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Social media as a conduit for resolving surgical challenges

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Wikipedia defines social media as a means of interactions among people in which they create, share, and exchange information and ideas in virtual communities and networks.

In 1965 Moore’s law stated that the volume required for a memory chip or processor would decrease by 50% every 18 months. This predicted exponential development rate has continued for the last 50 years and can be most visibly seen in everyday items such as smart phones or digital cameras. Whilst there is no clear explanation for this phenomenon it is most often attributed to the way in which ideas and technological breakthroughs are replicated throughout the industry and also transferable to different applications. It is the access to others’ knowledge that results in the rapid improvements.

We have recently had a paper accepted looking at Karolinska’s first 113 totally intracorporeal robotic cystectomies. Part of the published data is their complications and this includes a table of common complications with suggested solutions to avoid them. For example, when the results were analysed we found that 1 in 5 intracorporeal ileal conduits showed evidence of urinary leakage from the anastomoses. On reflection it was felt that this was probably due to the stoma spout being created after the undocking of the robot and that the anastomoses was put under too much tension. This part of the procedure had effectively been done blind. Their solution was to put the camera through one of the lateral ports when they pulled out the conduit through the stoma site, so that they could avoid rotation of the mesentery and tension on the anastomoses.

This was their experience and their insight and will not be the same as other series. But what if we created a table that surgeons shared and exchanged different insights into their more common or more severe complications, could we avoid making the same mistakes in our learning curves and improve our outcomes?

Consider the last time you were faced with a likely technical challenge during an upcoming case. Would it not be good to counsel the advice of a wider audience as you planned a robotic radical prostatectomy for a 200cc prostate and you worried about how to get the bladder down for a tension-free, watertight anastomosis? Sometimes small nuances of surgical technique do not get print space in the established surgical atlases or peer-review publications of surgical technique. Anecdote-based advice is sometimes essential to get through difficult cases, which is why it’s good to have a senior mentor available for advice as your own surgical experience develops.

But perhaps this is where the rapidity of communication and online archive in social media may have a role to play. Have we as a profession missed a trick in the directive to publish our results and our complications rates when we should be publishing and sharing our solutions to the complications? Could a blog of surgical tips and tricks for certain procedures provide a repository of surgical knowledge that others could both use and add to in a Wikipedia-style?

I hope we can utilise this blog to document our experiences of difficulties in robotic surgery with accompanying tips and tricks on how to avoid them. If we get enough then we could do something rather old fashioned, such as publishing them together in a table in a journal! Do leave a comment and let the world know what you think.

Justin Collins is a Consultant Urologist at Ashford and St Peters NHS Foundation Trust, UK and is a regular trainer on the faculty at IRCAD, Strasbourg, France. @4urology

 

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Think Twice About Operating on Fridays and Weekends and Stick to Golf Instead

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I recall participating many elective major procedures on Friday nights and Saturday mornings during my residency training, thinking to myself that not only should I be home, but this just can’t be good for the patient…can it? Well, apparently not.

A new population-based study by Aylin et al. published in the British Medical Journal suggests that patients undergoing surgery on Fridays and weekends have significantly higher of both 2-day perioperative mortality as well as 30-day mortality. Utilizing the robust information provided by the English National Health Service (NHS), the authors analyzed over 4 million elective cases performed in England from 2008-2011 and found a crude mortality rate of 6.7 per 1000 cases. While overall mortality seems low, after adjusting for confounding variables the authors found a stunning 44% and 82% statistically significant increase in 30-day mortality if an elective procedure was performed on a Friday or weekend compared to Monday, respectively. When analyzing 2-day mortality, the authors found a whopping 167% increase in mortality on a weekend compared with Monday.

A “weekend effect” has been proposed in prior studies, however these studies for the most part analyzed emergency admissions and included emergency surgeries on patients that were likely to be much sicker than the average patient. What makes this paper different, and thus more significant, is that it only analyzed elective procedures and is the first paper to suggest that with each successive weekday, patients are at increased risk of mortality, culminating with the highest risk on Fridays.

Data on urologic cases within this study remain unknown, as urologic procedures were not selected for sub-analysis. However, overall analysis included all elective procedures, which must have included high-risk urologic procedures such as cystectomy, nephrectomy, partial nephrectomy, prostatectomy, RPLND, and endourologic procedures on infected stones. Therefore, this data should still have relevance for urologists performing such high-risk procedures.

Why is this happening? We know that major complications from elective surgeries happen within the first 48 hours postoperatively (Cavaliere F, et al.). Therefore, patients that have surgery on Friday or over the weekend are at their most vulnerable when the hospital is most short staffed. Additionally, there has been concern that the more junior faculty and trainees bear the majority of weekend coverage, and are therefore most often the primary points of care over weekends, leading to potential failure to rescue due to inexperience. Finally, there is the issue of cross coverage and dialogue between hospital staff during the week and the weekends. How much can a covering physician truly learn about a potentially complicated patient from a simple sign-out?

More importantly, what can we do? Ideally, major cases should be scheduled earlier in the week to allow the patients to have care while all hospital staff are available during the remaining week or so of recovery. Endoscopic and same-day procedures should be scheduled later in the week. However, is this realistically possible? OR time can often come at a premium and is difficult to come by in some busy hospitals, especially for junior faculty. Therefore, such a change would have to come from the top hospital administrators and likely would meet resistance from more senior faculty.

When asked by The Guardian regarding these results, Sir Bruce Keogh, cardiac surgeon and director of the NHS, downplayed the results, stating that when he performed open heart surgeries he would often intentionally operate on patients later in the week to get more time in the ICU over the weekend. With all due respect to Sir Keogh, I just do not see the logic in this approach, and feel we should take these results more seriously rather than downplay them. The data presented by Aylin et al. seems pretty convincing to me: while overall mortality is low, patients getting surgery later in the week and on weekends are getting inferior care leading to inferior outcomes. We need to acknowledge this data, not ignore it or diminish it, and come up with some kind of reasonable and fair solution to the problem.

What say you, Urology community? If any field can come up with a solution, it’s us. Somehow, we need a system that allows all surgeons, young and old, to perform higher risk surgeries earlier in the week to prevent potential complications happening under the watch of an undermanned, inexperienced hospital staff over the weekend. In the meantime, I will try to use my free weekends for spending time with my wife, golf, and watching sports while trying my hardest to perform major surgery earlier in the week. Not only will this please my wife, it will likely improve the care of my patients.

Keith J. Kowalczyk, MD
Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA. @KeithKow

 

 

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Editorial: A promising solution for biofilm inhibition in the bladder, but is the application of wireless capsule cystoscopy practical?

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The study by Neheman et al. follows up on an idea first proposed in 2009 by Gettman and Swain to adapt wireless capsule endoscopy (WCE) technology for cystoscopy. Unlike the gastrointestinal tract where the small bowel is not endoscopically accessible making WCE appealing and advantageous, the idea of wireless capsule cystoscopy (WCC) competes with a minor procedure, office cystoscopy, that does not require anaesthesia or sedation and takes only a few minutes to perform. Furthermore, although the authors suggest that WCC would shift the labour associated with bladder cancer monitoring from practising urologists to ancillary health team providers, flexible office cystoscopy is a procedure already routinely performed by physician extenders in many offices. Nevertheless, the concept proposed by Neheman et al. is innovative and intriguing. The potential advantage of a wireless capsule cystoscope placed in the bladder safely for up to a 2-year time period, and thereby reducing the inconvenience and cost of repeated cystoscopies, could be a significant advance.

It should be emphasized that despite the title, no WCE was actually performed. The real value to the present study is the novel anti-biofilm mechanism developed that would be needed for any device implanted in the bladder for the long term. The device was housed in a semi-permeable silicone balloon filled with mineral oil that allowed a continuous slow diffusion of oil across the membrane. Based on the evidence provided in only one animal, it seems this continuous permeation of oil can interfere with surface protein adherence and consequently bacteria adhesion and biofilm creation. Certainly, this concept needs to be tested further in additional animals, aggressively exposed to bacteria, and for longer periods.

Although I am unconvinced that the concept of WCC provides significant value, the development of this biofilm inhibition technique could be pioneering. I read this study and wondered if ureteric stents and Foley catheters could be designed and impregnated with mineral oil to be released gradually. Perhaps the balloon of a Foley catheter could be redesigned and filled with mineral oil that is then released along the catheter’s entire length in a similar fashion. The true Holy Grail is the prevention of encrustation and biofilm formation on these relatively mundane devices whose chronic exchange for many patients is more costly than bladder cancer surveillance. I look forward to additional work from the authors exploring the potential of this technology.

Jeffrey A. Cadeddu
Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA

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Social media @BJUIjournal – what a start!

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When Prokar Dasgupta assumed the role of new Editor-in-Chief of the BJUI in January 2013, he outlined his vision and some of the major changes that the Journal would make as it transitioned to a new editorial team. After 10 years of progress under John Fitzpatrick, it was clear that we are now working in a much-changed publishing landscape, one which will change even more in the next few years. In particular, the way in which medical professionals receive information and interact with colleagues, patients, journals and other professional groups is unrecognisable from what it was just 2 or 3 years ago.

Social media is the driver of much of this change. It has transformed the way in which the current generation of trainees interact—Facebook, Twitter, YouTube, LinkedIn, Urban Spoon, Expedia, Trip Advisor, Instagram – all of these platforms are key conduits for how Generation Z experiences life. This generation will find the idea of a printed journal arriving in the post every month to be anathema. In a world with an ever-increasing amount of content being produced, and much competition for our limited attention span, Gen Z live their lives through mobile platforms capable of delivering the precise content they want, immediately to their devices. Not just that, this content, whether that be breaking news via Twitter, friend status updates on Facebook, job opportunities via LinkedIn, is delivered through vibrant media that allows them to engage and respond by liking, sharing, favourite-ing, re-tweeting and commenting, even as the content reaches them. All of this activity is done through convenient and increasingly pervasive mobile platforms while on the train to work, while queuing for a coffee, between cases in theatre, during a lecture, first thing in the morning, last thing at night. Gen Z will not seek out this type of content – it will seek them out and be delivered straight to their timeline/twitter-feed.

The BJUI is the first surgical journal to introduce an Associate Editor for Social Media. The aim is to devise and implement a strategy to ensure that the BJUI evolves in this new world; to ensure that the next generation of trainees find us a meaningful organisation to engage with and be informed, educated and entertained by. Our fellow Associate Editor, Matt Bultitude (Web) plays an important role here as do our publishers, our Executive team and Editor-in-Chief.

 

Our social media platforms

So what have we done? If you are on Twitter or Facebook you will have noticed that BJUI has come to life on these key social media platforms.

Between January and April 2013, our followers on Twitter have grown from by one third to over 1300, and continue to grow at over 100 followers per month. Through Twitter alone, we have generated huge traffic back to our website with over 3500 link clicks from the hundreds of interactions we have had during this period.

 

 

Advanced social media metrics allow us to measure all of this activity against other organisations active in urology. For example our Klout score has increased from 46 to 55 with a corresponding increase in our Peerindex rating. We are leading the field across all of the key domains we have targeted to date and continue to make progress as we introduce further changes at www.bjui.org in 2013.

Our Facebook site is now highly engaging and is constantly updated with news and content from our website.

 

 

We have recorded over 133 000 page impressions by 23 000 Facebook visitors in the first 3 months of 2013, a huge rise from previously, and all of this traffic gets directed back to content at www.bjui.org, whether that be a Journal article, blog, picture quiz or our new ‘Poll of the Week’.

 

 

Our YouTube site is updated with videos from authors and other multimedia content to complement citable articles published in the Journal. You will see a lot more content added here in coming months.

 

Blogs@BJUI

But perhaps the most talked-about area we have introduced is Blogs@BJUI. And although we are the first mainstream urology journal to introduce a blog site, other journals have done so with great success. In September, we visited the social media team at the BMJ to get some tips on how they had developed their social media strategy into the very successful multi-platform spectacular, which they now oversee. Juliet Dobson, Blogs Editor and Assistant Web Editor at the BMJ offered some excellent advice to help us get up and running and their former Editor, Richard Smith, remains one of the bloggers we most admire. BMJ Blogs is well worth a visit for aspiring bloggers to read some of the best.

We launched our new web journal on the 2 January 2013 to coincide with the new Editor taking the helm, and also published our first blog that day. From then until April 2013, Blogs@BJUI has featured the following:

  • 51 blogs contributed by 25 authors on three continents
  • 193 comments from all over the world, including opinion from some household names in academic urology
  • 16 editorial blogs from our specialty Associate Editors
  • 4 blogs from major urology conferences
  • Multidisciplinary contributions from both authors and comment-leavers

The topics have included everything from urology humour, through the European Working Time Directive, reality TV and an eminent urologist describing his recent personal experience of robotic radical prostatectomy. Our contributors have included many of the key opinion leaders in social media in urology, many of whom are rising stars or already established in academic urology. Also established urology opinion-leaders who are rather new to social media but enjoying the challenge! Other contributors are young trainees who have proved themselves to be talented bloggers already. Blogs@BJUI has been highly successful at driving traffic to the Article of the Week as improving quality remains our main objective.

Also of note is the impact that social media has made at urology conferences in the past few months. As part of a planned strategy, the BJUI social media team has been very active posting updates on Twitter, Facebook and YouTube from major urology conferences, thereby increasing the reach of these meetings to a much larger audience and also allowing those following on social media to engage pro-actively with the conference. This has been a very successful strategy; social media metrics confirm that the BJUI team has been leading the social media revolution at this year’s Annual European Association of Urology (EAU) Congress:

 

 

We had set a target that by the end of the first quarter we would have 1000 readers per month visiting Blogs@BJUI. By the end of the February, we had already had over 9000 visits to our blog site! Each reader spent over 3.5 min reading the web journal and many of them left comments or pushed out links using Twitter or Facebook. We have had many comments posted by readers from every corner of the world and have enjoyed some very humorous posts. For us, social media is all about engagement. We want to use these platforms to allow readers to passively engage with us by liking, sharing, tweeting content that they enjoy whether that is a full paper in the BJUI, a blog post, YouTube video, weekly poll or Picture Quiz of the Week. And for those who want to engage more actively, we strongly encourage you to join the conversation and add a comment.

So we have had a great start to our social media push at the BJUI. And there will be a lot more to come in the coming months. For those of you who are new to social media, we encourage you to dip your toes in by reading a blog or two and adding a comment. Before you know it you will have downloaded the Twitter app to your smartphone and you’ll be off and running! For the Twitterati, we thank you for all your enthusiasm in helping us get social media up and running at the BJUI and we look forward to your blogs, mentions, re-tweets and podcasts over the coming months. Social media is all about engagement – join the conversation @BJUIjournal.

Declan G. Murphy and Marnique Basto

Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia


Declan Murphy is Associate Editor for Social Media at the BJUI.
Follow him on Twitter @declangmurphy

Editorial: Robot-assisted partial nephrectomy in patients with recurrent disease: fiction or fact?

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In recent decades, the detection of small renal masses (SRMs) has steadily increased with an accompanying shift of treatment towards partial nephrectomy (PN). Indications for PN have successfully expanded to more challenging cases, and robot-assisted PN (RAPN), in particular, has attracted increasing attention (BJUI, Eur Urol); however, despite excellent cure rates for PN, parallel to the increasing number of patients with SRMs undergoing PN, cases of ipsilateral recurrence after PN are also expected to rise. In addition to the incomplete surgical removal of the primary tumour, unknown multifocality or the development of new tumours or metastasis, in a minority of cases recurrence originates at the previous surgical bed and can be considered a proper local recurrence. Retreatment in these patients represents a specific challenge with radical nephrectomy (RN), ablative treatment, repeat PN, and active surveillance in selected cases as therapeutic options. RN should be considered the least attractive option because of the further damage to renal function that it entails, yet it represents one of the most selected options worldwide. Besides ablative techniques, which should be considered under investigational circumstances only, repeat PN is one of the possible options, especially in cases of recurrences attributable to multifocality or bilateral nature.

Repeat open as well as laparoscopic PN (LPN) have been reported sparsely in the literature, but were shown to be associated with good functional and oncological outcomes given adequate laparoscopic experience and patient selection. Such procedures, however, might be challenging and fraught with complications. The role of repeat RAPN (as well as the role of repeat open PN) in this situation is yet to be defined. Nevertheless, given that current data show RAPN to be a more attractive minimally invasive PN technique compared with its standard laparoscopic counterpart, providing equal or better perioperative outcomes, its advantages may even be greater when repeat PN is indicated.

In the current issue of the journal, Autorino et al. report the first study on functional and oncological outcomes and feasibility of repeat RAPN in patients with recurrence after previous PN. Of 490 patients treated with RAPN, nine patients underwent RAPN for recurrent disease at a median time of 39.4 months after previous open or LPN. A total of 12 tumours were removed in these patients, and one third of operations were performed on solitary kidneys. No intra-operative complications were observed, and only two minor complications occurred postoperatively, which were managed conservatively. With regard to functional outcomes, there was a nonsignificant median postoperative decrease in estimated GFR of 7%. More importantly, all patients preserved adequate renal function, which meant that renal replacement therapy was not necessary. With regard to oncological outcomes, all surgical margins were negative and no recurrence was reported.

The results of another study cohort of five patients undergoing repeat RAPN for recurrent disease after open or LPN has recently been published by Jain et al. In their series, surgery was completed in all patients without conversion to RN or an open procedure; furthermore, no complications were reported and the median decrease in GFR was 10%.

Importantly, both series suffer from retrospective evaluation of selective and small sample sizes with a short follow-up, and comparative analysis with other treatment options was not performed; however, the effective comparator for RAPN in this setting has yet to been defined. Bearing in mind current data that demonstrate RAPN to be a preferable minimally invasive PN technique compared with its standard laparoscopic counterparts, the real competitor for RAPN seems to be open surgery. This point was recently also reflected by Mottrie et al. LPN, as a challenging procedure with a long learning curve, limited diffusion and prevalent application in less complex cases, cannot be considered an attractive comparator for RAPN. During the last 8 years, RAPN has become a promising technique which can overcome the technical difficulties of LPN. Three-dimensional vision, ‘endowrist’ technology, and optical magnification allow excellent vision of the operative field and optimum tissue dissection. These technical characteristics help surgeons to minimize ischaemia-time and facilitate accurate tumour excision. Intra-operative ultrasonography, contrast-enhanced sonography, and photodynamic diagnostics can further improve this procedure. It was already shown that the availability of robotic technology is associated with increased use of PN, and, hence, broader diffusion in routine clinical practice may also provide the possibility to outperform results of open PN, even in more complex cases, and will make minimally invasive PN possible and available for more surgeons and patients. Today, the spread of RAPN is only limited by its availability and the associated financial burden. Hence, LPN will currently be considered a cheaper alternative to RAPN in centres with laparoscopic experience and in those which lack the availability of the robot.

Finally, the study from the Cleveland group and the series by Jain et al. provide some valuable support to the feasibility and safety of repeat RAPN and demonstrate that previously performed PN is not a contraindication for RAPN.

 

Sabine Brookman-May1, Andrea Minervini2, Alessandro Volpe3, Vincenzo Ficarra4, Maciej Salagierski5, Martin Marszalek6,7, Marco Roscigno8, Bülent Akdogan9, Alkuin Vandromme10, Hans Langenhuijsen11, Oscar Rodriguez-Faba12, and Steven Joniau13 for the Renal Cancer Working Group of the Young Academic Urologists (YAU) Working Party of the European Association of Urology (EAU)

1Department of Urology, Ludwig-Maximilians-University, Campus Grosshadern, Munich, Germany, 2Department of Urology, University of Florence, Florence, 3Department of
Urology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, 4Department of Oncological and Surgical Sciences, Urologic Unit, University of Padua, Padua,
Italy, 5Department of Urology, Medical University of Łódź, Łódź, Poland, 6Department of Urology and Andrology, Donauspital, Vienna, and 7Department of Urology, Graz Medical University, Graz, Austria, 8Department of Urology, AO Papa Giovanni XXIII, Bergamo, Italy, 9Department of Urology, Hacettepe University, School of Medicine, Ankara, Turkey, 10Klinik für Urologie und Uroonkologie, Klinikum Braunschweig, Germany, 11Laparoscopy, Robotics and Endourology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, 12Uro-oncology Unit, Fundacio Puigvert, Barcelona, Spain, and 13Department of Urology, University Hospitals Leuven, Leuven, Belgium

 

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The BJUI Social Media Awards 2013

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The BJUI has been very pleased with the large amount of social media activity we have seen across our various platforms since January 2013 when the new-look Journal was introduced. Editor-in-Chief, Prokar Dasgupta, has decreed that he wants the BJUI to be “the most-read surgical journal on the web”, and has recognised the key role that social media plays in realizing this ambition. At the same time, the social media revolution that has engrossed Gen Y and Gen Z and which has transformed the way in which news is communicated, has now taken a foothold in scientific publishing and is evolving.

To recognise the rapidly growing interest in social media in urology, and also to acknowledge those who have played a major role in advancing social media in urology at the BJUI and elsewhere, we this year inaugurated the BJUI Social Media Awards, presented for the first time at the AUA recently. Individuals and organisations were recognised across 20 categories including the top gong, The BJUI Social Media Award 2013, awarded to an individual or organization who has made an outstanding contribution to social media in urology in the preceding year.

This year’s Awards Ceremony was held in the Dublin Square Irish Bar in San Diego during the AUA Annual Meeting. Sixty of the World’s leading social media enthusiasts (the “Uro-Twitterati”), gathered to meet up in person and to see who would be recognised. Sort of like the Oscars but without the wardrobe malfunctions. Yours truly played the role of MC. While most of the awards recognised genuine achievements in social media, there were a few “special” categories which recognised some reasonably strange activity propagated through social media channels!

Todd Morgan and Alex Kutikov, the brains behind Draw MD Urology and Urology Match who won the top award of the evening.

We were delighted to have recipients from all categories present at the ceremony including representatives from the AUA and EAU. The BJUI Social Media Awards Ceremony was competing with the European Urology Cocktail Reception a couple of blocks away but in the spirit of conviviality which we encourage, we welcomed European Urology Editor-in-Chief elect, Dr Jim Catto, and managing editor Cathy Pierce, who popped in for a drink and to collect the EAU awards.

A special thanks to my research fellow Dr Marni Basto who organised this year’s awards, and to Scott Millar and Helena Kasprowicz at BJUI in London who manage our social media and website activity.

For more pictures from the evening, please visit BJUI Associate Editor John Davies Flickr page.

 

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

Follow Declan on Twitter @declangmurphy 

 

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Creativity, Faster Horses, and Future Medicine

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I was at an international cricket match, when during one of the very few lulls in the action I noticed a camera operator.  He was riding a Segway around the field in order to get close to the action and vary his angle for the viewers at home. After observing the function of this Segway-Human-Camera complex, it struck me that the only superfluous component in the system was the man with the beer gut and ill-fitting shorts.  All he did was point, focus, and zoom a camera. This can just as easily be done by a director in a control room, or even independently by a smart enough camera. It is not a stretch to imagine a computerized mobile field camera that can track a ball, and “intuitively” widen and tighten shots. The only thing keeping our man on the ground in employment is that at present, he is cheaper than the technology to replace him. His days are numbered. Taking the example of manufacturing, human workers are already replaced or reduced when lifting, welding, or assembling robots become as cost-effective as their flesh-based competitors.  Machines don’t fatigue, take breaks, or form unions, and so are an attractive alternative to, well, us.

With accelerating technology at declining cost, any job that is based around performing concrete tasks is at threat. Fast food restaurants are almost there, car wash services have been there for years, we only have pilots in aircraft because we don’t fully trust computers, and what next? Postal services? Car mechanics?

Lucky for us, doctors could never be replaced. Right?  Actually wrong. There are already electronic systems that in some situations make faster and more accurate diagnoses and management plans [https://www-03.ibm.com/innovation/us/watson/]. Perhaps the role of the physician will soon be giving a “human” face to explaining why the computer has ordered this course of treatment. That is, until technology can generate an adequately “human” face.

We may be relatively protected in surgery at present due to such things as appreciating variable tissue structures, making complex decisions based on unexpected findings, and adapting the surgical plan based on our understanding of the patient’s priorities. Technology will get there eventually. Even now it is conceivable that a computer could control an endoscope in the collecting system of a kidney, identify and then vaporize a stone as well as a human surgeon. A computer removing an organ is surely just further along this same scale.

The best protection we have is creativity. At present, computers have mastered managing vast quantities of data rapidly, and performing physical tasks within specific guidelines. We just cannot compete in this arena. Our advantage is in the abstract. We are still better at thinking of creative solutions, unexpected improvements, and more pleasant alternatives. A quote attributed to Henry Ford points out that if he had asked his customers what they wanted, they would have said “faster horses”. A binary brain would have worked tirelessly to give them this.

In the long term, doctors may only be researchers, generating ideas for computers to assimilate data on, but even then machines will be snapping at our heels. Why can’t a computer generate combinations of chemotherapeutic agents for a randomized trial? Even our last bastions of humanity, the arts, are not guaranteed safety. A computer can understand the mathematics of music, learn what is and is not palatable to the human ear, and “create” music. The same could be said of agreeable angles and architecture. One has to wonder, however long it takes, if the era of the human healer is approaching its end?

 

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

 

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Editorial: Androgen deprivation therapy: further confirmation of known harms

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Androgen deprivation therapy (ADT) has been an established and effective treatment for men with asymptomatic metastatic prostate cancer for decades. Randomized trials have shown significant survival benefits when ADT is used, coupled with radiotherapy, for patients with locally advanced disease; however it is often used in patients where the benefits are less clear, such as for a rising serum PSA level after radical prostatectomy, and among patients who elect to take a more conservative approach to treatment for low-risk disease. In addition to the absence of data proving benefit, there are a number of adverse consequences attached to androgen deprivation which should be given serious consideration before beginning treatment. Most of the side effects of ADT are linked to its induced hypo-androgenic, and consequently hypo-oestrogenic, state. These include fatigue, vasomotor flushing, loss of muscle mass, weight gain, hyperlipidaemia and insulin resistance.

Osteoporosis and fracture are additional known consequences of ADT with a trend toward greater fracture risk with a higher number of doses of a GnRH agonist and/or longer duration of use. Studies indicate that men with non-metastatic prostate cancer treated with ADT experience an annual loss in bone mineral density of up to nine times that of men in the general population. The use of intermittent ADT, as opposed to continuous use, as a strategy to reduce the negative cardiometabolic and osteoporotic effects is unresolved; however, a report indicating that more recent treatment was associated with a greater risk of fracture, irrespective of cumulative dose, suggests the potential for some reversibility in bone loss post-treatment.

In the present issue of the BJU International, Lu-Yao et al. add to the literature in this area. In a study of nearly 76 000 men with prostate cancer, using data gathered as part of the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) cancer registry linked to Medicare claims data, the authors reported that patients at high risk for skeletal complications were, not surprisingly, more likely to experience a fracture associated with ADT use over a 12-year period compared with patients receiving ADT but at low risk for developing such complications. Furthermore, men who experienced a fracture were 40% more likely to die during follow-up than those without fracture. Patients were sorted into risk groups using an index which summed the number of known risk factors for incident fracture identified from Medicare claims in the 12 months before their prostate cancer diagnosis. Unfortunately, owing to the relatively small number of patients with more than one risk factor, the study was limited in its ability to establish a dose – response relationship between the baseline index and fracture risk. SEER-Medicare is an excellent resource to investigate both outcomes and treatment-related expense associated with cancer diagnoses in the USA; however, in this particular study, the reliability of behaviours included in the baseline index (i.e. smoking) is questionable as it would require both patient report of tobacco use as well as physician documentation as a billable claim. Still, one might argue that the heaviest smokers, whose behaviour would most likely be captured as part of a claim, would also be the most important group to capture in an index intended to predict fracture risk.

Interestingly, it was reported that patients at high risk for skeletal complications were significantly more likely to receive ADT than patients at low risk. This was driven in part by the use of primary ADT among elderly men (aged ≥80 years) with prostate cancer and consistent with the notion that when curative treatment is contraindicated (i.e. older patients and those with pre-existing comorbidities) treatment with ADT is more common. Lastly, these findings do not suggest any modification of fracture risk associated with ADT according to baseline risk index, which is consistent with reports of the impact of comorbid conditions and ADT on the risk of incident diabetes and cardiovascular events. This is an important observation in that it says, there is no group that is immune to the adverse effects of ADT – all men are at risk. In absolute terms, however, the men at the greatest risk of an ADT side effect (i.e. a fracture or diabetes) are the men who are at greatest risk of having that side effect even if they were not receiving ADT. The findings of Lu-Yao et al. reinforce the need for careful monitoring of all men receiving ADT. Moreover, when these data are combined with an earlier study that showed that primary ADT was associated with poorer survival than that for men with low-risk prostate cancer who were managed conservatively with observation alone, it should be a wake-up call for us to stop treating non-lethal cancer with lethal and toxic treatments, including ADT.

Jennifer L. Beebe-Dimmer*† and Stephen J. Freedland‡§
*Wayne State University School of Medicine, †Karmanos Cancer Institute, Detroit, MI, ‡Durham VA Medical Center, and §Duke University School of Medicine, Durham, NC, USA

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The BJUI and BAUS join forces at AUA in San Diego

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For the first time, the BJUI and our friends at the British Association of Urological Surgeons (BAUS), joined forces at the Annual Meeting of the American Urological Association to stage a satellite session focusing on some interesting areas of urology. While both BAUS and BJUI have long had strong relations and have worked together on many occasions, this was the first time we had an opportunity to present a full afternoon of plenary content at the AUA.

This year’s AUA took place in beautiful San Diego, a very popular destination for delegates, even those travelling all the way from the UK. The convention centre is very conveniently located and is state-of-the-art. The adjoining Marriott hotel hosts many of the satellite events and it was here on Sunday 5th May 2013 that the joint BAUS/BJUI session took place. We attracted over 200 delegates in the face of tremendous competition from parallel sessions and had a wonderful atmosphere all afternoon.

Prokar Dasgupta excited about this session at AUA Annual Meeting 2013

Part one was chaired by BAUS President Adrian Joyce and featured state-of-the-art lectures from Prof Tony Mundy, Dr Tamsin Greenwell, Dr Craig Rogers, Mr Ben Challacombe, Mr Simon Brewster , Dr Philippa Cheetham and Prof Mark Emberton.

The second session was opened by BJUI Chairman Dr David Quinlan who gave a great introduction before handing over to BJUI Editor-in-Chief Prokar Dasgupta who Chaired the session. This was a fascinating session which combined state-of-the-art addresses from well known BJUI editors/contributors Dr John Davis, Dr Peter Gilling and Dr David Ralph, along with an exciting overview of social media and digital publishing by Prokar Dasgupta, Casey Ng and myself. The future of publishing is certainly not in paper and attendees at this session were given a wonderful preview of how urology publishing might look in the future.

The joint session finished with the presentation of the BJUI Coffey–Krane Prize, which was accepted by Dr Christian Pavlovich on behalf of his team for their paper Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching. The Prize was presented by the great Dr Coffey who gave a humorous overview after his warm introduction by Dr Quinlan.

Dr Christian Pavlovich receives the Coffey–Krane Prize 2013 from Dr Donald Coffey,
Prof Prokar Dasgupta and Mr David Quinlan

Attendees enjoyed socializing over drinks following the session and toasted the strong relationship between BAUS, the BJUI and the AUA.

We look forward to similar conjoined events in the future and are particularly looking forward to the BJUI supporting the forthcoming BAUS Annual Meeting in Manchester from 17–20th June 2013.

 

Declan Murphy BJUI Associate Editor

Follow Declan on Twitter @declangmurphy

 

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AUA Blog – Day 3 and 4 – Monday and Tuesday

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The American Urological Association (AUA) 2013 national meeting remains in full swing in beautiful San Diego. Not sure what is going on with the weather (two days in a row of rain?), but plenty of great things going on inside the convention center.

The “main event” on Monday was Dr. Ballentine Carter’s presentation of the AUA’s new Guidelines on the Early Detection of Prostate Cancer . Dr. Carter spoke to a packed house (the Fire Marshall was turning people away!).

For those who missed the talk, the AUA added a second session on Tuesday. Further comments from the AUA can be found here. Whatever your opinion regarding the new guidelines, and there were many prominent urologists who voiced their concerns about the guidelines, urologists will need to be able to speak intelligently to patients and primary care physicians. In the same session, Dr. Michael Cookson gave the AUA Guideline presentation on castration resistant prostate cancer which seemed better received than the PSA Guidance which certainly got many urologists hot and bothered.

On Monday, the Young Urologists Forum focused on the business aspect of urology (something I heard very little about in training), with informative talks by Dr. Raju Thomas, Dr. Koushik Shaw and Dr. Neil Baum. Thanks to Dr. Mike Ost and the YU Committee for putting together a great program.

Speaking of young urologists, the Southeastern section took home first prize in the Second Annual Residents Bowl, besting the Western section in the finals on Monday.

Southeastern Section of AUA claim the honours in the Annual Residents Bowl

The Monday plenary session included discussions on the contemporary uses of neuromodulation and the management of iatrogenic ureteral injury. BJUI Editor-in-Chief Dr. Prokar Dasgupta, gave an informative lecture on the current applications of botulinum toxin in the lower urinary tract. Prostate cancer made it into the Endocrine Forum on Monday, with Dr. Scardino and Dr. Klotz debating the treatment of men with low risk prostate cancer. Jumping ahead, a similar debate was held during the Tuesday plenary between Dr. Carroll and Dr. Tewari with roles reversing somewhat as Dr Tewari argued the case for surveillance while Dr Carroll took us through some of the pitfalls.

Also on Monday, Dr. Vincent Laudone gave late-breaking news regarding the randomized trial between open and robotic radical cystectomy at MSKCC. Bottom line – no difference was found regarding oncologic or perioperative outcomes. In particular, the robotic approach did not reduce the complication rate which remained at about 60% in both arms. Cost difference, which seems to be on everyone’s mind, was not addressed. Other trials between open and robotic cystectomy remain ongoing and the jury appears out here.

Dr. Christopher Kane moderated a session debating the use of simulation in robotic surgery between Drs. Sundaram (pro) and Nadler (con). Dr. Kane concluded the debate by stating that basic robotic training is important but limited by cost and duty hour restrictions. In addition, further studies are needed to determine if virtual robotic training actually helps performance.

One of the more contentious areas of prostate cancer, HIFU and focal therapy, received much attention during various poster sessions this year. Abstract #553 reported five-year oncological outcomes following HIFU in the UK in over 500 patients. Disappointingly, 38% of men who had a biopsy had residual cancer. About one third of patients had androgen deprivation therapy upfront with a further 30% requiring salvage treatment. The authors described the disease-free outcomes as “reasonable”. Abstract #1356 from the same authors reported outcomes in 110 patients undergoing focal therapy using the same HIFU technology. Again, 38% of patients had a positive biopsy. Both of these papers provoked much reaction from the floor and across social media. These are experimental interventions which should only be undertaken in appropriate trials.

The aging US population (10,000 people turn 65 every day and will for the next 15 years) coupled with the average age of urologists (mid-50’s!) will create a serious manpower shortage over the next several years. As an illustration, abstract #153 reported that 14 counties in Oregon have zero urologists and men in those counties are more likely to get bladder cancer.

From Monday, abstract #1041 (awarded best poster for MP40), confirmed what habitual coffee drinkers already know – that high dosage coffee increases LUTS and urine volume compared to decaffeinated coffee or water. Dr. Tom Walsh and colleagues were awarded best poster (abstract #1241) for MP46 for evaluating a smartphone application to assess the penile deformity in men with Peyronie’s disease. Another best of session – Dr. Penson (@urogeek) and colleagues reported that men with prostate cancer today (CAESER) have more baseline dysfunction that men 20 years ago (PCOS) – abstract #449. There were many more great abstracts out there…too many to list in this blog.

The Urological Society of Australia and New Zealand hosted a great reception on Monday night. Several prominent uro-twitterati (including yours truly) and other urologic “heavy hitters” were in attendance.

Thanks to the Aussies and Kiwis for a wonderful event. Strangely, they were not serving Foster’s at the event.

Tuesday’s plenary included several sessions on the management of both low and high-risk prostate cancer. The main auditorium was absolutely packed for what was one of the best sessions of the week.

Dr Hein Van Poppel, Secretary-General Adjunct of the European Association of Urology (EAU), delivered an outstanding plenary on the management of high-risk localised prostate cancer. His clear message – surgery should always be considered first with radiotherapy and androgen deprivation therapy later if required – was very well received. Dr Ed Messing introduced a fantastic session on molecular markers in prostate cancer led by Dr’s Alan Partin, Dan Lin and Theo Van der Kwast. Key messages here were that the Phi test already has a role in clinical practice; PCA3/TEMPRSS2ERG fusion is emerging; and for sure, we will see genetic markers in clinical practice very soon. In fact the UCSF group generated a lot of media headlines on Tuesday evening when the commercialization of their genetic test was announced ahead of its presentation by Dr Cooperberg on Wednesday am.

So many other sessions it’s hard to know what to choose from. A mention of Dr Joel Nelson’s Critical Discussion session where he led Dr Reiter and Dr Brooks through the options for patients with progressive prostate cancer. This was a good way to present the key data in an engaging manner.

The AUA Guideline presentations on follow-up care for renal cancer and radiation after prostatectomy were given by Dr. Sherri Donat and Dr. Richard Valicenti, respectively. In addition, Drs. McVary and Kaplan debated the use of alpha blockers versus PDE5 inhibitors for BPH/LUTS.

Other highlights from Tuesday from the land of stones included abstract #1816 – people are 67% less likely to file short-term disability when treated with medical expulsive therapy versus ureteroscopy. A higher physical activity level improves the results of lithotripsy (#1824). In an earlier abstract (#67), physical activity was protected against stones in women. SO…get moving people! Lastly, 2 groups developed nomograms to predict stone-free rates after PCNL (abstracts #1526 and 1532). Thanks to Peter Steinberg and Michelle Semins (my stone peeps) for vetting abstracts.

Social media and twitter continued to have a significant impact at the meeting, with an increasing number of tweets every day. With so much going on at the AUA (seemingly at the same time), twitter provides an easy way for urologists to digitally multitask and get more out of the conference. Check out the metrics via Symplur.com which show huge social media activity (5.7m digital impressions) and also shows the BJUI and its team/contributors are among the top influencers once again.

 

#aua13 was the #1 trending conference over the past few days! The use of social media will only expand over the coming years, and urologists need to stay “ahead of the curve”. Perhaps the @Americanurol will offer a Plenary session on Social Media next year? I can honestly say that I got more out of the meeting this year, largely thanks to the use of twitter.

The AUA responded to a social media campaign and installed twitter-boards around the convention centre. Great to see the AUA engaging so well in social media.

Thanks to the AUA and San Diego for a great meeting! Looking forward to seeing everyone next year in Orlando. Until then, I encourage everyone to participate in the International Journal club on twitter (@iurojc) and to bring a friend!

 

Dr. Matthew Hayn

Follow Matt on Twitter @matthayn

 

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