Flying high as a kite

May 1, 2014/1 Comment/by Prokar Dasgupta

Some of my happiest memories are from my childhood. Part of it was spent in Lucknow where my mother had her ancestral home. An important city in Northern India, Lucknow was the seat of the Nawabs who built many beautiful palaces. One of these has a labyrinth, which many have entered only to get lost within its many chambers. Another, the Chhota Imambara is pictured on the cover. Lucknow is also famous for its cuisine with street vendors selling tasty kebabs. Above all, I remember many hours perched on the roof top of our home in the old town, flying kites, with my family. The sky above became a riot of colours. Today there is even a touring company offering nostalgic kite flying holidays in this ancient city.

In May, our Article of the Month comes from the King George Medical University, Lucknow. In a prospective, longitudinal comparison over six years, of a large number of patients undergoing urinary diversion after radical cystectomy, the authors demonstrate better quality of life after orthotopic neobladder rather than ileal conduit formation [1]. The mean age of the patients was in the mid 50s, which is perhaps why a significant number underwent neobladder formation. This article and the accompanying editorial from Urs Studer [2] are must reads for anyone involved in the management of bladder cancer. In the UK many of our patients are generally older with multiple co-morbidities and end up having ileal conduits. For the younger patients it is perhaps time for a rethink?

We also feature an excellent multi-institutional collaboration reporting on PCNL outcomes in England from the Hospital Episode Statistics (HES) database over a five year period. Mortality is rare after this procedure but 9% of patients have a readmission within 30 days [3]. While the HES like most other databases has its inherent limitations, the authors should be congratulated for analysing complex outcomes on nearly 6000 patients; in particular John Withington who is writing his thesis on the subject.

And finally – an invitation. If you are attending the AUA, we are again having a BAUS–BJUI–USANZ session on the afternoon of the 18 May. The faculty is international and the program even more exciting than it was last year. This is a further testament to the strong friendship that exists between our organisations and the AUA. The Coffey–Krane prize for the best paper published in the BJUI by a trainee, will be presented at the end of this session followed by the BJUI reception.

Many of you have loved our new design, layout and quality although this has led to a precipitous drop in our acceptance rate in favour of only the very best papers. Thank you for your support, which has given us the strength and resolve to fly high. The sky is the limit.

Prof. Prokar Dasgupta
Editor-in-Chief, BJUI
King’s College London, Guy’s Hospital#

References

Singh V, Yadav R, Sinha RJ, Gupta DK. Prospective comparison of quality-of-life outcomes between ileal conduit urinary diversion and orthotopic neobladder reconstruction after radical cystectomy: a statistical model. BJU Int 2014; 113: 726–732
Studer UE. Life is good with orthotopic bladder substitutes! BJU Int 2014; 113: 686–687
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

Engaging responsibly with social media: the BJUI Guidelines

April 30, 2014/1 Comment/by Declan Murphy

The final, peer-reviewed version of this paper has been accepted for publication in BJUI.
You can find it here. Please cite this article as doi: 10.1111/bju.12788

The social media revolution is well underway. Facebook, Twitter, YouTube, Instagram, Weibo, Blogger, LinkedIn, and many other social media platforms, have now penetrated deeply into our lives and have transformed the way in which we communicate and engage with society. The statistics are staggering. As of mid-2014, the total number of global users of the following platforms has exceeded billions of people from every nation in the world:
- Facebook – over 1.3 billion users
- Twitter – over 280 million active users
- YouTube – over 1 billion people view YouTube each month
- Instagram – over 200 million users
- LinkedIn – over 270 million users

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There is a huge difference between the number of people who visit your site (your basic traffic) and the number of people who actually do what you intend them to do. Many people make the mistake of focusing more on the traffic of their page or website when in reality they ought to invest and research on ways to make visitors make a purchase or subscribe to a newsletter or download an app, visit here to see example. Conversion rate can be described as the ratio of the total visitors to a website to the number of visitors who actually take action that the site is intended to make them take. Take, for instance, if you are an online retailer then the action you will intend for visitors to take will be the purchase of your wares. And if you are an Indian mobile app developer, your intended action will be the download of your apps. Conversion rate optimisation agency will help to improve your conversion ratio resulting in greater conversion/positive customer action.

Social media has also become very popular among-st healthcare professionals both on a personal and professional basis. The reach and engagement which social media enables, along with the incredible speed with which information is disseminated, clearly creates opportunities for advances in healthcare communication. However, because healthcare professionals also have serious professional responsibilities which extend to their communication with others, there are dangers lurking in social media due to the inherent lack of privacy and control.

As a result, major professional bodies have now issued guidance for their members regarding their behaviour using social media. These include bodies representing medical students, general practitioners, physicians, oncologists, the wider medical community, as well as major regulatory bodies such as the Federation of State Medical Boards and the General Medical Council (GMC) in the UK, whose role is to licence medical practitioners. The guidance from the latter, part of the GMC’s Good Medical Practice policy, has significant implications as failure to comply with this guidance could impact a doctor’s licence to practice. All health care providers engaging in social media need to familiarize themselves with the relevant institutional, local, and national guidelines and policies.

There are many examples of healthcare providers who have faced disciplinary action following content posted on social media platforms. For example, posting photos of a drunk patient to Instagram and Facebook [1] is likely to result in serious disciplinary and legal action. In another case, a doctor in the USA was dismissed from her hospital and censured by the State Medical Board when she posted online details of a trauma patient [2]. Although her posting did not reveal the patient’s name, enough information was posted for others in the community to identify the patient. Furthermore, a review of physician violations of online professionalism and disciplinary action taken by State Medical Boards in the USA demonstrated that this case was not isolated [3]. Over 90% of State Medical Boards reported that at least one of several online professionalism violations had been reported to each of them. The most common violations were inappropriate patient communication online, often of a sexual nature. While the most frequent plaintiffs were patients and their families, it is noteworthy that complaints by other physicians were reported in half of State Medical Boards. Overall, serious disciplinary action including licence restriction, suspension or revocation occurred in over half of cases. There is clearly a need for healthcare professionals to be aware of their responsibility when communicating online.

So what of urology and social media? There is no doubt that many urologists have embraced social media with great enthusiasm, and urology has been one of the specialties leading the way [4-7]. The BJUI has been at the forefront of this enthusiasm as we have implemented a wide-ranging and evolving social media strategy including an active presence on the main social media platforms, a popular blog site, and a strategy to integrate our journal content across these platforms [8]. We now also recognise achievements in social media in urology through our annual Social Media Awards and by introducing a formal teaching course at the 2013 British Association of Urological Surgeons (BAUS) Annual Meeting, the first such course at a major urology meeting. While continuing to encourage the development of social media in urology as one of our key strategies, we also recognise that there are risks inherent in engaging in social media and that clinicians must be aware of these risks.

We therefore propose the following guidelines for healthcare professionals to ensure responsible engagement with social media. Much of this content is in alignment with advice issued by the other bodies listed above.

Always consider that your content will exist forever and be available to everyone. Although some social media platforms have privacy settings, these are not foolproof and one should never presume that a post on a social media platform will remain private. It should instead be assumed that all social media platforms lack privacy and that content will exist forever.
If you are posting as a doctor, you should identify yourself. The GMC guidance has specifically commented on anonymity. They advise that if you are identifying yourself as a doctor then you should also give your name, as a certain level of trust is given to advice from a doctor. People posting anonymously should be very careful in this regard as content could always be traced back to its origins, particularly if it became a matter for complaint.
State that your views are your own if your institutions are identifiable. It is commonplace for clinicians to identify their institutional affiliation in their social media profile. While not an excuse for unprofessional activity, it is good practice to state that your views are your own, particularly if you occupy leadership positions within that institution.
Your digital profile and behaviour online must align with the standards of your profession. Whatever standards are expected of the licencing body for your profession must be upheld in all communications online. You should also be aware that what you post, even in a perceived personal environment such as Facebook, is potentially accessible by your employers. As employers they will have a certain standard of behaviour that they expect. For example, use of inappropriate language or images of drunkenness could result in disciplinary action.
Avoid impropriety – always disclose potential conflicts of interest. The American Society of Clinical Oncology (ASCO) includes this important point in their guidance. Influencers in social media can hold powerful sway and clinicians have a responsibility to use this influence responsibly and manage any potential conflicts.
Maintain a professional boundary between you and your patient. It is not unusual for patients to be interested in their doctor’s social network. While most people do not restrict their Twitter and instagram followers for public profiles (and therefore all tweets must uphold professional standards), it is reasonable to politely decline a friend request on Facebook by stating that you keep your personal and professional social networks separate. The BMA guidance specifically advises against patients and doctors becoming friends on Facebook and advises that they politely refuse giving the reasons why.
Do not post content in anger and always be respectful. It is considered inappropriate to post personal or derogatory comments about patients OR colleagues in public. Defamation law could apply to any comment made in the public domain.
Protect patient privacy and confidentially at all times. There is an ethical and legal duty to protect patient confidentiality at all times, and this equally applies to online communication including social media. If posting a video or image, consent needs to be obtained for this even if the patient is not directly identifiable. Content within a post or image, including its date and location and your own identity, may indirectly identify a patient to others. The GMC guidance also states that you must not ‘discuss individual patients or their care with those patients or anyone else’. Thus posting about a case you have just seen could be in breach of these recommendations.
Alert colleagues if you feel they have posted content which may be deemed inappropriate for a doctor. Quite unintentionally, colleagues may post content which may be regarded as unprofessional for any of the reasons listed above. Although a digital shadow may always persist, deleting the online content before it becomes more widely disseminated may help mitigate the damage.
Always be truthful and strive for accuracy. All online content in social media should be considered permanent. It should also be considered that anyone in the world could potentially access this content. Therefore, truthfulness and accuracy are simple standards which should be upheld as much as possible.

Social media is a very exciting area of digital communication and is full of opportunities for clinicians to engage, to educate and to be educated. However, risks exist and an understanding of the boundaries of professional responsibility is required to avoid potential problems. Adherence to simple guidelines such as those proposed here may help clinicians achieve these aims.

Declan G Murphy^1-2, Stacy Loeb³, Marnique Y Basto¹, Benjamin Challacombe⁴, Quoc-Dien Trinh⁵, Mike Leveridge⁶, Todd Morgan⁷, Prokar Dasgupta⁴, Matthew Bultitude⁴

¹University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia, ²Epworth Prostate Centre, Epworth Healthcare Richmond, Melbourne, Australia, ³New York University, USA, ⁴Guy’s Hospital, King’s College London, UK, ⁵Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA, ⁶Department of Urology, Queen’s University, Kingston, ON, Canada, ⁷Department of Urology, University of Michigan, Ann Arbor, MI, USA

References

ABC News. Chicago doctor allegedly posted photos of drunk patient on social media. Available at: https://jobs.aol.com/articles/2013/08/21/chicago-doctor-drunk-patient-photos-facebook/
Above the Law. ER doc forgets patient info is private, gets fired for facebook overshare. Available at: https://abovethelaw.com/2011/04/er-doc-forgets-patient-info-is-private-gets-fired-for-facebook-overshare/.
Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA 2012; 307: 1141-1142.
Prabhu V, Lee T, Loeb S et al. Twitter Response to the United States Preventive Services Task Force Recommendations against Screening with Prostate Specific Antigen. BJU Int 2014; doi: 10.1111/bju.12748
Loeb S, Catto J, Kutikov A. Social media offers unprecedented opportunities for vibrant exchange of professional ideas across continents. Eur Urol 2014; doi: 10.1016/j.eururo.2014.02.048
Loeb S, Bayne CE, Frey C, et al. Use of social media in urology: data from the American Urological Association. BJU Int 2013; doi: 10.1111/bju.12586
Matta R, Doiron C, Leveridge MJ. The dramatic rise of social media in urology: trends in Twitter use at the American and Canadian Urological Association Annual Meetings in 2012 and 2013. J Urol 2014; doi: 10.1016/j.juro.2014.02.043
Murphy DG, Basto M. Social media @BJUIjournal – what a start! BJU Int 2013; 111: 1007-1009

The final, peer-reviewed version of this paper has now been accepted for publication in BJUI. You can find it here. Please cite this article as doi: 10.1111/bju.12788

A word of advice

April 30, 2014/2 Comments/by Simon van Rij

I saw a patient recently who presented with a number of different symptoms on the background of a complex past medical history. I rang my senior who quoted me these words,

“Sometimes the questions are complicated but the answers are simple”

I’ll tell you where he got that quote from later

One CT scan later we had our diagnosis but it got me thinking about the advice we receive from senior colleagues.

During our formal urology training we are mentored by urologists who at times impart advice to enable us to become better. The words spoken in a timely manner or often a repeated manner can become etched into a young surgeon’s mind.

Now for 2 stories:

Early in my surgical training I sat dejected in the professor’s office. A life threatening complication had occurred in one of our team’s patients after major open surgery. I was ready to throw the towel in, to no longer perform large operations to therefore avoid complications. I would be safe if I only ever performed minor procedures for the rest of my career.

“There are no such things as small surgeries only small surgeons”.

Spoken by one who had been there and done that and come out the other side. Years later near the end of my training I was lucky to operate again with this surgeon and thanked him for his words of advice. However as often happens in a moment of stress, similar I imagine to the moment a diehard fan meets their rock star idol, I proudly repeated back his words only for him to correct me again, as I had spoken them in the wrong order.

Story two took place after a Saturday ward round over coffee. Real coffee – (flat whites as we call them in New Zealand) in the hospital café where there was time to talk – no theatre list, no private clinic to rush off to.

“The cheapest mistake you will ever make is the complications of others”

I was implored to chase after the complications that happen to all patients in the hospital. So as to learn as much from them and how they were managed to avoid it in my own practice in the future. It challenged me to investigate, to read, to apply knowledge, to sit up in the monthly audit and to ask questions of why things happen.

3 statements have helped guide my surgical training. Said in isolation they mean little and could even sound cliché. However coming from a respected mentor at an appropriate time in a personalised fashion they have proved of immense value. And the further beauty is they will have repeated value as I attempt to pass them on in the future. Which brings me back to the opening statement and the whereabouts of its origins. Indeed those words were not my consultants own but rather that of another doctor. Dr. Seuss to be exact and it only goes to show that advice is often where you least expect it.

(On further research I wonder if this is where he actually got the statement from

Advice’s You Need to Know About Hair Loss, According to Dermatologists

SAKSIT SRISUKSAI / EYEEMGETTY IMAGES

If you’ve noticed patchy or thinning spots on your scalp or a surplus of hair strands on your hairbrush or in the shower, you’re not alone. More than half of all women will experience noticeable hair loss, according to the Cleveland Clinic. In order to put a stop to shedding, though, you have to figure out the root of the problem. “Hair loss is not a diagnosis,” says Yolanda Lenzy, M.D., M.P.H.,board-certified dermatologist and licensed cosmetologist in Chicopee, Massachusetts. “Hair loss is a symptom. Once you get a specific diagnosis, then you can know the causes associated with that diagnosis.” You can check some of the best dermatologist melbourne on doctor to you site.

For starters, know that the term “alopecia” refers to all kinds of hair loss. There are two main types of alopecia, and then a variety of forms of hair loss within those two categories. In cases of non-scarring or temporary hair loss, the missing hair will eventually grow back. With scarring or permanent hair loss, permanent damage is done to the hair follicles so they won’t grow back. “With scarring hair loss, the goal is not for it to grow back, but to stop the progression,” says Dr. Lenzy. Below, are seven different kinds of alopecia —knowing which one you’re suffering from will help determine the proper treatment.

GETTY IMAGES

Non-scarring (Reversible) Forms of Hair Loss

Androgenetic alopecia

When people talk about male or female pattern hair loss — typically a receding hair line in men or thinning at the crown in women — that’s androgenetic alopecia. It’s the most common form of hair loss among all people. In fact, research shows that more than 50% of women will develop androgenetic alopecia by the age of 80. “It can come from either side of the family in men or women, skip a generation, and start earlier in the next generation that the one before it,” says dermatologist Carolyn Goh, M.D., Health Sciences Assistant Clinical Professor at the David Geffen School of Medicine and Director of the Hair and Scalp Disorder Clinic at UCLA. “However, some people have pattern hair loss without a family history of it.” While some women start showing signs of androgenetic alopecia in their teenage years, others won’t experience it until their 50s or 60s. “When nearing menopause, the decrease of estrogen means you have unopposed testosterone,” says Dr. Lenzy. “That elevated testosterone can convert to a hormone called dihydrotestosterone (DHT), which contributes to the thinning of the hair follicles — the follicles actually get smaller in this particular form of hair loss.”. If you have straight hair then consister a permed texture you should buy kinky straight hair.

MORE FROM GOOD HOUSEKEEPING

Telogen effluvium

Telogen effluvium is just a fancy name for excessive hair shedding — an annoyance that many people will experience at some point in their life. “A common cause is stress, usually meaning major life stressors or physical stressors like surgery, medication (including over the counter ones and supplements), weight loss, or a death in the family, to name a few,” says Dr. Goh. “It usually starts three to six months after a stressor and then lasts for three to six months.” Hypothyroidism and iron deficiency can also trigger telogen effluvium. “The beautiful thing about it is 70% of your hair strands are still in the anagen or growing phase,” adds Dr. Lenzy. “Because the hair follicles work in a cycle, you won’t go bald.”

Alopecia areata

This type of hair loss affects about 2% of people and usually appears as round smooth circles anywhere on the head without any redness, itching, or pain. “Alopecia areata is thought to be caused by an autoimmune process,” says Dr. Lenzy. “The body’s immune system makes some mistakes and produces T cells that attack hair follicles.”

Traction alopecia

Thinning and bald patches at the temples or where hair is frequently pulled tight can indicate traction alopecia. “This very common form of hair loss is caused by haircare and hairstyle practices — practices which place excessive tension or weight on the follicles like braids, ponytails, hair extensions, or locs.”

Scarring (Permanent) Forms of Hair Loss

Central centrifugal cicatricial alopecia (CCCA)

“Central centrifugal cicatricial alopecia tends to start on the top of the head with breakage and thinning, and often with some tenderness of the scalp,” says Dr. Goh. “It gradually spreads outward and can cause permanent hair loss.” CCCA is especially common among Black women. “Some recent studies have found that about 25% of people with this form of hair loss have a genetic mutation in one of the proteins that’s responsible for the formation of the hair follicle,” says Dr. Lenzy. On top of that, she notes that the same haircare practices that create tension and cause traction alopecia also contribute to CCCA.

Editorial: Life is good with orthotopic bladder substitutes!

April 30, 2014/2 Comments/by Urs E. Studer

In the present issue of the BJUI, Singh et al. [1] present the results of a non-randomized prospective study comprising 80 patients who underwent ileal conduit diversion and 84 who underwent orthotopic bladder substitution. Quality of life was assessed using the European Organisation for the Research and Treatment of Cancer quality-of-life questionnaire, the QLQ-30C, at 6, 12 and 18 months postoperatively. Physical and social functioning and global health status were significantly better in patients with orthotopic bladder substitution than in those who underwent ileal conduit diversion. Moreover, the postoperative financial burden was significantly lower for patients in the orthotopic bladder group than for those in the ileal conduit group, who required stoma appliances, a finding of particular importance not only in India, where the study was performed, but worldwide. The authors’ results are particularly impressive given their use of a questionnaire that included many items (‘Were you short of breath?’, ‘Did you need to rest?’, ‘Have you lacked appetite?’, ‘Have you been constipated?’, ‘Did you feel tense?’, ‘Did you worry’ or ‘Did you feel irritable?’, etc.) that can hardly discriminate between the quality of life of patients who underwent orthotopic bladder substitution and those who underwent ileal conduit diversion. To find significant differences between the two types of urinary diversion, despite such dilution factors, speaks strongly in favour of orthotopic bladder substitution.

The results of this prospective single-centre trial are of particular importance because, as the authors state, other investigators could not show such differences, presumably for a variety of reasons, such as too few patients or single follow-up assessments given at time points that varied from patient to patient. Quality-of-life assessment at similar follow-up time points, as performed by these authors, is important because, with adequate counselling, the postoperative function of orthotopic bladder substitutes improves over time.

Without a doubt, however, a poorly functioning orthotopic bladder substitute may lead to a poorer quality of life than a well-functioning ileal conduit diversion. Poor functional results and life-threatening complications can be largely avoided with ileal orthotopic bladder substitutes, provided the treating urologist has adequate knowledge of the procedure and the patient receives adequate postoperative education [2]. The major ways to ensure good results are:

appropriate patient selection (good renal function, regular follow-up possible);
the avoidance of damage to the sphincter apparatus and its innervation (individualized nerve-sparing cystectomy, minimum use of bipolar electrocautery near the pelvic plexus and membranous urethra);
the use of ileum instead of colon (better compliance) [3-5];
the avoidance of a funnel-shaped outlet that can result in kinking, outlet obstruction, residual infected urine and, in the worst case, lifelong need for clean intermittent catheterization (CIC) (Fig. 1).

By contrast to most other urological procedures, orthotopic bladder substitution requires proactive postoperative management [6] to ensure:

residual urine-free spontaneous voiding after catheter removal;
sterile urine to improve urinary continence and to reduce mucous production [7];
the prevention of salt loss syndrome and metabolic acidosis by increased salt intake and sodium bicarbonate substitution in the early postoperative period to ensure a base excess of +2;
a systematic increase in functional capacity by progressively expanding voiding intervals to obtain a reservoir capacity of ∼500 mL and, thus, a low end-fill pressure which ensures urinary continence day and night (the latter combined with the use of an alarm clock).

It is equally important to perform lifelong follow-up of patients and regularly at 6- to 12-month intervals so as to diagnose and treat early secondary complications, such as uretero-intestinal strictures or residual, infected urine. If the latter occurs, any form of outlet obstruction, such as ileal mucosa protruding in front of the bladder outlet, strictures or growth of inadvertently left prostatic tissue, must be looked for and treated. In our own experience, secondary outlet obstruction occurred in ∼20% of patients observed for 10 years. This rather high incidence is typical for intestinal bladder substitutes because when voiding, unlike the genuine bladder, there is no coordinated contraction of the reservoir wall which would result in an elevated voiding pressure which, in turn, would overcome an outlet resistance. Bladder substitutes empty mainly by gravitational force alone. If voiding is only possible by abdominal straining, then something must be wrong; therefore, instead of recommending CIC for patients who build up residual and consecutively infected urine, we strongly favour treating the outlet obstruction, usually on an outpatient basis. The avoidance of the need for CIC through surgical technique (no funnel-shaped outlet) and during regular follow-up by treating any potential cause of residual urine can substantially improve the patient’s quality of life. It also avoids the cost of catheters and the risk of infectious complications. Thanks to this active management and removal of any outlet obstruction, 96% of our patients followed for 10 years were still able to void spontaneously [8].

Urs E. Studer
Department of Urology, University Hospital Bern, Bern, Switzerland

Read the full article

References

Singh V, Yadav R, Sinha RJ, Gupta DK. Prospective comparison of quality-of-life outcomes between ileal conduit urinary diversion and orthotopic neobladder reconstruction after radical cystectomy: a statistical model. BJU Int 2014; 113: 726–732
Thurairaja R, Burkhard FC, Studer UE. The orthotopic neobladder. BJU Int 2008; 102: 1307–1313
Berglund B, Kock NG, Myrvold HE. Volume capacity and pressure characteristics of the continent cecal reservoir. Surg Gynecol Obstet 1986; 163: 42–48
Schrier BP, Laguna MP, van der Pal F, Isorna S, Witjes JA. Comparison of orthotopic sigmoid and ileal neobladders: continence and urodynamic parameters. Eur Urol 2005; 47: 679–685
Paananen I, Ohtonen P, Perttilä I et al. Functional results after orthotopic bladder substitution: a prospective multicenter study comparing four types of neobladder. Scand J Urol 2014; 48: 90–98
Varol C, Studer UE. Managing patients after an ileal orthotopic bladder substitution. BJU Int 2004; 93: 266–270
Zehnder P, Dhar N, Thurairaja R, Ochsner K, Studer UE. Effect of urinary tract infection on reservoir function in patients with ileal bladder substitute. J Urol 2009; 181: 2545–2549
Thurairaja R, Studer UE. How to avoid clean intermittent catheterization in men with ileal bladder substitution. J Urol 2008; 180: 2504–2509

EAU14 – Planning and executing a meeting session: perspective of the chairs

April 28, 2014/by John Davis

An interview with Prof. Noel Clarke on the EORTC-GU session

For an academic and/or key opinion leader in urology, the opportunity to plan and execute a meeting session is a tremendous honor, but one that comes with numerous challenges. The trivial but not-so trivial aspects involve the logistics: who will attend, who will speak, what do I do if a speaker cancels, what if the speakers do not stick to time, etc. Of course the easiest way to begin is to chair a session comprised of abstracts on a particular theme. This requires mainly the effort of preparing good questions for discussion and how to keep speakers on time (should we be nice?). The next level up is to plan a session with a broader theme that requires inviting specific speakers, framing debates, and then orchestrating it all into very usable take home messages for the audience. These are tremendous opportunities to come up with a vision for our field to consider.

At the EAU 2014, Prof Noel Clarke (GB) from our consulting editorial board was charged to organize the EORTC-GUCG session along with his co-chair Cora Sternberg (IT). I had a few questions for Prof Clarke, but really ended up just handing him my iPhone with the voice memo running and asking him how he went about planning the session:

“What we were trying to do was give a broad-based and sufficiently detailed overview of where we are in relation to different cancers and understanding of different cancer processes. And we tried to do that with specific reference to areas that have been strong in the EORTC-GU group in the past, particularly linking some of the trials that we’ve done with some of the basic science that is currently ongoing. And trying to project that forward as to how we might design future trials. And the emphasis really is on participation of clinicians with scientists and with data centers to try to overcome some of the problems associated with the prosecution of trials in the modern era. Hence our final talk with was Bertrand Tombal’s talk which is really how we would envisage planning and structuring trials as we go forward because it is certainly very different now than it was in the ‘70s when the EORTC was able to do really large scale trials, following on the ‘80s and 90’s to 2000’s [British pronunciation: “naughties”] where increasingly international trial groups, academic groups, found it difficult to get around the problems of finance, beaurocracy, new agents, interactions with Pharma, and so on. So that really was the essence of how we planned our session.”

Wow – what a gem. Didn’t really need a 2^nd question.

Figure 1: SPECTApros trial design

Prof. George Thalmann spoke on BCG therapy – an area in need of more standardized protocols and biomarkers for sensitivity/resistance. Ultimately we need successful treatment of CIS and prevention of NMIBC recurrence and progression. The first step towards success is with a high quality TUR that provides correct staging and therapy. On this note, he cited an EORTC study (Brausi et al. Eur Urol 2002) that showed 7.4-45.8% recurrence rates after TUR and adjuvant chemo when taken for first follow-up cysto. Next, the focus is on ideal BCG therapy in terms of timing, schedules and which strain of BCG. He cited RCT’s planed by SWOG and SAKK/EORTC looking at intradermal BCG 3 weeks before intravesical therapy to improve pre-existing immunity. Not all BCG strains perform equally, and there may need to be a prospective comparison. See Figure 2.

Figure 3: Prof. Necchi’s summary slide on the challenges of translational trials

Finally, Prof. Bertrand Tombal, Brussels (BE) presented “Next generation trials for urologists and uro-oncologists, where are we headed?” The introductory observation was that we are increasing the gap between what we know through evidence versus what we do in practice – including both things we do without quality evidence and things we do contrary to quality evidence. Specifically, less than 4% of articles in surgical journals are randomized trials, and most of those are evaluating medical therapies rather than surgery itself. Yet research is increasingly complex with regulatory demands, dependence on pharma, and related strategies to focus on large indications. The key recommendations were to raise important questions when it comes to benefit for patients, assess affordability, and bring trials to the patient rather than the other way around. The SPECTApros design was highlighted again with reference to its integration of nomograms predicting a specific outcome, imaging, and biomarker identification/validation.

So that’s the snapshot of the modern EORTC and I look forward to following the progression of these novel trial designs and strategies.

John W. Davis, MD FACS
Houston, TX, USA
Associate Editor, BJU International

Editorial: Going with the flow! Relieving LUTS and preserving ejaculation

April 23, 2014/1 Comment/by Tom McNicholas

Within the last few months of 2013, the Prostatic Urethral Lift procedure, using the UroLift^® implant device (NeoTract, Inc., Pleasonton, CA, USA), appeared on the global urology stage. UroLift has the unusual distinction of being both radically new and yet highly studied. The creative crossover study by Cantwell et al. [1] in the present edition of the BJUI adds to the positive evidence for this new treatment option for men with LUTS. Roehrborn et al. [2] have also recently published a high-quality randomized, blinded study. The accumulating published data indicates a new response profile of rapid relief from LUTS and improved urinary flow, while preserving sexual function, including the often overlooked but much valued benefit of preserving ejaculation. In September 2013, Urolift was approved by the US Food and Drug Administration (FDA) [3] and then subsequently by the National Institute for Health and Care Excellence (NICE) in the UK [4]. Gaining regulatory approval at the first attempt is a strikingly unusual achievement but one we can learn from.

The development of this technique began with initial work in 2005 showing that prostatic glandular tissue could be compressed and tethered to the outer prostatic capsule to open up the prostatic urethra [5]. Neotract and its clinical advisors then embarked on years of device development and iteration, culminating in the current version of the UroLift implant device and the currently preferred technique [6]. The rigorous development and clinical testing programme represents a master class in how a new minimally invasive procedure should be developed.

The process illustrates the benefits of cooperation between active clinicians and expert engineers. One particularly important element in this cooperation was the identification of the critical evidence that would be necessary to overcome regulatory hurdles but also to allow clinicians to understand and evaluate this procedure as they adopt it into practice. Neotract’s determination to produce high-quality data first, rather than publicising the method and developing the data to support it later, represents a refreshing change.

So, get a good and novel idea, develop the engineering, do the high-quality studies, et voila – approval! But is it as easy as that? No, the missing element is finance – lots of it. For a company to tread this recommended path, although required by regulators (and indeed by editors), takes a huge amount of money. An FDA pivotal trial of sufficient quality to convince is likely to cost upwards of $20 m. Few start-up companies or indeed established device companies will take that gamble on truly innovative solutions, particularly when economic conditions are tough. NeoTract and its UroLift technology persevered through the economic crash of 2008 and have continued to achieve key clinical milestones against fierce regulatory and financial headwinds. Given these formidable challenges, it is reasonable to wonder how many other developers with novel ideas would be capable of completing the course. Most, unfortunately, would fail.

for detailed instructions and video.

I encourage you to both review the data of Cantwell et al. [1] in this journal and take a look at the Prostatic Urethral Lift technique, as an innovation that is now available for wider adoption (Fig. 1). It does require judgement to select those most likely to benefit and endoscopic skill to achieve the maximum therapeutic benefit, but it appears to be an effective option for men poorly served by drugs, yet wishing to avoid the negative effects of existing surgical options. Additional studies continue to enrol participants, including a European randomized study, but the evidence currently available greatly exceeds that of most newly introduced minimally invasive developments. Why not take the opportunity to assess it yourself?

Tom McNicholas
Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, and University of Hertfordshire, Hatfield, UK

Read the full article

References

Cantwell AL, Bogache WK, Richardson SF et al. Multicentre prospective crossover study of the prostatic Urethral Lift for the treatment of LUTS secondary to BPH. BJU Int 2014; 113: 615–622
Roehrborn CG, Gange SN, Shore ND et al. The prostatic urethral lift for the treatment of lower urinary tract symptoms associated with prostate enlargement due to benign prostatic hyperplasia: the L.I.F.T. study. J Urol 2013; 190: 2162–2167
FDA. FDA News Release: new medical device treats urinary symptoms related to enlarged prostate. Available at: https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm368325.htm. Accessed 14 January 2014
NICE. https://guidance.nice.org.uk/IP/1032. Accessed 15 January 2014
Woo HH, Chin PT, McNicholas TA et al. Safety and feasibility of the prostatic urethral lift: a novel minimally invasive treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hypertrophy (BPH). BJU Int 2011; 108: 82–88
McNicholas TA, Woo HH, Chin PT et al. Minimally invasive prostatic urethral lift: surgical technique and multinational study. Eur Urol 2013; 64: 292–299

The 2nd BJUI Social Media Awards – April 2014

April 22, 2014/1 Comment/by Declan Murphy

Following the inaugural BJUI Social Media Awards presented at the 2013 AUA Annual Meeting in San Diego, this year’s awards moved across the Atlantic to the EAU Annual Congress in Stockholm. Both of these conferences play host to intense social media activity and it is fitting that the BJUI Social Media Awards gets to acknowledge the Uro-Twitterati on both continents! Individuals and organisations were recognised across 16 categories including the top gong, The BJUI Social Media Award 2014, awarded to an individual or organization who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the all-conquering Urology Match portal which continues to innovate in social and digital media. There had been much anticipation and speculation ahead of time about who would win the top and bottom gongs, and whether or not the King of Twitter, Ben Davies @daviesbj, would be acknowledged

In keeping with the informality of the 2013 BJUI Social Media Awards (held in an Irish Bar in San Diego), this year’s ceremony was held in the Acoustic Bar of the Scandic Grand Central in beautiful Stockholm. Fifty of the World’s leading social media enthusiasts in urology gathered to meet up in person and to see who would be recognised. Yours truly once again played the role of MC wearing my hat of BJUI Social Media Editor, ably assisted by Matt Bultitude, BJUI Website Associate Editor, and Editor-in-Chief Prokar Dasgupta.

The full list of awardees, along with some examples of “best practice” in the urology social media-sphere can be found on this Prezi (https://prezi.com/iukizmhni9_w/bjui-social-media-awards-2014/). The winners are also listed here:

Most Read Blog@BJUI – The Melbourne Consensus Statement – accepted by Matt Cooperberg on behalf of the authors
Most Commented Blog@BJUI – Dr Rajiv Singal, Toronto, Canada
Best Blog Comment – Dr John Davis, Houston, USA
Best BJUI Tube Video – Blue Light cystoscopy RCT – accepted by Shamim Khan on behalf of colleagues at Guy’s Hospital
Best Urology Conference for Social Media – EAU Annual Congress, Stockholm 2014
Best Social Media Campaign – Stacy Loeb, for her birthday party campaign
“Did You Really Tweet That” Award – Ben Davies, Pittsburgh, USA
Best Urology App – jointly awarded to BJUI (Matt Bultitude) and European Urology (Cathy Pierce) for new iPad apps
Innovation Award 2014 – @UroQuiz – Nathan Lawrentschuk, Melbourne, Australia (accepted by Paul Anderson)
#UroJC Award – Vincent Misral, Paris, France
Best Selfie – Mike Leveridge, Toronto, Canada
Best Urology Facebook Site – American Urological Association (accepted by Matt Cooperberg)
Best Urology Journal for Social Media – European Urology (Jim Catto)
Best Urology Organisation – Urological Society of Australia & New Zealand (David Winkle)
The BJUI Social Media Award 2014 – Stacy Loeb, New York, USA

BJUI Editor Prokar Dasgupta presenting awards to Jim Catto, Matt Cooperberg and Stacy Loeb

Many of the Award winners were present to collect their awards themselves, including the omnipresent Stacy Loeb who was awarded our top gong to huge applause.

A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar and Helena Kasprowicz, who manage our social media and website activity and who were present on the night.

For more pictures from the evening, please visit BJUI Associate Editor John Davis’ Flickr https://www.flickr.com/photos/jdhdavis/sets/72157643916525665/ page.

Declan Murphy is Associate Editor for Social Media at BJUI. He is a urologist in Melbourne, Australia

Follow Declan on Twitter @declangmurphy and BJUI @BJUIjournal

Not So Watchful Waiting?

April 16, 2014/1 Comment/by Meena Davuluri

SPCG-4 of Robotic Prostatectomy versus WW: April #urojc summary

This month’s twitter based international urology journal club, found by using #urojc, kicked off with the highly anticipated 20 year follow-up of the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4). This article had twitter buzzing in mid-March when it was published in the New England Journal of Medicine making it an ideal article for April’s journal club. This paper became an instant urology “classic.”

Bill-Axelson et al. published this 18 year follow up of a randomized control trial which separated individuals with early prostate cancer into two groups: watchful waiting or radical prostatectomy. Notable results of the study included a relative risk reduction of 44% from prostate cancer for those who underwent a radical prostatectomy compared to with watchful waiting with the NNT = 8, decreased use of androgen-deprivation therapy in this group, and the benefit of surgery being the most prominent in men <65 years with a 55% decrease in the relative risk of death due to prostate cancer.

Given that these results contradict the well known results of the Prostate Cancer Intervention versus Observation Trial (PIVOT), which started after the advent of PSA screening – the discussion of this article was particularly interesting. They are however, very different studies in terms of era and the populations studied.

During the 48 hour discussion period, key topics discussed were:

The applicability of these findings given the many advances in prostate cancer screening, diagnosis, and treatment since the 1990’s
The factors that influence the NNT
The impact of androgen deprivation therapy within both groups
How to weigh the impact of adverse effects including erectile dysfunction and urinary incontinence especially in the context of today’s treatment which includes radiation therapy, an option not addressed in this SPCG-4 study
The importance of this study should we face the possibility of shifting back to a pre-PSA era with the new USPSTF recommendations regarding PSA screening

As soon as the discussion opened, a question was posed if this was considered a contemporary cohort:

However, this thought was countered by:

The conversation continued to include the importance of time in NNT as pointed out Stacy Loeb. The point was later made, that the NNT might actually be lower with today’s advents of management in high-risk cancer patients.

There was a brief discussion on the statistic that 60% of the participants in the watchful waiting group underwent ADT treatment versus only 40% in the radical prostatectomy group.

Impact of adverse effects was also briefly discussed. The article stated that 84% of prostatectomy patients had ED versus 80% of the patients in WW. However, incontinence was only present in 11% of the watchful waiting group versus 40% of the surgery group. These statistics are interesting to compare, when the third option of radiation therapy is introduced. With RT being a viable alternative today compared to the 1990’s when the initial enrollment for the SPCG-4 study was done, weighing the risk/benefits of treatment becomes much more complicated.

The importance of weighing QOL was not forgotten during this discussion.

Finally, there was some great conversation alluding to the relevance of this study in the future given the new guidelines of the USTPSF which recommend against using PSA to screen for prostate cancer in healthy men of all ages on the account that there is no realized benefit.

Overall the importance of this study can be easily summarized as follows:

We welcomed a new member!

A huge thank you to the American Urological Association who supported the Best Tweet prize of a video box set. The winner is Fardod O’Kelly for the following tweet:

Thank you to everyone who joined the discussion. We look forward to seeing you at the May #urojc!

Meena Davuluri is a 3rd year medical student at Upstate Medical University in Syracuse, NY. She is interested in pursuing a career in Urology. Her interests include cost-effective decision analysis and health policy regarding healthcare delivery models. Follow her on Twitter @MeenaDavuluri.

Editorial: Tether your stents!

April 16, 2014/by Archana Fernando

Ureteric stents are commonly placed after ureteroscopy to protect the ureter and to facilitate subsequent stone fragment passage. They are known to be a cause of significant morbidity as judged by standardised validated questionnaires [1]. Whether placement of a stent is required at all is debatable, with randomised studies suggesting they are unnecessary after routine ureteroscopy [2]. The European Association of Urology (EAU) guidelines recommend stent insertion only ‘in patients who are at increased risk of complications’ and ‘in all doubtful cases to avoid stressful emergency situations’. Despite this, available evidence would suggest that we continue to commonly place stents [3].

If a stent is placed, the principal means of reducing morbidity is by minimising the stent dwell-time. One of the ways of doing this is to leave a stent with extraction strings/tether. This obviates the delay associated with scheduling cystoscopic extraction, the morbidity of cystoscopy and potentially reduces additional hospital visits if the patient is able to remove the stent at home.

Tethered stents are not widely used due to preconceptions about their tolerability, increased risk of complications (e.g. infection, migration) and accidental removal. Perhaps for this reason there have been few studies into the effectiveness of tethered stents in minimising stent-related morbidity to date, with only a handful in the past 30 years that have specifically addressed this issue.

In this issue of BJUI, Barnes et al. [4] report on the results of a prospective randomised trial analysing stented patients with or without the extraction strings attached, for both quality of life and postoperative complications after ureteroscopy for stone disease. This follows on from a retrospective series previously reported by the same group [5]. It is pleasing to see the authors, who originally concluded that randomised trials are needed in this area, actually get on and do the trial!

Two aspects of the trial methodology are worth highlighting: (i) the surgeons were not told that the patient was part of the study until they had made the decision to stent to minimise selection bias; (ii) patients completed the Ureteric Stent Symptom Questionnaire (USSQ) 6 weeks after stent removal as a control for their USSQ scores at postoperative days 1 and 6.

The headline results showed that there was no difference in quality of life and stent-related symptoms between patients with and without the extraction strings. There was also no difference in postoperative complications, emergency room visits or phone calls between the groups. What is surprising is that they found no difference in pain scores between self-removal and cystoscopic removal. This has not been our experience with tethered stents and may be due to the few men in the study. However, stent dwell-time was significantly less for patients with tethers compared with those without (10.6 vs 6.3 days, P < 0.001).

For urologists planning on using this technique it should be noted that the authors removed the original knot and shortened the string considerably to reduce the risk of accidental removal. For this reason the string was not attached to the patient’s skin.

This trial addresses many of the reservations urologists have about the use of tethered stents. Furthermore, reducing accidental removal and encouraging self-removal should be possible with improved patient education and selection. This was addressed by a study in New Zealand [6], which showed the feasibility of self-removal of stents.

The authors also acknowledged weaknesses in their study, which included failure to reach target enrolment, a 68% completion of trial surveys and a larger proportion of women in the study group due to male anxiety about self-removal of stents. In all, 15% of stents were inadvertently removed early and thus this technique should be used with caution in patients where early removal may be detrimental, e.g. in single kidneys. This does of course prompt the question: ‘If you are going to place a stent, how long does the stent need to stay for?’ and hopefully future trials may address this unanswered question.

Archana Fernando and Matthew Bultitude

Urology Department, Guy’s and St Thomas’ NHS Trust, London, UK

References

Joshi HB, Newns N, Stainthorpe A et al. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol 2003; 169: 1060–1064
Song T, Liao B, Zheng S, Wei Q. Meta-analysis of postoperatively stenting or not in patients underwent ureteroscopic lithotripsy. Urol Res 2012; 40: 67–77
Mangera A, Parys B. BAUS Section of Endourology national ureteroscopy audit: setting the standards for revalidation. J Clin Urol 2012; 6: 45–49
Barnes KT, Bing MT, Tracy CR. Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial. BJU Int 2014; 113: 605–609
Bockholt N, Wild T, Gupta A et al. Ureteric stent placement with extraction strings: no strings attached? BJU Int 2012; 110: 1069–1073
York N, English S. Self-removal of ureteric JJ stents: analysis of patient experience. Presented at AUA 2013, May 7; San Diego, CA, USA. Abstract no. 1979. J Urol 2013; 189 (Suppl. 4): e812

EAU14 – ESOU citations

April 14, 2014/2 Comments/by John Davis

Have You Read This?…A bibliography of cited papers on prostate cancer at the Joint Meeting of The European Section of Oncological Surgery (ESOU) and EORTC—Genito-Urinary Cancer Group.

At the BJUI, as with any journal, the published articles are peer reviewed and editorial board reviewed. The process starts with a triage editor who screens for basic methodology, importance of the topic, and potential for citation factor impact. The top 50% are sent for full peerreview, which includes 3 reviewers (ad hoc or from the board). Full review is organized by an associated editor who assigns (and then begs) the 3 reviewers to complete their task, and then makes a final recommendation to the editor in chief. I could go on about this interesting process, but the point is that a published paper is often really just the opinion of 4-5 experts in the field, including the editor. Once published, however, papers are then kept alive by repeated citation and meeting discussions, or disappear intoPubMed and forgotten. Future papers that cite a previously published paper will help the impact factor of that journal. But what about congress events and their cited works? At the EAU 2014, as with any congress, key opinion leaders are asked to give talks, make arguments, and prove their points. They may do so with personal experiences, videosor modern abstract quotes, but often they cite recent peer review publications. At the joint session meeting of the ESOU and EORTC-GUCG, I noted the following cited publications from the prostate cancer talks. How many have you read so far?

On the topic of circulating tumor cells (CTCs) in prostate cancer, Professor S. Osanto of Leiden (NL) cited (partial citations):

1. Hanahan D et al. The hallmarks of cancer. Cell 2000

2. Klein CA. Cancer. The metastasis cascade. Science 2008.

3. Gerlinger M et al. Intratumor heterogeneity and branched evolution revealed by multiregionsequencing. NEJM 2012

4. Allard WJ et al. Tumor cells circulate in the peripheral blood of all major carcinomas but not in healthy subjects or patients with nonmalignant diseases. ClinCancer Research 2004

5. de Bono JS et al. Circulating tumor cells predict survival benefit from treatment in metastatic castration-resistant prostate cancer. Clin Cancer Research 2008

6. Attard G et al. Characterization of ERG, AR, and PTEN gene status in circulating tumor cells from patients with castration-resistant prostate cancer. Cancer Res 2009.

7. Cristofanilli M. Circulating tumor cells, disease progression, and survival in metastatic breast cancer. NEJM 2004.

8. Goldkorn A et al. Circulating tumor cell counts are prognostic of overall survival in Southwest Oncology Group trial S0421: A phase III trial of docetaxel with or without atrasentan for metastatic castration-resistantprostate cancer. J Clin Oncol 2014.

From these papers, the conclusions were many and included: 1) CTS can detect early relapse, genomic signatures, target identification, and treatment decisions, 2) surrogate marker for response, and 3) emergence of resistance.

Next, the focus shifted to the popular technical points and outcomes of open versus minimally invasive radical prostatectomy. Bernardo Rocco (IT) cited the following papers in support of robot-assisted radical prostatectomy for high risk PCa

9. Yuh et al. The role of robot-assisted radical prostatectomy and pelvic lymph node dissection in themanagement of high-risk prostate cancer: A systematic Review. Eur Urol 2014

10. Montorsi et al. Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel. Eur Urol 2012.

11. Silberstein JL et al. A case-mix adjusted comparison of early oncological o utcomes of open and robotic prostatectomy performed by experienced high volume surgeons. BJU Int 2013.

12. Hu JC. Comparative effectiveness of robot-assisted versus open radical prostate cancer control. Eur Urol2014

13. Ploussard G et al. Pelvic lymph node dissection during robot-assisted radical prostatectomy efficacy, limitations, and complications—a systematic review of the literature. Eur Urol 2013.

14. Prasad SM et al. Variations in surgeon volume and use of pelvic lymph node dissection with open and minimally invasive radical prostatectomy. Urology 2008

15. Cooperberg MR et al. Adequacy of lymphadenectomy among men undergoing robot-assisted laparoscopic radical prostatectomy. BJU Int 2010

16. Feifer AH et al. Temporal trends and predictors of pelvic lymph node dissection in open or minimally invasive radical prostatectomy. Cancer 2011

17. Ficarra et al. The European Association of Urology Robotic Urology Section (ERUS) survey of robot-assisted radical prostatectomy (RARP). BJU Int 2013.

18. Gandaglia G et al. Is robot-assisted radical prostatectomy safe in men with high-risk prostate cancer? Assessment of perioperative outcomes, positive surgical margins, and use of additional cancer treatments. J Endourol 2014.

19. Ou Y.C. et al. The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D’Amico risk criteria. EJSO 2013.

20. Lavery HJ et al. Nerve-sparing robotic prostatectomy in preoperatively high-risk patients is safe and efficacious. Urol Oncol 2012.

21. Montorsi F. Robotic prostatectomy for high-risk prostate cancer: translating the evidence into lessons for clinical practice. Eur Urol 2014

From these citations, the conclusions were that: 1) RP is an adequate treatment for high risk prostate cancer, 2) robotic approach is not inferior to open as far as oncological outcome, 3) lymph node template and yield are adequate in experienced hands in RARP setting, 4) functional outcome after RARP in high risk is preserved, nerve sparing is feasible in selected patients, and 5) Costs of RARP are related to surgical volume and experience. So there you see a typical meeting presentation—13 papers in 15 minutes plus additional commentary and abstract data.

Next, Prof. Declan Murphy presented the Australian experience with robot-assisted RP for cT3a prostate cancer. With overlapping topics, it was no surprised some papers were recited from above including #9, #12,He cited:

22. Evans et al. Patterns of care for men diagnosed with prostate cancer in Victoria from 2008-2011. Med JAust 2013

23. Wilt T et al. Radical prostatectomy versus observation for localized prostate cancer. NEJM 2012

24. Connoly SS et al. Radical prostatectomy as the initial step in multimodal therapy for men with high-risk localized prostate cancer: initial experience of 160 men. BJU Int 2012.

From these citations, Prof. Murphy concluded that: 1) radical prostatectomy has minimal benefit for low risk men, especially older, 2) The biggest benefit is in high risk disease, 3) active surveillance is being embraced in Australia, 4) RARP is safe and effective with similar outcomes to ORP, 5) RARP has less positive margins and less additional therapy compared to ORP 6) extended PLND not limited by robotic approach.

Prof. Axel Heidenreich then took the opposite point of view in support of open radical prostatectomy. Despite the references above, he pointed out that there is still no long-term data for robotic prostatectomy, although not proving that with pathologic staging we would expect anything different. Cost of course can be quite better for open. He also cited for papers showing positive margins of < 12% in pT3 disease, compared to many other open and minimally invasive series where it is usually 25% and higher. Repeat citations: #9. He also cited:

25. Robertson C et al. Relative effectiveness of robot-assisted and standard laparoscopic prostatectomy as alternatives to open radical prostatectomy for treatment of localized prostate cancer: a systematic review and mixed treatment comparison meta-analysis. BJUI 2013.

26. Vora AA et al. Robot-assisted prostatectomy and open radical retropubic prostatectomy for locally-advanced prostate cancer: multi-institution comparison of oncologic outcomes. Prostate Int 2013

27. Punnen S et al. How does robot-assisted radical prostatectomy (RARP) compare with open surgery in men with high-risk prostate cancer? BJU Int 2013

28. Sooriakumaran P et al. A multinational, multi-institutional study comparing positive surgical margin rates among 22393 open, laparoscopic, and robot-assiste radical prostatectomy patients. Eur Urol2014

29. Alemozzafar M et al. Benchmarks for operative outcomes of robotic and open radical prostatectomy: results from the health professionals follow-up study.Eur Urol 2014

30. Davison BJ et al Prospective comparison of the impact of robotic-assisted laparoscopic radical prostatectomy versus open radical prostatectomy on health-related quality of life and decision regret. Can J Urol 2014

31. Bolenz C et al. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol 2014

From these citations, he concluded that 1) open radical prostatectomy is still viable, 2) not needed for low risk, 3) lack of long-term data for RARP, 4) no inferiority in terms of functional and oncological outcome, or quality of life, 5) better cost effectiveness, especially with median case load of < 300 RP’s per year.

I hope you find this reading list useful. Could you transfer such a bibliography to an effective review article? Probably not, and we can ask associate editor Quoc Trinh to comment or write a separate blog on the emerging field of systematic reviews, such as the multiple cited reference 9 by Yuh et al. A systematic review needs to conform to standards such as the PRISMA guidelines—see www.prisma-statement.org –which is “an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. Therefore we have an interesting difference in standards between a meeting presentation and a formal peer-reviewed systematic review—the former can hand-pick articles to make a point, while the latter must be thorough, transparent, and reproducible.

John W. Davis, MD FACS

Houston, Texas (USA)

Associate Editor, BJUI