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Editorial: Does HAL assistance improve outcomes in patients who receive postoperative intravesical therapy?

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There is growing evidence that hexaminolevulinate (HAL) fluorescence cystoscopy increases detection of bladder cancer at the time of transurethral resection of bladder tumours (TURBT) and that this results in lower recurrence rates [1, 2]. One limitation in many prior studies was the lack of standardisation about the use of immediate postoperative chemotherapy, which has been shown to reduce recurrence in patients with non-muscle-invasive bladder cancer [3]. This raises the question of whether the benefit of HAL in reducing recurrences would be eliminated if patients did in fact receive postoperative intravesical chemotherapy, which would help eradicate any missed residual tumour.

There have been several studies that attempt to bring clarity to this issue. A study by Geavlete et al. [4] randomised 362 patients suspected of having bladder cancer to HAL vs white-light (WL) TURBT with a single postoperative mitomycin C instillation given in all cases. The authors found that the recurrence rate at 3 months was lower in the HAL group (7.2% vs 15.8%) due to fewer ‘other site’ recurrences when compared with the WL group. There continued to be an advantage for the HAL group with lower 1- and 2-year recurrence rates compared with the WL group (21.6% vs 32.5% and 31.2% vs 45.6%, respectively). The study did not stratify patients specifically to those with low-grade non-invasive tumours but patients with single tumors had a trend toward less recurrence (23.3% vs 35.3%, P = 0.064).

Grossman et al. [2] published the long-term follow-up for 551 patients enrolled in a prospective, randomised study of HAL vs WL for Ta or T1 urothelial bladder cancer with similar rates of intravesical therapy in the two groups (46% and 45%, respectively). They found that the median time to recurrence was 9.4 months in the WL group and 16.4 months in the HAL group (P = 0.04) but they did not report specifically on patients who received postoperative intravesical therapy. A meta-analysis of raw data from prospective studies on 1345 patients with suspected bladder cancer evaluating HAL-assisted cystoscopy vs WL found that both patients with low- and high-risk disease had statistically significant lower recurrence rates [1]. This meta-analysis was unable to stratify based on use of postoperative intravesical therapy.

O’Brien et al. [5] performed a randomised prospective study of HAL-assisted vs conventional WL TURBT, with all patients scheduled to get a single treatment of postoperative intravesical mitomycin C. There were 86 and 82 patients with cancer in the HAL and WL groups who completed the 12 months follow-up, respectively. In this study, 63% and 77% of the HAL and WL patients received mitomycin C, respectively. There was an increased detection of carcinoma in situ (CIS) in the HAL group (26% vs 14%) but no significant difference in recurrence at 3 and 12 months. When stratifying by low-grade tumours, the 3-month recurrence rates for HAL and WL were 19% vs 9% and at 12 months were 16% vs 22%, so that no significant differences were noted but the study was not powered to evaluate this subgrouping.

What can be concluded then about whether HAL assistance improves outcomes in patients who receive postoperative intravesical therapy? It appears the results are inconclusive and this is not surprising. The risk reduction of postoperative intravesical chemotherapy is primarily limited to patients with a single low-grade papillary tumour and one would need to treat 8.5 patients with peri-TUR chemotherapy to prevent one recurrence [3]. The benefits of peri-TUR chemotherapy in patients at intermediate- and high-risk are not well established [6]. Most of the studies of HAL-assisted TUR have not treated with postoperative intravesical therapy systematically. The studies that have tried to uniformly give postoperative therapy have not been sufficiently powered to evaluate those patients most likely to benefit, namely low-grade non-invasive cancer. As such, one cannot determine whether the benefit of potentially detecting additional low-grade tumours by HAL in patients with low-risk disease could be matched by postoperative intravesical therapy and such a study would require a very large number of low-grade solitary papillary tumours. However, it would minimise the benefits of HAL to focus on the benefit in the lowest risk patients. A meta-analysis of randomised trials found that HAL reduced the risk of recurrence independent of level of risk, such that there was reduced recurrence in patients with CIS, T1 and high-grade disease [1]. These are patients for which immediate postoperative intravesical therapy has shown minimal benefit and for which the benefit of HAL cannot be explained away. Furthermore a small but meaningful number of low-risk patients can be found to have intermediate- or high-risk disease, which would change their subsequent management [4]. As such if one had to choose between approaches rather than apply both, the use of HAL would appear to result in a greater benefit in managing patients with bladder cancer.

Yair Lotan
Department of Urology, UT Southwestern Medical Center at Dallas, Dallas, TX, USA

Read the full article

References

  1. Burger M, Grossman HB, Droller M et al. Photodynamic diagnosis of non-muscle-invasive bladder cancer with hexaminolevulinate cystoscopy: a meta-analysis of detection and recurrence based on raw data. Eur Urol 2013; 64: 846-54
  2. Grossman HB, Stenzl A, Fradet Y et al. Long-term decrease in bladder cancer recurrence with hexaminolevulinate enabled fluorescence cystoscopy. J Urol 2012; 188: 58–62
  3. Sylvester RJ, Oosterlinck W, van der Meijden AP. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer: a meta-analysis of published results of randomized clinical trials. J Urol 2004; 171: 2186–2190
  4. Geavlete B, Multescu R, Georgescu D, Jecu M, Stanescu F, Geavlete P. Treatment changes and long-term recurrence rates after hexaminolevulinate (HAL) fluorescence cystoscopy: does it really make a difference in patients with non-muscle-invasive bladder cancer (NMIBC)? BJU Int 2012; 109: 549–556
  5. O’Brien T, Ray E, Chatterton K, Khan S, Chandra A, Thomas K. Prospective randomized trial of hexylaminolevulinate photodynamic-assisted transurethral resection of bladder tumour (TURBT) plus single-shot intravesical mitomycin C vs conventional white-light TURBT plus mitomycin C in newly presenting non-muscle invasive bladder cancer. BJU Int 2013; 112:1096–1104
  6. Kamat AM, Lotan YR. Perioperative intravesical therapy after transurethral resection for bladder cancer. J Urol 2010; 183: 19–20

Fellowships – a key ingredient or the ‘icing on the cake’?

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What is the ultimate endpoint of a residency or speciality training program? Is it to complete 5 or 6 years of training in core urological procedures? Is it to produce safe, competent independent urologists? Is it to achieve FRSC (Urol) certification? In an ideal world it would be a marriage of all three; a safe, competent, independent, certified, practising urologist ready and eager to tackle any urological referral. In reality, we know that not to be the case.

Urology is a broad and advancing speciality encompassing patients of all ages and both sexes involving a complexity of benign and malignant pathologies. It is unrealistic to be an expert in all the sub-specialties and be able to offer the best and least invasive treatments to our patients. Furthermore, with a necessary emphasis on patient safety, transparency and proficiency, surgical training programs face significant barriers in affording trainees the opportunity to operate, specifically in the working time directive era.

Fellowships are usually undertaken at the completion of higher surgical training scheme often in a centre of excellence overseas. Fellowships offer trainees intensive experience in their niche area. On completion of a coveted fellowship, trainees hope to have acquired and polished the required skills to practice independently in their chosen field.

A recent pan European survey of 219 urological residents demonstrated laparoscopy and robotics were available in 74% and 17% of centres respectively [1]. Only 23% of trainees report their exposure as ‘satisfactory’. 68% have not completed a laparoscopic radical nephrectomy as first operator. Despite this 81% are considering fellowships in laparoscopy.

Buffi et al., have called for a validated and structured training curriculum in robotic surgery [2]. Trainees acknowledge the challenges in the acquisition of such skills but the modularisation of training is the best way to learn a procedure. Step by step trainees can piece together the operations. Hours spent on simulators and in dry and wet laboratories enhances these techniques. Furthermore, the dual consoles offer invaluable experience in robotics, however, are scarcely available.

The governing bodies have a responsibility to maintain standards of training as well as a duty towards patients. Proficiency in modern techniques such as laparoscopy and robotics are deficient in most training programs. Training programs need to encompass these techniques in a modular fashion from an early stage to develop the skills of tomorrows’ urologists [3]. Fellowships will undoubtedly foster and enhance these skills but a core knowledge and technical proficiency even in a simulator setting should be encouraged.

In truth, our learning and development never should never stop.

‘Live as if you were to die tomorrow. Learn as if you were to live forever’ Mahatma Gandhi

Mr Gregory Nason is a Specialist Registrar in Urology at the University Hospital Limerick, Ireland

References

  1. Furriel FTG, Laguna MP, Figueiredo AJ, Nunes PT, Rassweiler JJ. Training of European urology residents in laparoscopy: results of a pan-European survey. BJU Int 2013; 112: 1223–28.
  2. Buffi N, Van Der Poel H, Guazzoni G,  Mottrie A, on behalf of the Junior European Association of Urology (EAU) Robotic Urology Section with the collaboration of the EAU Young Academic Urologists Robotic Section. Methods and Priorities of Robotic Surgery Training Program. Eur Urol 2013; epub ahead of print.
  3. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialing. J Urol 2011; 185: 1191-7.

Editorial: Better late than early for long-term survival in patients with recurrence after renal carcinoma

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In this paper, Brookman-May et al. [1] used a large multi-institutional database of over 13 000 patients from 23 centres in both Europe and the USA to examine the prognostic indicators of cancer-specific survival (CSS) in patients who had recurrence after primary surgery for RCC. Their analysis was based on a subset of 1712 patients who had recurrence during a median follow-up period of 50 months. All patients had undergone either radical nephrectomy or nephron-sparing surgery, with no evidence of metastasis at the time of surgery.

The authors have previously shown, in a related study based on a subset of 5000 patients from the same database, that lymphovascular invasion, Fuhrman grade 3–4, and pT stage > pT1 at the time of diagnosis were significantly associated with the development of late recurrence (defined as after >5 years) [2]. In this paper, the primary objective was to look at the effect of time to tumour recurrence (TTR) on CSS. In addition, clinical and histopathological comparisons were made between patients with early (<5 years) and late recurrence (>5 years).

Patients often want to know whether if they are recurrence-free after a period of time, their subsequent risk of dying from recurrence is reduced; this paper goes some way towards answering this question and showing that those with later recurrence had improved survival times. Specifically, the authors found that TTR was an independent predictor of CSS; i.e. if patients recurred early they had a worse CSS than those recurring late. This is similar to results from another group who reported that recurrent disease, particularly before 12 months, was associated with a poorer prognosis [3]. In the first 4 years of follow-up, a shorter TTR independently predicted lower CSS after recurrence [1]. When divided into those with early recurrence, Group A (N = 1402), and those with late recurrence, Group B (N = 310), patients in Group A were more likely to be male, of advanced age, have a greater tumour diameter and stage, have Fuhrman grade 3–4, with lymphovascular invasion and positive lymph node disease, than those in Group B. Patients in Group A had a 3-year CSS of 30% compared with those in Group B whose CSS was better at 41%. Age and gender were also independent predictors of CSS.

These results can help to guide the aftercare management of patients after primary surgery. Currently, primary surgery is the only recommended option for patients with localized RCC, although results from several phase III clinical trials looking at the role of adjuvant therapy, such as the SORCE, PROTECT and S-TRAC trials, are still awaited [4]. Furthermore, it is not known which group of patients are suitable for adjuvant chemotherapy, which is reflected in the subtly differing eligibility criteria for recruitment to the various trials [4]. The authors of the present study pointed out that a method of risk stratification may be useful to allow equal representation of early and late recurrence patients in treatment arms for clinical trials. Potentially, understanding the predictors of early recurrence may help to identify patients for whom adjuvant therapy may be beneficial.

Only 12% of patients with localized RCC in the present cohort developed recurrence after surgery [1]. This rate is lower than that found in the literature, where 20–30% recurrence rates of localized RCC have been reported [2, 5, 6]. Brookman-May et al. speculate that this lower rate is attributable to both an increase in early detection as well as improved surgical management in recent years. Furthermore, they acknowledge that the database is heterogeneous and that the study therefore has all the inherent limitations of a retrospective study.

The present paper clearly shows that the earlier the recurrence after surgery the lower the survival rate, but a clear strategy for the surveillance of localized RCC after primary surgery is currently lacking. Most follow-up protocols exercise a blanket ‘one for all’ policy with follow-up spaced at regular intervals to ensure patients who recur are detected early. Such a policy may not be intensive enough to detect early recurrence in some patients and may be excessive for the majority of patients where the risk of recurrence is low. Risk stratification of patients, by understanding the predictors of CSS after surgery, may help to tailor surveillance protocols to the individual and identify those for whom adjuvant therapy may be beneficial.

Kathie Wong and Ben Challacombe
The Urology Centre, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Read the full article

References

  1. Brookman-May S, May M, Shariat S et al. Time to recurrence is a significant predictor of cancer-specific survival after recurrence in patients with recurrent renal cell carcinoma – results from a comprehensive multi centre database (CORONA/SATURN Project). BJU Int 2013; 112: 909–916
  2. Brookman-May S, May M, Shariat SF et al. Features associated with recurrence beyond 5 years after nephrectomy and nephron-sparing surgery for renal cell carcinoma: development and internal validation of a risk model (PRELANE score) to predict late recurrence based on a large multicenter database (CORONA/SATURN Project). Eur Urol 2012; 64: 472–477
  3. Rodriguez-Covarrubias F, Gomez-Alvarado MO, Sotomayor M et al. Time to recurrence after nephrectomy as a predictor of cancer-specific survival in localized clear-cell renal cell carcinoma. Urol Int 2011; 86: 47–52
  4. Kim SP, Crispen PL, Thompson RH et al. Assessment of the pathologic inclusion criteria from contemporary adjuvant clinical trials for predicting disease progression after nephrectomy for renal cell carcinoma. Cancer 2012; 118: 4412–4420
  5. Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Five-year survival after surgical treatment for kidney cancer: a population-based competing risk analysis. Cancer 2007; 109: 1763–1768
  6. Breda A, Konijeti R, Lam JS. Patterns of recurrence and surveillance strategies for renal cell carcinoma following surgical resection. Expert Rev Anticancer Ther 2007; 7: 847–862

The bashful bladder: can we ever truly define?

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Commemorating the #urojc one year mark, Brian Stork reflected on the year that was, with a fun visual diagram on the most common words used during this period.

A fitting paper for moving into Season 2 of the #urojc, with the November International Journal Club discussion on Twitter was based on the paper “Detrusor Underactivity and the Underactive Bladder: A New Clinical Entity? A Review of Current Terminology, Definitions, Epidemiology, Aetiology, and Diagnosis” by Osman et al from European Urology, 26 October 2013.

Osman et al, attempted to provide clarity around the nonobstructive impairment of voiding function, referred to as detrusor underactivity and the underactive bladder, as a clinical entity, and provide consensus on the standardising of current concepts. In their attempt to achieve this aim, a wide ranging literature review was conducted on varying terms commonly pertaining to detrusor underactivity.

So, does definition matter when discussing bashful bladders?

Early discussion centred on how frustrating detrusor underactivity was as an entity in part due to lengthy and complex mathematical equations, 

difficult in defining, with Amrith Rao, adding another term into the mix,

and often concomitant disease processes.

Surgical intervention for a bashful bladder is not a new concept, with Amrith Rao noting a partial cystectomy for hypotonic bladder was offered in the 1970’s.

This lead to a clinical discussion with participants asked who would perform a TURP on a man with an underactive bladder as suggested by urodynamics? Nadir Osman brought to our attention a study published in The Journal of Urology by Djavan et al in 1997, which concluded patient age was the key factor in treatment failure. However, with no solid evidence, participants agreed it often came down to patient choice.

Although a smaller group of participants for this month’s discussion, conclusions included:

The main messages I took from this discussion were:

  1. This is an often forgotten and overlooked aspect of Urology practice
  2. To succeed in overcoming these obstacles, a standardised definition for DU / UD is needed

This month had a strong showing from Sheffield urologists and alumni including Nadir Osman, Kate Linton, Jake Patterson, Jim Catto, Henry Woo and Chris Chapple who was listening in from his newly created Twitter account. The winner of the best tweet prize for the November #urojc is Jake Patterson.  BMC Urology have kindly donated a complimentary manuscript submission to this open access journal (of course pending peer review process).

Whilst these non-oncology topics see smaller participation, these topics will continue to be supported to provide variety and to maintain interest to the general #urojc audience.

Helen Freeborn is an Australian Urology Trainee, currently completing a General Surgical year at Cairns Base Hospital, QLD. She is interested in surgical leadership and the power of social media in connecting health professionals. Twitter @DrHelenF

Editorial: Totally X-ray-free percutaneous nephrolithotomy: caveat emptor

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In the accompanying paper, Yan et al. [1] present the outcomes of their study on percutaneous nephrolithotomy (PCNL) guided only by ultrasonography (US).

This is the largest series (705 patients) to date on PCNL purely under US control and reports stone-free and complication rates that are consistent with those commonly reported for PCNL guided by X-ray or by a combination of X-ray and US.

Since its introduction more than three decades ago, PCNL has traditionally been performed under fluoroscopic control by the majority of urologists, even though US guidance has now gained wide acceptance as a means of achieving renal access. Now, the most important international guidelines suggest that US be used in addition to fluoroscopy [2]. US guidance has the following advantages: it minimizes radiation exposure, allows the detection of viscera that can sometimes lie in the trajectory of the puncturing needle and avoids contrast-related complications. Furthermore, US provides imaging of the collecting system in three-dimensional orientations and helps to distinguish between anterior and posterior calyces with great accuracy. Nevertheless, the innovative concept proposed by Yan et al. [1], with their impressive series, concerns the whole procedure (puncture, creation of renal access and final look to rule out eventual residual fragments), and not only the safe accomplishment of the puncture solely under US guidance.

Caution should be taken in interpreting their results. This is a purely retrospective study which guarantees only a low level of evidence (3B). In addition, even though major complications arising during the creation of access were not reported in the paper, doubts remain about the safety of using only US guidance in monitoring the dilatation process by either balloon or coaxial dilators. The following questions still need to be addressed. How can the progression of dilators be monitored to avoid excessive inadvertent medial advances with the accompanying high risk of collecting system perforation? How can false passage of a working guidewire be detected early by US? What about obese patients in whom the effectiveness of US is generally impaired?

To balance the risks and benefits of guidance solely by US, a middle ground could be represented by US guidance aided by ureteroscopic monitoring of the dilatation process using the so-called ‘Endovision technique’ [3], as is possible during endoscopic combined intrarenal surgery (ECIRS) (Fig. 1). In view of the risks, it should be stressed that, even though PCNL guided solely by US is an attractive option, biplanar C-arm fluoroscopy should always be present in the operating room.

It is well known that radiation hazard is directly proportional to cumulative radiation exposure time, so US guidance provides an obvious advantage in terms of absence of radiation for patient and operating room staff, but is the extent of this advantage really known? It is important to underline that the amount of radiation exposure during PCNL is not particularly great, measuring on average 0.56 mSv for the patient and 0.28 mSv for the urologist [4]. By contrast, unenhanced CT involves a significant radiation exposure of 8.6 mSv [5], which is of course particularly relevant for patients with stones, who are often quite young and likely to experience recurrence. According to the ‘as low as reasonably achievable’ (or ALARA) principle, replacing CT scans with US in the follow-up would have a much greater impact on reducing radiation exposure in adult patients (in the present series patients undergo two CT scans after surgery, at 48 h and 4 weeks, and one preoperative CT scan!) than would renouncing the safety guaranteed by X-ray monitoring during endourology.

Finally, it is of paramount importance to stress that, in the current climate in which malpractice litigation related to endourology continues to rise [6], it is still advisable that PCNL guided solely by US should be performed only in trials for which approval of the local institutional review board has been obtained.

To conclude, Yan et al. [1] propose an alternative approach to PCNL that involves solely US guidance, but some doubts remain. Only further well designed, prospective, comparative and possibly randomized studies will allow us to draw definitive conclusions.

Guido Giusti
Head of Stone Center & European Training, Center in Endourology, Humanitas Clinical and Research Center, Milan, Italy

Read the full article

References

  1. Yan S, Xiang F, Yongsheng S. Percutaneous nephrolithotomy guided solely by ultrasonography: a 5-year study of >700 cases. BJU Int 2013; 112: 965–971
  2. Türk C, Knoll T, Petrik A et al. 2013 EAU Guidelines on Urolithiasis
  3. Scoffone CM, Cracco CM et al. Endoscopic Combined intrarenal surgery in galdakao-modified supine valdivia position: a new standard for percutaneous nephrolithotomy? Eur Urol 2008; 54: 1393–1403
  4. Kumari G, Kumar P, Wadhwa P, Aron M, Gupta NP, Dogra PN. Radiation exposure to the patient and operating room personnel during percutaneous nephrolithotomy. Int Urol Nephrol 2006; 38: 207–210
  5. Katz SI, Saluja S, Brink JA, SForman HP. Radiation dose associate with unenhanced CT for suspected renal colic: impact of repetitive studies. AJR Am J Roentgenol 2006; 186: 1120–1124
  6. Duty B, Okhunov Z, Okeke Z, Smith A. Medical malpractice in endourology: analysis of closed cases from the State of New York. J Urol 2012; 187: 528–532

Editorial: How many cores are needed to detect nearly all prostate cancers?

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Virtual prostate biopsy and biopsy simulation: lessons to be learned

Prostate biopsies, transrectal or transperineal, still constitute the pillars of prostate cancer detection today [1]. With the lack of reliable imaging tools (new MRI techniques are promising but still investigational [2]); random biopsies offer the sole adequate cancer detection option [3]. However, random biopsies are far from efficient in detecting all tumours and even less efficient in detecting all significant cancer ‘spots’. To improve sensitivities and specificities, increasing the biopsy core numbers, targeting more lateral aspects and encouraging repeat biopsies have been recommended [4]. Recently, HistoScanning™ [5] and template biopsies [6] have been introduced to further improve biopsy quality and efficiency. The latest innovations include the fusion of MRI pictures with the TRUS image to offer optimal targeting of suspicious areas [7]. And yet, these efforts are far from solving the main problem. How can we perform a biopsy and be confident to detect most of the cancers, i.e. significant malignant areas.

The present study [1] does, what should have been done a long time ago, namely to create a reliable and reproducible biopsy simulation model to allow the investigation of various biopsy schemes, core lengths and numbers. Based on a series of 109 radical prostatectomy specimens, a three-dimensional (3D) prostate and prostate cancer model was created using novel 3D slicer software and various prostate biopsy schemes were simulated. Using this method, the detection rate for tumours with a tumour volume (TV) of ≥0.5 mL plateaued at 77% (69 of 90) using a 12 core (3 × 4) scheme, standard 17-mm biopsy cutting length without anteriorly directed biopsy (ADBx) cores. Twenty of 21 (95%) tumours with a TV of ≥0.5 mL not detected by this scheme originated in the anterior peripheral zone or transition zone [1].

Confirming our earlier data with the Vienna nomograms [8], increasing the biopsy cutting length and depth/number of ADBx cores (14–18 cores) improved the detection rate for tumours with a TV of ≥0.5 mL in the 12-core scheme [1]. The best biopsy scheme used a 22-mm cutting length and a 12-core scheme with additional volume-adjusted ADBx cores. Using this combination, 100% of ≥0.5 mL tumours in prostates <50 mL in volume and 94.7% of ≥0.5 mL tumours in prostates >50 mL in volume were detected.

Certainly, these numbers will not be reproducible in real-time TRUS or transperineal biopsies (detections rates of 95–100% as seen in this simulation model, cannot be achieved without adequate imaging tools, which are not available yet), but they aid significantly in rethinking our biopsy strategy. So, if we summarise the present findings and combine them with published data, the future will demand a TRUS-fusion biopsy technique, involving 14–18 cores (or more if volume increases), involving the anterior zones of the prostate and using a 22-mm cutting length of the biopsy core vs a 15–17 mm core as is used currently. Obviously real-time prospective trials are needed to confirm these findings but nothing indicates that the outcome would be otherwise.

Bob Djavan
Department of Urology, New York University School of Medicine, NYU, New York, NY, USA

Read the full article

References

  1. Kanao K, Eastham JA, Scardino PT, Reuter VE, Fine SW. Can transrectal needle biopsy be optimised to detect nearly all prostate cancer with a volume of ≥0.5 mL? A three-dimensional analysis. BJU Int 2013; 112: 898–904
  2. Delongchamps NB, Peyromaure M, Schull A et al. Pre-biopsy Magnetic Resonance Imaging and prostate cancer detection: comparison of random and MRI-targeted biopsies using three different techniques of MRI-TRUS image registration. J Urol 2013;189: 493–499
  3. Djavan B, Rocco B. Optimising prostate biopsy. BMJ 2011; 344: d8201
  4. Thompson I, Thrasher JB, Aus G et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 2007; 177: 2106–2131
  5. Simmons LA, Autier P, Zát’ura F et al. Detection, localisation and characterisation of prostate cancer by prostate HistoScanning(™). BJU Int 2012; 110: 28–35
  6. Huo AS, Hossack T, Symons JL et al. Accuracy of primary systematic template guided transperineal biopsy of the prostate for locating prostate cancer: a comparison with radical prostatectomy specimens. J Urol 2012; 187: 2044–2049
  7. Sonn GA, Natarajan S, Margolis DJ et al. Targeted biopsy in the detection of prostate cancer using an office based magnetic resonance ultrasound fusion device. J Urol 2013; 189: 86–92
  8. Djavan B, Margreiter M. Biopsy standards for detection of prostate cancer. World J Urol 2007; 25: 11–17

The impact of the BJUI and what influences it today: does impact factor matter?

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Over the last decade, urological researchers have been increasingly interested with, and driven by, the impact factor (IF) of the journal to which they are submitting. This bibliometric tool measures the way in which a journal receives citations of its articles over time. IF is calculated by dividing the number of current citations a journal receives for articles published in the two previous years, by the number of articles published in those same years.

Although IF represents a proxy for the popularity of a journal within its field, several academic and scientific organizations now use the IF to judge the value of a scientist or of a research team using it for national and international academic evaluations. This questionable policy has generated a vicious circle that has driven authors to prefer journals with higher IFs and, consequently, journal editorial boards (and publishers) to plan (soft or strong) strategies to increase this index. As a result a higher IF attracts the best articles in the field and increases the number of subscriptions to a journal. There are a number of potential biases influencing the IF values including self-citation, the number of articles published per year, and the type of articles accepted. We will explain how all of these nuances can play a significant role in calculating the IF.

Some journals subtly suggest that authors and reviewers cite articles published in their own journal within the references of newly submitted papers. This slightly dubious practice can bias the true value of the IF. Reassuringly when looking at the urological journals, the self-citation factor generally seems to play a limited role, as most journals have a percentage <10%. The policy of the BJUI Editorial Board does not support a self-citation practice. The decision to start each BJUI issue with some editorial comments (the Editor’s Choice section) is only to offer to readers the opportunity to have expert comment on the most important papers published within each edition. Indeed, the invited authors are only requested to cite the featured article and no others from the BJUI.

The number of papers published per journal volume and throughout each year is another significant factor influencing the IF value. Table 1 clearly shows the wide variability in the number of papers published from 2010–2011 in the different urologic journals. The new BJUI policy is to significantly reduce the number of published papers/year. Reflecting this decision, the BJUI Editorial Board has agreed to significantly improve the review process with the aim of selecting only the most relevant and original of the submitted manuscripts. A new rapid triage review process should allow us to select only the best 30–40% of submitted manuscripts to send to 3–4 experts for a more focused and precise review process. This mechanism has produced a significantly increased rejection rate in favour, we hope, of a better selection of topics and papers for our readership [2].

Table 1. Items cited in 2012 and items published in 2010–2011 in the most important urological journals. Data from ISI Web of Journal Citation Reports (JCR)
Abbreviated Journal Title Cites in 2012 Items published in 2010–2011 Impact Factor
EUR UROL 4.662 445 10.476
NAT REV UROL 580 121 4.793
PROSTATE 1.395 963 3.843
J UROLOGY 4.864 1316 3.696
J SEX MED 2.638 751 3.513
BJU INT 3.323 1091 3.046
WORLD J UROL 673 233 2.888
UROLOGY 2.843 1173 2.424
CURR OPIN UROL 360 164 2.195

 

Bibliometric analyses have shown that review articles are cited more frequently than full original research papers. Therefore publishing good quality review articles written by expert opinion leaders in the field represents an excellent strategy to increase a journal’s IF. Although, we recognize the impact of review articles on IF, the current policy of the BJUI remains unchanged with only relatively few review articles included in each issue. As a result we will continue to give maximal attention to the clinical and basic research papers.

Finally the IF is in many ways only an index of the popularity of a journal because it equally weights citations from highly reputed journals alongside citations from more obscure journals [1]. However a journal’s true credit is also based on the prestige of the citing journals and the Eigenfactor scores is currently used to reflect this measure. Table 2 shows that the BJUI is third of all urological journals according to this less popular bibliometric tool. Another contemporary measure of impact, particularly influenced through the internet is the “Klout Score”. This system, which uses social media analytics to rank users according to online social influence via the Klout Score, giving a numerical value between 1 and 100. The BJUI currently has a score of 56, higher than its contemporaries. Therefore we can conclude that the BJUI today is a journal with a good reputation throughout the urologic field.

Table 2. Relationship between prestige (Eigenfactor® Score) and popularity (Impact Factor score) of urological journals. Data from ISI Web of Journal Citation Reports (JCR)
Rank Abbreviated Journal Title Eigenfactor® Score Impact Factor IF rank
 1 J UROLOGY 0.08109 3.696 4
 2 EUR UROL 0.05503 10.476 1
 3 BJU INT 0.04248 3.046 7
 4 UROLOGY 0.03896 2.424 11
 5 J SEX MED 0.01738 3.513 6
 6 PROSTATE 0.01624 3.843 3
 7 J ENDOUROL 0.01571 2.074 15
 8 NEUROUROL URODYNAM 0.00897 2.674 10
 9 WORLD J UROL 0.00750 2.888 8
10 INT J UROL 0.00582 1.734 16

 

The editorial board of a traditional urological journal like the BJUI must take into consideration both the IF and other scoring systems as indicators of its popularity and prestige. The strategies we employ to give better bibliometric parameters should predominantly reflect an increase in the quality of the papers published as we must remember that the journal is primarily produced for the readership and not just for those who wish to publish in it [3].

Vincenzo Ficarra1, Associate Editor,
Ben Challacombe2, Associate Editor,
Prokar Dasgupta2, Editor in Chief

1Department of Experimental and Clinical Medical Sciences, Urology Unit, University of Udine, Italy. 2King’s Health Partners, London UK

References

  1. Franceschet M. The difference between popularity and prestige in the sciences and in the social sciences: a bibliometric analysis. J Informetr 2010; 4: 55–61
  2. Dasgupta P. The most read surgical journal on the web. BJU Int 2013; 111: 1–3
  3. Schulman CC. What you have always wanted to know about the impact factor and did not dare to ask. Eur Urol 2005; 48: 179–181

Original publication of this editorial can be found at: BJU Int 2013; 112: 873–874, doi: 10.1111/bju.12472

One year on and “The International Urology Journal Club on Twitter” still going strong

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November marked the first anniversary of the International Urology Journal Club on Twitter. As far as we are aware, our #urojc was the first journal club on Twitter using the asynchronous format. Prior to our commencement and unknown to us, a very successful real time journal club had been established with great success. Our major challenge was to enable engagement from our global community and clearly the way forward was to use the asynchronous chat format. This has since proved to be the innovation that has enabled true global participation. Other specialties have since followed our model.

When we started, we were fortunate to be in a specialty group where there were already significant numbers on Twitter and we were able to rally up the troops for the first #urojc discussion in November 2012. In the first month of our existence, we had around 50 followers and since then there has been a steady growth in those following the #urojc account and as we reached our one year anniversary, we had hit the magic 1000 follower mark.

Before all is relegated to faint memory, it is important to acknowledge the supporters and Best Tweet (Hall of Fame) winners over the past 12 months.

A couple of the novel prizes, were not sur‘prize’ingly from Urology Match.

Thanks to all of you who have supported this project as participants and followers of the #urojc discussions. A shout out to BJUI for allowing us to have the audience of the BJUI Blogs to communicate and publicize our activities. Thank you to the supporters of the Best Tweet Prizes and the journals who have kindly allowed open access of articles discussed. A special thanks to authors who have been kind enough to make themselves available for the discussion – having author insights adds a special touch that is simply not possible with any other journal club format.

We have been off to a strong start for our second year and look forward to the continued success of this novel form of CME by social media.

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

The Inaugural Annual Academic Sessions Joint Meeting of BAUS and SLAUS

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BAUS / SLAUS 2013 Conference Report: 4th – 7th November, Colombo, Sri Lanka
Day 1

Greetings from Colombo, Sri Lanka. Home of the Inaugural Meeting of BAUS / SLAUS. The gathering, held in cool Colombo was off to a great start at Asiri Surgical Hospital. It was inundated with delegates from all over Sri Lanka and the UK, who had come to learn and exchange opinions. The conference started with a focus on LUTS. Mr. Mark Speakman (Taunton, UK) emphasizing importance and correct terminology used in treatment of this condition. This was followed by Mr. Pallavoor Anandaram (Wrexham, UK) and Mr. Ian Pearce (Manchester, UK) talking on medical management the pros and cons, with great debate and participation from delegates. This was followed by Mr. Peter Acher (Southend, UK) covering surgical management of LUTS.  

Lunch was held on the rooftop terrace, with gourmet Sri Lankan cuisine. The afternon was filled with laparoscopic talks led by Mr. Christian Brown (London, UK) with Mr. Sanjeev Madaan (Dartford, UK) reflecting on use of cryotherapy importance, technique and complications.

In addition there was also a live surgical link up with Mr. Ranjan Thilagarajah (Chelmsford, UK) conducting live robotic surgery at Kings College. This was streamed to Australia, USA, Sri Lanka and the UK.

In true Sri Lankan fashion, the day concluded with a welcome dinner, and exchange of gifts for the Faculty. All in readiness for a new day!!!

Day 3

The day kicked off to a bright start discussing complex MDT cases, with a combined panel from the UK and Sri Lanka. Involved in discussions were Dr. Serozsha AS Goonewardena (Colombo, Sri Lanka), Prof. Raj Persad, Mr. Sanjeev Madaan, Miss Sanchia Goonewardene (London, UK). There were a variety of cases covered including prostate, bladder and renal cancer and a variety of management strategies discussed.

As before, local gourmet cooking was served for lunch, with the afternoon moving onto a series of lectures. Firstly was Mr. Ian Pearce (Manchester, UK) on how to get a paper published. Secondly, Miss Sanchia Goonewardene on UK training, followed by Mr. Sohan Perera (Colombo, Sri Lanka) on Sri Lanka training. Mr. David Tolley (Edinburgh, UK) then covered aspects of educational involvement from the college, and the afternoon ended with Mr. David Jones (Gloucester, UK) explaining the process of internal review. A welcome address was conducted by Mr. Anura Wijewardane (Colombo, Sri Lanka), then Chief Guest Mr. Mark Speakman spoke, before an address by the Guest of Honour, Dr. Athula Kahandaliyanage (Colombo, Sri Lanka).

Both Mr. Mark Speakman and Mr. David Tolley were awarded Honurary Fellowships by SLAUS, before a vote of thanks was conducted by Dr. Ajith Malalasekera (Secretary, SLAUS).

The evening concluded with a cultural show and reception, just what all needed. 

 
Day 4

The day kicked off with Mr. Vincent Gnanapragasam (Oxford, UK), lecturing on risk stratification on prostate cancer. Mr. Gurpreet Singh then spoke on surgical management of LUTS, including objective assessment of obstruction. An audience vote was taken for surgical treatment, with the vote almost unanimously being in favour of bipolar. Then Mr. Peter Acher spoke on HoLEP, giving the pros and cons of the system. Mr. Christian Brown spoke on greenlight laser, therapy and protocol involved. This revealed a ground breaking moment as he presented new data on green light vs. TURP (unpublished).

Overactive bladder symptoms and treatment were then discussed by Ms. Tharani Nitkunan (Surrey, UK), including at times a mixed response to treatment. Mr. Roger Walker (Epsom, UK) then spoke on stress inconvenience and use of mid urethral tape. Complications of tapes were then covered by Mr. Simon Fulford. Mr. Pravin Menezes (Sunderland, UK) then discussed non communicable disease and types of stone. 

Mr. Mark Stott (Exeter, UK) then spoke on urosepsis and mortality, highlighting the importance of preventing urosepsis and early antibiotic therapy. Dr. Anuruddha M Abeygunasekara (Colombo, Sri Lanka), then spoke on GU TB. This was especially interesting to the UK delegates, like that we do not see.

Mr. Mark Speakman then gave the SLAUS lecture on prostate cancer incidence and trials involved.

After lunch, uro-oncology was covered by both Mr. Thiru Gunendran (Manchester, UK) and Prof. Raj Persad. Also during the afternoon was the trainees forum ranging from stone disease to uro-oncology to new techniques for urethral pull-through for management of membrano prostatic disease.

After tea came management of spinal cord injury by Mr. Simon Fulford and Mr. Julian Shah, before facilitation of UK fellowships by Mr. Ranjan Thilagarajah and management of vesico-vaginal fistulae by Mr. Julian Shah.

The evening ended with a closing ceremony and banquet. 

Sanchia Goonewardene and Raj Persad*
Homerton University Hospital, London and *Bristol Urological Institute, Southmead

[caption id=”attachment_10517″ align=”alignleft” width=”800′ label=’ Faculty member, Miss Sanchia Goonewardene and President Elect of BAUS, Mr. Mark Speakman at the Faculty Dinner, Pegasus Reef Hotel, Sri Lanka.

Editorial: Regaining continence after radical prostatectomy: RARP vs. ORP

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Functional outcomes represent relevant criteria to evaluate the success of radical prostatectomy (RP) in the treatment of localised and locally advanced prostate cancer. Indeed, while the primary goal of RP remains the complete extirpation of the primary tumour, patients’ satisfaction can be negatively affected by urinary incontinence and/or erectile dysfunction after RP.

In this issue of BJUI, Geraerts et al. [1] evaluated urinary continence recovery and voiding symptoms in a well-conducted, single-centre, prospective non-randomised study comparing two contemporary series of patients who underwent either open retropubic RP (RRP) or robot-assisted RP (RARP) for clinically localised or locally advanced prostate cancer. Patients were assigned to each group according to their or their surgeon’s preference. High-risk prostate cancers were preferably treated with an open access to offer a more accurate extended lymphadenectomy. The study showed that the urinary continence recovery rate was significantly shorter in the RARP group than in the RRP group (16 vs 46 days; P = 0.008). Interestingly, the RA approach remained an independent predictor of time to urinary continence recovery on multivariable Cox regression analysis (P = 0.03; hazard ratio [HR] 1.52, 95% CI 1.03–2.26). Therefore, this study confirmed previously published results. In 2003, Tewari et al. [2] reported a shorter time to recovery of urinary continence in patients who underwent RARP (44 days) than those who received RRP (160 days). In 2008, Kim et al. [3] reported a median time to continence in RARP patients of 1.6 months, significantly lower than the 4.3 months in the RRP patients. Interestingly, Geraerts et al. [1] identified other independent predictors of time to continence, such as patient’s age >65 years (P = 0.02; HR 0.67, 95% CI 0.45–0.96) and the preoperative continence status (P = 0.004; HR 1.69, 95% CI 1.18–2.43). In all, 28% of patients who received RRP and 34% of those who underwent RARP were preoperatively defined as incontinent using a symptom-specific questionnaire [1]. These patients classifiable as ‘Cx’ according to the Survival, Continence and Potency (SCP) classification [4] represent a confounding population in the Geraerts et al. study who should be evaluated separately.

An interesting question is whether the reported difference in time to continence in favour of RARP is also significant from the clinical perspective. Urinary continence in patients who underwent RARP recovered 1 month early than those treated with traditional RRP. The King’s Health questionnaire seems to confirm a positive effect of this outcome on the patient’s quality of life (QoL). Indeed, there were better results in the RARP compared with RRP group at 1 and 3 months after RP. Moreover, at 12 months after RP, patients who underwent RRP were more physically limited (P = 0.01) and took more precautions to avoid urine loss (P = 0.01) than those who received a RARP [1]. These data seem to be in conflict with the reported overlapping 12-month urinary continence rates (96% in RRP and 97% in RARP group). Moreover, looking at the 12-month urinary continence rate, the Geraerts et al. study does not confirm the results of a recent cumulative analysis of available comparative studies showing a better 12-month urinary continence rate after RARP compared with RRP (odds ratio 1.53; P = 0.03) [1].

Interestingly, the 12-month urinary continence rate reported after RRP by Geraerts et al. is significantly higher (96%) than the values reported in the comparative studies included in the meta-analysis (88.7%) and in the most important and recent RRP non-comparative series (60–93%) [5]. This aspect appears to confirm the important role of surgeon experience. Indeed, in this Belgium series most of the open procedures were performed by an expert surgeon with experience of >3000 RRPs, and thus able to reach excellent functional outcomes for urinary continence recovery. In favour of robotic surgeons, we could consider that they were able to reach overlapping results after <200 cases.

In conclusion, the study published by Geraerts et al. [1] showed that modern RP in expert hands is able to achieve excellent results for urinary continence recovery regardless of the approach. However, pure and RA laparoscopy has pushed open surgeons to improve technical and postoperative aspects to achieve comparable outcomes. RARP can offer some advantages over traditional RRP, above all for the time to reach urinary continence. This advantage seems to have generated a better QoL profile in patients who underwent RARP at 12 months after RP.

However, the choice between the two techniques must be taken according to all the most relevant parameters including perioperative, functional (continence and potency) and oncological outcomes. Therefore, we strongly support the publication of clinical series or comparative studies reporting results according to the ‘trifecta’, ‘pentafecta’ or SCP systems [6].

Vincenzo Ficarra†°, Alessandro Iannetti* and Alexandre Mottrie†
†OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium, °Department of Experimental and Clinical Medical Sciences – Urology Unit – School of Medicine, University of Udine, and *Department of Surgical, Oncologic and Gastrointestinal Sciences, Padua, Italy

Read the full article

References

  1. Geraerts I, Van Poppel H, Devoogdt N, Van Cleynenbreugel B, Joniau S, Van Kampen M. Prospective evaluation of urinary incontinence, voiding symptoms and quality of life after open and robot-assisted radical prostatectomy. BJU Int 2013; 112:936–943
  2. Tewari A, Srivasatava A, Menon M, Members of the VIP Team. A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution. BJU Int 2003; 92: 205–210
  3. Kim SC, Song C, Kim W et al. Factors determining functional outcomes after radical prostatectomy: robot-assisted versus retropubic. Eur Urol 2011; 60: 413–419
  4. Ficarra V, Sooriakumaran P, Novara G et al. Systematic review of methods for reporting combined outcomes after radical prostatectomy and proposal of a novel system: the survival, continence, and potency (SCP) classification. Eur Urol 2012; 61:541–548
  5. Ficarra V, Novara G, Rosen RC et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012; 62: 405–417
  6. Ficarra V, Borghesi M, Suardi N et al. Long-term evaluation of survival, continence and potency (SCP) outcomes after robot-assisted radical prostatectomy (RARP). BJU Int 2013; 112: 338–345
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