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EAU Annual Meeting 2013 – Final thoughts

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The BJUI team was most impressed with this year’s EAU Annual Congress which has just concluded in Milan. The scientific content was excellent – topical plenary sessions from key opinion leaders; lively poster sessions; superb video sessions and very high-quality courses run by the European School of Urology. The EAU are to be congratulated on consistently raising the bar with the quality of this meeting which is reflected in the huge delegate numbers again this year.

The last two days had a number of highlights, some of which we summarise here:

  • The Plenary on lower urinary tract symptoms – management of side-effects included a wide variety of presentations including an specific talks on new potential drug treatments which certainly wouldn’t be considered main-stream at the moment. It will be interesting to monitor how trials with beta-3 agonists, botulinum toxin and PDE5 inhibitors go over the next few years for this potentially huge market. Professor Marberger finished the session discussing if TURP remains the gold standard for BPO. The answer may be that it is not, although it remains the ‘reference’ to which all other treatments must match. It is interesting to see how delegates reacted to this on Twitter such as Dr GomezSancha who tweeted to his 251 followers:

 

We are not sure if all would agree but we do enjoy seeing the debate bouncing around the Twittersphere!

  • Prevention of infections – chaired by T.E. Bjerklund Johansen, this plenary updated us on resistance to antibiotics which is increasingly a problem and has led the lay press to describe this as an Apocalypse and more recently as big a risk as terrorism. Dr Kahlmeter then discusses the implications for urology in this video interview with the EAU. This is a highly topical area and we are pleased to see key urology meetings showing leadership here to address these broad concerns.
  • Urological Surgery in Renal Transplant Patients – this session was very emlightening for urologists who work alongside bust renal transplantation services. The transplant population have many challenging urological issues and Dr Jon Olsburgh from Guy’s & St Thomas’ in London provided an excellent overview of some of these. He outlined very nice strategies for stones in patients who have received an allograft and also for those considering kidney donation. A summary can be found in the EUT Newsletter from Day 3.
  • There were many poster sessions throughout each day – too many to be honest for us to keep track of.  Fear not though – keep an eye on the BJUI blogs for the Best of the Best Posters coming soon. We would also direct you to Twitter where you will find some excellent commentary from the many active Tweeters who attended various poster sessions. Just search under the #eau13 hashtag. Watch out in particular for tweets from the Montreal/Detroit group who presented much work and were particularly active on Twitter (@qdtrinh, @peepeedoctor, @jdsammon, @maxinesun and others).
  • Souvenir Session and EAU Guidelines on Live Surgery: The last day featured an excellent souvenir session which overviewed some of the key messages for the meeting. European Urology Editor-in-Chief Elect , Jim Catto, reviewed Urothelial cancers and observed that PET scanning has most value for evaluating distant disease rather than pelvic lymphadenopathy when compared to CT scanning. The management of small renal masses, a dominant topic this year, also . The highly-anticipated EAU Guidelines on Live Surgery were presented very nicely by Section Chairman Keith Parsons and were very well received. There are sometimes competing goals here and these guidelines will ensure that the best interests of patients are maintained while maximising the educational value of these very popular sessions.
  • Breaking News: this final session had a number of headlines, one of which was data from Peter Wiklund’s group in Sweden which suggested that long-term cancer outcomes for localised prostate cancer patients are better for those who underwent surgery rather than radiotherapy. Also data from Bertrand Tombal showing a greater than 50% reduction in cardiovascular morbidity for patients on the GnRH antagonist degarelix when compared with those on GnRH analogues. Further detail of this are awaited.

Lastly, we would again like to congratulate EAU and all the active Tweeters who contributed so much to the social media side of this year’s meeting. The final data from Symplur show huge activity which greatly expanded the reach and engagement of this meeting:

We are also very pleased that the BJUI team dominated the metrics for key influencers of #eau13 which reflects well on the strong social media strategy which we have put in place since January 2013. We were delighted to visit the busy EAU Communications back-office on the last day of the meeting to congratulate Communication Manager Evgenia “Zhenya” Starkova and her talented team who did a fantastic job running the Congress and EAU websites, twitter, facebook, video interviews etc and who we enjoyed interacting with through the week. Zhenya’s team kept tweeters engaged by awarding a “Tweet of the Day”:

EAU Official Tweets of the Day for the conference:

Friday –  “Small renal masses, debate continues: surveillance vs biopsy vs partial vs radical neph. Individualised care is key.” @HamidAbboudi

Saturday – “#eau13 this is not just the European meeting now. It is the world meeting! What an event.”
@benchallacombe

Sunday – “It’s going to be a tough act for Stockholm to follow! Great congress so far! #eau13”@SJGore

Monday – “I suspect #eau13 will be remembered as 1st major urology meeting to do social media seriously. It’s been great fun!”@MattBultitude

So we look forward to EAU Annual Congress 2014 which takes place in Stockholm from 11-15th April 2014. We wish Scientific Chair Arnulf Stenzl and the team at EAU Central Office all the best with planning for next year’s meeting!

We will be back with more conference coverage from the Urological Society of Australia and New Zealand Annual Scientific Meeting that takes place in Melbourne next month (#usanz13).

 

Declan Murphy & Matt Bultitude
BJUI Associate Editors

 

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Editorial: What is the optimal length of time for SNM testing?

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The authors are to be commended for their unique investigation of an extended stage 1 SNM test period. To our knowledge, no other series has included a minimum 4-week duration and microbiologic testing. Optimal duration for the test phase has not been elucidated and initial responses are likely compounded by a short-term placebo effect that may dissipate after time. Knowledge of when maximal improvement occurs would define a population of true responders and reduce implant failure rates. This series shows the feasibility of an extended test phase in a small cohort, but does not identify the optimal length of time for testing.

One must question how many responders are in the 2- to -4 week interval and if such patients would do as well with earlier implantation. Current testing with permanent leads and externalized hardware is cumbersome and not always convenient for activities of daily living, especially showering. Furthermore, knowing the sampling interval used by the authors to assess response and the time at which the majority of patients reached the established implant criteria could clarify the time needed for maximal response. In this small cohort, however, the difference would fail to show significance.

As the authors note, a low stage 2 failure rate is important in an era with rising concern over health care expenditure, but it generates questions on what to do for responders
who have symptomatic improvement >50% but <70%. Do we risk not helping an individual who has 50% improvement in order to reduce stage 2 failures, and how do we justify making this quality-of-life decision? The low stage 2 failure rate in this study may have resulted from the strict criteria for stage 1 success, specifically a 70% or greater response, and not necessarily the prolonged test phase.

Notably, there were no infections in this series despite an extended stage 1 test phase. This is considerably lower than the 5–7% infection rate reported in the literature (Urology, Eur Urol). Perhaps the degree of hygiene and antibiotic regimen contributed to the lack of infectious complications, but concern remains that such results are not generalizable. Infectious events not captured in this series may become evident with a larger sample size and surely the rate will be greater than zero. Granted, the results of this study add to our knowledge of SNM, it is not conclusive that the outcomes can be applied to the population at large, and further evidence from randomized trials are needed to identify the balance between benefits and risks associated with an extended test phase.

Brian K. Marks and Sandip P. Vasavada
Center for Female Urology and Reconstructive Pelvic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

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Day 3 at EAU Annual Meeting

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Day 3, St Patrick’s Day, saw the Irish trying to lift their spirits having been beaten by Italy in the Six Nations rugby tournament the evening before. Cathy Pierce from European Urology donned a shamrock for the day but declined Declan’s suggestion to serve Guinness instead of champagne for the Platinum Journal’s cocktail hour.

Our day started with the BJUI Editorial Board Meeting hosted by new Editor-in-Chief, Prokar Dasgupta. There was much enthusiasm for the new-look of the Journal and for the return to a once-monthly print edition. The new web interface is receiving huge traffic and the close integration with our social media platforms has proved very popular to date. It is clear that the future for urology journals will require a much broader vision than the production of a print journal and we are excited by the suggestions made by our learned editorial board members for how we might achieve that.

The main plenary on day 3 addressed contentious issues involving the upper urinary tract. Prof Pilar Laguna opened the packed session by overviewing challenges in diagnosis of upper tract tumours and the role of new technologies in improving diagnostic strategies here. Tim O’Brien moderated a debate on surgical approaches for upper tract TCC, which featured some stunning video from Dr Traxer. Key messages from this session (summarized very nicely by EUT Congress News) included:

  • Dr Shariat: “Treatment is more and more based primarily on the risk of the tumour and efficacy of therapy rather than practical limitations; role of LND during segmental ureterectomy remains to be evaluated.”
  • Dr Brausi: “Lymphadenectomy (LND) improves disease staging and helps in selecting patients who can benefit from chemotherapy; several retrospective studies suggest the potential therapeutic role of LND during nephronureterectomy for transitional cell carcinoma of the upper urinary tract.”
  • Dr Traxer: “Regarding endoscopic treatment, flexible URS (ureterorenoscopy) for diagnosis is recommended, and new tools for better detection are needed such as narrow band imaging (NBI).

One other highlight from the plenary was provided by Dr Shahrokh Shariat who presented evidence to support the use of partial ureterectomy instead of nephroureterectomy for patients with upper tract TCC. In a large, retrospective, multi-institutional study, using matched-pair analysis, they reported that segmental ureterectomy provided similar oncological and renal functional outcomes when compared to nephro-ureterectomy.

Three back-to-back poster sessions on stone disease covered the topics from basic science to ESWL, ureteroscopy and PCNL. Olivier Traxer’s group presented their comprehensive series of classifying complications in flexible uretero-renoscopy using the modified clavien grading system. They reported on over 1000 patients and this data will provide a contemporary benchmark for us to advise our patients on the expected incidence of these complications. Dr András Hoznek reported a new online programme (also available from the Apple AppStore) for the metabolic work-up of stone disease.

This is an area that traditionally urologists have done poorly and it is hoped that innovations such as this will ensure a standardisation of investigations and it is hoped that future developments will allow patients to analyse their diet and fluid intake to make individual recommendations (personal communication O.Traxer). There was much debate about the use of simulators for PCNL and Mahesh Desai chairing the session commented that this is surely where the future lies in training young urologists. Finally, Lucarelli et al. reported on functional renal loss after iatrogenic injury causing obstruction to the upper urinary tract. They confirmed 1970s animal experiments that there was a clear benefit to dis-obstruction within 2 weeks compared with delayed treatment using both eCrCl and MAG-3 renograms.

Continuing a recurrent theme for this year’s EAU Annual Meeting, Dr Inderbir Gill and Dr Mike Jewitt debated the role of surveillance versus surgery for the management of small renal masses. Clearly there is a role for surveillance here, especially in older patients, but until there is more certainty about the precise nature of these masses based on better imaging and biopsy strategies, then partial nephrectomy will remain the standard here. This image of Dr Gill tweeted out by @hendrikborgmann shows him somewhat impressed about the idea of not doing surgery!

Watch out for more contention today as Dr Gill debates Dr Alex Mottrie over laparoscopic versus robotic-assisted partial nephrectomy. We have already seen much minimally-invasive partial nephrectomies at this year’s meeting thanks to the various video and live surgery sessions. Ben Challacombe was not happy with the blood loss during conventional laparoscopy on show yesterday and clearly thinks the robot is the answer!

Social media continues to grow significantly at #eau13 with significant growth in Twitter traffic:

(Statistics courtesy of www.symplur.com)

After resolution of some teething issues with the complimentary wifi that EAU provide at the meeting, delegates and those watching from further afield really got the conversation going throughout the day and there was a constant stream of commentary and humour streaming out using the #eau13 hashtag. Organisers of major urology meetings should take note of the fact that social media will be increasingly embraced and having good wifi access (complimentary please) throughout the venue will be considered essential by smart-device-wielding delegates.

More from the team tomorrow!

Matt Bultitude – BJUI Associate Editor (Web)
Declan Murphy – BJUI Associate Editor (Social Media)

 

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The Daily Blog from EAU 2013: Day 1 and 2

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Saluti di Milano! This week the BJUI team are bringing you live updates from the European Association of Urology Annual Meeting in one of Europe’s most beautiful destinations – Milan. Our team has been Tweeting, Facebooking and now blogging from Europe’s premier urology gathering. In fact, we are the leading influencers in social media at this year’s meeting as shown by the metrics updated at Symplur where we registered the official hashtag #eau13.

 

 

Social media has really taken off at this meeting with the EAU Media team having formalized a strategy to promote social media. By just following #eau13 on your smart device you will receive a constant stream of interesting news and gossip from our team, from the excellent EAU Twitter-feed, and from the increasing number of others who are getting active in social media. One of the features we really like is the live twitter feed running on all the LCD screens detailing sessions around the venue:

 

This is something we first used at the Australasian Prostate Cancer Conference in Melbourne in 2012 and we are presenting outcomes from our social media initiatives at that meeting at the forthcoming BAUS meeting in Manchester.

But back to Milan. You have got to admit that one of the attractions of the EAU Annual Meeting is that it usually takes place in Europe’s favourite cities. – Paris, Milan, Stockholm. In the past ten years the EAU meeting has grown from a relatively modest meeting with variable scientific content, to a truly world-class event with very high-quality plenary sessions, poster presentations, video sessions, courses and satellite events. As of close of business on day two today, there were over 10,000 urologists and health professionals registered (and @benchallacombe was awarded Tweet of the Day by the EAU for letting the world know!), with another couple of thousand industry representatives. This is a big meeting! Over 14,000 delegates are expected before the close of the meeting.

The meeting actually started on Friday with a special all-day International Consensus meeting looking at chemoprevention of prostate cancer and five satellite symposiums. Dr Schroder re-iterated his stand that “PSA screening significantly reduces mortality. Harms are identified and quantified; they do not exceed the benefits”. The panel of experts from around the world intend producing a consensus statement on early detection, prognostic markers to predict high-grade disease, and the most appropriate clinical preventions strategies. There were also the “Urology Beyond Europe” meetings which allow urological associations from 11 other regions to run sessions at EAU. This certainly reflects the fact that the EAU meeting is a truly global event, maybe moreso than the AUA meeting. This year there are delegates from over 100 countries . This year’s meeting kicked off in spectacular style two days ago with a lavish opening ceremony featuring an operatic performance from La Scala in the main auditorium:

As I arrived in Milan at 0700 on Friday, I spent most of the day in a groggy mess trying to shake off the jet lag having spent 24 hours on a plane. I did make it in to hear Dr Urs Studer issue a call to young urologists at the opening session to “widen your interests, be aware of urology’s many aspects and don’t be a keyhole specialist”.

Saturday morning kicked off in the spectacular style we have got used to with the festival of live surgery that is the European Section of Urological Technology (ESUT) Section meeting. The ESUT has consistently been the most-highly attended Section meeting at the EAU for a number of years and this year was convened in conjunction with the new EAU Robotic Urology Section (ERUS) and the Urolithiasis Section. The main eUro auditorium was packed for most of the day as many thousands of delegates watched the live feed from the operating theatres at San Raffaele Hospital.

 

Over the day, there were 20 cases of which ten were live and the remainder pre-recorded the previous day. The technical quality was outstanding with all broadcasts in high-definition and some robotic procedures in 3D. The ESUT along with EAU and ERUS will be announcing the new EAU Guidelines on Live Surgery on the closing day of the meeting which will address concerns about the governance and ethical considerations of live surgery. I have blogged about this previously and we all welcome the leadership that EAU/ESUT and ERUS have demonstrated in this area.

Competing with ESUT for numbers on Saturday were six other section meetings, 22 poster sessions, two video sessions, 12 courses and seven sponsored satellite sessions. Myself and other editorial board members and contributors to the BJUI have been tweeting highlights and photos from these various sessions. Here are a few of the headlines:

  •        PSA screening in men aged 55-69 reduces prostate cancer-specific mortality by 31%. Dr Monique Roobol presented the latest findings from the ERSPC study and also showed no benefit to PSA screening for men aged 70-74 in the world’s largest PSA screening study. In another poster, Dr Roobol also showed the addition of the Prostate Health Index (PHI) to the ERSPC Risk Calculator added a net benefit increasing the area under the curve from 0.56 to 0.73.
  •        MRI guided prostate biopsies: a lively session saw the role of multiparametric MRI being debated by a number of experts. Should we only biopsy patients who have a lesion demonstrable on MRI?? A step too far for now but mpMRI and fusion biopsies will be a hot topic for the next couple of years.
  •        Innovation & Infection: this most-aptly named session addressed the highly-topical area of urological infections which has attracted much media attention in recent times with increasing warnings of antibiotic resistance. This is reaching crisis proportions in some regions and commonly performed procedures such as prostate biopsy are of particular interest.
  •        BPH surgery complications are under-estimated: a large French study has shown that complication rates following TURP and open prostatectomy in real clinical practice compared to clinical trials. A review of over 260,000 patients undergoing BPH surgery revealed a re-operation rate of 4.7%, clot retention in 3.4% of TURPs and urethral stricture in 2.7% of patients. 420 men (0.18%) underwent surgery for urinary incontinence.
  •        Robotic partial nephrectomy – there is clearly increasing adoption of robotic partial nephrectomy with a number of posters and videos featuring already. A key message is that larger, more complex tumours can successfully be managed with this approach in experienced centres. The role of fluoresce-guided robotic surgery is evolving.
  •        From young to old: An interesting theme at this year’s meeting has been an overview of the urologist’s role of managing the ageing urinary tract. A plenary session yesterday was dedicated to this and a particular message was the rising role of surveillance for small renal masses in older patients. More harm can be done from intervention than surveillance in this group
  •        Stone prevention – a packed auditorium at the EULIS section meeting heard that stone prevention strategies instead of treatment modalities should be explored for recurrent stone formers with rapid screening of diet including internet-based approaches. Dr Knoll presented a staggering analysis of 200,000 stones from Germany(!) showing an increase in calcium oxalate composition and surprisingly stable levels of uric acid (considering the rising obesity levels). Newer imaging modalities such as dual-energy CT may help to identify stone composition which may help tailor treatment.

Of course, a lot of other activity goes on around the periphery of meetings like this. Yesterday I attended the Consulting Editors meeting of European Urology where outgoing Editor-in-Chief Francesco Montorsi welcomed newly appointed successor, Jim Catto from Sheffield in the UK. Jim takes over the reins in January 2014 and we look forward to the new ideas he will bring to the Platinum Journal. Today we have the BJUI Editorial Board meeting which is a great opportunity to meet with our friends and colleagues from round the world who are doing a fantastic job under new Editor-in-Chief Prokar Dasgupta.

 These meetings are also a great opportunity to catch up with colleagues from around the world. We are posting pictures on our Facebook site this week and you will see photos on Twitter also.

Pictured at the Duomo – Ben Challacombe (London), Stacy Loeb (New York), Declan Murphy (Melbourne)

Stay following #eau13 and join the conversation!

 

Declan Murphy

T: @declangmurphy

Associate Editor (Social Media) BJUI

Uro-Oncologist, Melbourne

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Editorial: Specimen fascia width reflects nerve-sparing technique

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The authors have reported a pathological analysis showing that various levels of nerve-sparing technique were reflected in the radical prostatectomy (RP) specimen. Intriguingly, the authors found that the fascia width on the left side was much wider than the right side in the RP specimen with the interfascial nerve-sparing technique. This is important information for robotic surgeons. Looking at the literature, almost twice as many positive surgical margins have been reported on the left side in patients treated with laparoscopic RP and robot-assisted RP (RARP). Secin et al. also reported similar results, which revealed the tendency for left-side dominance of positive surgical margins. These results seem to be in large part due to the left side being more technically challenging, resulting in less precise dissection.

For lymph node dissection, our own unpublished data of 1005 patients who underwent RARP indicates that the mean lymph node yield is higher on the left side (7.5 vs 7.1, P = 0.004), while the author’s previous study found a higher lymph node yield on the right side. Although, we could not establish which factors contributed to the contrary results, it seems that side preference also exists when performing robotic lymph node dissection.

While the da Vinci Surgical System® has been shown to eliminate innate hand dominance, the observed findings were of novice robotic surgeons and meticulous dissection of the neurovascular bundle is usually performed using a dominant hand even in experienced robotic surgeons. Moreover, differences in robot instruments of both arms and assistant positioning may also play a role in different outcomes by laterality. Nevertheless, the da Vinci Surgical System provides surgeons with magnified three-dimensional vision equally on both sides and promotes meticulous lateral dissection. We think that the imprecision of surgery on the left side could be overcome if surgeons are aware of the potential difference in laterality. Finally, we congratulate Ko et al. for their novel work. A follow-up study with multiple surgeons and analysis that reflects the effect of the surgeon’s learning curve on the outcomes would also be informative.

Kwang Hyun Kim and Koon Ho Rha
Department of Urology, Yonsei University College of Medicine, Seoul, Korea

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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 ten years of progress under Professor John Fitzpatrick, it was clear that we are now working in a much-changed publishing landscape, one that 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 unrecognizable from what it was just two or three 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.

My role as Associate Editor (Social Media) at BJUI, has been 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 organization to engage with and be informed, educated and entertained by. My fellow Associate Editors, Dr Matt Bultitude (Website), Dr Ben Challacombe (Innovation) and Dr Quoc-Dien Trinh (Health Services Research), play important roles here as do our publishers, our Executive team and Editor-in-Chief at BJUI.

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.

 

Since 1st January, our followers on Twitter have grown by over 20% to 1151 and we have generated huge traffic back to our website with over 2000 link clicks from the 500 interactions we have had during this period.

 

Advanced 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 53 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 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 73,000 page impressions by 11,000 Facebook visitors in the first two months of 2013, a huge rise from previously, and all of this traffic gets directed back to content at 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.

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, Matt Bultitude and I 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 that 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 I most admire. BMJ Blogs is well worth a visit for aspiring bloggers to read some of the best.

We launched our new website on the 2nd January 2013 to coincide with the new Editor taking the helm, and also published our first blog that day. From then until the 28th February 2013, Blogs@BJUI has featured the following:

  • 35 blogs contributed by 25 authors on three continents
  • 133 comments from all over the world
  • 8 editorial blogs from our specialty Associate Editors
  • 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. I am quite pleased that the most-read blogs in January and February were written by two young trainees of mine in Melbourne. But I am sure the self-appointed King of Twitter, Ben Davies, and other established stars of urology social media will be vying for such coveted titles as the months go by.

I 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 minutes per blog and many of them left comments or pushed out links to our blogs 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 to any of our blogs.

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 – watch for our activity during the upcoming conference season and look forward to the results of the inaugural BJUI Social Media Awards to be announced at the American Urological Association Annual Meeting. For those of you who are new to social media, I 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, I thank you for all your enthusiasm in helping us get social media up and running at the BJUI and I 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 Murphy is a uro-oncologist in Melbourne and is Associate Editor of Social Media at the BJUI. Follow him on Twitter @declangmurphy

Does Michelangelo’s David have an increased risk of prostate cancer?

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Recently when researching on the Italian Renaissance master Michelangelo and his suffering with kidney stones, I stumbled upon a project on his famous masterpiece David. At the precise time, I was browsing BJUI and came across the article by Motofei et al, on the sexual side effects of finasteride as related to hand preference (right-handed or left-handed) for men undergoing treatment of male pattern baldness. This manuscript reminded me of several articles that measured different parts of the male body and correlated with the risk of prostate cancer. With this paper on my mind and at the same time looking at David, it just occurred to me whether I could predict the possibility him getting prostate cancer!

Let’s start from the beginning. Being born as a male, he had acquired a 1 in 6 chance of being diagnosed with prostate cancer and 1 in 36 chance that he would have died from it. The moment David stood erect as a toddler; the risk of getting prostate cancer became a reality. Indeed, the authors of the study go on to claim the link of erect posture of humans with BPH and infertility. For those interested, the theoretical aspects of erect posture and its effects on the male reproductive tract can be found in this review.

It is worth analyzing the David’s anthropometric measurements and bodily features from head to toe and correlate them to the current available evidence. David’s height has been calculated at being 497 cm. This, in real life would probably make him around 5’ 8” to 6’. According to the findings of the PLCO trial, being tall increased his risk of developing more aggressive prostate cancer and at a younger age. This is supported also by the findings of the ProtecT trial, which demonstrated that for high-grade tumours, there was a 23% increase in risk per 10 cm increase in height. The study group’s meta-analysis of published literature also support the increased risk of prostate cancer with increasing height.

Let us start from his head. Fortunately, David is not bald. Recent evidence suggests a strong correlation between vertex pattern androgenic alopecia and significant risk of prostate cancer. Looking at the elegance of the face, it is quite obvious that he is a clean-shaven man. Fortunately, being white, the age at which he started shaving indicating early or delayed adolescence, does not seem make his chances of getting prostate cancer worse.

Going on to his chest, it is apparent that David did not suffer from Gynaecomastia. There is considerable controversy in the literature regarding the association of gynaecomastia and future risk of prostate cancer. A cohort study following men with histologically proven gynaecomastia did not find any increased risk of prostate cancer but surprisingly showed an increased risk of testicular cancer. David’s chest, abdomen and back lack excess dense body hair. A Japanese study has shown that dense body hair raises the risk of prostate cancer!

A lot of research has gone into determining whether David is a right-handed or a left-handed man. If you take a closer look at the statue, the sling is held by the left hand and a rock on the right, suggesting that he could indeed be left handed, like his creator Michelangelo! Although no specific research has been carried out in prostate cancer, it has been shown in a few studies that women who are left handed are more prone to get breast cancer as compared to those who are right handed. The authors claim the effect of prenatal hormones on the foetus that determines the dominance of the side can also have effects on the breast tissue. A study found that men who were exposed to DES in utero were more likely to be left-handed. Similarly mouse experiments have shown an increased risk of prostate cancer in those exposed to DES. So, there may be a connection between left-handedness and risk of prostate cancer!

Coming to his fingers: The ratio of second to fourth digit length (2D:4D) would allow us to further assess the risk. It is now understood that the 2D:4D ratio is determined by Homeobox (Hox) a and d genes that also regulate urogenital system. What is even more interesting is the study that showed the patients with a lower 2D:4D ratio have higher risks of undergoing prostate biopsy and prostate cancer. The same group indeed went on to prove that a lower digit ratio was related to high percentage core cancer volume and higher Gleason score!

Fortunately, David’s waist circumference (WC) is within reasonable limits, thereby reducing his risk of prostate cancer. A recent study has shown that increased WC seems to be associated with high-grade disease at the time of biopsy.

It is obvious looking at David that he was not circumcised. Although aesthetically pleasing for many, there is considerable debate in the medical as well as philosophical literature whether David was circumcised or not?! Not being circumcised unfortunately increases his risk for prostate cancer.

There is a huge controversy about the size of David’s flaccid penis. Penis size has not (yet) been shown to correlate with risk of prostate cancer. Although, indirectly you conclude that because the 2D:4D digit ratio has been correlated with penis size and as shown above 2D:4D ratio has been correlated with prostate cancer. Therefore, the smaller the penis, greater the risk of prostate cancer! With so many manuscripts being published on 2D:4D ratio, I decided to research more on it and landed up on the Wikipedia page. I was astonished to find the various conclusions that have been reached with the curious case of 2D:4D ratio, including a recent study in Germany that found its correlation with male to female transsexuals!

Although not possible, but of interest would have been to measure David’s anogenital distances from anus to upper penis and from anus to scrotum. A study published in BJUI showed that a higher measurement between the anus and the penis was associated with lower risk of prostate cancer. As you may have guessed, yes there is research going on finding a relationship between anogenital distance and the 2D:4D ratio!

My interest then turned to David’s feet. Looking at it, it does seem that he would have been wearing a shoe size of 10 or 11 at least. Does it matter? Comparing his shoe size and the length of his flaccid penis, I was just reminded of the seminal paper by Jyoti Shah et al, which disproved that shoe size has got to do anything with the size of the penis. However, contrary to this paper, a study confirmed significant evidence of older age at the maximal shoe size (20.1 versus 17.6 years, P <0.05) was associated with increased risk of prostate cancer. Yes, as you may have guessed by now, there is a relationship between the 2D:4D to your penis size!

To conclude on the observations, there are several factors that increased David’s risk and several others that are protective, as shown in Table 1. I would leave it to the reader’s judgment, whether you would recommend a PSA test for David or indeed climb on to him and measure the most important parameter, the 2D:4D ratio!

Amrith Rao is a Consultant Urological Surgeon at Wexham Park Hospital, Wexham, UK. His views are his own. @urorao

 

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Get Angry People

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Hello colleagues. You look stressed. Your blood shot eyes have little golden crusty particles stuck in them. Oy. And your face has taken on a sickly grey hue. Have you missed me my pasty, swollen friend? Of course not. You are too busy with EHR, surgery, robots, family, research, horse meat chatter, papal scandals, Twitter, Facebook  and emails. Relax my people! Have you not read any of the latest research on productivity?

It is clear – my hard working friend – that you are not resting enough. A multitude of bio-shrinko-sociologic studies have proven as much. Did you read Tony Schwartz’s New York Times essay entitled: “Relax, You will be more Productive”. In it we learn that you can only work effectively for 90 minute intervals. In fact there is a biologic basis for this assertion.  Borrowing from sleep cycle experts and psychologists who have studied successful athletes, musicians, and artists it is a biologic factoid that we can only concentrate in 90 minute packages. That is all you need to know. Start compressing your operative cases to 90 minutes! Never mind that 90 minutes would only incorporate the bladder removal portion of your operation. We can do the nodes and reconstruction after my jog and light lunch of spinach tofu salad.

Want some more advice from the productivity experts? Of course you do. I am here to solve your problems today. Perhaps you have missed the latest and greatest TED talks on “The Art of Stress-Free Productivity”. Spend some time listening to this profound man – a Mr. Ted Allen. Find him here on YouTube. Let me paraphrase his advice: create a project list of everything that has a defined beginning and end in your life. Everything. Go ahead start writing it all down people. You need to look and update your lists every week. You need to sort, prioritize, collate, and make a master list that is all encompassing. You can not? Why? Because you are a surgeon and lead a life of uncertainty. Weak brother. Weak.

Fine. Let me suggest another tact: Get your pens out please. Read this essay by a famous oncologist Dr. Stephanie J. Lee entitled “Tips for Success As an Academic Clinical Investigator” published in the Journal of Clinical Oncology this past month. Ooh how the urotwitterati loved this essay. For days the reviews were glowing. And she does have some great words in this essay (chronophage is the best). To be clear there are 43 tips! Thankfully the last one is “Have fun!”. The others have a more pedantic and ridiculous tone – like “surround yourself with people of high standards, skills, work habits, and compatibility”. This amounts to making sure you work with eHarmony.com compatible co-workers – it’s a must for academic success but sadly impossible to implement. Other gems: “work many hours” (check!), “work efficiently” (uhhh I have residents), “think deeply and clearly”, “make a to-do list”, and “study others you admire”. The productivity list reads like a moral sermon from a high school teacher only less helpful.

Have I depressed you enough? I hope not. I want you angry. Very angy. Why? You must not have read the article by Nakamura et al “Prognostic Value of Depression, Anxiety, and Anger in Hospitalized CAD Patients for Predicting Adverse Cardiac Outcomes” in this week’s American Journal of Cardiology. You see anger my obese, stressed-out urology friend PREVENTS adverse cardiovascular outcomes (hazard ratio 0.34, p <0.01). So perk up my friends! Get angry – it’s good for you.

Benjamin Davies is Assistant Professor of Urology at the University of Pittsburgh; Program Director, Urologic Oncology Fellowship and Chief, Division of Urology Shadyside Hospital. His views are his own. @daviesbj

 

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Individualised reporting of surgical outcomes in the UK

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Its happening and its happening fast. What the cardiothoracic surgeons in the UK have lived with for 8 years is coming to a specialty near you very soon. Individual urological surgeons results to be published openly, in the press in the UK from summer 2013.

It’s a massive change to the way we work and to the way surgical data is presented. No longer will the interesting elements of the urological literature be studies of the results of a few surgeons in a few centres of world renown but rather the performance of outliers. Reports will start to reflect what is achieved throughout the nation not in one or two centres in that nation. Warts and all if you like.

There are risks. Big risks. For surgeons and for patients.

Will surgeons who operate on high risk cases be smeared because they appear to be underperforming?

Will patients who are high risk be denied operations because surgeons subliminally start to make recommendations that are good for the surgeon but not for the patient?

Will surgeons continue to train junior surgeons or will juniors simply cut the stitches?

Why should surgeons carry the can for the performance of the whole team?

Will sample sizes be big enough to ensure that results could not be due to chance?

What outcomes should we be measuring in order to judge the quality of many operations?

Who should collect the data – the surgeons or independent reviewers?

Are surgeons going to be tabloid fodder?

Is it simply time to head for the hills with a cigar and a bottle of red…..

In cardiac surgery all these were live questions and they have worked it out. Standards have been shown to be astonishingly high. Will urology be the same? The specialities have been challenged to come up with a plan. Why not contribute to that process and add to the blog….

Tim O’Brien is a Consultant Urological Surgeon at Guy’s and St Thomas’s NHS Hospital, London. His views are his own.

 

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Editorial: The need to devise a better means of training

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There is increasing concern that current UK trainees at the end of their training are less experienced than their previous counterparts and continue to require more education, skills and support when they assume their consultant posts in the form of mentoring.

It is generally accepted that the numbers of hours required to become an ‘expert’ is 10 000–30 000 and currently in the UK our trainees experience =6000 h of training. Much of this is due to the impact of the European Working Time Directive (EWTD) and the government ‘New Deal’ initiative on junior doctors contracts introduced in 2003. The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD. Skills training has therefore been seen as the mechanism to resolve the situation, encompassing the acquisition of both technical and non-technical skills. The challenge therefore is to devise innovative ways of training within the limit of fewer hours and training, not service, must become the priority for trainees and for those surgeons, departments and hospitals that train them.

Contemporary urology training is moving out of clinical practice and simulation is increasingly used to provide a safe and supportive learning environment for learning and maintaining skills. However, this needs the following criteria:

• An agreed curriculum

• Agreed set of standards

• A validated form of assessment

• The availability of local and national skills centres

• Educators and trainers

The problem is that traditionally the UK has few training centres, together with a lack of trained manpower and funding. However, controversy still remains over the efficacy of simulation for training and those who are able to fund such projects comment on the paucity of available data in relation to the predictability of future outcomes and patient safety.

Projects such as the Simulation and Technology enhanced Learning Initiative (STeLI) initiative documented in this paper are important contributors to the evidence base. The programme aims to establish the feasibility and acceptability of a centralised, simulation-based system incorporating both skills and non-technical skills aspects of training. The latter involving crisis resource management using the SimMan model to teach team-working, decision-making, and communication skills in various settings between senior and junior trainees. Not surprisingly senior trainees scored significantly better on virtual reality simulators, bench-top box trainers and the European wet-lab training facility, as well as in human patient simulation training in crisis resource management (CRM) using SimMan, than junior trainees. The interesting point raised in this paper is that the trainees’ behaviour shows the value of inclusion of the CRM training and the interplay between technical and non-technical skills. Non-technical skills have often been sidelined in courses focusing on technical skills acquisition and this paper highlights the importance and added-value of incorporating such a skill set into future course content and curricula.

Thus, there is no doubt that some surgical skills can be learned in the laboratory and although this will never be a substitute for operative experience, the first steps of training can be accelerated with potential reduction of risk to patients. Increasingly data from sources such as the STeLI project underline a better appreciation of the importance of the training in non-technical skills, which equip surgeons in working under stress and more importantly working as a team player. However, the ultimate test for simulation is whether the model and content is able to reduce surgical errors, improve patient safety and reduce operative time and costs. To try and answer these questions BAUS in conjunction with the Specialist Advisory Committee (SAC) in Urology have recognised that the technology is there but there is a need to identify trainers keen to train, with the nomination of a national lead for simulation to develop a national strategy to deliver a viable programme aligned to the curriculum to try and answer the important question: ‘Does simulation enhance real-life performance of a surgical technique?’.

Adrian D. Joyce
St James’ University Hospital, Leeds LS9 7TF, UK

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