Category: BJUI Blog

Editorial: Is botulinum toxin not the solution to OAB after all?

January 9, 2013/3 Comments/by Dirk De Ridder

Dirk De Ridder
Department of Urology, University Hospital Leuven, Belgium

The article by Mohee et al. highlights a problem that is often neglected: the outomes we see in clinical trials do not predict the success of the therapy in real life. We know this from anticholinergics: the study results are good, but the performance in real life is much poorer. Only 20-40% will continue to take the medication.

For botulinum toxin in OAB it is surprising to see that even in experienced hands only 38.7% of patients continued with the treatment at 36 months. The reasons to abandon the treatment were retention, the need for CISC and urinary tract infections. Moreover, 8.6% of the patients had no response at all after the initial injection.

Of course infections could have been avoided by using prophylactic antibiotics, but the other issues remain. How to explain the primary failures? How to manage the risk of CISC?

Given the fact that most patients abandoned the treatment within the first 3 years, more research would be needed on how to increase the treatment adherence of the patients after the initial injection.

This challenging article also stresses the fact that in a time where only RCTs stand a good chance of being published in journals, good retrospective cohort studies can be extremely important too.

Read the full article

Ten stories of 2012, part II

January 8, 2013/by Quoc-Dien Trinh

Thanks for all the helpful input regarding my first blog post. Constructive criticism is always helpful, especially if I am to get better at this.

If you haven’t read it, part 1 is here.

So, in no particular order, part 2 of 2:

+ Metastatic prostate cancer – it’s getting complicated…

2012 was a year of hope for metastatic prostate cancer patients. First, Enzalutamide (also known as MDV3100), in the context of a phase III RCT, was shown to prolong the survival of men with metastatic prostate cancer after chemo. And just when we thought the year was over, Abiraterone, which was previously shown to improve survival in patients with metastatic prostate cancer after chemotherapy, was found to be beneficial even in chemo-naive patients. All this translates into more complicated algorithms for castrate-resistant prostate cancer. That said, my question is the following: what happens if these drugs are effective at treating localized prostate cancer? It seems that some medical oncologists are trying to figure that out. Prostatectomists, murky waters lie ahead! Oh wait, I’m part of that group.

+ The changing landscape of surgical education

Times They Are a-Changin’. Residents are working less but don’t sleep more. 16-hour work day restrictions. More women are admitted into surgical fields. Protected nap (sleep) time during calls. Residents not covering floor consults during the day (those are actually the rules where I work). Most trainees now value quality of life above anything else, possibly even the quality of their training (do read this beautiful piece by a Urologist in JAMA: ‘Considering Life Before Lifestyle‘. Yet, the amount of knowledge a resident needs to consolidate during residency is at least 10-fold greater than what the old geezers had to learn back in the days (the current Campbell-Walsh is 134 chapters, 4320 pages). Whether or not you agree with any of the above (which is irrelevant anyways, because it’s happening whether you like it or not), attending surgeons and urologists are finding it hard to adapt or understand. “Honey, things were much harder back when I was a resident…” How do we evolve as a sub-specialty without compromising surgical education (or lengthening residency)? Status quo is not an option.

+ Radiotherapy for prostate cancer – what’s up with that?

A nice observational study from Sheets et al in the JAMA thematic issue on Comparative Effectiveness Research showed that “use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction“. Yet, Jacobs et al, using the same dataset and almost the same study years, showed that the risks of salvage therapy and complications are comparable between the two modalities, for most patients. And let’s not get started about proton-beam therapy. Whilst this costly approach is gaining precedence in the treatment of localized prostate cancer, severe doubts exist regarding its efficacy. The bombshell: another observational study from Yale, based on Medicare data: “Although proton radiotherapy is substantially more costly than IMRT, there was no difference in toxicity in a comprehensive cohort of Medicare beneficiaries with prostate cancer at 12 months post-treatment“. Ouch. To be perfectly honest (sometimes I’m told I should shut up), it would be hypocrisy for robotic surgery fanboys to condemn proton beam therapy right now. As we all know, it took years before convincing observational data showed that robotic radical prostatectomy is better than open, at some levels. Maybe someone responsible will actually perform a prospective comparative effectiveness assessment between these modalities. As an avid blogger suggests, maybe the proton beams and the robots should fight for world domination.

+ Urology at the forefront of the social media revolution

As a group, we should be proud of how we embraced social media in 2012. In the field of medicine, where anything novel is usually met with smirk and mockery (see: surgery, robot-assisted), social media has been surprisingly well received, thanks to a tight-knit community of twitter champions (if you’re new to twitter, you should definitely follow urologymatch.com’s list of key opinion leaders (KOLs) in Urology. Moreover, the first International Urology Journal Club was held in November 2012 and has been a global success ever since. I’m sure that 2012 was only the start. It will be exciting to see the role of social media in upcoming international meetings such as the EAU, AUA and BAUS. Virtual high-five everyone!

+ Be inspired.

OK, so this one has nothing to do with Urology, or Medicine for that matter. Here’s a toast to the events that shook 2012, and let’s hope that 2013 will be a great year!

Quoc-Dien Trinh
@qdtrinh

Quoc-Dien Trinh is a minimally-invasive urologist and co-director of the Cancer Prognostics and Health Outcomes Unit. His research focuses on patterns of care, costs and outcomes in prostate cancer treatment.

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International Urology Journal Club on Twitter

January 3, 2013/9 Comments/by Henry Woo

International Urology Journal Club on Twitter: The Beginnings of a New Application of Social Media in Urology CME

The International Urology Journal Club on Twitter almost came about by accident, although the formation of such was an inevitability. Over the course of 2012, a number of research papers have been the subjects of discussion amongst urologists on Twitter.

The standout paper as example for discussion in 2012 was the PIVOT study. This generated comments that were difficult to follow unless you were following all of the many participants. Although one could find the majority of the tweets in chronological order by doing a search under the tab “Discover”, it was still dependent upon whether the term PIVOT was used in the tweet or not – it was quite often the case that a comment was made without the term PIVOT being used and these would be missed by a search for PIVOT. In essence, a form of journal club was already happening although there was no organized manner by which all comments could be filed or arranged to provide context. When limited to 140 characters, a tweet can easily lose context if it cannot be connected to other tweets it may refer to or be in reply to. The use of a hashtag provides a filing system for related tweets and had all participants in the PIVOT study discussion used the hashtag #PIVOT, a search under that term would have enabled easy following and review of the discussion pertaining to that topic. The use of a hashtag does require general agreement by contributors that this will be the agreed filing (this is what I call it even though it is not a universal way of describing it) system for the tweets. It also meant that inclusion of long twitter handle names such as @cooperberg_ucsf would not eat into the precious 140 character limit to which we wish to make comment – as we are a tolerant, respectful and good humoured community, we of course continue to tolerate this blight on our character count. (I have incidentally shortened my Twitter name from @DrHenryWoo to @DrHWoo as a donation of 4 precious characters to those who wish to engage me on Twitter).

So how did the International Urology Journal Club on Twitter come about? It all started with Canadian urologist Michael Leveridge sending a few live tweets from his local journal club and nominally used the hastag #quroljc, which stood for Queens Urology Journal Club. A number of urology colleagues around the world, including myself, were intrigued by this.

Following an exchange of tweets, we came to realization that we were effectively engaging in a Twitter urology journal club. We soon realized that in order to do this effectively, we needed a hashtag to which we could all tweet our journal club responses and the hastag #urojc was born.

According to the exchange of tweets above, we can credit Michael Leveridge for coining the hashtag #urojc. On Twitter, it does not take long for the message to spread.

To administer Journal Club, an administrative account @iurojc and specific blog account was established. You will note that the administrative account is @iurojc and not @urojc since the latter had already been taken by another urologist. The #urojc blog carries information about the journal club as well as the tweet logs from the discussions.

In short, a recently published manuscript is selected for each month’s discussion. Such manuscripts are usually those that have been published online ahead of print in order to offer the most cutting edge research discussion. Discussions occur on the first Sunday or Monday of each month depending on which time zone you are in. Tweet discussion is carried out in an asynchronous manner over the course of 48 hours. Since commencing in November 2012, there has been a truly global engagement and with the amplification effect of Social Media, we have seen in excess of 50,000 impressions (a Twitter metric of reach). A novel approach to this format of journal club is the invitation and participation of the lead author and/or corresponding author associated with the paper for discussion – there is no question that this significantly enhances the value of the discussion.

Prior to the commencement of the first #urojc discussion, it was suggested that there should be a prize for the best tweet. This has now been instituted and a #urojc Hall of Fame is now in the making. With the Best Tweet prize for November 2012 being awarded to Ben Davies, it has only fueled his belief that he is indeed the urological King of Twitter. He is, however, the inaugural prize winner and at the top of the list of the #urojc Twitter Hall of Fame. The winner of the December Best Tweet Prize was another Ben, namely Ben Jackson. We thank Urology Match and Nature Reviews in Urology for donating the prizes for November and December respectively. Whilst there were suggestions of a Ben conspiracy, we cannot promise that the January Best Tweet Prize, which has been donated by the Urological Society of Australia and New Zealand (USANZ) will be awarded to a non-Ben participant.

It is our belief that the #urojc is the first truly international clinical journal club discussion taking place on Twitter in an organized manner. Whilst there are local real time Twitter journal club chats and similar discussions in non-clinical areas of health care, this is again a demonstration of how urologists lead the way with the embracement of technology to advance health care. For now, the discussions are on a monthly basis with a focus on uro-oncology. As interest grows, the plan is to expand to twice monthly with the mid-month discussion being on topics such as endourology or voiding dysfunction or female urology or any other area of interest. Do follow @iurojc and put forward your suggestions for papers to discuss. Again remember that the Twitter user name is slightly different to the hashtag, which is #urojc.

We look forward to having you join us for the next #urojc.

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

January #urojc paper will be on PHI by @LoebStacy jurology.com/article/S0022-… ncbi.nlm.nih.gov/pubmed/23206426

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“The most read surgical journal on the web”

January 2, 2013/3 Comments/by Prokar Dasgupta

It is an enormous privilege becoming the new Editor-in-Chief of the BJUI. As an academic it has been my ultimate dream. Thank you for this exciting opportunity to serve our readers and authors. I also wanted to express my gratitude to our editorial board and reviewers without whom this journal would not exist.

Early one morning during the BAUS annual meeting 2012, I had the great pleasure of having breakfast with John Fitzpatrick. He has done wonders with the BJUI and I wish to thank and congratulate him for his excellent leadership, international collaboration and innovative approach, which has established the journal as a global landmark in urology. I asked him to describe his most important contribution to the BJUI in one word. The answer without hesitation was ‘colour’.

John immediately asked me the same question. With equal conviction I uttered the words that would describe the BJUI in the next 5 years –’the web’.

The other day I made my usual trip to the Guy’s Hospital, King’s College London, library. I love reading the new journals as well as archived copies that are stored on the first floor. I have done so regularly for the last 10 years. On this occasion I requested our friendly librarian to guide me towards the new editions of Science and the N Engl J Med. Rather to my astonishment, she said that the first floor had been shut and there were no paper journals there anymore! Instead she directed me to a computer terminal where I could browse every scientific journal with my college user name and password. It was then that I realised that my own library had stopped subscribing to paper journals. I have since learned that many other libraries have done the same. Libraries and not urologists are the largest subscribers of the BJUI. If they do not want paper journals they are just not going to buy them.

Welcome to the green revolution.

Over the next few years it will be my mission to make the BJUI the most read surgical journal on the web. We have not made the mistake of assuming that this is what all our readers want. Therefore, while we make the transition to the web, the paper version continues, but with a few differences. We will be reducing the number of paper issues to once a month. Our readers have told us that as soon as the first edition comes out of its plastic cover, the next one arrives. This is often rather overwhelming for a busy urologist who may find it challenging to find the important messages. A direct result of reducing the number of volumes is that fewer papers will ultimately be published and the acceptance rate will fall to ~15%. A triage system has been introduced whereby papers that are not felt to be suitable for the new journal are returned immediately to the authors. This is not a reflection of the quality of the papers but reduces wastage of valuable time and allows the articles to be submitted elsewhere without delay.

The BJUI website www.bjui.org has been entirely redesigned and, in keeping with our main mission statement, I have gathered a dedicated new team of enthusiastic innovators. You will notice that unlike other journals we have Associate Editors for innovation, impact, web, social media and design. These are young urologists with unique skills allowing us to deliver the BJUI on an exciting web-based platform that will evolve continuously. I hope you can join us on this journey.

The busy modern surgeon has a short attention span. If we cannot attract them to our key messages within 30 seconds of reaching our landing page, it is unlikely that they will stay there for 3 minutes rather than go elsewhere. Extensive studies and searches on web-based metrics have made these facts obvious to me. These are the realities of modern academic publishing. The web-based journal will have a much wider readership, not just amongst urologists but also other doctors, nurses, students and most importantly patients and their families.

With this in mind we have introduced the ‘article of the week’, almost like the headline news of The Times. If most urologists read just this on their iPads or smart phones, rather than ever even look at the paper version, we have successfully made our point. This month one such article is the updated Partin tables. As a predictive tool, they are important to urologists and patients alike and will allow our readers to counsel patients about the potential outcomes after treatment of their prostate cancer.

Another new feature is the BJUI blog for immediacy, HuffPost style; the days of writing a letter to the editor that gets published a year later are no more. Instead, your opinions will be moderated and appear real time on the website. The debate will be timely, educational and enjoyable.

Social media, especially Twitter, will play an important role in highlighting the most important content and allowing rapid interaction during international meetings. We have engaged the services of a group specialising in social media and I urge you to follow the BJUI on Facebook and Twitter. Who knows ‘tweetations’ might become as important as the impact factor, one day soon.

Finally, I wanted to especially thank Francesco Montorsi for inspiring me during dinner one autumn evening in Milan, where I had been invited to review a European Union grant application. The lesson I learnt from him was humility. As the Editor-in-Chief I always remember an important tale published by Hans Christian Andersen in 1837. ‘The Emperor’s New Clothes’ describes what happens when a vain king is paraded by two rogue weavers in his invisible new clothes through the streets of his own capital. I hope I will always manage to avoid the ‘emperor syndrome’. My job is to serve our readers and focus above all on the one thing that is of utmost importance to the BJUI – quality.

Prokar Dasgupta

Twitter: my #eurekamoment #pennydrops #babyvomit

January 2, 2013/4 Comments/by Declan Murphy

I remember distinctly when the penny dropped for me. It was about 2am on a warm summer’s night in early January 2012 (apologies to those of you shivering in the Northern Hemisphere). I had my one-week old son in one arm, swinging between sleeping and spewing, and an iPad in my other hand, providing distraction between nappy changes and feeds. The sleep-deprivation had dulled my senses considerably and my brain was capable of no more than light reading.

It was then I read a piece in the New York Times online about the power of Twitter in medical communication. Previously, I thought Twitter was the domain of Lady Gaga, Justin Bieber, Kim Kardashian (Kim who?) and various narcissistic cricket and football players. It seemed like puerile nonsense for a generation that I no longer belonged to. However, reading this opinion piece made me think again. It was clear that there is a whole generation of significant academic clinicians, researchers and publishers who have embraced social media and who use Twitter, in particular, to disseminate their work with a speed and reach that is simply unachievable through any other medium. I was struck by various examples of how key scientific publications are first flagged on Twitter and how within hours, responses are made by key opinion leaders and these responses are again disseminated rapidly around the Twittersphere. And although none of the examples were based around urology, it was clear to me that oncologists and surgeons were getting on board the social media rollercoaster.

So between nappy changes and having wiped some baby vomit off my iPad, I logged onto Twitter and created a username. I searched for prostate cancer and urology and quickly found my way to a few key resources and super-users who seemed to have a very active Twitter presence and who were tweeting content that immediately appeared of interest to me. Within a few minutes I had identified a few highly valuable Twitter users to follow and within their lists of followers and those who they were following, I quickly built up a useful stream of tweets dropping into my timeline. And then of course, a few of these Twitterers started following me back, which was mildly exciting. Within a few days and having posted a few tweaks, I began to feel part of the Twittersphere.

As the weeks went by, I continued to be astounded by just how fast information travels on Twitter. While I get emails with the table of contents for the various journals that I subscribe to, these only drop in my inbox every few weeks. Also, because there are a number of significant journals that I do not subscribe to (non-urological mostly), there are many papers published out there that do not come immediately to my attention. Depending on which Twitter sites you follow, all key papers related to your area of interest find their way into your timeline instantaneously as soon as they are published. Not just that, very interesting comment from others also gets to you very quickly. For example, key findings in prostate cancer tend to be picked up by the major US news sites who then invite comment from key leaders in major cancer centres. A typical example is that of the PSA screening recommendations made by the United States Preventive Services Taskforce in June 2012, which provoked huge controversy. Twitter came to life and key opinion leaders such as Matt Cooperberg (@cooperberg_ucsf) helped drive the conversation through Twitter and blogs (e.g.The Huffington Post blog) at lightning speed. These comments get tweeted out and responses to these comments also get blogged and within hours of a paper being published you have news of the paper, expert comment and wider reaction…… all in 140 characters or less!

And while none of us have much time in the day to add an extra task, I find that waiting for my coffee in the morning or while the resident puts an arterial line in my next patient, there are a few spare moments in the day where the Twitter app on my iPhone comes to life. Twitter is perfectly suited to the smart phone user and that is where the majority of tweets around the world are generated from. It is also perfectly suited for one of the other very exciting areas in which I have seen Twitter play a very useful role – that of conferencing. At the EAU in Paris, a small but energetic group of Twitter users started tweeting content from various sessions at this large meeting and started engaging with other Twitter users around the world. For me, I believe conferencing is about to be transformed by the power of social media but more about that soon.

For now, at the new BJUI, we want to grow the audience and get you all to join the conversation. Through Twitter, blogging, Facebook, YouTube and other social media platforms, we are building for the future of communication in urology. The next generation of trainees will be deeply embedded in all of these platforms and will expect to be engaged through them. We are entering a new generation of medical communication – come join the conversation.

Declan Murphy
@declangmurphy

Declan Murphy is Honorary Clinical Associate Professor at the Department of Surgery, University of Melbourne, St Vincent’s Hospital and Director of Robotic Surgery at the Peter MacCallum Cancer Centre. He had previously been consultant urological surgeon at Guys & St Thomas’ NHS Foundation Trust in London.

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Ten stories of 2012, part I

January 2, 2013/2 Comments/by Quoc-Dien Trinh

It is now my turn to welcome you to the BJUI blog. We [the editorial team] hope that you will be as excited as we are about the future. For my first blog posts, I decided to recap the year 2012 in ten stories. These are topics that caught my attention in 2012, and are certainly not representative of what others might think as ‘important’. Nonetheless, I hope that you will find this curated collection of some interest, and maybe stir a little controversy or two. Happy 2013!

In no particular order, part 1 of 2:

+ The re-election of Barack Obama

The bottom line is that the Patient Protection and Affordable Care Act, AKA Obamacare, will happen. What does this mean for American Urologists? Read the excellent review article by Kirk Keagan and Dave Penson on this sweeping piece of legislation aimed at addressing health care costs and disparities. From the paper: “Perhaps most germane to urologists, the ACA will restrain revenues generated from ancillary services, such as in-office imaging and via a bolstered Stark law that will prohibit physicians from referring Medicare patients to a hospital in which they have an investment or ownership interest.” Word on the street is that the AUA is not too happy. Is America ready for Cheesecake medicine?

+ Is robot-assisted radical prostatectomy really better?

Against a background of Jim Hu’s landmark JAMA paper, we learned new things with respect to the robot-assisted (RARP) vs. open RP (ORP) polemic. First, objective data shows that RARP has overtaken ORP as the main surgical approach for prostate cancer in the U.S (Link)(Link). Second, perioperative outcomes of RARP are better (Link)(Link)(Link). Third, RARP costs more. Fourth, nobody knows for functional outcomes (Link)(Link)(Link). Either way, some people really seem to hate robotic surgery, with a vengeance.

+ PSA screening – the controversy that refuses to die…

2012 will be forever (well, at least for nerdy urologists) remembered as the year the USPSTF downgraded PSA screening to a ‘D’ recommendation. In case you live in a cave, that means that “the science shows that more men will be harmed by PSA screening than will benefit. The expected harms are greater than the small potential benefit.” Nice rebuttal by Carlsson et al from MSKCC here. Nonetheless, primary care providers don’t seem to care, as up to 43.9% of men above the age of 74 were still getting screened in 2010. Conversely, in an article emphatically subtitled ‘Less is More’, the evidence shows that the incidence of prostate cancer is, for the first time in decades, decreasing. Prostatectomists, better find something else to do (just trolling, no hate mail please).

+ PSA screening – the Twitter Wars

2012 was a breakthrough year for social media in Urology. In the past year, Twitter has gained considerable traction in our field, thanks to the presence of Tweet (and real world) leaders such as Matt Cooperberg, Tony Finelli, Alex Kutikov, Mike Leveridge, Stacy Loeb, our own Declan Murphy, Dave Penson, Maxine Sun and the self-proclaimed King of Twitter himself, Ben Davies. That said, December hosted some lively exchanges on PSA screening. It started with a nicely-written-yet-a-little-oversimplistic blog post and accompanying tweet by @CBayneMD in favour of PSA screening, which led to some epic jostling between @cooperberg_ucsf (pro-screening) and @kennylinafp (against screening, wrote the evidence review for the USPSTF), amongst others. @daviesbj summary here. Oh yeah, be sure to follow me on Twitter as well as the BJUI itself.

+ The PIVOT trial

Timothy Wilt, of USPSTF fame, strikes again. Here’s one man who won’t be getting a Christmas card from an Urologist anytime soon. After representing the USPSTF at the 2012 AUA Town Hall Meeting (brave), Wilt et al’s PIVOT trial demonstrated that “among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality, as compared with observation, through at least 12 years of follow-up.” Despite its many limitations and flaws (read Ian Thompson’s excellent accompanying editorial here), the lay press suggested in light of this trial that RP does not save lives.

Quoc-Dien Trinh
@qdtrinh

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Editorial: What have we learned from the Partin table update?

January 2, 2013/by John Davis

The controversies surrounding a physician’s best treatment strategy advice to an individual patient with clinically localized prostate cancer create a continuing need for advanced statistics. Historically, the Partin tables [1] were one of the first statistical tools that physicians and patients found readily usable. The tables have been updated and always focused on prediction of pathologic stage from standard clinical variables. The next commonly cited/used tool was the Kattan nomogram [2] that carried the prediction the next step to the endpoint of biochemical relapse. By 2008, Shariat et al catalogued over 100 predictive tools published from 1966 to 2007 on various endpoints of prostate cancer [3].

What have we learned from this update of the Partin tables?

The pre-operative grade distribution has shifted up slightly with no change in prostatectomy grade/stage distribution. The authors discuss possible causes such as changes in interpreting the Gleason scoring system, shifts in selection for surgery away from lower grade patients, and a possible plateau in stage migration.
The tables have split off Gleason 3+4, 4+3, 8, and 9–10, and found the latter significantly more aggressive, while Gleason 4+3 and 4+4 are more similar. Gleason 9–10 must have a pattern 5 component >5% and may therefore have more aggressive biology. On the other hand, two cases of prostate cancer may have identical volumes of 4 pattern, but if one adds additional 3 pattern, that additional tumour foci paradoxically lowers the sum to 7, but perhaps not the risk of non-organ confined stage.
In the past, the tables were commonly used to predict pT3 stage, with possible change in management away from surgery as that risk increased. Clearly the literature on surgery for higher risk disease has matured, and augmented by the adjuvant/salvage radiation literature such that it is less likely to use the tables for this reason any more. On the other hand, prediction of N1 disease for the purpose of omitting a lymph node dissection remains a useful tool. In this update, using a <2% cut-off you would essentially omit all node dissections in Gleason 6 with PSA < 10 and cT1c/cT2a, while continuing with a dissection for any dominant Gleason 4 pattern. It is noteworthy that this experience was largely based upon standard templates, and those advocating extended templates will find these N1 rates too low. Indeed, when our center adopted the extended template using a robotic technique, the N1 rate for high-risk disease was 39% and 9% for intermediate risk [4]. Moving forward, what tools do we need to provide useful statistics to our patients? Updating old tools with more contemporary patient cohorts is certainly a worthy exercise. Multicentre study based tools will be required for endpoints such as positive surgical margins, quality of life, biochemical recurrence, and other endpoints that may be significantly affected by the experience of the treating physician. Beyond this, the next step should be adaptive nomograms that update in real time rather than en masse every 4–5 years [5].

John W. Davis
Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

References
1 Eifler JB, Feng Z, Lin BM et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int 2013; 111: 26–33
2 Kattan MW, Eastham JA, Stapleton AM et al. A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer. J Natl Cancer Inst 1998; 90: 766–71
3 Shariat SF, Karakiewicz PI, Roehborn CG, Kattan MW. An updated catalog of prostate cancer predictive tools. Cancer 2008; 113: 3075–99
4 Davis JW, Shah JB, Achim M. Robot-assisted extended pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP): a video-based illustration of technique, results, and unmet patient selection needs. BJUI 2011; 108: 993–8
5 Vickers AJ, Fearn P, Scardino PT et al. Why can’t nomograms be more like Neflix? Urology 2010; 75: 511–3

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Editorial Commentary: Rising to the Challenge

December 20, 2012/by admin Z.9

BJUI Editorial Commentary: Rising to the Challenge.
Roger S. Kirby and John M. Fitzpatrick

Before 1995 there were effectively no charities in the UK the aim of which was to support research, education and training in urology. As a consequence, around that time, four charitable organisations sprung up and have since gone on to ﬂourish; now, together, they raise >£20 million per year.

Kirby RS, Fitzpatrick JM. Rising to the challenge. BJU Int 2012, Vol 110, Issue 11.

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