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Quality has no boundaries

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The new year has arrived bringing with it new expectations of success. It gives us the opportunity to reflect on 2013 and plan for the year ahead. We hope you enjoyed the new web journal www.bjui.org that we have introduced. It has certainly increased our full paper downloads each month which means that our readers do care. Thank you! Your loyalty makes the many hours of hard work – 24/7 – all worthwhile. We have an international team which allows someone, somewhere to be making constant improvements to the BJUI for your reading pleasure.

Many of our readers while congratulating us, commented that perhaps we had focussed on being of greater relevance to the younger generation. Imagine my surprise when at a recent Men’s Health meeting in London, my old chief came up to me for a discussion about the controversies of PSA testing following publication of the AUA guidelines [1] and a consensus statement from down under on blogs@BJUI [2]. He had read it all on the web much earlier than when these articles eventually make it to the print journal. Like him, many of our readers see and read an article or blog online but do not necessarily comment on it. As a new metric, we will start indicating the number of times an article is read in addition to the number of comments it receives.

At the BJUI we do not make New Years resolutions. It is much easier to act. During our editorial board meeting last October it became obvious that we were receiving high quality papers from all over the world. In this issue, we have the great pleasure of showcasing a superb article on circumcision from Uganda [3]. Men with or without HIV, which is highly prevalent in Africa, tend to heal well after circumcision. This does not appear to be affected by their CD4 counts. This is a large study, relevant to all urologists and I would urge you to read it and the accompanying editorial from Paul Hegarty [4].

This article also gave us the idea of highlighting the geographical location of the article of the month on the front cover. Another inspirational concept from Tet Yap our associate editor for design. More about that in coming editions.

Finally Maxine Sun is back with a SEER study showing that the extent of lymphadenectomy during radical nephrectomy in patients with nodal metastasis, does not affect survival. Like any database, missing entries may have confounded the results and it is critical from a scientific standpoint to understand the resultant bias [5]. For those wishing to learn health services research a good starting point is to read the Sun Blog on SEER at our web journal.

Here’s looking forward to interacting with you in 2014.

Prokar Dasgupta
Editor in Chief, BJUI

Guy’s Hospital, King’s Health Partners

References

  1. Ballentine Carter H. American Urological Association (AUA) Guideline on prostate cancer detection: process and rationale. BJU Int 2013; 112: 543–547
  2. Murphy D. The Melbourne Consensus Statement on Prostate Cancer Testing. blogs@BJUI. Available at: https://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing/. Accessed 20 November 2013
  3. Kigozi G, Musoke R, Kighoma N et al. Male circumcision wound healing in HIV-negative and HIV-positive men in Rakai, Uganda. BJU Int 2014; 113: 127–132
  4. Hegarty P. Circumcision – follow up or not? BJU Int 2014; 113: 2
  5. Sun M, Trinh Q-D, Bianchi M et al. Extent of lymphadenectomy does not improve the survival of patients with renal cell carcinoma and nodal metastases: biases associated with the handling of missing data. BJU Int 2014; 113: 36–42

Original publication of this editorial can be found at: BJU Int 2014; 113: 1. doi: 10.1111/bju.12575

Editorial: Circumcision – follow-up or not?

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There is an excellent study from Uganda in this issue of the BJUI [1]. It looks at the rate of healing of men undergoing prophylactic circumcision. Some had HIV; others not. What they termed ‘complete wound healing’ was an intact scar without a scab, sutures or a sinus – effectively a ‘sealed’ wound. There are several useful data therein:

  • all men had healed by 6 weeks; the median being 4 weeks.
  • HIV status did not appear to delay wound healing, even with low CD4 counts.
  • the patient was 95% likely to judge wound healing correctly himself.
  • routine circumcision can be safely carried out by trained medical officers.
  • a complication rate of 0.5% was reported.

So what follow-up, if any, is necessary after circumcision? Based on this population it would appear that a well instructed/consented patient can be relied on to judge healing after prophylactic circumcision. They probably do not need follow-up provided their expectations are managed well, and there is ease of access to return should problems arise.

However, this may not be generalizable to men having circumcision for phimosis or other abnormality of foreskin. These patients may have delayed healing, meatal issues or a urethral stricture upstream. Histopathological examination of abnormal foreskins is sensible also as further treatment/follow-up may indicated.

I recommend a read of this superb paper.

Paul K. Hegarty
Consultant Urological Surgeon, Mater Private, Cork, Ireland

Read the full article

Editorial: Too many men still undergo needless prostate biopsy

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Multiple studies have shown that only one in three or four men with a raised PSA level prove to have prostate cancer and many men suffer potentially life-threatening complications from transrectal prostate biopsy. There is an urgent need for better risk stratification of men with elevated PSA levels. Any such test should have a high negative predicative value (NPV; small number of significant cancers missed) but also a high positive predictive value (PPV; i.e. the yield would be high and there would be very few false positives) to diminish the number of unnecessary biopsies. Multiparametric MRI (mpMRI) of the prostate, especially with a stronger 3 T magnet, has been advocated for this purpose. The parameters refer to the separate MRI sequences used, typically at least three. Sequences can not only study the anatomy of the gland (standard T2-weighted MRI), but there is also a measure of the tissue cellularity (diffusion-weighted MRI), vascularity (dynamic contrast-enhanced MRI) or biochemistry (magnetic resonance spectroscopy). Initial data have shown promise but the changes seen on these various sequences can be subtle and interpretation is subjective. Naturally observer experience plays a large part but a standardised scoring system, the so called Prostate Imaging Reporting and Data System (PIRADS) system, has been proposed to improve reporting performance [1]. Each parameter is scored on a scale of 1–5 according to the likelihood of cancer. Scoring systems are always a compromise between the NPV and PPV, and so far there is no agreement where the threshold for each parameter should be set. In the original document, the authors proposed that a score of 4 or 5 signifies a high likelihood or almost certainty of cancer, whilst scores of 1 or 2 denote a high likelihood of benign tissue. A score of 3 is evens. The paper by Kuru et al. [2] shows a high NPV only when the threshold was set at the low level of 2 for each parameter. Predictably, at this threshold the PPV was extremely low, and therefore many men would still undergo unnecessary biopsy. Another similar paper advocated a mean threshold of 3, but even then the PPV was 38% with a NPV of 95% [3]. Both these papers are retrospective studies, in particular the MRI readings were done retrospectively. Nevertheless, the low PPV is disappointing. The results of prospective studies with multiple readers are keenly awaited and I hope that that these will find a higher PPV for mpMRI, and we can to move to an era when fewer men undergo needless prostate biopsy.

Uday Patel
St George’s Hospital, London, UK

Read the full article

References

  1. Barentsz JO, Richenberg J, Clements R et al. ESUR prostate MR guidelines 2012. Eur Radiol 2012; 22: 746–757
  2. Kuru T, Roethke M, Rieker P et al. Histology core-specific evaluation of the European Society of Urogenital Radiology (ESUR) standardised scoring system of multiparametric magnetic resonance imaging (mpMRI) of the prostate. BJU Int 2013; 112:1080–1087
  3. Portalez D, Mozer P, Cornud F et al. Validation of the European Society of Urogenital Radiology scoring system for prostate cancer diagnosis on multiparametric magnetic resonance imaging in a cohort of repeat biopsy patients. Eur Urol 2012; 62: 986–996

The Bengal Urological Society’s Golden Jubilee

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We recently celebrated the Bengal urological Society’s Golden jubilee!

Earlier known as the “Calcutta Urology Association”, the society was founded in the year 1963 and is the oldest urological society in India. My guess is that it is probably one of the oldest societies that aimed to establish a separate existence of urology. What’s your take on that?

It was a privilege to have Prof Prokar Dasgupta with us for this event. The demonstration of the robotic surgery by the master himself was exhilarating.

 


Dr Prokar Dasgupta, receiving the “Award of Excellence”

The feedback from the urological community and especially the residents has been phenomenal. I am sure that the light has been ignited in the minds. We are planning to take concrete steps to help serve our community better.  The idea of a “Reverse Movember” (shaving off our moustaches) for prostate cancer sounds exciting and will be great if I am able to implement it!

Amit Ghose

Editorial: Diabetes mellitus and non-muscle-invasive bladder cancer: not just a coincidence?

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Urologists are familiar with the plethora of comorbidities affecting patients with bladder cancer. Many are smoking-related, such as respiratory disease, ischaemic heart disease and peripheral vascular disease. Other conditions are associated with an ageing, increasingly obese population. Rieken et al. [1], present intriguing observations suggesting an association between diabetes mellitus (DM), its treatment and the prognosis of non-muscle-invasive bladder cancer (NMIBC). In a retrospective, multicentre cohort study of 1117 patients diagnosed with NMIBC, the authors conclude that patients taking metformin have better recurrence-free survival compared with patients with diabetes who did not take metformin. The Kaplan–Meier curves even hint at improved outcomes for patients taking metformin compared with the population without diabetes, although the difference did not reach statistical significance. Only 125 patients (out of 1117) had DM, of whom 43 were prescribed metformin. Outcome measures were recurrence and progression, with comparison of cancer-specific mortality not possible because of the low frequency of events. The study population was treated between 1996 and 2007, so re-resection was not routine, and rates of postoperative intravesical chemotherapy and adjuvant chemotherapy/immunotherapy were low. Treatment for some patients was therefore suboptimal by current standards, and there may have been differences between the multinational institutions.

The association between type 2 diabetes and the incidence of several cancer types (e.g. breast, colorectal and pancreatic) is well documented. The biological mechanisms responsible are unclear [2], and a causal relationship is debated. Postulated mechanisms include the effects of hyperinsulinaemia, hyperglycaemia and signalling pathways involving the IGF receptors. The protective effect of metformin is similarly unclear, although the authors cite studies indicating anti-proliferative properties.

A number of large cohort studies have endeavoured to show there is a higher risk of cancers in populations with diabetes. The challenge for such studies is the relatively low incident rate of bladder cancer in the population (17.1 per 100 000) [3]. Additionally, studies using general practice databases encounter problems obtaining data relating to bladder cancer characteristics. The increased detection of bladder cancer in the population with diabetes is a potential confounder, as monitoring using urine analysis is more likely.

Rieken et al. [1], in taking the opposite approach by identifying their cohorts on the basis of confirmed diagnosis of NMIBC, present accurate data regarding cancer characteristics but accept there is a potential for lack of accuracy in the recording of DM and treatment using chart review. We are not able to draw any conclusions regarding the severity of DM, its complications or compliance with prescribed medication. Future studies would be strengthened by incorporating tests such as HbA1c concentration as a marker for glycaemic control. Additionally, they do not specify the type of diabetes, although the reader can speculate that patients treated with metformin had type 2 DM. It is important to recognize that the pattern of cancer risk appears to be different for type 1 diabetes [4].

Whilst detailed discussion of the management of DM is outside the remit of a urological study, there are some important factors to be considered. Metformin is frequently recommended as a first-line agent in the management of type 2 DM [5]. It follows, therefore, that patients treated with metformin may be different from those requiring second- or third-line drugs and drug combinations; thus the cohort treated with metformin may be younger, exhibit better glycaemic control, and have improved renal function compared with those treated with other drugs and exogenous insulin. An important consideration is that rather than a protective effect being exerted by metformin, it may be that other hypoglycaemic agents have an adverse effect on NMIBC outcomes. Pioglitazone has recently been associated with an increased incidence of urothelial cancer when taken for >2 years, although effects on prognosis are not established [6]. Were the patients with diabetes not taking metformin in fact treated with hypoglycaemic agents implicated in the aetiology of bladder cancer? When considering the plausibility of biological mechanisms, the time-lag between exposure to carcinogen and the development of bladder cancer is pertinent. There is a prolonged time-lag between exposure to cigarette smoking and the development of bladder cancer, so are we ready to accept that drug exposure for a short time-scale is protective or causative? Finally, we must consider the clinical relevance of these findings. As metformin is the current first-line therapy, it may be contraindicated in those not prescribed it and conversion may not be possible.

Notwithstanding the above caveats, when treating patients with NMIBC we are often embarking on a lifelong process of treatment and surveillance. We are obliged as doctors to consider the implications of common comorbidities in order to tailor treatment. In much the same way that we now consider metabolic syndrome when evaluating erectile dysfunction, in the future we may need to consider NMIBC and DM together, and work collaboratively with other healthcare professionals to optimize the management of both conditions.

Joanne Cresswell
Department of Urology, James Cook University Hospital, Middlesbrough, UK

Read the full article

References

  1. Rieken M, Xylinas E, Kluth L et al. Association of diabetes mellitus and metformin use with oncological outcomes of patients with non-muscle-invasive bladder cancer. BJU Int 2013; 112: 1105–1112
  2. Johnson JA, Carstensen B, Witte D et al. Diabetes and cancer (1). Evaluating the temporal relationship between type 2 diabetes and cancer incidence. Diabetologica 2012; 55: 1607–1618
  3. Cancer Research UK. Bladder cancer, average number of new cases per year and age-specific incidence rates, 2006–2008. Cancer Research UK, 2012
  4. Zendehdel K, Nyren O, Ostenson CG, Adami HO, Ekbom A, Ye W. Cancer incidence in patients with type 1 diabetes mellitus: a population-based cohort study in Sweden. J Natl Cancer Inst 2003; 95: 1797–1800
  5. NICE. NICE Clinical Guideline, 66, 2008
  6. Azoulay L, Yin H, Filion K et al. The use of pioglitazone and the risk of bladder cancer in people with type 2 diabetes: nested case-control study. BMJ 2012; 344: e3645

The Spirit of Christmas

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It’s that festive time of year when everything in London seems to be subsumed by the preparations for Christmas festivities. I thought therefore that it might be appropriate to devote a few thoughts to the sadly departed Tim Christmas, the outstanding surgeon and urologist to the Charing Cross and Royal Marsden Hospitals who died two years ago and always loved his namesake festivities. Tim and I go back a long way. He was a medical student at the Middlesex Hospital in London when I was a trainee, and senior registrar at St Bartholomew’s when I was a Consultant there. He and I wrote a book together on prostate cancer, and we had some great times together at work and at AUA, EAU, SIU and ICS as well as other meetings in various parts of the globe.

Tim was a classic eccentric Englishmen, a great wit and an exceptional surgeon. Like Sir Lancelot Spratt he eschewed keyhole surgery in favour of a “maximally invasive” approach; this made him the acknowledged expert in the UK of para-aortic lymph node dissection and thoraco-abdominal excision of renal tumours with involvement of the inferior vena cava. Two technically difficult procedures which he learnt from his friend and mentor Bill Hendry. Bill like Tim was an exceptionally gifted surgeon.

Tim was a surgeon’s surgeon and a tremendous character (read Tim’s BJUI Obituary here). He is fondly remembered by fellow urologists, nursing staff and patients alike. Although Christmas comes once a year, sadly there will only be one Tim Christmas, the surgeon and we have lost him prematurely. He was a one-off, a product of his own special era, and we will most certainly never see his like again. If you have fond memories of or anecdotes about Tim please post them on this blog;  Tim has been sending to all of the patients baskets from Gift Tree and try to make their life a little happier, Merry Christmas to you all.

Roger Kirby, The Prostate Centre, London

Looking to plan the ideal Christmas function for your boss, workmates or staff? End of year is a busy time for everyone, and it’s refreshing to know that a relaxing time can be had on a skippered, catered function cruise.

It’s unbelievable and quite surprising that how fast, over half the year has already passed and it just seems like you celebrated New Year’s Eve last month. With the first half already over, don’t hope for the second half to stay back any longer and before you know it, Christmas will be knocking on your door waiting to tell you there’s a Santa stuck in your chimney. Now, with Christmas, comes the great office parties and the hassle you have to go through every year to organise everything to the point that it is pitch perfect. Because who wants a party ruined on Christmas Eve and especially not if it’s your responsibility. It’s only fitting that such a party, where your number of people is somewhere between 2 and 35, is done with a Boat Hire. They have the absolute best options and services for your office Christmas Party celebrations where all you have to do is make the booking and forget about doing anything else. The company will look after all your specifications and needs before arranging the experience of a lifetime for you at this year’s Christmas party.

If you are looking to make a huge impression on your staff then I fully suggest you to rent a yacht in montauk, some professional agencies offer a mesmerising package where you can charter a private boat for up to 35 people to take them on a cruise of the beautiful Yarra river. The package will include food and beverages that will be served onboard the cruise and can be tailor-made according to your requirements. If the number of people you’re taking with you is less than 10, then you can book the eco-friendly package and cut off the extra expenses. The new addition to the latest cruise packages given by a Boat Hire include a progressive dinner or lunch cruise of the Yarra River, and stopping at three different restaurants for a three-course meal, be it lunch or dinner.
If you’re looking to have a Christmas party and have a great adventure, then you can easily avail the self-drive hire where you can pack your picnic and cruise on the Yarra River. There will be boats available to you that can seat up to 12 passengers and you will require no boat license to hire and drive.

Boat Hire are offering three different routes for your Christmas party and you can book any one of the three. The first route is either of the three: Yarra river or Maribyrnong River or Williamstown, next up is St Kilda and Port Melbourne. All you will have to do is book a schedule and mention the number of people you’re planning to bring with you along with your contact and payment details. The hassle part of the deal is for us to look after and you to relax. What’s even better is that a Boat Hire are willing to offer packages according to all amounts of budgets and sizes and can make a special carved out plan according to your needs. If there was ever any easiness while planning a Christmas party.

Editorial: Minimally invasive surgical training: do we need new standards?

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The pan-European survey conducted by Furriel et al. [1] in this issue of BJUI is a timely address of a hot topic in urology.

More than 20 years have passed since the first laparoscopic nephrectomy was performed by Clayman et al. [2] in 1991, and now all urological major interventions have been performed with one or more different minimally invasive techniques (standard, single-site or robot-assisted laparoscopy); some of them have passed the judgment of time becoming ‘gold standard’ treatments, while others are still under evaluation. Specifically, the European Association of Urology (EAU) guidelines recommend laparoscopic radical nephrectomy as the ‘standard of care’ over open surgery, report favorable outcomes for robot-assisted laparoscopic radical prostatectomy, and propose as optional treatments laparoscopic or robot-assisted partial nephrectomy and radical cystectomy [3].

Obviously, this surgical revolution brings two major new issues: (i) Starting from academic and training centres, hundreds of Urology Departments throughout Europe need to update their surgical knowledge and expertise, making senior urologists perform up-to-date procedures; (ii) Residents and young urologists require adequate and possibly standardised training in minimally invasive surgery, learning at least the basic laparoscopic skills. The study by Furriel et al. [1] correctly highlights both problems.

First, according to the survey, penetration of laparoscopy in the most important urological training centres is unexpectedly low. In fact, more than one out of four centers (26%) do not perform minimally invasive surgery, even for the ‘standards of care’, such as laparoscopic radical nephrectomy. Moreover, as the survey was conducted specifically on the topic of minimally invasive surgery, it is probable that unexposed residents were less interested in responding, making the data of penetration probably even worse than reported. This fact reflects a serious problem present in most training centres. While previously surgery slowly evolved, laparoscopy and technology brought sudden innovations, putting several senior urologists ‘out of the game’. Hence, today, training is needed not only for residents, but also for consultants. In the meantime, it is important that residents are trained in centres were minimally invasive surgery is already widely available. In this perspective, European educational authorities should endeavour to certificate the residents’ training centres, for example on the basis of adherence to EAU guidelines. Academic or non-academic training centres not adherent to guidelines (and thus not performing minimally invasive surgery) should therefore be deprived of residents.

Secondly, training residents in minimally invasive surgery can be approached in different ways, from low-cost self-made dry laboratories to expensive virtual reality or robotic three-dimensional simulators. According to the survey, >40% of centres have no training facilities available. It has been shown that self-built, cheap, dry laboratories are as efficient in training as the industrial ones [4], so that it is not a matter of costs but a matter of interest. We strongly believe that watching surgical videos, observing live surgeries and using (low-cost or not) dry laboratories are fundamental steps in acquiring the basic skills in laparoscopy, while the modular training proposed by Stolzenburg et al. [5] for laparoscopic radical prostatectomy is the best live training model and can be exported to other kinds of surgery, such as radical or partial nephrectomy. In the centres where robot-assisted surgery is available, working as a table-side assistant is another good way to acquire laparoscopic skills.

A great debate is currently ongoing about credentialing in minimally invasive surgery training [6]. Pragmatically, when the European training centres are certificated for adherence to the EAU guidelines, there will be no need for a specific credentialing in laparoscopic skills, because it will be included in the standard training path, together with endoscopic and open surgery.

In conclusion, the survey by Furriel et al. [1] shows that times are changed: the old axiom ‘big cut, big surgeon’ is not valid anymore. The emerging urological generations know it, and ask to be adequately trained. Training centres must evolve, because in 2013 minimally invasive surgery has formally to be considered as part of the standard urological armoury.

Antonio Galfano and Aldo Massimo Bocciardi
Department of Urology, Ospedale Niguarda Ca’ Granda, Milan, Italy

Read the full article

References

  1. Furriel F, Laguna MP, Figueiredo A, Nunes P, Rassweiler JJ. Training of European urology residents in laparoscopy: results of a pan-European survey. BJU Int 2013; 112: 1223–1228
  2. Clayman RV, Kavoussi LR, Soper NJ et al. Laparoscopic nephrectomy. N Engl J Med 1991; 324: 1370–1371
  3. EAU Guidelines, edition presented at the 28th EAU Annual Congress, Milan 2013. ISBN 978-90-79754-71-7. EAU Guidelines Office, Arnhem, The Netherlands. Available at: https://www.uroweb.org/guidelines/online-guidelines/. Accessed September 2013
  4. Beatty JD. How to build an inexpensive laparoscopic webcam-based trainer. BJU Int 2005; 96: 679–682
  5. Stolzenburg JU, Schwaibold H, Bhanot SM et al. Modular surgical training for endoscopic extraperitoneal radical prostatectomy. BJU Int 2005; 96: 1022–1027
  6. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialing. J Urol 2011;185: 1191–1197

Beyond our wildest dreams

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In this podcast Prokar Dasgupta summarises the success of the BJUI over 2013. For more on podcasts, including how to record your own, go to Podcasts Made Simple.

 

If anyone had suggested to me in January 2013 that our full article downloads would increase by 15% and the Melbourne Consensus Statement on PSA testing would be viewed over 5000 times @ BJUI.org, I would have stared at them in disbelief. The launch of our web portal in addition to an innovative paper journal, has achieved just that. And much more. We remain one of the Big Three in urology with a Klout score greater than any of our colleagues. These are impossible to achieve via papyrus alone.

The common theme amongst all the fantastic innovation that our Associate Editors have introduced is the highest quality of original articles that we have attracted and published this year. I wanted to take this opportunity to highlight them and thank all our authors for sending us their best manuscripts.

The updated Partin tables (2006–11) remains our most cited paper published in 2013 [1]. It is sheer coincidence that I selected it as our first article of the month in January. It has allowed surgeons to avoid lymphadenectomy during radical prostatectomy in non-palpable Gleason 3+4 disease as the risk of a positive lymph node is <2%. The accompanying 3 minute video on the BJUI Tube channel is an excellent summary for the busy urologist.

I had to appease a number of oncologists when Cooperberg and colleagues showed that radiation for prostate cancer was about 2.5 times more expensive than radical prostatectomy in a comprehensive lifetime cost-utility analysis [2]. Peace was rapidly established at the annual meeting of the British Uro-Oncology group (BUG) where I participated in a balloon debate on the subject this autumn.

The thematic variations continue. It seems that 12 weeks of Tadalafil is effective in ejaculatory and orgasmic dysfunction in patients with ED [3]. Sexual medicine remains an exciting section of the BJUI and I am grateful to the andrologists on our editorial board for diligently reviewing the large number of papers that we receive from investigators in this field.

And finally we had two practice changing randomised trials in stone disease. Plasma vaporisation performed better than balloon dilatation for creating PCNL tracts [4]. For the curious, there is a video demonstrating the method if you wish to learn it.

The Portland trial has a simple message that you just can’t ignore; a single dose of NSAID before ureteric stent removal prevents severe pain afterwards. This is going to become standard of care if it has not already [5].

Many of our readers will wonder why we continue with a paper journal when the web has been so successful? The map here shows our global reach, which includes a number of subscribers who prefer to, or by necessity, read the print journal (∼30%). Moreover in a BJUI Online Poll, 75% of our readers reported taking the paper journal out of its plastic sheath and reading it, with over 50% doing so within a week. The transition will thus take longer and while the web remains our main portal, the beautifully designed paper BJUI will still land on your doorstep.

Prokar Dasgupta
Editor in Chief, BJUI

Guy’s Hospital, King’s Health Partners

References

  1. Eifler JB, Feng Z, Lin BM et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int 2013; 111: 22–29
  2. Cooperberg MR, Ramakrishna NR, Duff SB et al. Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost-utility analysis. BJU Int 2013; 111: 437–450
  3. Paduch DA, Bolyakov A, Polzer PK, Watts SD. Effects of 12 weeks of tadalafil treatment on ejaculatory and orgasmic dysfunction and sexual satisfaction in patients with mild to severe erectile dysfunction: integrated analysis of 17 placebo-controlled studies. BJU Int 2013; 111: 334–343
  4. Chiang PH, Su HH. Randomized and prospective trial comparing tract creation using plasma vaporization with balloon dilatation in percutaneous nephrolithotomy. BJU Int 2013; 112: 89–93
  5. Tadros NN, Bland L, Legg E, Olyaei A, Conlin MJ. A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial. BJU Int 2013; 111: 101–105
Original publication of this editorial can be found at: BJU Int 2013; 112: 1051–1052. doi: 10.1111/bju.12524

 

 

 

Would you really do a radical prostatectomy on a man with known metastatic prostate cancer?

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This year’s final #urojc concluded with intense discussions on the role of local treatment (LT) in metastatic prostate cancer. One study author, @mbwilliams95 joined the conversation to provide valuable insights.

 

 

 

Despite the fact only a small number of Stage IV patients had LT between 2004-2010 (post docetaxel era), this population based study revealed statistically significant differences between overall survival (OS) and disease specific survival (DSS).

Treatment Patient number 5 yr OS (%) DSS (%)
Radical prostatectomy
(RP)		 245 67.4 75.8
Brachytherapy(BT) 129 52.6 61.3
No surgery or radiation (NSR) 7811 22.5 48.7

 

So, can this be the start of a paradigm shift?

We may need to question our conventional approach.

Although some would consider performing RP in this population,

Others disagreed

Tzelepi et al (J Clin Oncol 2011 Jun 20;29(18):2574-81) suggested that potentially lethal cancers persist in the primary tumor and may contribute to progression. This is a possible explanation for this study’s findings, which echoed earlier results by Swanson et al (J Urol. 2006 Oct;176: 1292-8) and Shao et al (Eur Urol 2013 May 21. [Epub ahead of print]). However, SEER lacks information regarding the extent of bony metastasis, an entity that undoubtedly influences patient survival. Furthermore, patients treated with RP were 10 yrs younger than the NSR group (62 vs 72), and had a higher proportion of those with PSA <20.

To reduce bias produced by significant comorbidities, authors excluded those dying within a year of diagnosis and found the 5-yr OS continued to be higher in patients undergoing RP (76.5%) or BT (58.2%). However, patients with three or more of: age ≥70 yr, cT4 disease, PSA ≥20 ng/ml, high-grade disease, and pelvic lymphadenopathy had a 5-yr OS survival (38.2%) and a DSS probability (50.1%) similar to NSR patients.

Several contributors identified that Will Rogers phenomenon may be at play

Ultimately, the jury is still out on what is the most effective treatment of significant prostate cancer

Studies (in addition to the follow-on cohort study arising from this review), are underway

To conclude, it has been

In spite of the global participation, much of the banter involved our US urological colleagues.  On this basis, the Best Tweet Prize has been awarded to a provocative tweet from our UK colleague Ben Challacombe (@benchallacombe).

Thank you to European Urology (@EUPlatinum) for allow open access to the article discussed this month.  Thank you to Nature Reviews Urology for supporting the Best Tweet prize, which is a complimentary 12 months on-line subscription to the journal.

We look forward to seeing you at the January #urojc.

 

Dr Janice Cheng is an Australian Urology Trainee, currently based at Western Hospital. She has an interest in teaching, and enjoys laparoscopies, endoscopies, as well as male/female incontinence management. Twitter @JustUro

Headline news: “Doctors and nurses may face jail for neglect”?

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It has been an important few weeks in for doctors in the United Kingdom, sensationalist headlines have been on the front pages of many of the national newspapers: “Doctors and nurses may face jail for neglect”

This has all stemmed for the publication of the Francis report and Berwick review into patient safety. They detail recommendations on how the National Health Service (NHS) can learn and improve the standard of patient safety. The Berwick report was led by Professor Don Berwick, an international expert and former adviser to US president Barack Obama, in patient safety. He was asked by the British Prime Minister David Cameron to carry out the review following the publication of the Francis Report into the breakdown of care at a Mid Staffordshire NHS Foundation Trust Hospital.

Stafford Hospital is an NHS hospital in the West Midlands area of England where hundreds of hospital patients died as a result of substandard care and staff failings between January 2005 and March 2009. The Mid Staffordshire Trust failed to provide safe care in the wards, people lay starving, thirsty and in soiled bedclothes. Decisions about which patients to treat were left to receptionists, inexperienced junior doctors were put in charge of critically-ill patients, and nurses switched off equipment because they did not know how to use it. The culture of the hospital Trust was one of secrecy and defensiveness. The inquiry highlights a whole system failure.

Both reports highlight the main problems affecting patient safety in some hospitals in the NHS and makes recommendations on how to address them. It says that the health system must, amongst many things, recognise the need for wide systemic change by abandoning blame as a tool and trust the goodwill and good intentions of the staff. The use of quantitative targets must be approached with caution and they should never displace the primary goal of better care.

The main headline grabbing item was the recommendation that the UK Government should create a new general offence of willful or reckless neglect or mistreatment applicable both to organisations and individuals.

Organisational sanctions might involve removal of the organisation’s leaders and their disqualification from future leadership roles, public reprimand of the organisation and, in extremis, financial sanctions but only where that will not compromise patient care.

Individual sanctions should be on a par with those in Section 44 of the Mental Health Capacity Act 2005 in UK law, which states that a person can be found guilty of an offence if he ill-treats or willfully neglects a person who lacks capacity and if convicted could be sentenced to imprisonment for a term not exceeding 5 years or a fine or both.

So does this affect us as urologists?

As doctors our first duty of care is towards our patients and patient safety should be our number one priority. However, in light of the report there is the possibility of a custodial sentence to individual(s) where the standard of care falls far short of expectations and blatant neglect is proven. In the age of clinical teams, proving that one individual was at fault is very difficult.

There has been a recent case in the UK press in which a surgeon has been jailed for two and a half years for manslaughter for gross negligence of a patient.

In another case in Australia a 63-year-old American surgeon working in a hospital in Queensland faced complaints from hospital staff that he had botched operations, misdiagnosed patients and used poor surgical techniques. He was arrested in the US in 2008 and extradited to Australia to stand trial. He was jailed for seven years in 2010 after being convicted of criminal negligence leading to the deaths of three patients.

These are two isolated cases but both demonstrate that the days when problematic surgeons were quietly retired are over. Our actions will be scrutinised by an ever demanding public with complications not just being discussed in mortality and morbidity meetings locally but in some cases publicly and in extreme situations in the courts.

My question to the readers is: what happens to clinical staff in your individual countries when clinical negligence and neglect is accused? Is jail time a possibility if proven?

 

Jonathan Makanjuola is a Urology Trainee, Innovator and techie based at King’s College Hospital, London, United Kingdom. @jonmakUrology

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