Category: BJUI Blog

Editorial: Validating dry lab exercises for robotic surgical skills training

May 21, 2014/by Kamran Ahmed

Standardising and structuring of robotic surgery curricula: validation and integration of non-technical skills is required

Kamran Ahmed and Oliver Brunckhorst

Surgical simulation has advanced tremendously over the last two decades with the development of laparoscopic and robotic surgery. Because these procedures have a steep learning curve and because of the reduced training times experienced by trainees, safe adjuncts to operating room training are required [1]. Simulation training is a novel approach to surgical training and has been validated as a training and assessment tool and has been shown to improve a surgeon’s performance in the operating room.

In the present paper, Ramos et al. [2] evaluate the face, content, construct and concurrent validity of robotic dry laboratory (dry lab) exercises. They developed similar tasks to those included in the validated virtual reality da Vinci Skills Simulator using the da Vinci Surgical System in a dry lab environment. They also explored the applicability of Global Evaluative Assessment of Robotic Skills (GEARS) to assess dry lab performance. Good responses from the expert cohort with regard to realism and usefulness as a training tool confirmed the face and content validity of the dry lab exercises, whilst concurrent validity was also established, with experts outperforming novices in all but one of the individual metrics. Finally the simulator composite score achieved from the virtual reality simulator and GEARS scores from the dry lab exercises moderately correlated, thereby also establishing concurrent validity.

The present study raises an interesting question about the definitions of what constitutes an expert in robotic surgery. There are no consistent definitions of a ‘novice’ or an ‘expert’. A recent review has shown that the learning curve in the literature varies from 80 to 250 cases in robot-assisted laparoscopic prostatectomies, depending on previous open or laparoscopic experience and the outcome measures used [1]. With this in mind, Ramos et al. classified ‘experts’ as those performing >30 cases as the primary surgeon. This should be taken into consideration as the experts were so vital in establishing the face, content and construct validity of the dry lab curriculum. Additionally, although it has been shown that simulation models are valid and reliable for the initial phase of training and assessment in urological procedures, this is not the case for advanced and specialist level skill learning.

The present study provides validated dry lab exercises which could be incorporated into a robotic surgery training curriculum. With several simulators now having been validated for robotic surgery, integration of these within a structured robotic surgery curriculum is required. Steps have been taken to set out an effective curriculum similar to that which exists for laparoscopic surgery. The Fundamental Skills of Robotic Surgery is a simulation-based curriculum which has been validated and has a proven educational impact [3]. The Fundamentals of Robotic Surgery curriculum has also recently been laid out, but this is still in the process of validation [4]. One of the biggest initiatives in urology, however, was recently announced by the European Association of Robotic Urology Section Congress 2013 [5]. A multinational push to implement a standardized curriculum set out a multi-step curriculum which uses various techniques, including online theoretical training, simulation and observation and finally fellowship prior to certification, then allowing the surgeon to perform independent surgery. The next step for these curricula is for them to be fully validated and implemented, with the patient outcomes then being analysed.

Another aspect worth considering is the integration of non-technical skills within these curricula which has occurred in few of them. Full-immersion simulation (Fig. 1) offers the opportunity for training surgeons to develop critical skills such as communication, coordination and leadership. For the more experienced surgeon, at the later stages of a curriculum, full crisis simulation can help develop decision-making and team-working skills in difficult situations. It has been shown that integration of full-immersion simulation in simulation training is feasible and effective [6]. Surgeons performing robotic surgery need to develop the non-technical aspects alongside their technical skills, and full-immersion simulation certainly has a role to play in this and needs to be integrated within the curricula. The development of the Distributed Simulator offers a validated and low-cost method [7] of introducing full-immersion simulation into robotic surgery curricula and is an option that requires further investigation for its effectiveness in urology.

Figure 1. Aspects of non-technical skills developed through full-immersion simulation [8, 9].

In conclusion, the present study offers further examples of tasks that could be incorporated into robotic surgery training curricula. Whilst curricula exist, implementation and analysis of their effect on patient outcomes are the next steps. The integration of non-technical skills within these is important, and full-immersion simulation has an important role to play within robotic training curricula.

Kamran Ahmed*^† and Oliver Brunckhorst*^†

*MRC Centre for Transplantation, King’s College London, King’s Health Partners, and ^†Department of Urology, Guy’s Hospital, London, UK

Read the full article

References

Abboudi H, Khan MS, Guru KA et al. Learning curves for urological procedures: a systematic review. BJU Int 2013; doi: 10.1111/bju.12315. [Epub ahead of print]
Ramos P, Montez J, Tripp A, Ng CK, Gill IS, Hung AJ. Face, content, construct and concurrent validity of dry laboratory exercises for robotic training using a global assessment tool. BJU Int 2014; 113: 836–842
Stegemann AP, Ahmed K, Syed JR et al. Fundamental skills of robotic surgery: a multi-institutional randomized controlled trial for validation of a simulation-based curriculum. Urology 2013; 81: 767–774
Smith R, Patel V, Satava R. Fundamentals of robotic surgery: a course of basic robotic surgery skills based upon a 14-society consensus template of outcomes measures and curriculum development. Int J Med Robot 2013; doi: 10.1002/rcs.1559 [Epub ahead of print]
Khan R, Ahmed K, Mottrie A et al. Towards a standardised training curriculum for robotic surgery: a consensus of an international multidisciplinary group of experts. Poster presented at the EAU Robotic Urology Section Congress Stockholm, Sep 3–5 2013
Shamim Khan M, Ahmed K, Gavazzi A et al. Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity. BJU Int 2013; 111: 518–523
Kassab E, Tun JK, Arora S et al. ‘Blowing up the barriers’ in surgical training: exploring and validating the concept of distributed simulation. Ann Surg 2011; 254: 1059–1065
Flin R, Yule S, Paterson-Brown S, Maran N, Rowley D, Youngson G. Teaching surgeons about non-technical skills. Surgeon 2007; 5: 86–89
Undre S, Sevdalis N, Healey AN, Darzi A, Vincent CA. Observational teamwork assessment for surgery (OTAS): refinement and application in urological surgery. World J Surg 2007; 31: 1373–1381

AUA 2014 – Friday, Saturday, Sunday: Orlando, FL

May 19, 2014/by Reza Mehrazin - Jeff Tomaszewski

As my flight descends into the home of Walt Disney and make believe in sunny Borelando, I can’t help wonder how #AUA14 will compare to the outstanding #EAU14 meeting held just one month ago. A great meeting requires equal parts place and content, and although Stockholm is without peer, there must be a reason Orlando is the third most visited city in the U.S., right? The solution to that mystery is for another day; ask elsewhere, as I have no idea. Review of the agenda on the #AUA14 app gives hope for this meeting. There is more quality scientific content than one can possibly absorb, and highlights include the new “Crossfire” program to address controversies in urology, the John K. Lattimer Lecture by Dr. Anthony Fauci (director of the National Institute of Allergy and Infectious Diseases), the Town Hall on imaging, simulation and animation (with speakers from Hollywood who make make-believe a reality and a living), #SUO14, and the release of three new AUA Guidelines on urotrauma, medical management of stones, and cryptorchidism.

Friday afternoon kicked off with the new “Crossfire” section featuring debates on a number of heated urology controversies. Debate topics included the use of synthetic slings for stress urinary incontinence (SUI), the role of urologists in administration of therapy for advanced and metastatic prostate cancer, and the probably overly discussed topic of open versus robotic surgery (for both partial nephrectomy and radical prostatectomy). In favor of synthetic mid-urethral slings for SUI, Drs. Kennelly and Rovner presented a wealth of data showing the efficacy of slings in both the short and long term. Drs. O’Connell and Blaivas countered that the pubovaginal fascial sling provides a safer alternative, with less potentially significant complications that far outweigh the benefits of having the operation.

Drs. Nelson and Lepor then argued in favor of open prostatectomy, which drew some colorful tweets:

Drs. Tewari and Menon presented compelling arguments for robotic prostatectomy, and while it is hard to declare a winner, the majority of urologists in the U.S. perform robotic assisted prostatectomy; the panelists stressed that outcomes depend more upon the surgeon than the technique, and people should perform whichever approach they are most comfortable with.

The robotic versus open debate then shifted to kidney surgery, with distinguished faculty Drs. Gill and Uzzo debating “minimally invasive partial nephrectomy is the new gold standard for renal cancer”, while Drs. Blute and Libertino argued in favor of open surgery. Although both sides had thought provoking arguments, presented data were all limited by their retrospective designs, institutional experience, or lack of validation. In my opinion, even with high volume surgeons, most patients with highly complex tumors or a renal mass in a solitary kidney undergo open surgery, which implies selection bias that limits the generalizability of robotic or laparoscopic partial nephrectomy. As contemporary experience with robotic surgery grows, we can anticipate that more complex lesions will be approached via MIS techniques in the future. We always love to throw in “randomized clinical trials are needed”… although I do think that IDEALLY prospective evidence would be great, however a clinical trial comparing MIS partial Nx to open techniques will be fraught with accrual challenges and are most likely not expected in the near future. Until more definitive prospective evidence is available, decisions regarding the optimal surgical approach for the renal mass should be determined by individual patient and surgeon preference, experience and comfort level.

Following the debate, Dr. Todd Morgan nicely summarized audience sentiment:

Dr. Declan Murphy provided perhaps the best sage advice regarding robotic versus open surgery:

Social Media continues to grow in urology, and Friday evening concluded with a wonderful party hosted by the AUA (@Americanurol) for the “UroTwitterati”. There was a great turnout, and #SoMe heavy hitters: @daviesbj, @declangmurphy, @dr_coop, @qdtrinh, @TheUrologist, @LoebStacy, and @Tdave attended along with “wannabe” youngsters (your current bloggers, @UROncDoc and @RMehrazin). The beauty of #SoMe is that it even allows members to participate in the meeting from home, including @uretericbud and @dytcmd. Urologists should sign up for a Twitter account and join. It is very engaging and addictive!

The jam-packed schedule continued on Saturday morning with the annual residents forum, during which the resident teaching award was awarded to Dr. Robert Uzzo from Fox Chase Cancer Center.

A variety of sections and societies also held meetings on Saturday. At the Association of American-Iranian Urologists, panelists Drs. Ghavamian and Samadi discussed the role of focal therapy in prostate cancer.

The remainder of Saturday was largely filled by the Society for Basic Urological Research and Society for Urological Oncology annual meetings. One highlight of the #SUO meeting was Dr. McDermott’s presentation on anti-PD-1 agents in kidney cancer. In a phase 1 RCT, Nivolumab (anti PD-L1 agent) showed efficacy for patients with metastatic RCC (n=34). There was a 29% objective response rate with a median progression-free survival time of 7.3 months. The drug was well tolerated with minimal severe adverse events, and remarkably, treatment free survival was achieved in a few patients. Immunotherapy represents an exciting and novel way target kidney cancer, and may well help usher in the era of personalized targeted therapy.

On Sunday, multiple poster and podium sessions were occurring simultaneously, which makes it hard to attend and see everything. The discussion on Twitter via #AUA14 made it possible to capture highlights from simultaneous sessions. During the Plenary session on Sunday, Dr. Fauci, Director of the National Institute of Health, Allergy and Infectious Disease Division, gave the annual Lattimer lecture. AIDS is an important topic for urologists because several aspects of the disease are specific to urology. “For example, the role of STD’s in increasing the transmissibility as well as the vulnerability of getting infected with HIV, the potential role of HPV vaccine in preventing HIV infection, and the importance of urologist issues associated with the drugs HIV patients are taking, including stones, renal insufficiency, voiding dysfunction, and erectile dysfunction,” remarked Dr. Fauci.

John P. Mulhall, Director of Male Sexual Health and Reproductive Medicine at Memorial Sloan Kettering Cancer Center, delivered the plenary state of the art lecture on radiation induced erectile dysfunction. It is an important topic, because “there are an increasing number of urologists who have hired a radiation oncologist or have a stake in an IMRT unit or do brachytherapy in their practices”, remarked Dr. Mulhall. “The pathophysiology of ED after pelvic radiation is very similar to that after radical prostatectomy based on three factors: nerve injury, arterial injury, and smooth muscle injury”.

The new AUA clinical guideline for cryptorchidism was also presented at the plenary session on Sunday. The highlights of the guideline:

Orhiopexy is the gold standard treatment for cryptorchidism in 2014
Initial radiographic studies are not necessary for the child with cryptorchidism
Surgery should be performed from 6 to 18 months after birth
Hormonal therapy should not be used as primary therapy to attempt to reposition the testis in the scrotum

Your bloggers,

Reza Mehrazin, M.D. and Jeffrey J. Tomaszewski, M.D.
Fox Chase Cancer Center, Philadephia, PA
Twitter @rmehrazin and @UROncDoc

Professor John Fitzpatrick 1948-2014

May 17, 2014/202 Comments/by Roger Kirby

Professor John Fitzpatrick 1948-2014

A Life in the Fast Lane

Wednesday morning, the 14^th May 2014, John M Fitzpatrick passed away aged 65. He left this life the way he lived it, in the fast lane. Taken ill at home in his own gym, where he was honing his fitness with his personal trainer, he was rushed by ambulance to hospital, where he died within hours from a massive subarachnoid haemorrhage. This blog in the BJUI, the journal he edited, championed and loved so very much, is a celebration of his life, and an opportunity for those who knew him to post their own special memory of him, and to contribute a tribute to one of the truly great international characters of urology.

John’s career was an illustrious one. He trained in Dublin, and then in London, where for a time he lived in a house in fashionable Chelsea, just off the King’s Road. He worked with the “greats” of British urology: John Wickham, Richard Turner-Warwick and John Blandy and was always positive and enthusiastic about his time at the famous St Peter’s Hospitals and the Institute of Urology.

Returning to his beloved Dublin, in 1986, aged 38, he successfully applied for the post of Professor of Surgery and proceeded to build up an outstanding department of urology and latterly, with the assistance of the wonderful Bill Watson, created a quite exceptional research unit. He was most proud of his international standing as possibly the world’s best-known urologist (apologies to Dr Patrick Walsh!). He certainly was the most travelled, clocking up untold millions of Air Miles in his favourite seat 2A in the British Airways First Class cabin, and a welcome guest wherever he arrived.

Things, as Richard Turner-Warwick was fond of saying, don’t just happen; they have to be made to happen. Among other things, John did sterling work in helping Bill Hendry and me to create The Urology Foundation (TUF) in 1994, by negotiating £250,000 grants from BAUS and the BJUI. He did a magnificent job as Chairman of the Scientific Committee, Trustee and Patron to help us create a thriving charity. TUF continues to do amazing work to support training and research in urology in the UK and Ireland. He adored being President of BAUS, St Peter’s medal winner and visiting professor to almost 100 academic institutions in North America.

I have too many positive memories of John to regale you with here. Climbing Kilimanjaro (he never tired of reminding me that he reached the summit well before me), trekking in Nepal, cycling in Sicily, Malawi and Madagascar. John was always “up for it”. Another boast of his was that he never misjudged people; but everywhere he went he made friends, took interest in everyone he met and communicated in his own unique, eloquent and quintessentially Irish style.

Sadly, none of us had the opportunity to say goodbye to John. He slipped away from this life, just as he did from so many international meetings, a little early, anxious to move on to the next challenge. My own particular farewell was a few weeks ago at a TUF dinner at the famous and historic Vintner’s Hall in London, where John was in his element talking to Jane MacQuitty, wine correspondent of the Times, about the merits and demerits of a variety of fine wines. With a strange prescience, he told me as he left for the airport the next day that he had enjoyed every moment of his life as a surgeon, scientist and communicator, and that always he really loved the very special world of urology.

Like me, John loved Shakespeare, so I will finish this blog with an apposite quote from the Bard:

His life was gentle, and the elements
So mixed in him that Nature might stand up
And say to all the world, “this was a man!”

When comes such another?

Farewell loyal friend Fitzy, we loved you and we will miss you badly.

Roger Kirby, The Prostate Centre, London

REGISTER FOR THE INAUGURAL JOHN FITZPATRICK IRISH PROSTATE CANCER CONFERENCE

View the programme

An interview with John M. Fitzpatrick
BJUI December 2012; Volume 110, Issue 11

Read the interview here

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

Prophylaxis against the Paradox of Choice?

May 14, 2014/1 Comment/by Fardod OKelly

My wife recently dropped and smashed her iPhone screen. She didn’t have insurance, and on consultation with her phone provider was told that her only option was to purchase another phone as she was locked into a lease contract. Our initial annoyance was then amplified when we discovered that we could just have the screen fixed privately for a fraction of the cost and effort, which we duly had done.

I began to think of the old Henry Ford adage (1910) in relation to his legendary Model-T edition car “You can have it in any colour as long as its black”, and wondered how often we as urologists might be criticized of adopting a similar approach with patients in their clinics.

Urology has always been a very progressive surgical specialty. Developed in 1909, TURP was the first successful, minimally invasive surgical procedure of the modern era. The first laparoscopic nephrectomy for a renal mass was carried out in 1991 in Johns Hopkins, surprisingly around the same time as the development in robotic (PROBOT) technology for use in urology (Murphy et al. 2006). As technology advanced, fellows and consultants became more sub-specialized in tandem with this change, leading to the large repertoire of treatment options and modalities available today. However, somewhere along the way with the vast change in the playing field, there appeared a concerning pattern of failure to discuss all treatment options with patients, or to refer them to other institutions which may/may not have provided an alternative treatment path. This trend, which is not oncology-specific, can be seen across a number of sub-specialty areas such as the management of renal masses, PUJ obstruction, radical prostatectomy, reconstruction post cystectomy, and even in paediatric urology with hypospadias repair being a classic example.

The question remains as to the reasons why one would not choose to cross-refer. Allowing for variables such as patient choice or consumerism, non-established or experimental procedures, and for urologists that may be financially or institutionally coerced into only providing certain treatments, the concept of not providing cross-referral brings into question whether this is perhaps down to financial considerations, a belief that referrals will not be reciprocated back, leading to a reduction in patient base and de-skilling, or a strong sense of paternalism where the urologist genuinely feels that they can offer a superior treatment package. This theme has previously been shown by Miller et al. who described how many patients with kidney cancer were offered treatment based on the surgeon’s practice style rather than on the characteristics of their disease.

However, given a choice of a number of options, it has previously been shown many times, that patients are more likely to build a strong rapport with the first specialist clinician they meet, and therefore likely to revert back to the first treatment option. Perhaps a lack of cross-referral is based on a pre-emptive sense of patient autonomy. Often the greatest power of autonomy is relinquishing it, and letting the consultant decide the best course of treatment offers the greatest solace. Despite the optimism and favorability of newer technology and techniques, and a general demand for minimally invasive procedures (Duchene et al. 2011), no-one is simply advocating technology for its own sake, or that a robotic-assisted circumcision could be currently seen as acceptable, however the idea of communication, cross-referral and the confidence in asking for further sensible treatment options should always be embraced.

In many ways, our annoyance with the mobile phone screen could have been avoided had the mobile provider been honest, and provided us with further options. It may not have stopped us from fixing the screen elsewhere due to institutional constraints however; a rapport and confidence would have been maintained.

One would do well to find a specialty in which the addition of a constructive (competitive) second opinion has not driven progress. Cross-referral is not a matter of failure, nor a lack of progress, but a continued determination to ensure the highest level of patient care available, to improve patient perception of the specialty as one committed to open communication, and a means to foster concrete inter-institutional relationships. Should we have to document that a second modality opinion was at least sought by the specialist, or waived by the patient?

“The single biggest problem in communication is the illusion that it has taken place” – G.B. Shaw

Fardod O’Kelly is a Specialist Registrar in Urology at AMNCH, Tallaght, Dublin 24, Ireland. Twitter @FardodOKelly

Editorial: How are we doing with percutaneous nephrolithotomy in England?

May 14, 2014/by Roger Sur

Over the past several years, with publications of studies evaluating multiple aspects of nephrolithiasis using large databases, our overview of kidney stone disease has vastly expanded. The most recent addition by Armitage et al. [1], published in this issue of BJUI, gives us a view of percutaneous nephrolithotomy (PCNL) outcomes in England that we otherwise would have difficulty seeing without tapping into a database study. Several salient features of this investigation are worth pointing out.

With any study comes the uncertainty of its validity. Evidence-based medicine (EBM) theory dictates we first ask ‘Are the results valid?’ rather than ‘What are the results?’. This study reports similar outcomes to a prior database study of the BAUS, giving us confidence that data from different sources still produce somewhat similar outcomes, hence adding validity to both studies [2]. Moreover, it is further reassuring that the type of epidemiological source of the information was derived from completely different origins, i.e. Armitage et al. [1] used an administrative database from Hospital Episode Statistics (HES) to create their outcomes while the BAUS used a voluntary online prospective database for British surgeons.

The second question that forms the basis of EBM is ‘What are the results?’. The HES data confirmed several findings of PCNL seen in other studies, including in both international series from the Clinical Research Office of the Endourological Society (CROES) as well as American administrative database studies using the Nationwide Inpatient Sample (NIS) [3-5]. Overall complications occur anywhere from 6% to 15% of the time, with the most common complications including infection and bleeding. Compared with these recent studies, the HES study reports lower bleeding, UTI and sepsis rates, which the authors admit could represents an under-reporting phenomenon. Mortality is an exceedingly rare event in all these studies. Overall, complication rates are comparable and give us assurance that they align approximately with other worldwide data. Another important finding with the HES database is the decreased length of stay for patients over time. Lastly, from a physician credentialing standpoint this study has relevant findings. It suggests that the HES administrative database may be a viable source of information to assist in the surgeon validating process.

Weaknesses of administrative database studies include the lack of detail that prospective clinical databases provide. Clinically pertinent PCNL endpoints are inherently absent for both patient and surgical domains. Missing patient information includes stone size, stone-free rates, and patient obesity, which are all reflections of clinical case difficulty. Missing critical surgical information includes where (upper, mid or lower calyx), who (urologist or radiologist) and how (balloon, serial dilators) access is obtained. As mentioned above, the uncertainty of under-coding clinical information always exists.

Why are large database studies, including this article, important? These studies are timely given the recent advocating of retrograde ureteroscopic treatment of large renal calculi [6]. Publication of low complication rates with equal efficacy in an outpatient setting has made ureteroscopic treatment of partial and staghorn renal calculi attractive. Even laparoscopic anatrophic nephrolithotomy has been advocated to further challenge the ‘gold standard’ treatment of PCNL [7]. It is therefore clinically important that British PCNL complication rates are low and that length of stay is decreasing to affirm the role that PCNL has with large renal calculi.

The role of PCNL surgery for renal calculi continues to develop but, more importantly, the value of these large epidemiological studies also continues to grow. They help us to look not only from the ground level but also give us perspective from a different, if not ‘higher’ level, which taken together helps shapes our interpretation of PCNL.

Roger L. Sur

Department of Urology, UC San Diego Health System, San Diego, CA, USA

Read the full article

References

Armitage JN, Withington J, Van der Meulen J et al. Percutaneous nephrolithotomy in England: practice and outcomes described in the hospital episode statistics database. BJU Int 2014; 113: 777–782
Armitage JN, Irving SO, Burgess NA, British Association of Urological Surgeons Section of Endourology. Percutaneous nephrolithotomy in the United Kingdom: results of a prospective data registry. Eur Urol 2012; 61: 1188–1193
de la Rosette J, Assimos D, Desai M et al. The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J Endourol 2011; 25: 11–17
Mirheydar HS, Palazzi KL, Derweesh IH, Chang DC, Sur RL. Percutaneous nephrolithotomy use is increasing in the United States: an analysis of trends and complications. J Endourol 2013; 27: 979–983
Ghani KR, Sammon JD, Bhojani N et al. Trends in percutaneous nephrolithotomy use and outcomes in the United States. J Urol 2013; 190: 558–564
Aboumarzouk OM, Monga M, Kata SG, Traxer O, Somani BK. Flexible ureteroscopy and laser lithotripsy for stones >2 cm: a systematic review and meta-analysis. J Endourol 2012; 26: 1257–1263
Aminsharifi A, Hadian P, Boveiri K. Laparoscopic anatrophic nephrolithotomy for management of complete staghorn renal stone: clinical efficacy and intermediate-term functional outcome. J Endourol 2013; 27: 573–578

Ejaculatory Function and Treatment for Male LUTS due to BPH

May 12, 2014/1 Comment/by Ben Jackson

This month’s twitter-based international urology journal club discussed “Impact of Medical Treatments for Male LUTS due to BPH on Ejaculatory Function: A Systematic Review and Meta-analysis”, published online in the Journal of Sexual Medicine. The discussion was enriched by the participation of Asst. Prof. Giacomo Novara (@giacomonovara) of the University of Padua, the senior author of the paper.

There was general consensus that this was a well constructed paper addressing an important and sometimes neglected side-effect of a group of medications that most urologists use commonly. The principal messages of the paper were:

Ejaculatory dysfunction (EjD) was significantly more common with alphablockers (ABs) in general than placebo
This effect was mainly seen with selective ABs (tamsulosin and sildosin). Non-selective ABs (doxazosin and terazosin) had similar rates of EjD to placebo.
Finasteride and dutasteride both cause EjD, and to a similar extent as each other.
Combination therapy (5ARI + AB) resulted in a three-fold increase in EjD compared to either monotherapy

The authors were congratulated on the amount of work that had obviously gone into the analysis. There was a discussion of some of the technical aspects of how to conduct a systematic review (SR) and meta-analysis. The PRISMA guidelines are a mandatory standard, and are recommended to anyone considering undertaking one. @LoebStacy also recommended the Cochrane handbook as a useful source of info. @DrHWoo asked whether Jadad scores had been used to rate RCT quality. They were not used in this study, but are one method of assessing RCT quality for an SR. @chrisfilson and @jleow advocated the Cochrane Collaboration’s tool for risk of bias assessment (found in Section 8.5 of the handbook), as an alternative.

After the technical aspects, discussion focussed on how best to avoid EjD in men who are concerned about it. @linton_kate asked whether PDE5 inhibitors were an option in this regard. General consensus was that they are an option, especially where LUTS and erectile dysfunction (ED) coexist, but concerns were expressed about the cost (which varied country by country, but is generally far in excess of the cost of ABs) and by @nickbrookMD about the uncertainty surrounding their mechanism of action for LUTS improvement.

Several correspondants were using PDE5Is in clinical practice for this indication however, including @VMisrai. It was pointed out however, that alfuzosin also offers a reduced risk of EjD compared to other ABs, and is substantially less expensive than PDE5Is. Alfuzosin was not evaluated in this paper, however @giacomonovara agreed that it was an option in men with LUTS who wish to avoid EjD, especially where ED is not a concern. @DrHWoo pointed out the Rosen data demonstrating the correlation between increasing LUTS and decreasing erectile function, but indeed (as suggested by @JCLinMD) treatment of LUTS, e.g. with an AB, may in itself improve erectile function.

Discussion moved on to 5ARIs. @giacomonovara stated that these agents had a broad spectrum of potential effects on ejaculatory/erectile function. @shomik_S raised the issue of whether 5ARIs could cause irreversible sexual side-effects. This is certainly a medicolegal concern, and undoubtedly some men report persistent effects on libido and sexual function, although a firm causal link has not been established.

The medicolegal theme was further explored with a discussion on what to warn patients of when commencing these medications. All were agreed that patients commencing ABs/5ARIs, including those undergoing medical expulsive therapy for stones should be warned about EjD. There was some discussion however, about whether patients commencing a 5ARI should be warned about the increased rates of high-grade prostate cancer seen in the PCPT and REDUCE trials. This increase may be an artefact of more effective cancer detection, but none-the-less @loebStacy was of the opinion that it should be included in pre-treatment counselling.

But is all the concern about sexual side-effects justified? It was pointed out that many patients are prepared to tolerate sexual side-effects in return for improvement in their LUTS.

Regardless, this paper from @giacomonovara and co-authors provided useful insight and stimulated a valuable discussion. Undoubtedly, some patients are very concerned about EjD and this paper will help all urologists who treat male LUTS to address these concerns.

Winner of the Best Tweet Prize was David Gillatt for his response to the discussion regarding the needs of various nationalities for PDE5I. Special thanks to the SIU for offering a prize of free registration to the 2014 SIU Congress in Glasgow. Also special thanks to Wiley for allowing open access of the article for the May #urojc discussion.

Ben Jackson has completed urological training in the East Midlands, and is now undertaking a fellowship at St. Vincent’s Hospital, Sydney. His principal clinical interest is urologic oncology.
Twitter @Ben_L_Jackson

Reaching a consensus…robotic radical cystectomy

May 9, 2014/4 Comments/by Declan Murphy

What is your impression of a “consensus statement”? We have these periodically in urology and they do tend to get widely read. One wonders, how difficult could it be for a bunch of urologists to reach a consensus on something?? Especially if, at the end of the day, we are all agreeing to cut something out?! It’s not like radiation or doing nothing are on the cards for this particular topic! How difficult could it be?

Well, let me give you a peak into the workings of the robotic-assisted radical cystectomy (RARC) Consensus Conference which took place at the City of Hope Hospital in California last weekend, the findings to be known as “The Pasadena Consensus Statement on RARC”. This two-day conference took place in the beautiful foothills of the San Gabriel Mountains in Southern California, and was hosted by Dr. Tim Wilson, Chief of Urology at City of Hope. The event was co-ordinated by the eminent New England Research Institute, led by Dr. Ray Rosen, and funded by a generous philanthropist affiliated with the hospital. The format of the meeting was familiar, as there has already been a Pasadena Consensus Statement on robotic-assisted radical prostatectomy, which was published in European Urology in 2012 along with four systematic reviews, all of which have been highly-cited. The conference invited a group of leaders in radical cystectomy, open as well as robotic, to participate and the resulting faculty features some highly-published figures in muscle-invasive bladder cancer, including some of the pioneers of RARC. These include:

Tim Wilson, City of Hope, California
Bernie Bochner, Memorial Sloan-Kettering, New York
Peter Wiklund, Karolinska, Sweden
Khurshid Guru, Roswell Park, New York
Eila Skinner, Stanford University, California
Joan Palou, Fundacio-Puigvert, Barcelona
Jim Catto, Editor-in-Chief, European Urology, Sheffield
Giacomo Novara, Padua, Italy
Bertrand Yuh, City of Hope, California
Declan Murphy, Peter MacCallum Cancer Centre, Melbourne
Magnus Annerstedt, Stockholm, Sweden
Arnulf Stenzl, Tuebingen, Germany
Kevin Chan, City of Hope, California
Jim Peabody, Vattikuti Urology Institute, Detroit

Photo courtesy of Dr Jim Catto.

The goal was to review the current evidence for RARC (by way of systematic reviews and other detailed review), and to agree a “Best Practices” white paper. We had been split into working groups and had submitted slides overviewing our topics ahead of time. The two-day schedule then allowed presentation of these slides with (very) detailed critique and discussion. Systematic review maestro Giacomo Novara had worked with Bertrand Yuh to complete the systematic reviews prior to the conference and findings from these also informed much discussion. Bernie Bochner (the most knowledgeable person I have ever met on the topic of muscle-invasive bladder cancer!), kindly agreed to present the findings from the MSKCC randomised controlled trial which are key data in this area. This paper is about to be submitted so the Pasadena group will be able to include these findings in the final papers.

So was it a cosy chat in the Californian sunshine with much nodding of heads on key topics? Well, occasionally! The group were very sociable with very lively interaction, but there was certainly robust discussion on certain topics. Some of these leaked out on Twitter as one might expect with a few prominent uro-twitterati in the room (@jimcatto, @giacomonovara, @declangmurphy, @joanfundi, @AStenzl, @jamesopeabody), and with a lively response from social media enthusiasts from around the world getting involved in the #RARC conversation (@dytcmd, @@uretericbud, @daviesbj, @dmsomford, @matthayn, @kahmed198, @uroegg, @UROncdoc, @urogill, @urorao, @nickbrookMD, @joshmeeks, @wandering_gu, @urologymatch, @urology_verona, @chrisfilson, @mattbultitude, @clebacle, @chapinMD, @ggandaglia, @urogeek, and more) – every corner of the globe involved!

At certain times, the weight of data for open radical cystectomy was difficult to counter, and led to lively discussion between Bernie and Khurshid. For confidentiality reasons, we can’t reveal key findings until the final papers have been written and published, but Twitter does allow a sneak peak:

A general lament was the lack of high-quality data overall, as tweeted in this quote from Arnulf Stenzl:

However, some of the big publications from the pioneering centres, especially the data from the International Robotic Cystectomy Consortium (IRCC), and the RCT from Memorial have given us plenty to consider.

Having been involved in another large consensus statement recently (The Melbourne Consensus Statement on the Early Detection of Prostate Cancer), I can tell you that these statements feature very robust discussion before consensus is reached, and occasionally consensus is not reached leading to topics being omitted. The chosen faculty for such statements are highly-knowledgeable leaders in the field, but often have views which are highly discordant. The Chair has a great challenge to moderate so that the final statements are agreeable to all, and I am sure that the Pasadena Statement on RARC will prove of great interest to all working in this field.

[The Pasadena Consensus Statement Best Practices white paper will be published in European Urology in coming months, along with two systematic reviews and a Surgery in Motion technique paper]

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

Disclosure – Declan Murphy received support to cover travel and accommodation costs through the New England Research Institute. No industry support was received by any participants in this conference.

New technology for prostate cancer…beyond robotics!

May 8, 2014/12 Comments/by Addie Wootten

Urology has led the way introducing new technology for men with prostate cancer. Robotic surgery, focal therapy, nanoknife, cyberknife – the list goes on. But have we fully embraced the everyday technology we all have access to in our care for men with prostate cancer? There are a growing number of Apps designed to support prostate cancer patients and improve quality of life. If you type ‘prostate’ into the iTunes App store about 82 results are found, but many of these are fundraising events, journals and staging tools, many of which are not patient friendly. Whilst there is an increasing appetite for patient-centered tools – focused on supporting and empowering patients in managing their health and wellbeing – we still have some way to go in this regard.

As a clinical psychologist working in urology, I often hear patients and their families describing their feelings of uncertainty and loss of control. Furthermore, Australia is a huge country with vast rural and remote areas and many patients that live in these areas find it very difficult to access the information, advice and support they require to ensure optimal outcomes from their prostate cancer.

The benefits of harnessing technology in the pursuit of improved health and wellbeing via improved patient engagement and access to services are clear; so why not use this technology to improve the care we provide to men with prostate cancer?

We have developed an online prostate cancer portal www.PROSTMATE.org.au

PROSTMATE provides tailored information, access to self-help interventions, a personal record of treatments and other milestones, a PSA graphing function and a regular check-up that records self-reported ratings across 5 quality of life domains and graphs these over time. PROSTMATE also offers telehealth (web-enabled video) consultations with prostate cancer nurses and allied health clinicians.

A complex and dynamic algorithm has been designed to tailor the extensive library of information to match the user type and stage of treatment for each person using PROSTMATE. Recommended library information is delivered to the user via their private dashboard and this information automatically updates when information has been read. This aspect of PROSTMATE was designed to help prostate cancer patients navigate to the information most relevant to them and their circumstances, and to reduce the often overwhelming feeling of information overload.

The timeline provides an opportunity for patients to record all their prostate cancer milestones including their treatments, test results, medical appointments, personal journal entries and more. The timeline’s graphical illustration of PSA results and self-reported quality of life over time also allows users to keep track of things as simply as possible.

The telehealth consultations are one of the most exciting aspects of PROSTMATE as they connect men, and their families with expert prostate cancer nurses and psychologists (and hopefully in the future exercise physiologists and physiotherapists) whom they may not have had access to in their routine care. We know that many men, particularly men from rural and remote areas, find it very difficult to access allied health services and we hope that delivering clinical consultations via telehealth will facilitate improved access to services as well as overall improvements in quality of life in the long-term; not to mention the potential savings made through reduced travel time, time off work and reductions in patient loads in busy outpatient clinics.

PROSTMATE launched to the general public in November 2013 and since then has attracted more than 700 new members. We have received overwhelming feedback supporting the use of technology in the care of everyone affected by prostate cancer. It’s surprising how many men and family members feel isolated by the traditional medical model and we are delighted that we can harness the power of technology to empower and connect people to their health and wellbeing.

PROSTMATE is free to join and has been supported by generous philanthropic funding. Our program is continually evolving as we learn what is most useful to our members, and through this, we intend to expand and develop new components and functionality in the near future. You can become a member yourself by selecting health professional in the sign up pages to see what PROSTMATE might offer your patients.

Visit www.PROSTMATE.org.au and follow us on Twitter @PROSTMATE

Dr. Addie Wootten
Clinical Psychologist
eHealth Research Manager
Australian Prostate Cancer Research
Twitter: @addiewootten @PROSTMATE

Editorial: Cryosurgery for clinical T3 prostate cancer

May 7, 2014/by Osamu Ukimura

There are limited data available on the outcomes of cryosurgery for clinical T3 prostate cancer, and as such, the role of cryosurgery for clinical T3 disease is currently undetermined [1]. Modern cryosurgery of the prostate, utilizing gas-based third-generation technology, a real-time monitoring system with ultrasonography and thermocouples, is associated with a low complication rate [7], although comparative outcomes of the different treatment modalities and long-term follow-up data remain to be seen.

Several aspects of cryosurgery can make it difficult to adequately control locally advanced prostate cancer. First, cryosurgery for clinical T3 cancer requires unique surgical expertise to control local disease while minimizing side-effects. Secondly, staging of locally advanced prostate cancer is challenging – it is difficult to accurately identify the extent of extracapsular extension, seminal vesicle involvement and/or lymph node metastasis. Thirdly, challenges in managing clinical T3 disease include the requirement of a more extensive ablation technique to appropriately target the extraprostatic disease and seminal vesicle involvement as well as treatment for possible microscopic metastasis, which might not be clinically detectable.

Two recent randomized trials compared outcomes of external beam radiation therapy with those of cryosurgery (including cT3 diseases with use of neo-adjuvant androgen deprivation therapy [ADT]), with contrasting results [2, 3]. Chin et al. [2] reported superiority of biochemical disease-free survival favouring external beam radiation therapy in relatively more advanced (bulky) disease, while Donnelly et al. [3] reported significantly fewer positive biopsy rates favouring cryosurgery in the relatively less advanced disease. These findings could suggest that more advanced bulky cases that require wider local control of bulky extraprostatic diseases are not suitable for cryosurgery, while in appropriately selected cases with fewer extraprostatic diseases, cryosurgery is an acceptable option (when combined with neo-adjuvant ADT). Although appropriately extended cryo-lesions that achieve lethal temperatures can control extraprostatic disease, there is a certain limitation in the extension of cryo-lesions without injury to vital peri-prostate organs, such as the urinary sphincter, rectal wall, bladder wall and ureters.

Evolving accuracy of preoperative diagnostic imaging to assess extraprostatic disease can enhance outcomes, and staging tissue sampling from suspected extraprostatic disease could also identify actual microscopic extension of the extraprostatic disease [4]. A recently updated nomogram predicting lymph node invasion [5] suggests that the probability of lymph node invasion in patients with cT3, PSA level >10 ng/mL, and biopsy primary Gleason grade 4 is 20% or greater. Clearly, the preoperative risk assessment of lymph node involvement using such a modern calculator is pertinent for appropriate patient selection. Finally, management decision should be made by a multidisciplinary team.

When combined with radiotherapy, neo-adjuvant ADT for high-risk and locally advanced prostate cancer has been associated with clinical benefit; however, when combining neo-adjuvant ADT with prostatectomy, there is pathological down-staging and reduction in the surgical positive margin but minimal improvement in overall or disease-free survival [6]. The role of neo-adjuvant and adjuvant ADT when combined with cryosurgery is still unknown. Clearly, a prospective study is needed to determine the optimal duration and method of ADT (whether to use LHRH analogue or combined blockade) and to analyse the side-effects, the quality of life and the cost-effectiveness of a combination of cryosurgery with ADT for cT3a and cT3b prostate cancer.

Osamu Ukimura, Andre Luis de Castro Abreu, Andrew J. Hung and Inderbir S. Gill
USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Read the full article

References

Babaian RJ, Donnelly B, Bahn D et al. Best practice statement on cryosurgery for the treatment of localized prostate cancer. J Urol 2008; 180: 1993–2004
Chin JL, Al-Zahrani AA, Autran-Gomez AM, Williams AK, Bauman G. Extended followup oncologic outcome of randomized trial between cryoablation and external beam therapy for locally advanced prostate cancer (T2c-T3b). J Urol 2012; 188: 1170–1175
Donnelly BJ, Saliken JC, Brasher PM et al. A randomized trial of external beam radiotherapy versus cryoablation in patients with localized prostate cancer. Cancer 2010; 116: 323–330
Ukimura O, Coleman JA, de la Taille A et al. Contemporary role of systematic prostate biopsies: indications, techniques, and implications for patient care. Eur Urol 2013; 63: 214–230
Briganti A, Larcher A, Abdollah F et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol 2012; 61: 480–487
Shelley MD, Kumar S, Wilt T, Staffurth J, Coles B, Mason MD. A systematic review and meta-analysis of randomised trials of neo-adjuvant hormone therapy for localised and locally advanced prostate carcinoma. Cancer Treat Rev 2009; 35: 9–17
Ward JF, DiBlasio CJ, Williams C, Given R, Jones JS. Cryoablation for locally advanced clinical stage T3 prostate cancer: a report from the Cryo-On-Line Database (COLD) Registry. BJU Int 2014; 113: 714–718

Brown Sauce and honest reporting

May 2, 2014/6 Comments/by James Duthie

The British are fond of a condiment called Brown Sauce. The product itself leaves me unmoved, but the thing I find interesting about Brown Sauce is that it purports nothing about itself whatsoever, other than a description of its colour. It claims no link to any known product of nature, just a factual statement about its appearance. Consider, for instance, tomato ketchup. If an independent lab discovers that a ketchup is, in fact, only 5% tomato and 95% starch, sugar, salt, and flavor enhancer 621, people will be justifiably irate about the “tomato” claim. If, on the other hand, Brown Sauce is eventually proven to be made from asbestos and drowned kittens, the manufacturers can quite rightly state that they only said it was brown.

The same kind of plain speech is often missing in surgery. The truth has often been a casualty in the patient consent process due to a combination of ignorance, fear, avarice, or ego on the part of the surgeon. Whatever the motivation, when we explain rates of risks and benefits to the patient before us, many of us are not giving an honest report of our own outcomes. In the case of the battle between robotic and open radical prostatectomy, for example, real-world complication rates are often ignored in favour of Walsh’s rates on one side, and Patel’s on the other. Surgeons are certainly not all the same. If you have ever considered who you would allow to perform surgery on yourself the chances are you have written a very short short-list. When we tell a patient that the rate of complication x from procedure y is only 5% and we have not audited our own outcomes, we are likely giving the rates produced by the high-volume specialist centres that had the expertise, numbers, and clout to get their rates published in a reputable journal. Most surgeons do not work in those centres.

There is an on-going debate on whether hospitals should be compelled to publish their procedure-specific outcome data, so that the public can make informed decisions about their surgical care. I think this misses the point. Yes, there are potential hazards to compulsory publishing; centres of excellence may have worse outcomes than others due to operating on the sickest patients with the slimmest hopes of success, one major complication in a lower volume centre can skew the data, and there is the potential to develop a culture of suspicion and dishonesty, but the real point is more personal. We should honestly report to the patient in front of us from our own results as a matter of honesty and ethics, regardless of hospital policies. We can then (hopefully) reassure them that our outcomes are comparable to those published, and they can expect good quality care from us. If we cannot reassure them of this, our audit process will inform us of our shortcomings and we can seek to address them. We might even consider leaving certain procedures to a colleague who is better at it than us. A bitter pill, maybe, but arrogance is the enemy of improvement.

It can be a nuisance to collect and collate operative data. It can be painful to discover that we are not as good at something as we had assumed. Thankfully surgeons are mature adults who can take these challenges on the chin, and use the results to make our patient care better. Can’t we?

Otherwise, the information we give our patients is “pork-pies”, which is Cockney rhyming slang for lies, and no amount of Brown Sauce can make those pies palatable.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1