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BJUI Annual Awards

July 10, 2019/by Admin

Trainees who have a paper accepted for publication in the BJU International Journal are eligible for one of the following three BJUI Journal Prizes, which are awarded annually, based on the authors’ geographical location when they conducted the research.

The BJUI Global prize

This is awarded to authors who are trainees based anywhere in the world other than the Americas and Europe. The prize is presented at the USANZ annual meeting. In 2019 the BJUI Global prize was presented to Dr Amila Siriwardana from St Vincent’s Prostate Cancer Centre in Sydney, Australia for his article: Initial multicentre experience of ⁶⁸gallium‐PSMA PET/CT guided robot‐assisted salvage lymphadenectomy: acceptable safety profile but oncological benefit appears limited.

The Coffey-Krane prize

The Coffey-Krane prize is awarded to authors who are trainees based in The Americas and it is presented at the AUA annual conference, which was held this year in Chicago. There were two winners this year: Jeffrey J. Tosoian and Meera R. Chappidi from the Johns Hopkins University School of Medicine in Baltimore, USA for their work on: Prognostic utility of biopsy‐derived cell cycle progression score in patients with National Comprehensive Cancer Network low‐risk prostate cancer undergoing radical prostatectomy: implications for treatment guidance.

The John Blandy prize

The John Blandy prize is awarded to authors who are trainees based in Europe. The prize is presented at the BAUS annual conference and the winner gives a presentation. The 2019 award was given to Isabel Rauscher from the Technical University of Munich in Germany, who gave a talk at the conference in Glasgow in June. Her article is entitled: Value of ¹¹¹In‐prostate‐specific membrane antigen (PSMA)‐radioguided surgery for salvage lymphadenectomy in recurrent prostate cancer: correlation with histopathology and clinical follow‐up.

BJUI Vattikuti Foundation Robotics prize

This prize is a one-off prize awarded for the best robotics paper recently published in the BJU International Journal. The prize is sponsored by the Vattikuti Foundation and voted for by an independent panel. The research was carried out by a team from the Yonsei University College of Medicine in Seoul, South Korea on: Does robot‐assisted radical prostatectomy benefit patients with prostate cancer and bone oligometastases?

Article of the week: 68Ga‐PSMA PET/CT predicts complete biochemical response from RP and lymph node dissection in intermediate‐ and high‐risk PCa

July 10, 2019/by Admin

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this month, it should be this one.

Gallium‐68‐prostate‐specific membrane antigen (⁶⁸Ga‐PSMA) positron emission tomography (PET)/computed tomography (CT) predicts complete biochemical response from radical prostatectomy and lymph node dissection in intermediate‐ and high‐risk prostate cancer

Pim J. van Leeuwen*, Maarten Donswijk^†, Rohan Nandurkar^‡, Phillip Stricker^§¶, Bao Ho**, Stijn Heijmink^††, Esther M.K. Wit*, Corinne Tillier*, Erik van Muilenkom*, Quoc Nguyen^§, Henk G. van der Poel* and Louise Emmett^‡§**

*Department of Urology, ^†Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands, ^‡Faculty of Medicine, University of New South Wales Sydney, ^§The Australian Prostate Cancer Research Centre-NSW, The Garvan Institute of Medical Research, ^¶St Vincent’s Clinic, **Department of Theranostics and Nuclear Medicine, St Vincent’s Hospital Sydney, Sydney, New South Wales, Australia and ^††Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands

Read the full article

Abstract

Objective

To determine the value of gallium‐68‐prostate‐specific membrane antigen (⁶⁸Ga‐PSMA)‐11 positron emission tomography (PET) /computed tomography (CT) in men with newly diagnosed prostate cancer.

Patients and methods

We analysed results of 140 men with intermediate‐ and high‐risk prostate cancer. All men underwent ⁶⁸Ga‐PSMA‐11 PET/CT and multiparametric magnetic resonance imaging (mpMRI) before radical prostatectomy (RP) with extended pelvic lymph node (LN) dissection. For each patient, the clinical and pathological features were recorded. Prostate‐specific antigen (PSA) was documented at staging scan, and after RP, at a median (interquartile range) of 110 (49–132) days. A PSA level of ≥0.03 ng/mL was classified as biochemical persistence (BCP). Logistic regression was performed for association of clinical variables and BCP.

Results

In these 140 patients with intermediate‐ and high‐risk prostate cancer, 27.1% had PSMA PET/CT‐positive findings in the pelvic LNs. Sensitivity and specificity for detection of LN metastases were 53% and 88% (PSMA PET/CT) and 14% and 99% (mpMRI), respectively. The overall BCP rate was 25.7%. The BCP rate was 16.7% in men who were PSMA PET/CT LN‐negative compared to 50% in men who were PSMA PET/CT LN‐positive (P < 0.05). The presence of PSMA‐positive pelvic LNs was more predictive of BCP after RP than cT‐stage, PSA level, and the Gleason score, adjusted for surgical margins status.

Conclusions

⁶⁸Ga‐PSMA‐11 PET/CT is highly predictive of BCP after RP, and should play an important role informing men with intermediate‐ or high‐risk prostate cancer.

Editorial: Preoperative PSMA‐targeted PET imaging: more than just a tool for prostate cancer staging?

July 10, 2019/by Michael Gorin

The presence of lymph node metastases at the time of prostate cancer diagnosis has significant implications for treatment. According to current guidelines from the National Comprehensive Cancer Network, men with positive lymph nodes on initial staging imaging should be offered treatment with androgen deprivation (± abiraterone) along with consideration for external beam radiation therapy [1]. In contrast, men with clinically localised high‐ or very‐high‐risk prostate cancer have the option of undergoing radical prostatectomy. Unfortunately, currently available diagnostic imaging modalities (i.e. contrast‐enhanced CT and MRI) fall short in their ability to accurately identify lymph node metastases, which are often small and difficult to discern from other structures within the pelvis. Thus, there exists a conundrum: if we cannot accurately detect lymph node involvement, how can we appropriately manage it?

In this edition of the BJUI, Leeuwen et al. [2] report on the utility of molecular imaging with ⁶⁸Ga‐PSMA‐11 positron emission tomography (PET)/CT in the preoperative staging of men with prostate cancer. To date, the greatest clinical utility of PSMA‐targeted PET has been in the management of men with biochemically recurrent prostate cancer [3]. In the present study by Leeuwen et al. [2], 140 patients with newly diagnosed intermediate‐ or high‐ risk prostate cancer underwent ⁶⁸Ga‐PSMA‐11 PET/CT before radical prostatectomy with extended pelvic lymph node dissection. Surgical pathology served as the reference standard to which findings on ⁶⁸Ga‐PSMA‐11 PET/CT were compared. In total, 27.1% of men were found to have radiotracer uptake in their pelvic lymph nodes, resulting in a sensitivity of 53% and a specificity of 88%. In contrast, multiparametric MRI had a sensitivity of only 14%, albeit with a higher specificity of 99%. These findings are in line with prior studies evaluating the diagnostic performance of PSMA‐targeted PET imaging for preoperative prostate cancer staging [4]. Of greater interest, however, is the authors’ observation that positivity on ⁶⁸Ga‐PSMA‐11 PET/CT was strongly associated with postoperative PSA persistence (i.e. failure to cure). More specifically, after controlling for Gleason score, surgical margin status, and preoperative PSA level, positivity on PET/CT had an odds ratio of 5.87 (95% CI 1.30–26.59) for biochemical persistence. Furthermore, men with pN1 disease and a positive preoperative PET/CT (i.e. true positives) were over three times more likely to experience biochemical persistence than patients with pN1 disease and negative imaging (71.4% vs 21.4%). Thus, PSMA‐targeted PET not only stands to inform clinical staging, but also has the potential to offer independent prognostic information.

A future line of investigation is to explore the biological basis of the authors’ observation regarding PSMA as a prognostic marker. One explanation is that PET/CT identified men with higher volume lymph node metastases (a known prognostic factor), whilst patients with smaller more curable nodes were negative on imaging. After all, the authors state that the imaging test did not detect any pathologically positive lymph nodes <2 mm. Furthermore, only 27% of positive lymph nodes between 2 and 4 mm showed radiotracer uptake. Unfortunately, the authors did not account for differences in the volume of nodal metastases in their analysis. A second possible explanation for the authors’ observation is that PSMA is upregulated through the same signaling pathways that drive an aggressive prostate cancer phenotype, allowing for PSMA expression to provide prognostic information independent of tumour volume. Indeed, others have previously shown that PSMA expression, as measured by immunohistochemistry, corresponds with increasing tumour grade, stage and risk of biochemical failure [5]. Of course, these concepts are not mutually exclusive and further investigation is needed in order for PSMA‐targeted imaging to be rationally applied as a prognostic test.

References

NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer (Version 4.2018). 2018. Accessed November 2018. Available at: https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf.
Leeuwen, PJ, Donswijk, M, Nandurkar, R et al. Gallium‐68‐prostate‐specific membrane antigen (⁶⁸Ga‐PSMA) positron emission tomography (PET)/computed tomography (CT) predicts complete biochemical response from radical prostatectomy and lymph node dissection in intermediate‐ and high‐risk prostate cancer. BJU Int 2019; 124: 62– 8
Han, S, Woo, S, Kim, YJ, Suh, CH. Impact of ⁶⁸Ga‐PSMA PET on the management of patients with prostate cancer: a systematic review and meta‐analysis. Eur Urol 2018; 74: 179– 90
Gorin, MA, Rowe, SP, Patel, HD et al. Prostate specific membrane antigen targeted ¹⁸F‐DCFPyL positron emission tomography/computerized tomography for the preoperative staging of high risk prostate cancer: results of a prospective, phase II, single center study. J Urol 2018; 199: 126– 32
Minner, S, Wittmer, C, Graefen, M et al. High level PSMA expression is associated with early PSA recurrence in surgically treated prostate cancer. Prostate 2011; 71: 281– 8

What’s the diagnosis?

July 5, 2019/by Admin

This patient underwent a robotic partial nephrectomy and then underwent this scan (from Nouhaud et al. BJUI 2019)

No such quiz/survey/poll

Re: Suture Techniques during Laparoscopic and Robot-Assisted Partial Nephrectomy

July 4, 2019/by Admin

Letter to the Editor

Suture Techniques during Laparoscopic and Robot-Assisted Partial Nephrectomy: A Systematic Review and Quantitative Synthesis of Peri-Operative Outcomes

Dear Sir,

We would like to congratulate the authors of this systematic review [1] highlighting the evolution of suture techniques for partial nephrectomy in the era of minimally invasive surgery. The authors note the “significant technical modification” for the replacement of intracorporeal free-hand knot tying with a sliding clip technique [2]. This technique has revolutionised the practice of PN and reduced the risk of the “cheese cutting effect” with the conventional suturing techniques. It is worth noting that this laparoscopic technique was first described by Agarwal et al in the BJUI in 2007 [3]. Indeed one of the authors of this SR also published on the robotic application of this technique in a publication in European Urology in 2009 (2), which also was remiss in referencing the original description of the technique by Agarwal et al., published 2 years prior.

This oversight aside, the authors should be commended for helping to frame the evolution of surgical techniques across minimally invasive approaches over time, with the ultimate goal of complete tumour excision, minimal complications and maximal functional preservation, since we’re using more technology now a days for advance study of medicine, like robots or CT scanners, although the cost of these CT scanners could be high, the value is worthy because they help a lot in the medicine area. While this paper’s title suggests a focus on suture techniques during surgery the authors concluding remarks do not address this focus. We believe suturing techniques will continue to evolve, and that there will be further technological, and technical innovation that will further improve outcomes for patients and will make more meaningful additions to the published literature in this field.

Brian D Kelly, Christophe Orye, Homi Zargar, Anthony J Costello and Dinesh Agarwal

Correspondence: Dinesh Agarwal, Urology Unit, Level 3 Centre, Infill Building, The Royal Melbourne Hospital, City Campus, Grattan Street, Parkville 3050 Victoria, Australia.
e-mail: [email protected]

References

Bertolo, Riccardo et al. Suture Techniques during Laparoscopic and Robot-Assisted Partial Nephrectomy: A Systematic Review and Quantitative Synthesis of Peri-Operative Outcomes. BJU Int 2018; 123:923-46 doi:https://dx.doi.org/10.1111/bju.14537.
Benway, Brian M et al. Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes. Eur Urol 2009; 55:592-9 doi:10.1016/j.eururo.2008.12.028.
Agarwal, Dinesh et al. Modified Technique of Renal Defect Closure Following Laparoscopic Partial Nephrectomy. BJU Int 2007; 100:967-70 doi:10.1111/j.1464-410x.2007.07104.x.

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Article of the week: Examining the relationship between complications and perioperative mortality following radical cystectomy: a population‐based analysis

July 3, 2019/by Admin

If you only have time to read one article this month, it should be this one.

Examining the relationship between complications and perioperative mortality following radical cystectomy: a population‐based analysis

Matthew Mossanen*^†‡, Ross E. Krasnow^§, Dimitar V. Zlatev*, Wei Shen Tan**^¶, Mark A. Preston*^†, Quoc-Dien Trinh*^†‡, Adam S. Kibel*^†, Guru Sonpavde^†, Deborah Schrag^†, Benjamin I. Chung^††and Steven L. Chang*^†††

*Division of Urology, Harvard Medical School, Brigham and Women’s Hospital, ^†Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, ^‡Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, ^¶Division of Surgery and Interventional Sciences, Department of Urology, University College London, **Department of Urology, Imperial College Healthcare, London, UK, ^§Department of Urology, Georgetown University, Washington, DC, USA and ^††Department of Urology, Stanford University Medical Center, Stanford, CA, USA

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Abstract

Objective

To examine the incidence of perioperative complications after radical cystectomy (RC) and assess their impact on 90‐day postoperative mortality during the index stay and upon readmission.

Patients and methods

A total of 57 553 patients with bladder cancer (unweighted cohort: 9137 patients) treated with RC, at 360 hospitals in the USA between 2005 and 2013 within the Premier Healthcare Database, were used for analysis. The 90‐day perioperative mortality was the primary outcome. Multivariable regression was used to predict the probability of mortality; models were adjusted for patient, hospital, and surgical characteristics.

Results

An increase in the number of complications resulted in an increasing predicted probability of mortality, with a precipitous increase if patients had four or more complications compared to one complication during hospitalisation following RC (index stay; 1.0–9.7%, P < 0.001) and during readmission (2.0–13.1%, P < 0.001). A readmission complication nearly doubled the predicted probability of postoperative mortality as compared to an initial complication (3.9% vs 7.4%, P < 0.001). During the initial hospitalisation cardiac‐ (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.9–5.1), pulmonary‐ (OR 4.8, 95% CI 2.8–8.4), and renal‐related (OR 3.6, 95% CI 2–6.7) complications had the most significant impact on the odds of mortality across categories examined.

Conclusions

The number and nature of complications have a distinct impact on mortality after RC. As complications increase there is an associated increase in perioperative mortality.

Editorial: Radical cystectomy complications and perioperative mortality

July 3, 2019/by Nikhil Vasdev

Bladder cancer is the second most prevalent urological cancer, with 25% of cases being muscle invasive, which requires radical therapy as per National Institute for Health and Care Excellence (NICE) guidance [1]. Radical therapy often involves radical cystectomy (RC), which is an incredibly complex operation with common postoperative complications and significant mortality rates [1,2]. It is suspected to have a 30‐day mortality of between 1% and 3%, with this increasing to 10% in the >80 years age group [2, 3], and a 90‐day postoperative complication rate of 50–60% [4].

This complex procedure and its complication rates contribute to a myriad of factors that result in bladder cancer being the most expensive cancer, per patient, to care for and to treat [2, 4]. We congratulate the authors on producing this substantial paper investigating how postoperative complications are associated with overall mortality [5]. Logic dictates that the more complications a patient experiences, the worse the postoperative outcome and, ultimately, the higher the risk of mortality. This paper has succeeded in providing quantifiable data, not only on the overall correlation but by providing adjusted odds ratios (ORs) based upon the nature of the complication.

Whilst a 90‐day prospective study would have been ideal, we recognise this would have been much harder to perform and would have resulted in a much smaller cohort. This retrospective study will therefore suffer from selection bias and unmeasured confounders, as the authors have identified. It should also be noted that these results may not extrapolate to a global population due to data only being collected from a private healthcare system. The coding of clinical diagnosis is often overestimated due to funding that comes with diagnosis and treatments. Despite these biases, this is still the largest set of data investigating the association of RC complications and mortality.

The analysis of the data found that there was a ‘threshold’ limit for the number of complications postoperative patients could experience; patients experiencing four or more complications had a drastic increase in mortality (OR 76.6, P < 0.05) [5]. While all postoperative patients have close monitoring and enhanced recovery pathways, and any patients with postoperative complications will be repeatedly assessed, in an ideal world, patients who have experienced three or more complications would have increased monitoring (high dependency unit/intensive therapy unit).

The breakdown of complications by physiological system was unsurprising, with pulmonary (OR 6.5, P < 0.001), cardiac (OR 4.4, P < 0.001), and renal (OR 2.6, P < 0.001) complications being most associated with increased mortality [5]. Although this information does provide some guidance into specific monitoring methods for high‐risk patients, such as capnography, continuous blood pressure, and renal function monitoring.

While additional demographic and operational information was gathered, the only information collected pertaining to medical health was the Charlson Comorbidity Index (CCI), which meant the authors were unable to ascertain any correlation between the nature of the complications experienced and any predisposing condition of that physiological system. Schulz et al. [6] have recently published a report examining RC morbidity and mortality rates in relation to American Society of Anesthesiologists (ASA) grading and found that patients with an ASA score ≥3 had significantly more high‐grade complications, required more perioperative interventions, and had a higher mortality rate (7.6% vs 3.2%; P = 0.002). Mossanen et al. [5], have taken some of these factors into consideration using the CCI, but unfortunately ASA grade was not part of the data collected.

Due to the nature of the database collection method, the authors were unable to determine other important confounders such as smoking status, exercise tolerance, and the severity/specific details of the complications experienced. Sathianathen et al. [7] showed in October 2018, that smokers were almost twice as likely to have Clavien–Dindo III–V complications following RC, with the most common complications being pneumonia, myocardial infarction, and wound dehiscence.

In our view, Mossanen et al. [5] have provided the urological community with not only quantifiable evidence to support the maxim of ‘more complication, worse outcome’ but they have also identified a vital threshold that can be used clinically to support postoperative patients. This guidance, when paired with clinical judgement, could result in additional monitoring and multi‐disciplinary care in high‐risk patients, ultimately reducing RC mortality rates.

by Alex Hampson, Amy Vincent, Prokar Dasgupta and Nikhil Vasdev

References

National Institute for Health and Care Excellence (NICE). Bladder cancer: diagnosis and management. NICE guideline NG2, February 2015. Available at: https://www.nice.org.uk/guidance/ng2. Accessed September 2018
Shabsigh, A, Korets, R, Vora, KC et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009; 55: 164– 76
Froehner, M, Brausi, MA, Herr, HW, Muto, G, Studer, UE. Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol 2009; 56: 443– 54
Stitzenberg, KB, Chang, Y, Smith, AB, Nielsen, ME. Exploring the burden of inpatient readmissions after major cancer surgery. J Clin Oncol 2015; 33: 455– 64
Mossanen, M, Krasnow, RE, Zlatev, DV et al. Examining the relationship between complications and perioperative mortality following radical cystectomy: a population‐based analysis. BJU Int2019; 124: 40– 6
Schulz, GB, Grimm, T, Buchner, A et al. Surgical high‐risk patients with ASA ≥ 3 undergoing radical cystectomy: morbidity, mortality, and predictors for major complications in a high‐volume tertiary center. Clin Genitourin Cancer 2018; 16: e1141– 9
Sathianathen, NJ, Weight, CJ, Jarosek, SL, Konety, BR. Increased surgical complications in smokers undergoing radical cystectomy. Bladder Cancer 2018; 4: 403– 9

What’s the diagnosis?

June 28, 2019/by Admin

No such quiz/survey/poll

BJUI in the news: prostate urine risk

June 27, 2019/by Admin

A recent BJUI article, A four‐group urine risk classifier for predicting outcomes in patients with prostate cancer, by Shea Connell and coworkers from Norfolk and Norwich University Hospital (NNUH) has been featured on various news outlets including the BBC and ITV in the UK following its online publication.

The article describes a new urine test, the Prostate Urine Risk, for predicting potentially aggressive prostate cancer meaning many men may avoid needing invasive biopsies and unnecessary treatment. It is likely to be one of a range of tests including blood tests and MRI scans which will enter routine clinical practice for prostate cancer diagnosis.

The research team was led by Prof Colin Cooper, Dr Daniel Brewer and Dr Jeremy Clark, all from the University of East Anglia’s Norwich Medical School, with the support and expertise of Rob Mills, Marcel Hanna and Prof Richard Ball at the NNUH.

Read the full article

Article of the month: NICE Guidance – Prostate cancer: diagnosis and management

June 26, 2019/by Admin

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this month, it should be this one.

NICE Guidance – Prostate cancer: diagnosis and management

Read the full article

Overview

This guideline covers the diagnosis and management of prostate cancer in secondary care, including information on the best way to diagnose and identify different stages of the disease, and how to manage adverse effects of treatment. It also includes recommendations on follow‐up in primary care for people diagnosed with prostate cancer.

Who is it for?

Healthcare professionals
Commissioners and providers of prostate cancer services
People with prostate cancer, their families and carers

Context

Prostate cancer is the most common cancer in men, and the second most common cancer in the UK. In 2014, there were over 46,000 new diagnoses of prostate cancer, which accounts for 13% of all new cancers diagnosed. About 1 in 8 men will get prostate cancer at some point in their life. Prostate cancer can also affect transgender women, as the prostate is usually conserved after gender-confirming surgery, but it is not clear how common it is in this population.

More than 50% of prostate cancer diagnoses in the UK each year are in men aged 70 years and over (2012), and the incidence rate is highest in men aged 90 years and over (2012 to 2014). Out of every 10 prostate cancer cases, 4 are only diagnosed at a late stage in England (2014) and Northern Ireland (2010 to 2014). Incidence rates are projected to rise by 12% between 2014 and 2035 in the UK to 233 cases per 100,000 in 2035.

A total of 84% of men aged 60 to 69 years at diagnosis in 2010/2011 are predicted to survive for 10 or more years after diagnosis. When diagnosed at the earliest stage, virtually all people with prostate cancer survive 5 years or more: this is compared with less than a third of people surviving 5 years or more when diagnosed at the latest stage.

There were approximately 11,000 deaths from prostate cancer in 2014. Mortality rates from prostate cancer are highest in men aged 90 years and over (2012 to 2014). Over the past decade, mortality rates have decreased by more than 13% in the UK. Mortality rates are projected to fall by 16% between 2014 and 2035 to 48 deaths per 100,000 men in 2035.

People of African family origin are at higher risk of prostate cancer (lifetime risk of approximately 1 in 4). Prostate cancer is inversely associated with deprivation, with a higher incidence of cases found in more affluent areas of the UK.

Costs for the inpatient treatment of prostate cancer are predicted to rise to £320.6 million per year in 2020 (from
£276.9 million per year in 2010).

This guidance was updated in 2014 to include several treatments that have been licensed for the management of
hormone-relapsed metastatic prostate cancer since the publication of the original NICE guideline in 2008.
Since the last update in 2014, there have been changes in the way that prostate cancer is diagnosed and treated. Advances in imaging technology, especially multiparametric MRI, have led to changes in practice, and new evidence about some prostate cancer treatments means that some recommendations needed to be updated.