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Editorial: Impact of ERSPC study on PSA testing in the Netherlands

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General practitioner (GP)’s view on screening for prostate cancer in the Netherlands: the impact of a randomized trial

I am grateful to be given the opportunity to provide an editorial comment on a so-far unique publication investigating the impact of results of the European Randomized study of Screening for Prostate Cancer (ERSPC) on the attitude of Dutch GPs in requesting a serum determination of PSA in men aged >40 years. Access to data from one of the major health insurance companies and the structure and data acquisition of regional laboratories in the Netherlands provided an opportunity to carry out the project. This included the differentiation of age groups, of primary as opposed to repeat PSA testing and, in the case of the hospital database, of repeat PSA testing within 1 year, which provided the opportunity to address the primary goal of the study: the evaluation of the difference in primary PSA testing rates as well as follow-up testing before and after the 2009 publication of interim data from the ERSPC study. The fact that a Dutch translation of this publication and a recommendation by the Dutch Association of General Practitioners (Nederlands Huisartsen Genootschap, NHG) were mailed at the same time and the fact that GP guidelines had not been changed since 2005 in the Netherlands provided an important basis for the reported study.

Two different databases were used and PSA testing was evaluated 1 year before and 1 year after March 2009 (excluding the month March 2009). An overview of the data acquisition and results is given in Table 1. In brief, the data based on insurance claims show a significant decrease in PSA use before and after the 2009 publication. This decrease was less pronounced or not seen at all in men aged 70–80 or >80 years. The study selectively identified men in the ERSPC region of Rotterdam after exclusion of those assigned for re-testing in the screening arm. In line with earlier investigations, the PSA testing rate in the Rotterdam region was considerably higher then in the rest of the Netherlands. This effect was blamed on increased awareness and possibly on the motivation of men randomized into the control group of the study. The so-called ‘hospital database’ refers to a regional GP laboratory. It remains unexplained why only 2098 men of the total of 9766 men who were identified as having undergone primary PSA testing (Tables 1 and 2 in the study) were included in the analysis. These data show that there was no overall difference in testing before and after the ERSPC publication, but the proportion of re-testing decreased significantly between the two periods.

Table 1: Data acquisition and results.

Several comments can be made on this study. First, information provided on the insurance claims database allows an estimate of the proportion of men in whom PSA is evaluated (123 996/715 000 = 17.3%) and of those who undergo primary PSA testing for early diagnostic purposes (66 848/715 000 = 9.4%). The overall figure contrasts sharply with the results of a study by the Central Bureau of Statistics in the Netherlands, published in 2006. The study shows PSA use of 30–40% for the age groups 60–70 years or older.

Second, as the authors acknowledge, the differentiation between primary PSA tests for the purpose of early diagnosis and for other purposes may not be entirely reliable; however, the bias resulting from possibly incorrect assumptions is likely to be small.

Third, the sub-analysis of data coming from the Rotterdam region is likely to show the impact of greater awareness resulting from written informed consent before randomization and the effect of randomization into a control group. The data confirm an earlier evaluation of this subject (reference 7 in Van der Meer et al.) and at the same time provide a rough estimate of the level of contamination which may take place in the ERSPC study, Rotterdam region.

Fourth, it is interesting to see how age and previous PSA values influence the request for repeat PSA studies. It is counterintuitive (Table 3 in Van der Meer et al.) that even in the critical PSA range 4–10 ng/mL a significant decrease of PSA use within 1 year was seen. The multivariate analysis shows that study period before and after 2009, PSA categories and age groups are all significantly related to the decrease of PSA re-testing within 1 year.

Finally, as one of the initiators of the ERSPC study, I should like to refer to two important follow-up publications (Schröder et al., Heijnsdijk et al.) that point to the over-diagnosis and over-treatment of prostate cancer as the main reasons why the almost 30% reduction in prostate cancer mortality in screened men cannot (yet) be used for establishing population-based screening. For these reasons, the authors fully agree with the viewpoint of the Dutch GP Association and the recommendation against routine use of PSA-driven screening for prostate cancer; however, as pointed out in the last sentences of their paper instruments are now available to decrease over-diagnosis and the rate of unnecessary biopsies. In addition to that, it should be realized that men who are well informed and wish to be tested for prostate cancer cannot be refused PSA testing. To assist this process, the International Society of Urology (SIU) and the international movement ‘Movember’ have recently made available on their websites a validated decision aid for men who wish to be tested, their GPs and their treating urologists.

Fritz H. Schröder
Erasmus Medical Center, Rotterdam, The Netherlands.

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Bladder Cancer: a stagnant foe?

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This month’s topic for the Twitter-based International Urology Journal Club #urojc was bladder cancer, with a paper titled ‘Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades’ by Zehnder et al, published online in July 2013. Open access to the paper was kindly provided by the BJUI.

 Zehnder and colleagues undertook a retrospective analysis of the University of Southern California cohort and identified 1488 patients with muscle invasive bladder cancer who underwent radical cystectomy and extended pelvic lymph node dissection between 1998 and 2005. They also included 190 patients from the University of Bern cohort to determine outcomes in patients with clinical N0 disease who were upstaged on pathology to node positive disease. Analysis, performed based on decade of intervention, showed no significant difference in overall survival (OS) or recurrence free survival (RFS) over the three decades. 10-year RFS was 78-80% for organ confined, lymph node negative, 53-60% in locally advanced, LN –ve and 30% in LN positive patients.

 

 

Firstly, it has certainly been suggested that the overall survival and cancer free survival outcomes are not as good in broader population based studies (Ontario Cancer Registry). Why?

 

 

 

 

Analysis of the SEER database has shown that cancer specific survival and overall mortality has not improved for any clinical stage of bladder cancer and in fact suggests that the incidence is increasing in the United States.

 

 

And of course, we must always look at the study design and determine whether the outcomes are reflective of the patient populations that we see in practice.

 


 

The roles of neo- and adjuvant chemotherapy were discussed at length. Only 6% of patients received neoadjuvant chemotherapy, with worse OS and RFS in multivariate analysis. The use of adjuvant chemotherapy actually almost doubled from the 80’s to 90’s, stable in the 00’s at 29%.

 

  

 

 

 

 

 

If neoadjuvant chemotherapy is so widely recommended, why has its use failed to take off?

 

 

 

 

 

 

 

Jim Catto suggested an excellent clinical pathway for the implementation of neoadjuvant chemotherapy.

If indeed bladder cancer is the poor cousin of prostate cancer, why has progress stagnated and what can we change?

 

 

 

 

 

 

 

 

 

 

So what are my humble take home messages from the discussion surrounding this month’s #urojc paper?

  1. Current data suggests that we have made no significant progress in bladder cancer outcomes over the past 30 years
  2. Early referral and diagnosis coupled with timely intervention key; be wary of progression in context of high grade NMIBC
  3. Both surgeon volume and hospital volume are thought to be independent predictors of overall survival. Patie nts do best at a high volume facility under the care of a high-volume Uro-oncologist in a multidisciplinary context
  4. Neoadjuvant chemotherapy, despite randomized controlled trial evidence in favour of its use, has poor uptake in a real world setting. Advances in dense dose regimens (MVAC and Phase III GC underway) with resultant improvement in progression free survival, lower toxicity profile and fewer dose delays make for an attractive partner to radical cystectomy and extended pelvic lymph node dissection.

To finish with the words of the self-proclaimed Urology King of Twitter, Dr Ben Davies:

 

 

 

Winner of the best tweet prize for July’s #urojc was Mike Leveridge from Queens University, Canada – he was certainly a little frustrated with the apparent lack of progress we have made. The July #urojc Best Tweet Prize was kindly supported by the Nature Journal “Prostate Cancer Prostatic Diseases” which is edited by Dr Stephen Freedland and will be a complimentary 12 month online access to the journal.

 

 

 

 

 

 

Do join us for the August #urojc which commences on Sunday 4th/Monday 5th depending on your time zone.

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

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Editorial: Botulinum toxin-A for overactive bladder: formulations, dosing and clean intermittent catheterisation

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The article by Ravindra et al., in this issue of the BJUI, tries to address an important question of comparing the 2 commonest types of botulinum toxin-A (BTX-A), Ona- and AbobotulinumtoxinA. In their institution they changed from OnbotulinumtoxinA to AbobotulinumtoxinA and thus compared results of their different case series for patients with overactive bladder syndrome. Very few studies have tried to address this issue for botulinum toxin-A use in the urinary tract and to my knowledge there are no head to head studies. The authors found the 2 types of BTX-A equivalent in terms of voiding diary parameters, ICIQ questionnaires, patient reported global satisfaction and duration of effect but noted a significant difference for clean intermittent self catheterisation (CISC) rates (23% OnabotulinutoxinA vs 42% AbobotulinumtoxinA). The dose used for OnabotuliumtoxinA was 200 IU and for AbobotulinumtoxinA was 500 IU initially and then later 300 IU. One must bear in mind some important considerations which limit the impact of the result. Namely the non-randomised, retrospective nature of the study and the fact that the study was not designed or powered to assess the BTX-A formulations in this way. The primary endpoint in this case was a patient reported satisfaction measure indicating that 85% had ‘better’ or ‘much better’ symptoms which I think is a fair reflection in my experience. Furthermore there were significant gaps in data acquisition particularly for voiding diary, PVR and ICIQ data which again is not that uncommon in retrospective studies. No urodynamic data was included which I think may also have been interesting to look at when assessing outcomes and CISC rates.

None the less the study generates some interesting discussion about the formulations, optimal dosing and the dosing equivalence. The study is one of the first to report on the use of AbobotulinumtoxinA at 300 IU as most studies utilised 500 IU. In view of the move to lower doses of OnabotulinumtoxinA to treat refractory OAB of 100–150 IU, this dose seems appropriate. Evidence from a large dose ranging RCT using OnabotulinumtoxinA suggests no further efficacy beyond doses of 150 IU but an increase in voiding dysfunction. Interestingly CISC rates are still high at 300 IU in this study. A recent systematic review tried to assess the 2 formulations in aspects of BTX-A use for various lower urinary tract dysfunction. Due to the heterogenousity of the studies, a lack of standardised or high quality data a direct comparison between the 2 was not formally possible. It was noted that OnabotulinumtoxinA has been studied more extensively compared to AbobotulinumtoxinA and with both formulations CISC rates could be high at the doses used in this study (OnabotulinumtoxinA 43%; AbobotulinumtoxinA 35%). Assessing the compound muscle action potential of the extensor digitorum brevis muscle in healthy volunteers has suggested an AbobotulinumtoxinA to OnabotulinumtoxinA ratio of 1.57:1 (95% confidence interval: 0.77–3.20 units) with the data indicating that a dose-equivalence ratio of 3:1 was just within statistical error limits but ratios over 3:1 were too high. The same author following a review of the literature in treatments outside the urinary tract suggest a ratio of 2–2.5:1 maybe the most appropriate. An animal model of spinal cord injury and neurogenic detrusor overactivity to compare the 2 formulations has recently been published. The minimal effective dose of Abo- and OnabotulinumtoxinA was found to be 10 IU and 7.5 IU, respectively, for significant changes in cystometry.

When should CISC be instigated? Practice seems to vary considerably and thus results difficult to compare. Many clinicians will base CISC decisions on a cut off, typically 100–200 mL or on whether patients are symptomatic with their PVR. Chapple has suggested >40% of the functional capacity as a significant PVR and this to me seems entirely logical. Future studies should consider this as an endpoint regarding CISC.

At present, the decision as to which formulation is used in clinical practice is often based on local pharmacy regulation and financial considerations. Licensing is undoubtedly going to have a significant influence on this practice. OnabotulinumtoxinA is now licensed for use in many parts of the world to treat neurogenic detrsuor overactivity and has recently been approved by the FDA in the USA to treat refractory OAB. At the time of writing this editorial, no formulation is currently approved for refractory OAB in the UK.

Arun Sahai
Consultant Urologist & Honorary Senior Lecturer, Department of Urology, Guy’s Hospital MRC Centre for Transplantation, King’s College London, King’s Health Partners

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Thriving & Surviving As A First Year Consultant

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“You never have a second chance to make a first impression.” 

How you initially come across to your colleagues, the nurses and your patients as a newly appointed consultant can set the tone for your consultancy for the rest of your career. Once an opinion (winner or loser) has been formed about you, it is virtually set in stone. It is much too important to leave these things to chance. In your first year you will either sink, float or swim!

 ‘Thriving and Surviving as a new consultant’ [1] is a course by The Urology Foundation (TUF) specifically designed to help consultants at the start of their careers take control of situations and to become good leaders, colleagues and, most importantly, good medics. Good communication and presentation skills are vital to how others perceive and respond to you; fortunately these can be learned and developed. More importantly, leaders are not born, they can be made and it is possible to improve and hone your skills and attributes so that you can become a more confident and natural leader.

A good or natural leader always features a strong resume. a robust resume not only emphasis an excellent impression on the interviewer but also step up your confidence. the primary and most vital factor that contributes to obtaining an honest job is that the resume. Building knowledgeable resume that stands call at the gang can sometimes end up to be an intimidating, confusing and stressful task. But, with the advancement in technology building knowledgeable resume has become quite easy.

The resume builder online is one such innovation that has made professional resume building easy, efficient and fewer stressful. The professional resume builder saves tons of quality time which may be utilized for other purposes like gaining education or developing skills. you only got to fill within the details within the appropriate fields mentioned within the resume template online and knowledgeable resume is produced in minutes.

Last weekend,  a number of newly, or about to be appointed, consultants attended an interactive two-day course in Leeds where subjects such as team building and development were discussed. “The team” was considered to be the colleagues, managers, nurses and other healthcare professionals involved in the urological care of patients. We discussed and debated how we could create the “Manchester United” department of urology, delivering the best possible in patient treatment and care.

A new consultant shouldn’t try to change too much at first, but instead carefully assess and evaluate the lie of the land. Learning about the department, associated departments and the hospital itself takes time and trouble. It is good though to have at least five SMART (Specific, Measurable, Achievable, Realistic and Time-constrained) goals to be achieved within the first year of his or her appointment. But what should these be? Do let us know.

The medical defence organisations recognise that the first year of a consultant’s career is one of exceptionally high risk for complaints and litigation. We focused therefore on avoiding pitfalls, dealing with complications, and responding to complaints and serious untoward incidents (SUOs).

Navigating your way though the dangerous waters of your first year as a consultant can be a very tricky business. We would love to hear about your experiences in that situation, or, if you attended the course, what you thought of it and how we could do it better.

Roger Kirby, The Prostate Centre, London

Louise de Winter, Chief Executive, The Urology Foundation

[1] The course was made possible by an Educational Grant from Takeda UK Ltd. Takeda had no involvement in the content of organisation of the meeting.

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Why I care about social media – and why you should too

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I was born in the ‘Eighties’. I was a teenager when the Internet first became accessible to the general public and a medical student when Facebook was launched in 2004. It seems improbable and surreal that my time spent ‘liking’ and ‘poking’ Facebook posts from college acquaintances would someday be of any use to my career and research. Indeed, ‘I was there’ at the very beginnings of social media, but I had little idea of what it would become.

The social media revolution started in the early millennium, with the emergence of blogs: microsites consisting of topical entries usually displayed in reverse chronological order. Blogs, such as Deadspin or Gizmodo, became pillars of the new era, breaking news at an unprecedented pace and gaining millions of page views by the second. Meanwhile, the print media were slow to adopt a digital strategy, often branding the aforementioned websites as ‘hacks’ or ‘teenagers with a lack of journalistic integrity’. Almost simultaneously, a website called Wikipedia was launched on 15 January 2001 by Jimmy Wales and Larry Sanger, a ‘social’ alternative to bulky reference books, such as the Encyclopaedia Britannica. Fleetingly, Wikipedia rose to fame and grew at an exponential rate, drawing along a significant chunk of web traffic. It caught idlers with such haste that some felt the need to ban the website from classrooms. Oh my, have things changed. In September 2010, Arthur Sulzberger Jr, Chairman and publisher of The New York Times, announced that the prestigious journal would cease to exist in print, sometime in the not-so-far future. In related news, the Chicago-based company behind the Britannica announced that it would stop printing the revered reference encyclopaedia after >200 years in press.

The adoption of new technology in any and every field follows a simple bell curve, as described in a sociological model by Joe Bohlen et al. at Iowa State University. The hypothesis indicates that the first group of individuals to use a new product is called ‘innovators’, followed by ‘early adopters’. The early and late majorities follow these, and the last group to ultimately adopt a product is called ‘laggards’. ‘Medicine’ as a collective crowd is usually the laggard. On one hand, it is reasonable and understandable that a field with such enormous responsibilities be as meticulous and practical in the process of adopting new drugs, technologies or paradigms. It is entirely within the realm of comprehension that a new drug must succeed at many stages of testing to show unequivocal safety and efficacy before being accepted into medical practice. Yet, on the other hand, most would safely agree that institution, tradition and dogma dominate the world of medicine, and most notoriously in surgical sub-specialties. Not unlike our most recent history in adopting robotic surgery, met initially with ferocious and apocalyptic discontent, many contemporary leaders in our field display excessive scepticism towards social media, even when its dissemination is widespread through all echelons of society. In an era where wars and revolutions are being fought over Twitter, and where the likelihood of experiencing an influenza pandemic can be accurately predicted based on relevant social media buzz, I am not sure what doctors are waiting for to accept social media for what it is – an inevitable revolution in how we communicate.

As many of you ponder whether or not to embrace social media, there is good evidence that medicine has finally absorbed the latest innovation. I could cite many factual titbits to demonstrate that this is in fact true. I could provide propensity-matched-instrumental-variable-adjusted analyses to show its benefits. Yet, wise men once said that stories, not statistics, drive change: here are some stories of how social media has already transformed our field.

The ‘uro-twitterverse’ is now a rich and engaging planet of its own. Since November 2012, >100, I am not making the numbers up, users engage in a monthly Urology journal club on Twitter, enhanced by the presence of the lead investigator of the study open for discussion. Even the most prestigious of first-tier Ivy League institutions would not be able to attract lead authors to attend every single journal club, even less to convince a pool of key opinion leaders from around the world to comment and critique these studies.

Every day, I know that I can turn to my fellow ‘Twitterati’ to ask a hard clinical question. Should I perform a lymph node dissection in this patient with prostate cancer? What is the value of positron-emission tomography-CT to assess recurrence in a patient with bladder cancer? What is the recommended evaluation for a patient with suspected interstitial cystitis? Across 24 standard time zones, I know that an answer is a couple of seconds away. Somewhere in the world, a knowledgeable authority is answering my tweet, either while reading the morning news at breakfast, between two major cases in the operating theatre, or checking the Internet right before going to sleep. Having Twitter on my smartphone is a click away from being at a grand rounds talk, with everyone – from Benjamin Davies to Stacy Loeb – in attendance.

Every year, physicians travel thousands of miles to attend medical conferences. Many academics converge at these meetings with the hope of building relationships with potential collaborators. Twitter has brought the academic world under a single digital roof. Most of my research collaborators are on Twitter. I exchange direct messages with them every day to discuss research, grant and collaborative opportunities. I met several of my peers and collaborators on Twitter before actually gathering in person. In fact, many have questioned the need for so-called ‘formal’ medical conferences in the new digital era. While I am not ready to cancel my annual trip to the AUA and the European Association of Urology meetings – especially when they are being held at exotic destinations, such as San Diego and Milan, these social phenomena suggest that change is inevitable.

As much as we like the world we are accustomed to living in, there is little doubt that scientific journals, professional societies, and medical institutions need to adapt to this growing revolution. And, as regrettably experienced by traditional portals, e.g. the print media, those who do not will struggle to remain relevant. Of course, there are caveats to social media. How do we set boundaries between patient care and personal endeavours? Regardless of these issues, society has dreamt forever of the open and free opportunities provided by social media. The world cannot wait.

At BJUI, we are using social media, especially Twitter and Facebook, to highlight the most important international studies published in the journal, e.g. July’s ‘Article of the Month’ from Taiwan comparing tract creation using plasma vaporization with balloon dilatation in percutaneous nephrolithotomy.

Quoc-Dien Trinh
BJUI Associate Editor Health Services Research,
Department of Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.

 

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A benedictory ode to urological live surgery

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This blog was originally published as a comment article in BJU International, 112: 11–12. doi: 10.1111/j.1464-410X.2012.11780.x

 

With the explosion and expansion of information technology, instantaneous dissemination of medical knowledge across the globe is a reality and here to stay. Performing live surgery to an audience, whether to the medical community or to the general public, has raised much controversy and continues to be hotly debated even today. While a recent article by a very senior urologist concentrated on the drawbacks of live surgery, little was written about the benefits [1]. We begin our debate with this ‘Benedictory Ode’ to live surgery:

Came the news about cancer of the prostate
Surgery, radiation or I had to be castrate
I was won over by the argument of the daVinci Robot
Surgical smile assured me protection of the lover’s knot
I was asked to be a patient for live surgery
I thought to myself, is it a circus or butchery?
Should I be scared, Should I be excited?
But was convinced many will be benefitted
My choice was voluntary and informed
Consent on the dotted line was performed
The day came and the day went
Surgery was smooth without a dent
Some might argue that I was a damn fool
But I am proud to have been an educational tool

Anonymous Patient

When did ‘live surgery’ really begin? Probably the answer would be as early as the birth of medicine itself. Medicine and surgery as we know them today have been based upon the ‘teacher–apprentice’ model for centuries. Whenever the ‘teacher’ became famous, apprentices from surrounding towns, and subsequently from surrounding countries, would flock to watch the way a diagnosis was made or indeed how the surgery was performed. In historical documents from the Middle Ages through to the Renaissance, we are reminded of the amphitheatre that was built especially to demonstrate anatomical dissections and surgeries. Indeed the very origin of the term ‘operating theatre’ probably stems from the fact that operations were carried out to an audience in a theatrical manner, as beautifully portrayed in many medical paintings across the world.

The birth of the first transmission of surgical procedures can be traced back to the famous British Broadcasting Corporation (BBC) series ‘Your Life in Their Hands’. This was first aired in 1958 and eight episodes were then broadcast over the next two months. This innovative series was conceived with three goals: to investigate new medical techniques; to applaud the medical profession; and to provide ‘reassurance’ for citizens at home. At the end of that period, the BBC had received 909 letters from viewers praising the programme and only 37 letters from viewers who were against it [2].

Professor Arthur Smith rightly points out the death of a patient that occurred in 2006 during live surgery organised by The Japanese Society of Thoracic Surgeons [1]; however, we should highlight that the very next year, the Japanese Society for Cardiovascular Surgery, the Japanese Association for Thoracic Surgery and the Japanese Society for Vascular Surgery collaborated in the development of guidelines for performing live surgeries [3]. In their guidelines, they rightly emphasize the need for feedback on the outcome of a patient who has undergone live surgery:

‘When a fixed interval has elapsed after live surgery, the surgeon must report on the postoperative course followed by the patient at an organized Society or research meeting. By this means, the body organizing such a meeting can investigate each of the cases in which live surgery has been conducted, and assesses the appropriateness of the use of live surgery in each.’

Recognizing the need for guidance for physicians and institutions with regard to live surgery, organisations such as the General Medical Council, AUA and the Royal College of Surgeons have published relevant guidelines. In their paper, Challacombe et al. [4] elegantly discuss the various aspects of the ethics of live surgery and highlight the important issues of patient consent and disclosures. We have followed the above guidelines for live robotic surgery to an audience and also to conduct the first live webcast in the UK of a robotic prostatectomy. Contrary to the norm, extra care is taken during live surgeries. Indeed, this may be an advantage for the patient as shown in Table 1. The operating surgeon is always an expert and, in our case, the surgeon was well trained to listen, respond to questions and operate without any hesitation. It is safe to assume that not all surgeons will achieve this high standard in their career. It is also vital to have a moderator who can manage the questions appropriately and convey them to the operating surgeon at the appropriate time.

In the era of evidence-based medicine, no debate can be complete without presenting supporting data from the literature. Several studies across different specialties have looked at the outcomes of patients who have undergone live surgeries. None of the studies showed any adverse outcome in the cohort of patients who subjected themselves to live surgery. Recently, a study analysed the outcomes of patients undergoing robotic partial nephrectomy as a live broadcast as compared with a cohort treated without observers [5]. The authors concluded that live robotic surgery is associated with excellent patient outcomes that compare favourably with cases performed under normal operating procedures. There is further evidence that live surgery as part of a course has a powerful impact on the practice patterns of a urologist [6]. Surprisingly, there is no published evidence in the literature that these patients come to any harm. There are several surveys of surgeons across specialties in the literature with contradictory views on live surgery, but there is no denying that transmission of live surgeries is becoming more and more popular, as evidenced by the packed rooms at all major urological meetings.

Conclusion

Performing live surgery on a patient is here to stay and will be an integral part of the dissemination of medical knowledge. The obligation that the medical society has towards the field of live surgery is to ensure that the operation is performed by the ‘right surgeon on the right patient in a right environment and with the right intentions’.

 

Amrith R. Rao and Omer Karim
Department of Urology, Wexham Park Hospital, Wexham, Berkshire, UK

References

1    Smith A. Urological live surgery – an anathema. BJU Int 2012; 110: 299–300 Full Article (HTML)

2    van Lingen A. Your life in their hands. Published online 27 November 2006. Accessed at https://www.birth-of-tv.org/birth/assetView.do?asset=1413260435_1164637516. Accessed 28 August 2012

3    Misaki T, Takamoto S, Matsuda H, Shigematsu H. Joint Committee for the Establishment of Guidelines for the Live Session of Thoracic and Cardiovascular Surgery. Published August 2007. Available at https://jscvs.umin.ac.jp/eng/live.html. Accessed 28 August 2012

4    Challacombe B, Weston R, Coughlin G, Murphy D, Dasgupta P. Live surgical demonstrations in urology: valuable educational tool or putting patients at risk? BJU Int 2010; 106: 1571–1574 Full Article (HTML)

5    Mullins JK, Borofsky MS, Allaf ME et al. Live Robotic Surgery: are outcomes compromised? Urology 2012; 80: 602–607 Web of Science®

6    Altunrende F, Autorino R, Haber GP et al. Immediate impact of a robotic kidney surgery course on attendees practice patterns. Int J Med Robot. 2011; 7: 165–169. doi: 10.1002/rcs.384 Full Article (HTML)

 

 

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Editorial: PCNL tract creation: think plasma vaporization

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Surgical planning and access are important factors for successful stone-free outcomes in patients undergoing percutaneous nephrolithotomy (PCNL); however, PCNL has a high risk of haemorrhagic complications (reported transfusion rates of up to 12%), which curtail surgery and result in suboptimum outcomes. Access to the pelvicalyceal system remains the major risk for bleeding, often associated with an off-set tract, splitting of the infundibulum/pelvis and/or angulated sheath, and requiring inordinate torque. The ideal tract dilatation method is still being debated, with differing reports on operating time and blood loss (Urol Int 2003, BJU Int 2005, J Endourol 2008, J Endourol 2011).

The present study evaluates a new method for percutaneous renal access, reporting a shorter operating time, a lower drop in haemoglobin levels and a shorter hospital stay, with no patient requiring transfusion. A patient selection bias might exist, which would explain the low complication rate. Also, the vaporization bubbles and the bleeding could result in difficult views, requiring a high level of expertise in plasma vaporization. The authors did not observe peri-nephric space fluid extravasation or dislodging of the single safety wire. Despite the promising outcome, the reproducibility of this technique remains to be seen, but this is a promising account of reducing bleeding and operating times and maintaining better visualization in PCNL.

Joe Philip
Department of Urology, Southmead Hospital, Westbury-on Trym, and University of Bristol, Bristol, UK

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In Defence of Lance…

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As this year’s Tour de France starts and we wonder if Chris Froome can take over from Sir Bradley this blog thinks about previous Tours with some sadness. As an oncologist treating testicular cancer the Tour used to be a reminder of one of the great successes of modern oncology. Seeing Lance Armstrong on the podium showed how chemotherapy can overcome even poor prognosis testicular cancer. Lance was an inspiration to our patients. I doubt there has been a happier sight on the chemotherapy day unit at Guy’s Hospital than seeing the young men cheer Lance as he surged past Jan Ullrich, whilst they were receiving their chemotherapy.

So rather than become too melancholy I thought I would use this blog to provide a little balance to all the stick Lance has been taking. Whilst Lance as a cyclist is tarnished forever, the other aspect of his story seems to have been forgotten. The incredible part is that he overcame such aggressive disease and was able to ride competitively. He should therefore remain an inspiring figure for those of us treating testicular cancer, and more importantly for young men battling this disease. Whilst as oncologists we quote impressive survival figures, for patients an example of someone who has survived is far more tangible.

So I have been re-reading ‘It’s not about the bike’ (how ironic that title seems now!). The chapters dealing with diagnosis, treatment and recovery are informative and remain inspiring. It’s easy to see why it became and could still be a touchstone for young men battling testicular cancer.

Whilst many will argue that Armstrong’s well publicised battle against cancer was just part of his ego let’s not forget that it takes guts in the macho world of professional sport to admit illness and potential weakness. Many famous men have been affected by cancer but all too often don’t feel able to talk about it or use their position in a positive way. Armstrong was the polar opposite, happy to provide inspiration and also to raise millions for his cancer charity. He also raised the profile of testicular cancer and the need for ongoing research and there remain many important unanswered questions in this disease:

  • Who need’s adjuvant treatment?
  • What adjuvant treatment should we give?
  • How to minimise toxicity of treatment?
  • Long term toxicity and survivorship issues
  • Why are some patients’ cisplatin insensitive?
  • The role of RPLND and metastatectomy
  • The best second line chemotherapy
  • And many others…..

TUF Cycling Across the Andes: More intrepid cyclists supporting research into urological cancers. For more information visit www.theurologyfoundation.org or www.actionforcharity.co.uk.

So as this year’s Tour de France winds its’ way towards those punishing Alpine stages perhaps we should draw a line and move back to Armstrong as the inspiration for the next generation of men with testicular cancer. I for one will always enjoy that ascent on Alpe D’Huez and how it shows we can over come even the worst disease. So Lance your boys still need you! It’s time to eat a very large slice of humble pie and rewrite the book, warts and all, so that you can be an inspiration to the next generation of men with testicular cancer.

Simon Chowdhury is a Consultant Medical Oncologist at Guy’s, King’s and St Thomas’ Hospitals, London. He is actively involved in clinical trial research into urological cancers.

 

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Canadian Urological Association annual meeting at Niagara Falls

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The Canadian Urological Association held its annual meeting in the city of Niagara Falls, Ontario from June 22-25, 2013. Traditionally this meeting signals the start of summer in Canada and after a prolonged cool and wet spring the hot weather arrived as everyone convened. The central location in our vast country assured that the meeting was well attended with attendance far exceeding expectations. Even though I probably have seen this place two dozen times since childhood the physical spectacle of this natural wonder of the world never fails to awe.

Even renewing acquaintances with the venerable old Maid of the Mist after many years provided a memorable experience.

The meeting started on Saturday and as with other international societies, many specialty sections held their meeting on this day. These included the Canadian Urological Oncology Group (CUOG) as well as the Canadian Endourological Group (CEG). A Multi-Disciplinary Collaborative meeting for Genitourinary Cancers also took place. Canadian urology has long enjoyed a fruitful and respectful relationship with our radiation and medical oncology colleagues. The featured speaker of CEG was Dr. Brian Matlaga from @brady_urology who spoke about the role of technology assessment and health economics and how they will intersect to alter care in the treatment of urolithiasis over the next decade. I suspect the same debate will occur in many other domains of our specialty. The first of many Educational Forums also began on Saturday with a review of the management of castrate-resistant prostate cancer.

Sunday served as the formal start to the meeting with the first plenary sessions and a number of abstracts presented. Dr. Patrick Walsh from Hopkins was the keynote speaker to start things off and gave an outstanding evidence-based review as well as personal account of where we are in prostate cancer care and how we can work to improve things.

Day 1 ended with the annual CUA fun night. The CUA annual meeting has always enjoyed a reputation for being a very social meeting. Our country is relatively small and the urological community is well connected. While everyone took advantage of walking behind the falls in tunnels within the Niagara Escarpment the highlight of the night was the debut of the band “The Void”. Six talented urologists from across the country held court and provided a very high-calibre performance to the delight of everyone. They have been hired back for #cua14 in St Johns Newfoundland and I suspect will offer a member’s discount.

Monday June 24 brought more great abstracts and vigorous discussion. A major highlight for me was an outstanding talk given by @Robert_Uzzo of @FCCCUroOncology on the management of renal cell carcinoma in the elderly. It was a tour-de-force that was in large part philosophical discussion on managing risk and probability in clinical decision-making supported with good evidence. It was a talk that could easily be applied to most of what we do as urologists.

Dr. Andrew Macneilly the long-time program director at the University of British Columbia gave the CUA Scholars Fund address that surveyed training of residents and implications in a future environment where job prospects may be tight and where concerns about whether we have adequate volumes to teach operative skills will continue to grow.

As with the AUA and EAU the Canadian Urological Association has a well-established set of guidelines. New guidelines approved at this meeting include:

1. Management of Castrate Resistant Prostate Cancer
2. Postoperative Surveillance of Upper Urinary Tract Urothelial Carcinoma
3. Management of the Small Renal Mass

The President’s dinner on Monday night was very well attended. Dr. Klotz teamed up with half of the other member of The Void as well as Dr. Andrew Hussy from Stratford, Ontario to form a proficient jazz quartet. Four CUA Scholars Awards were given that night. Congratulations to Dr. Robert Hamilton of University of Toronto, Dr. Geoff Gotto from the University of Calgary, Dr. Lysanne Campeau from McGill University and Dr. Andrew Fiefer aka @urologymd1, also of the University of Toronto. The major disappointment of the night for me personally was the late collapse in the Stanley Cup Finals of my beloved Boston Bruins.

The final day brought with it more great educational forums and abstract presentations. A highlight for me was an address given by Dr. James Orbinski, the co-founder of Dignitas International and former president of Medicins Sans Frontieres. It was a brilliant overview on humanitarianism, global health and our role as urologists and citizens of the developed world. I think we have a strong obligation to promote these themes in our specialty.

Finally #cua13 was the year that the use of Social Media arrived in full force at the CUA.

A twitter board was set up in the main meeting hall to provide a real-time update of the conversation.

A good WIFI connection, which has been an issue at other recent meetings, served everyone very well. With a growing number of Canadian urologists now on twitter (joining early adopters including @_theurologist_, @urooncmd, @qdtrinh and myself). As these analytics show, 78 people participated via twitter during the actual meeting.

Many international colleagues joined in and @mattbultitude even made the top 10 from across the pond.

This form of communication has greatly enhanced our ability to connect and exchange ideas with colleagues from around the world. All urologists would be well advised to explore this technology. A nice primer with a Canadian perspective by @cmaer on the use of social media and twitter for physicians can be found here. At the recent #USANZ13 meeting use of Social Media for Urology was part of the scientific agenda as this presentation by @declangmurphy illustrates. I would like to see the number of participants at #cua14 surpass 200!

Of course living in Toronto made leaving on Tuesday from Niagara Falls about as easy an escape as one can make from any meeting. As we approach summer (at least in the Northern Hemisphere) I wish everyone a safe and restful time and look forward to continuing to engage with colleagues over the next year.

Dr Rajiv K Singal is a Urologist at Toronto East General Hospital and Assistant Professor in the Department of Surgery at the University of Toronto.
Follow him on Twitter @DrRKSingal

 

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Editorial: Laparoscopic and robotic approach to staging nodes in penile cancer

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In recent years, efforts to reduce morbidity from lymphadenectomy for penile cancer were based on surgical procedures to reduce the area of lymph node dissection. The proposition of extensive video-endoscopic inguinal lymphadenectomy, a technique still experimental, is to reduce the morbidity of conventional surgery without affecting the maximum chance of oncological control of locoregional disease. Therefore the initiative of using the help of a robot to facilitate the implementation of this procedure is very welcome.

The authors present an excellent study on their initial experience with robotic assisted video-endoscopic inguinal lymphadenectomy (RAVEIL). I understand that for better comparison of the dissection area with open surgery these authors have opted to use an additional incision in the inguinal fold. However this area is the least vascularized area of the field of dissection because the lymph nodes are resected above and below this additional incision. It would be better to make an incision at the upper limit of the dissection. This approach was used in open surgery with low complication rates. The rate of necrosis (10%) and wound breakdown (10%) seems high for a minimally invasive approach. Possibly, when no additional incision is used to complement the procedure these rates will become lower.

Antonio A. Ornellas
Hospital Mario Kröeff, RJ, Brazil, and Department of Urology, Brazilian National Cancer Institute, RJ, Brazil

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