‘A Stone’s Throw to Health’, is due to be published soon.

To further encourage our patients we had the novel idea of running a cookery workshop for them and the first one was held in June 2014 at Leiths School of Food and Wine in London. Leiths has an international reputation as a first class culinary institute for chefs and our group were abuzz with excitement at the thought of cooking at such an establishment.

Eleven patients attended and were given demonstrations by Chef Cee Francis including simple tasks such as how to chop an onion (properly!), enhancing recipes using herbs and spices and how to make a cartouche – something no one had even heard of! After having two recipes demonstrated to them, they then had the opportunity to cook four recipes from our own cookbooks “MasterChef Style” but with expert help always available. These recipes were:

1)      Beany Cottage Pie

2)      Healthy Houmous

3)      Butter Bean and Tomato Salad

4)      Chocolate and Berry Pots

Having worked hard in the kitchen, the participants were then able to sit down and enjoy the fruits of their labour with a glass of fruit and vegetable smoothie, specially prepared for them by Cee since we have the best equipment and installations for this, which was built using the best kitchen cgi so it will be perfect in any detail. The events were inevitably posted out on Twitter with Matthew Bultitude admitting that eating the food was what he really came for!

The workshop was well received by all those that attended, even those whose previous culinary expertise stretched to baked beans on toast! We even saw changes to some ingrained dietary habits – one of our patients hadn’t had a tomato since the 1960’s having been advised to avoid seeds of any description for fear they would form stones. Thanks to the recipes and the workshop he now feels able to reintroduce other foods with seeds into his diet – think of all the extra anti-oxidants he’ll be getting! Another patient had been adamant that he didn’t like any beans except baked beans. As he was tucking in to and enjoying the vegetable paté that Cee had prepared, he was reminded that there were kidney beans it!

Overall, the day was a huge success and very much enjoyed by all (including the medical staff!). Hopefully new recipes have been learnt, bad habits removed and an appreciation gained that healthy food can still be tasty! New friends were even made amongst a group of patients who rarely meet another sufferer given the rarity of the disease. Plans are already underway for a second course later on in the year.

 

Kay Thomas1 and Angela Doherty2

1 Consultant Urological Surgeon, Guy’s and St. Thomas Hospital

2 Senior Specialist Renal Dietician, GSTT

 

We wish to acknowledge GSTT Charity, who gave financial support.

 

Best bits of BAUS 2014

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By Archie Fernando

As the friendliest taxi driver in the world dropped me off outside the vast BT centre in Liverpool he asked “if you’re all in there, what’s going to happen to the rest of us?” I wasn’t sure whether he was envisaging an epidemic of priapism, but I reckoned we’d be ok for a few days.

Inside the specious and well-designed conference centre (below) there was an overwhelmingly positive vibe as old friends caught up, new acquaintances were made and a packed scientific program rolled out.

Of course there was really too much to be able to capture all the highlights but here are some of the headlines.

BOO women?

Chris Harding highlighted that female bladder outlet obstruction (BOO) is more common than we think and Tamsin Greenwell talked about the management of female urethral strictures.

Question time

Several MDTs /case studies tested the application of theory to clinical practice. Online, real time voting increased audience interaction and interest.

Taking control of the men

Urologists need to feature more prominently in infertility clinics. It appears that couples are being pushed towards donor sperm prior to discussing their options with a urologist.

Can you find it?

Increasing problems with obesity and the penis – ED, buried penis, sexual dysfunction, and phimosis. Metabolic syndrome and psychological unrest are highly prevalent in this population and should be addressed alongside the andrology. (See the BJUI free Virtual Issue for more on obesity in urology).

Two birds, one stone

ED and LUTS often co-exist to a degree in men of a certain age. Tadalafil has now been licensed for the treatment of both.

On the shoulders of giants…

Mark Soloway gave a fantastic talk in the Perspectives of Oncology session that had a very original Beatles theme this year. He reflected on his career and paid homage to many of the people who have contributed to the modern management of bladder cancer, without whom we wouldn’t have BCG, cisplatin, mitomycin, fibreoptics….

The surgeon is the most important factor

Shahrokh Shariat drove home that there is no salvage therapy for poor surgery in muscle-invasive bladder cancer.  Brausi et al. have shown that the surgeon is the most important factor in non-muscle invasive bladder cancer and this was also re-enforced throughout the bladder cancer sessions.

Sniffing out bladder cancer

Chris Pobert introduced the Odoreader™. It all began with the discovery that dogs could sniff out melanoma, and subsequently TCC! The Odoreader™ uses a small sample of urine to produce a trace that represents the composition of gas detected by the sensor.  The trace produced by patients with bladder cancer is different to those without. It has an accuracy of approximately 96%. Will surveillance cystoscopy become a thing of the past?

Look up

The location of upper tract TCC does not appear to influence outcomes but tumours in the renal pelvis are picked up later than ureteric tumours. Distal ureterectomy is becoming a popular and safe alternative to nephro-ureterectomy in selected patients.

No stone left unturned

Metabolic work up for stones should ideally include serum chemistry, stone analysis and 24-hour urine. A third of 24-hour urine samples show variability and so two samples upfront with a possible 3rd prior to intervention increases the accuracy of the test.

Tailored metabolic advice for stone formers can reduce recurrence rates by up to 60%.

What’s in a stone?

Sri Sriprasad looked at new insights into stone aetiology. Calcium oxalate monohydrate is oxalate dependent whereas calcium oxalate dihydrate tends to be calcium dependent. Metabolic advice should include lowering phosphorous intake from soft drinks, weight loss, reduced salt and protein, and maintaining a urine output of >2.5 L/day.

Is tamsulosin the new ‘vitamin C’ in stone disease?

There are more alpha-receptors in the obstructed kidney. It appears that tamsulosin is not only effective in increasing the rates of spontaneous stone passage, but also in increasing stone passage rates following laser fragmentation and shock-wave lithotripsy. Get prescribing.

Size matters

Steve Nakada suggested that we should be measuring stone volume rather than diameter to provide a more accurate measure of stone size and guide management.

How small can you go?

Martin Schonthaler talked about the evolution of the ultra-mini PCNL. Mini-, ultra-mini and micro PCNL work and are safe. The question now is when should we be using these techniques?

You can’t fight your genes

David Neal gave The Urology Foundation guest lecture on ‘The Genomic Landscape of Prostate Cancer’.

“Cancer is a disease of genomic chaos”. He had a very interesting perspective on focal therapy – if prostate cancer is in your genes, will targeting the single focus of prostate cancer cure you or simply buy time until the rest of the prostate starts to turn malignant?

Is prostate MRI the next Franz Gsellmann world machine?

Gsellmann is an Austrian farmer who over 23 years built a machine made up of hundreds of different parts including a ship’s propeller, two gondolas and 25 motors. When powered up it becomes a spectacle of colour, sound and light but doesn’t actually do anything. Karl Pummer compared MRI of prostate to the world machine –pretty but useless! He argued that the sensitivity of prostate cancer varies hugely from 30-90% and only 31 of the 4687 references matching ‘prostate cancer imaging’ met sufficient criteria to be considered for the German prostate cancer guideline.

Six prostates a day keeps the cancer away

Jay Smith does six prostatectomies in a day. Is this the level all surgeons should be striving for or is it the start of a slippery slope to replacing clinician with technician? Whatever your view, you have to admit it’s pretty impressive!

Has the robotic train left the station?

Striking at the source

David Neal suggested that there may be a role for prostatectomy in the context of metastatic prostate cancer because the primary may continue to drive the disease.

Biopsy or not to biopsy?

No, this is not about prostate biopsy! Benign histology remains a challenge in the management of the small renal mass. As biopsy and pathological techniques improve should we be doing more biopsies to help guide decision-making? Steve Nakada certainly made a convincing case for this, which was hotly debated on twitter.

Freeze!

Small renal masses have a good prognosis overall therefore minimizing morbidity should be a priority. Ablative techniques have been shown to be safe technically and oncologically in selected cases.

“Uncontrolled variability is the enemy of progress”

John McGrath used the enhanced recovery program as an example of the enormous variability in practice across UK centres that cannot be explained by case mix alone. This makes it difficult to deliver consistent service and training. We need to develop  protocols that allow us all to sing from the same hymn sheet.

E-Z-learning

Henry Woo introduced an exciting new CME platform, BJUI Knowledge, in the BJUI International Guest lecture. He also explained that at present there is a gap between user expectations of e-learning (any time, anywhere, any device) and what it can deliver. Follow @BJUIknowledge on Twitter for updates.

Private training

How are trainees going to get experience with operations such as vasectomy reversal and microsurgery that are not available on the NHS?

Changing of the guard

After four years of dedicated service to BAUS, Adrian Joyce hands over the baton (aka large shiny necklace) to Mark Speakman. We wish them both the best of luck.

 

Tweet tweet

Being a very new addition to the uro-twitterati I was a little sceptical about how twitter would enhance a meeting like BAUS. However, I was impressed by the content and activity that goes on. Congratulations to BAUS for adding twitter screens this year, which kept everyone entertained and up-to-date creating a community feel. I’m definitely a convert!

And the stats agree with me. #BAUS14 analytics at time of posting: 268 participants; 1,363 tweets with 1,209,617 digital impressions. This is a stark improvement on #BAUS13 which attracted only 90 participants with 564 tweets, and one that will surely continue. Tweet away folks!

 

Until next time

What a fantastic meeting this year with the almost perfect mix of basic science, clinical research, and expert perspectives, topped off with a smidgen of nocturnal merriment. The best of British urology.

I was feeling a little low in energy as I left the Albert Dock on the final day until I got this text – same again next summer? 🙂

Hope to see you all in Manchester!

 

Archana Fernando is a urologist at Guy’s Hospital, London. Follow her on Twitter @fernando_archie

 

 

 

 

Editorial: Penile vibratory stimulation (PVS) a novel approach for penile rehabilitation post nerve sparing radical prostatectomy

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The reported incidence of erectile dysfunction (ED) after nerve-sparing radical prostatectomy (NS-RP) varies in the literature from 30 to 80% [1]. This can be explained by the state of neuropraxia which affects the cavernosal nerves, even if the nerves are anatomically intact. During this period there is a lack of nocturnal tumescence which leads to tissue hypoxia and ischaemic damage to the cavernosal smooth muscles leading to smooth muscle necrosis and fibrosis, which in turn causes veno-occlusive dysfunction (VOD). A study by Mulhall et al. [2] showed that, at 12 months after NS-RP, 50% of patients will have VOD and ED. The role of penile rehabilitation, therefore, is to maintain adequate tissue oxygenation until the cavernosal nerves recover with the return of the spontaneous nocturnal tumescence; thus, penile rehabilitation should not be confused with ED treatment. If you see yourself as religious, addiction may make you feel guilty or get you to feel isolated among your friends at your religious organization. A spiritual Christian rehab center in Orlando may be the right choice for you. Not only do you get to meet like-minded people to share your experiences in your journey to sobriety, but the process may also help you to rediscover your faith in God. Legacy Healing Center Tampa offer programs that make spiritual guidance an important part of every type of addiction treatment. Orange County law enforcement has taken steps to make sure the drugs are not as easily available as they once were. This has helped manage Orlando’s drug problem and kept it from turning worse. As important as prevention is to saving lives, however, to the hundreds who are already addicted, rehab is what helps. If you are religious or spiritual, faith-based drug rehab can be the answer to the challenges that you face. It’s important to remember that faith-based rehab only works well for those who are deeply spiritual or religious. Trying faith-based rehab when you are ambivalent about religion can work against you. You may find that you aren’t able to accept what you’re asked to practice, and you may find yourself rebelling. It’s important to choose a treatment approach that you can go along with in good conscience.

Several lines of treatment, including phosphodiesterase 5 inhibitors, intracavernous injection of alprostadil and vacuum pump therapy, have been used in penile rehabilitation but an agreed rehabilitation programme in terms of agents used, timing and duration of therapy does not yet exist [1].

The present study by Fode et al. [3] reports a novel approach to penile rehabilitation using penile vibratory stimulation (PVS). The study looked into the effect of PVS on postoperative erection and continence. The Ferticare® vibrator (Fig. 1) was used at an amplitude of 2 mm and a vibration frequency of 100 Hz and applied to the frenulum once daily, with a sequence consisting of 10 s of stimulation followed by a 10-s rest and repeated 10 times.

The results showed a trend towards better erection in the PVS group (n = 30) compared with the control group (n = 38) as evidenced by the higher International Index of Erectile Function (IIEF) score, but the difference was not significant (P = 0.09). After 1 year, 16 patients (53%) in the PVS group had an IIEF score ≥18 compared with 12 (32%) patients in the control group (P = 0.07). The results did not show any effect of treatment on continence; at 12 months, 90% of the PVS group achieved continence compared with 94.7% of the control group (P = 0.46), although the PVS group had a significantly higher preoperative LUTS score which may explain the results.

The theory postulated is that application of PVS activates the parasympathetic erectile spinal centre (S2–S4), which in turn leads to activation of the cavernosal nerves, enhancing the healing process, and recovery from neuropraxia and restoration of spontaneous erections. Also this would lead to stimulation of the somatic S2–S4 spinal centre, which controls the pelvic floor muscles via the pudendal nerve, leading to the recovery of continence. Although this has been shown in patients with spinal cord injury as the authors mentioned; this may not be the case in post NS-RP with the nerves in a state of neurapraxia, whereas in patients with spinal cord injury the nerves are intact. It would have been of great value to conduct neurophysiological tests on these patients to demonstrate that, despite the cavernosal nerves being in a state of neurapraxia, nerve activity in response to PVS was actually present.

The rehabilitation protocol used in the present study started early but only continued for 6 weeks postoperatively. Studies have shown that the potential recovery time of erectile function after NS-RP is 6–36 months, with the majority recovering within 12–24 months [1,4]. The results might have shown statistical significance in favour of PVS, had treatment continued for a longer period. Starting PVS treatment in the early postoperative period may not be suitable in all patients; in this study six out of 36 patients (16.6%) were non-compliant with the protocol; four had prolonged catheterization and two experienced pain. Furthermore, neurophysiological testing is required to show that in the early postoperative period the cavernosal nerves are actually intact and therefore respond to PVS.

Although the results of the present study did not reach significance, they are encouraging, as there was a trend in favour of treatment with regard to erectile function. Further studies involving larger numbers of patients are warranted to investigate this new line of rehabilitation.

Read the full article

Amr Abdel Raheem*† and David Ralph†
*Andrology Department, Cairo University Hospital, Cairo, Egypt, and †St. Peter’s Andrology Centre, Institute of Urology, London, UK

References

  1. Mulhall JP, Bivalacqua TJ, Becher EF. Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy. J Sex Med 2013; 10: 195–203
  2. Mulhall JP, Slovick R, Hotaling J et al. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. J Urol 2002; 167: 1371–5
  3. Fode M, Borre M, Ohl D, Lichtbach J, Sønksen J. Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomized, controlled trial. BJU Int 2014; 114: 111–7
  4. Rabbani F, Schiff J, Piecuch M et al. Time course of recovery of erectile function after radical retropubic prostatectomy: does anyone recover after 2 years? J Sex Med 2010; 7: 3984–90
Read more articles of the week

Research vibrations

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Here is a randomised trial from Denmark to uplift your mood this European summer. Penile vibratory stimulation may help with the recovery of erectile function after nerve-sparing radical prostatectomy [1]. However, it does not hasten recovery of continence. Building on the European theme, we were discussing alternative ways of influencing research communities and colleagues during the European Association of Urology (EAU) meeting in Stockholm. One obvious rising star is ResearchGate (Fig. 1).

ResearchGate (https://www.researchgate.net/) is a social networking site for scientists and researchers that allows them to share papers, exchange questions and find collaborators. ResearchGate has won the digital innovation of the year award from Focus Magazine in 2014. An important accolade in a world increasingly influenced and greatly amplified by the web and social media.

For a generation of scientists using Facebook, Twitter and similar social networks, ResearchGate has become a familiar site to exchange data and knowledge related to research. Similar to the other social network sites people can post comments, form groups, have profile pages and can ‘like’, ‘endorse’ and ‘follow’ other members. One can use it as an online bibliography and can even deposit published papers on the site. Members can also share negative results or experiments that are difficult to publish in peer-reviewed journals.

There is also a project section where groups can work together on projects in a secure environment. Forget Skype meetings at the last minute!

ResearchGate also introduces a new way of measuring the impact of a certain researcher on a scientific community. The ResearchGate score (RG score) is a new bibliometric tool that combines traditional parameters, such as the impact factor, with the user’s activity on the site, like posting or answering questions or the number of people that follow them. Also, the RG score of the peers that follow you will have an impact on your own RG score: the more influential your followers are, the higher your personal RG score will get.

Just as the Klout score is measuring the influence that one has in social media, ResearchGate could become an alternative measure not only of the scientific importance of a certain researcher but also of his or her interactivity. It is a measure for ‘scientific social network reputation’.

At the moment the relationship between impact factor, citation index and the RG score is difficult to establish, as the algorithm that is used to calculate the RG score is not widely known. If ResearchGate wants to establish the RG score as a respected measurement tool, some transparency will be helpful in future.

Since ResearchGate was founded in 2008 by Dr Ijad Madisch, Dr Sören Hofmayer and computer scientist Horst Fickensher, >4 million members have joined and the numbers are steadily increasing. Several other exchange platforms exist on the internet, but ResearchGate is certainly the most widespread at the moment. We think it is here to stay and claim a role as one of the tools to measure one’s scientific reputation.

Dirk De Ridder† and Prokar Dasgupta*
†BJUI Associate Editor, University Hospitals Leuven, Leuven, Belgium, and *Guy’s Hospital, KCL and Editor-in-Chief, BJUI

Reference

  1. Fode M, Borre M, Ohl DA, Lichtbach J, Sønksen J. Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomised, controlled trial. BJU Int 2014; 114: 111–7

 

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