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Editorial: ‘Discontent is the first necessity of progress’, Thomas A. Edison

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This study from Kaag et al. [1] investigates predictors of renal functional decline after radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC). They evaluate early (2 months) and late (6 months) predictors of renal functional decline, finding that on a multivariable model only age at surgery and preoperative renal function were independently associated with early postoperative function. This is an intuitive finding whereby we expect older patients and those with lower renal function to have a more dramatic decrease in renal function after RNU.

Age, preoperative renal function, and Charlson score were associated with late functional recovery. The latter is a counterintuitive finding, as higher Charlson score was associated with less decrease in renal function. Charlson comorbidity was not significant on univariate analyses. Why it would become significant on multivariate is unclear. Whether it is an artifact related to study methodology or is a real phenomenon will require further study.

Unquestionably, this study [1] adds to the growing discontent of our current management of UTUC. The authors cogently discuss the issues related to better risk stratification as a natural consequence of instituting a neoadjuvant chemotherapy paradigm in those with high-risk disease. Multiple retrospective studies have failed to show a benefit of adjuvant chemotherapy, whereas now we have a matched-cohort study showing significant rates of downstaging and complete remission [2], and as well significantly improved 5-year survival, with institution of a neoadjuvant paradigm [3]. One cannot view the dismal outcomes of this disease without being discontent and wishing for progress. We need to continue getting out the message to not only urologists who reflexively institute RNU in patients with a risk-unstratified upper tract filling defect, but as well many medical oncologists who can only function based on guidance from level I data, which for this disease, will be a long time coming.

Read the full article

Surena F. Matin

Department of Urology, MD Anderson Cancer Center, Houston, TX, USA

References

1 Kaag M, Trost L, Thompson RH et al. Pre-operative predictors of renal function decline following radical nephroureterectomy for upper tract urothelial carcinoma. BJU Int 2014; 114: 674–9

2 Matin SF, Margulis V, Kamat A et al. Incidence of downstaging and complete remission after neoadjuvant chemotherapy for high-risk upper tract transitional cell carcinoma. Cancer 2010; 116: 3127–34

3 Porten S, Siefker-Radtke AO, Xiao L et al. Neoadjuvant chemotherapy improves survival of patients with upper tract urothelial carcinoma. Cancer 2014; 120: 1794–9

Lessons learned from Asian Urology

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Glasgow has been in the news a lot this year. The fantastic Commonwealth Games were followed by an excellent Société Internationale d’Urologie (SIU) meeting with its unique Scottish flavour. This month we move our attention to two other nations that have hosted the SIU – China and India. We present two large studies, which are well worth your reading pleasure, not just because of their sheer size but also for their messages and citability.

Since the initial discovery in 2007 of ketamine-associated cystitis by Shahani et al. [1] in Canada, scattered cases had also been reported in some European countries including the UK. However, the gravity of this ketamine problem was subsequently found to be far greater in Asian countries, particularly Hong Kong, Taiwan, Mainland China and Malaysia.

Although ketamine-associated uropathy is a medical problem, it takes root in much deeper social problems, and in turn perpetuates these problems and produces new issues. As the devastating effect of ketamine abuse on the society is unveiled, there are numerous collaborations between Hong Kong and Mainland China to combat it. Government and non-government organisations join hands in educating the public, youths in particular, on the irreversible damage that ketamine can cause to body and mind. More stringent laws have been enacted against drug traffickers, with high-profile enforcements. Abundant funds have also been set up to encourage research in this field.

With all these concerted efforts, according to official statistics in Hong Kong and Mainland China, the number of ketamine abusers is on the decline. However, this is no reason for complacency, as the numbers of abusers we capture probably represent only the ‘tip of the iceberg’. More and more evidence is indicating a substantial population of undiscovered ketamine abusers, who sniff ketamine stealthily at home for years without being noticed by their families.

Any effective solution to ketamine-associated uropathy [2] must involve identifying and extending help to this vast hidden group of abusers. The problem is daunting by its sheer magnitude. There are in addition, delicate issues of privacy, rights and self-esteem that require great sensitivity and patience. It is a job that requires experts from different specialties to cooperate. Urologists must work with social workers, teachers, paediatricians, psychiatrists, psychologists, nurses, occupational therapists and others. Last but not least, parental and family support is paramount in helping our youth to win this fight.

For those endourologists busily treating stone disease we highlight the evolution of shockwave lithotripsy (SWL) over 25 years in >5000 patients [3]. In many parts of the world, not just Asia, extracorporeal SWL (ESWL) has seen a drop in its popularity in parallel with an increase in the use of percutaneous nephrolithotomy (PCNL) and ureteroscopy. Patients seem to be more inclined to be stone-free with fewer interventions even if these are of an invasive nature.

For those readers more interested in immediacy through our web journal, the Best of China virtual supplement is the one not to miss. There have been many calls for a BJUI Android app from our friends in the East. We are almost there!

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Peggy Sau-Kwan Chu and Prokar Dasgupta*

Division of Urology, Department of Surgery, Tuen Mun Hospital, Hong Kong *King’s College London, Guy’s Hospital, London, UK

References

1 Shahani R, Streutker C, Dickson B, Stewart RJ. Ketamine-associated ulcerative cystitis: a new clinical entity. Urology 2007; 69: 810–2

2 Tam YH, Ng CF, Pang KK et al. One-stop clinic for ketamine-associated uropathy: report on service delivery model, patients’ characteristics and non-invasive investigations at baseline by a cross-sectional study in a prospective cohort of 318 teenagers and young adults. BJU Int 2014; 114: 754–60

3 Jagtap J, Mishra S, Bhattu A, Ganpule A, Sabnis R, Desai M. Evolution of shockwave lithotripsy (SWL) technique: a 25-year single centre experience of >5000 patients. BJU Int 2014; 114: 748–53

 

What’s the Diagnosis?

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 Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

This image is from a recent paper by from Zacharakis et al, BJUI 2014. This operation is 5 days post low-flow prispism.

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Editorial: Where next in ketamine uropathy? Dedicated management centres?

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Tam et al. [1] in this month’s BJUI publish the largest prospective cohort to date on ketamine uropathy (KU). KU is a growing international problem since initial reports in 2007 from Canada and Hong Kong, where ketamine is second only to heroin in popularity amongst drug takers [2, 3]. Prevalence of KU may be higher than previously thought with up to a quarter of people misusing ketamine reporting urinary symptoms [4].

Importantly, the Tam et al. [1] paper demonstrates the benefit of stopping ketamine amongst those presenting with KU. Dose, frequency and dependency upon ketamine have been reported as risk factors for developing KU [1, 4]. Achieving cessation is not always straightforward following identification, assessment and urology input. Consistent with the Winstock et al. [4] recommendations a multi-disciplinary approach is required to assess symptoms and risk profile. The recommendation of Tam et al. of a one-stop clinic is thus appealing.

The key to diagnosing KU, is a focused history including specific drug use, performing non-invasive uroflowmetry investigations and upper tract imaging. Urologists need to be aware of motivational interviewing strategies, and incorporate them in their assessment. Presenting symptoms include dysuria, frequency, urgency and pain that may be consequent on the small contracted bladder that develops in KU. The diagnosis should exclude other bladder diseases and cystoscopy and biopsy is advised [5]. If left late, pain and bladder contraction can be so severe that bladder augmentation, cystectomy and neobladder or ileal conduit may be required [6]. It is strongly advised that ketamine use is stopped before, as ketamine metabolites will be readily absorbed through bowel and potentially lead to a fatal overdose.

In the Tam et al. [1] paper, renal ultrasonography (US, performed on a second visit) showed hydronephrosis in 8%. However, their client uptake for renal US was only 50%. Having a one-stop KU clinic with integrated US is more patient-friendly and consistent with our unit’s one-stop clinic approach [7]. Management of hydronephrosis and reversal of renal impairment is crucial and more definitive surgical management may be warranted. Renal failure secondary to KU may rise as the numbers of ketamine users continues to climb.

What makes KU interesting and difficult to manage is the stigmatising nature of illicit drug use that makes patients uncomfortable in disclosing ketamine use. Patients may not recognise the causal link between ketamine use and their discomfort. Instead symptoms may be attributed to other pathologies such as UTIs, sexually transmitted infections (common in high-risk drug use behaviour), excessive alcohol or caffeine consumption or be mistaken for ‘K cramps’, which may be a direct result of ketamine itself [8]. Pain team input may be required. The Bristol unit report managing KU pain with buprenorphine patches, co-codamol (combination of codeine phosphate and paracetamol) and amitriptyline [5], whereas the Tam et al. [1] unit prefer a combination of diclofenac, anti-cholinergics and opioids.

Promoting early treatment seeking will help reduce the time between symptom onset and assessment. However, due to the nature of ketamine patients, their history may be unreliable, follow-up intermittent and compliance poor. These issues may lead to a delay in presentation and referral.

Ultimately, what is required is a raised awareness among users of the potential for ketamine to cause irreversible bladder and upper tract harm. While abstinence may be the most attractive option for clinicians this remains an unrealistic and unhelpful approach for many users including those most at risk. Consideration needs to be given to support users to reduce harm and to maintain abstinence once achieved. Stopping ketamine may require psychological, addiction and even psychiatric support.

Importantly, clinicians should accept that ketamine users are interested in their own health and wellbeing. They may appreciate learning strategies to minimise their harm risk. Harm reduction strategies as outlined in the Global Drug Survey Highway Code (stay well hydrated, have breaks between use periods, and avoid alcohol use) not only encourage safer use but can raise awareness of symptoms suggestive of KU [9].

Given the complexity of ketamine patients and the fact that users share information, provision of high-quality care from a dedicated understanding team has obvious advantages. An age-appropriate unit including a urologist, psychiatrist, pain management consultant and a sexual health expert provides a comprehensive approach. A one-stop clinic, as described by Tam et al., may expedite initial assessment but withdrawal from ketamine requires long-term investment to achieve overall improvements in KU outcomes.

The key message to get out to the ketamine-using community is that as a rule, marked improvement in function follows cessation of ketamine use. There is an increasing role for the urologist to be a source of credible information to ketamine users and healthcare professionals. Finally, dedicated management centres offering a holistic approach to the management of these patients seems ideal. This will concentrate exposure and understanding of KU, which we hope will help continue to improve management of this difficult condition.

Read the full article

Claire F. Taylor, Adam R. Winstock* and Jonathon Olsburgh

Young Onset Urology Clinic, Urology/Renal Unit, Guy’s and St Thomas’ Hospital, and *South London and Maudsley NHS Trust, London, UK

References

1 Tam YH, Ng CF, Pang KK et al. One-stop clinic for ketamine-associated uropathy: report on service delivery model, patients’ characteristics and non-invasive investigations at baseline by cross-sectional study in a prospective cohort of 318 teenagers and young adults. BJU Int 2014; 114: 754–60

 

2 Chu PS, Kwok SC, Lam KM et al. ‘Street ketamine’-associated bladder dysfunction: a report of ten cases. Hong Kong Med J 2007; 13: 311–3

 

3 Shahani R, Streutker C, Dickson B, Stewart RJ. Ketamine-associated ulcerative cystitis: a new clinical entity. Urology 2007; 69: 810–2

 

4 Winstock AR, Mitcheson L, Gillatt DA, Cottrell AM. The prevalence and natural history of urinary symptoms among recreational ketamine users. BJU Int 2012; 110: 1762–6

 

5 Wood D, Cottrell A, Baker SC et al. Recreational ketamine: from pleasure to pain. BJU Int 2011; 107: 1881–4

 

6 NgCF,ChiuPK,LiMLetal.Clinical outcomes of augmentation cystoplasty in patients suffering from ketamine-related bladder contractures. Int Urol Nephrol 2013; 45: 1245–51

 

7 Coull N, Rottenberg G, Rankin S et al. Assessing the feasibility of a one-stop approach to diagnosis for urological patients. AnnRCollSurg Engl 2009; 91: 305–9

 

8 Winstock AR, Mitcheson L. New recreational drugs in the primary care approach to patients who use them. BMJ 2012; 344: e288

 

9 Global Drug Survey Ltd. Global Drug Survey Highway Code. Available at: https://www.globaldrugsurvey.com/wp-content/uploads/2014/04/The -High-Way-Code_Ketamine.pdf. Accessed September 2014

 

What’s the Diagnosis?

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Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

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Editorial: Extent of lymph node metastases

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The role of prostatectomy in lymph node metastasized prostate cancer has been subject to changing opinions. Classically, a nodal dissection was performed as the initial step in the procedure and prostatectomy was avoided in men with cryosection-proven metastases. Biochemical recurrence during the first 3 years occurs in the majority of men with pN1 disease [1]. Early data from randomized trials shows only a 50% prostate cancer-specific survival 12 years after prostatectomy and nodal metastases without immediate adjuvant treatment [2]. Recently, Passoni et al. [3] showed a higher 10-year overall survival of 82.8% in men with nodal metastases, of whom the majority were treated with adjuvant androgen ablation and/or radiotherapy. This percentage is remarkably similar to the treatment arm of the earlier-mentioned study reported by Messing et al. [2], which showed a 10-year disease-specific survival of >80%. At 10 years about half the patients who died, did so from prostate cancer; therefore, although reasonable intermediate range survival can be obtained in men with nodal metastases of prostate cancer, the major cause of death remains prostate cancer when surgery is applied at the age of 65 years. Although adjuvant androgen ablation may improve survival, as suggested by the above-mentioned observations, some men may not experience recurrence after resection of nodal metastases and would experience the toxicity of androgen ablation unnecessarily. The identification of these men would reduce costs and toxicity.

Passoni et al. [3] presented a multicentre study on prognostic factors after prostatectomy for node-positive disease. The number of removed nodes (median 10) seems relatively low compared with the 17 reported in their earlier single-centre study, but may be a good reflection of urological practice in general. By comparison, the percentage of men who underwent adjuvant radiotherapy in the multicentre study was low (16%). Data from da Pozzo et al. [4] suggest that adjuvant radiotherapy may be of benefit in men with limited nodal metastases. It would be of interest to study whether men with a later biochemical recurrence would be those that did experience recurrence only locally and therefore would be those most likely to benefit from adjuvant (or salvage) radiotherapy.

In the current study by Passoni et al. [1] in the BJUI, the follow-up was relatively short (16 months). Earlier data from this author group showed that number of positive nodes and lymph node density were good predictors of cancer-specific survival after prostatectomy. This earlier observation is now confirmed in a multicentre analysis with a different endpoint: biochemical recurrence. What is notable is the fact that this confirmation was obtained in a series of patients with fewer nodes removed. The value of the marker ≤2 positive nodes becomes limited with the observation that this group contained 85% of men in their series. The second marker found, the size of the node, showed a more general distribution but as a single marker had no predictive value. The differences in Harrel’s c values from the base model containing other clinical characteristics are limited and reproducibility of measures needs attention. Still, the observation that extent of nodal metastases is of prognostic value after surgery is notable.

Ideally, markers could predict the absence of further disease progression in men after prostatectomy for nodal metastasized prostate cancer. None of the studied characteristics fulfill this need because at 36 months after prostatectomy the majority of men, even those in the best prognostic group, do experience biochemical recurrence that will result in prostate cancer-related death. Gleason score is a strong predictor of the presence of nodal metastases [5], and some have suggested that nodal Gleason grade is of prognostic value in men with pN+ disease. Until these markers have been further evaluated, it remains important to address the fact that reported cancer-specific survival in most men with pN+ disease is >10 years [6]. Although tempting to speculate that prostatectomy and (extended) lymph node dissection plays a role in this, the almost inevitable development of biochemical recurrence reported in the current study by Passoni et al. [1], even in patients in the best prognostic group, stresses the systemic nature of this disease which will require a multimodality approach in most men at some point.

Read the full article

Henk G. van der Poel

Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands

References

1 Passoni N, Fajkovic H, Xylinas E. Prognosis of patients with pelvic lymph node metastasis following radical prostatectomy: value of extranodal extension and size of the largest lymph node metastasis. BJU Int 2014; 114: 503–10

2 Messing EM, Manola J, Yao J et al. Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy. Lancet Oncol 2006; 7: 472–9

3 Passoni NM, Abdollah F, Suardi N et al. Head-to-head comparison of lymph node density and number of positive lymph nodes in stratifying the outcome of patients with lymph node-positive prostate cancer submitted to radical prostatectomy and extended lymph node dissection. Urol Oncol 2013; 29: 29.e21–8

4 Da Pozzo LF, Cozzarini C, Briganti A et al. Long-term follow-up of patients with prostate cancer and nodal metastases treated by pelvic lymphadenectomy and radical prostatectomy: the positive impact of adjuvant radiotherapy. Eur Urol 2009; 55: 1003–11

5 Ross HM, Kryvenko ON, Cowan JE, Simko JP, Wheeler TM, Epstein JI. Do adenocarcinomas of the prostate with Gleason score (GS)</=6 have the potential to metastasize to lymph nodes? Am J Surg Pathol 2012; 36: 1346–52

6 Touijer KA, Mazzola CR, Sjoberg DD, Scardino PT, Eastham JA. Long-term outcomes of patients with lymph node metastasis treated with radical prostatectomy without adjuvant androgen-deprivation therapy. Eur Urol 2013; 65: 20–5

What’s the Diagnosis?

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Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

This image is from a recent paper by Rosenberg et al. BJUI 2014 that explores the effect of intravesical instillation of green tea extract (GTE) on a rat model of bacterial cystitis.

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Rocktober – Keep on rocking #urojc

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We celebrated the two-year anniversary of the international urology journal club this month (@iurojc) with record participation. There were over 500 tweets in the 48 hour discussion of this month’s article, published in New England Journal of Medicine on September 18, 2014, Ultrasound versus Computed Tomography for Suspected Nephrolithiasis. It was a true multidisciplinary discussion with nephrologists, EM docs, and study author, radiologist Rebecca Smith-Bindman tweeting.

This was a multi-institutional prospective randomized control study evaluating bedside and radiology ultrasonography versus CT as the first test performed for patients presenting to the ED with flank or abdominal pain. Patients who initially underwent ultrasound could also receive a CT if the provider felt necessary based on clinical presentation and ultrasound findings. In terms of the primary endpoints, authors found no significant difference across the three groups in high-risk diagnoses with complications related to missed or delayed diagnoses. There was significantly less 6-month cumulative radiation exposure in patients assigned to the ultrasonography groups compared to those assigned to CT. Conclusions of this study in the form of a tweet: Get US first #noharmdone #lessradiation.

Conversation first focused on clarifying the main conclusions of this article. Notably, ED physicians were the focus of this study, who care whether the patient will be admitted or sent home. Information about size, location, etc of stones was omitted from the study since the goal was not definitive stone treatment.

Some of the limitations of the study were brought up early on. First of all, obese patients were excluded (men >129 kg and women >113 kg).

Additionally, the definition of being diagnosed with a stone only applied to individuals who reported passing a stone or having a stone surgically removed.

Much of the conversation focused on how this approach may be beneficial in recurrent stone-formers, although at least a KUB likely needed before taking a patient to the OR.

One of the main issues seemed to be the practicality of universally applying the “ultrasound first” approach. Many institutions do not have ultrasound readily available during night or weekend hours.

ER folks disagreed, and thought that point-of-care ultrasound could be easily adopted.

@soph_cash suggested urologists be the ones to perform ultrasound. Although an important skill to learn, the idea was quickly put to rest.

Author Rebecca Smith-Bindman made a brief appearance in support of the evidence in the study.

Coincidentally, the twitter-based nephrology journal club, #nephjc, discussed the same article this month. @hswapnil tweeted a useful chart comparing radiation doses (think about this next time you eat a banana) https://www.xkcd.com/radiation/

Although the conclusions among nephrologists were similar, @uretericbud said it best:

Overall, the consensus seemed to be that the paper presents good evidence for starting with ultrasound in the ED but applying this in all institutions may be difficult. Ultrasound also has limited use for urologists who are focused on stone treatment rather than catastrophic misses. Finally, some concluding thoughts from participants:

Thank you to all the tweeps over the last two years who have provided knowledge, insight, and a healthy dose of comedy to make #urojc such a huge success. Plugging an idea floated by @CanesDavid…

This month’s best tweet prize was sponsored by one beautiful thing vintage furniture.

Lastly, here are the symplur analytics for the month.

Ariel Fredrick is a PGY-2 urology resident at Lahey Hospital in Burlington, Massachusetts.

 

Editorial: Is surgery a never ending learning process?

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The concept of the learning curve is one of the most important issues in surgery and also one of the most overlooked. In the present issue of BJUI, Abboudi et al. [1] present an interesting review paper evaluating the concept of the learning curve in urological procedures. Specifically, the authors have conducted a methodologically consistent systematic review on the literature focused on the learning curve of some urological procedures, including mainly radical prostatectomy (RP), robot-assisted partial nephrectomy (RAPN) and percutaneous nephrolitotomy [1]. Surprisingly, nothing was available for BPH treatments, which are among the most prevalent urological procedures. 

Most of the studies are focused on robot-assisted RP (RARP), but the available literature is of poor methodological quality, including mainly surgical series evaluating a limited number of surgeons, with a heterogeneous selection of outcomes from which to study the learning curve and a focus on short-term outcomes. Conversely, the literature on retropubic RP or laparoscopic RP is of higher quality, including a few very large multi-institutional studies encompassing the performances of several surgeons (reference nos. 24, 26, 29 and 30 in the review) and adopting sophisticated statistical methodology; however, the current interest for these procedures is quite limited, RARP being more commonly preferred. With the above-mentioned limitations in mind, what we have learnt is that RARP operating time plateaus after 50–200 cases, positive surgical margin (PSM) rates after 50–1600 cases, and continence and potency after 200 cases [1]. Such data are only partially in line with the findings of a recent prospective Australian study [2], not included in the present systematic review, which evaluated the learning curve with RARP of a high-volume open surgeon (>3000 retropubic RPs performed before the study beginning). In that study, Thompson et al. [2] demonstrated that performances with RARP surpassed those with retropubic RP after ∼100 cases for sexual function scores and PSM rates in pT2 cancers, whereas ∼150 cases were needed to reach the same target with urinary function scores. Moreover, RARP performances kept on improving, with sexual and urinary scores plateauing after 600–700 and 700–800 cases, respectively. Similarly, with regard to PSMs, it was demonstrated that PSM rates in pT2 and pT3–4 cancers plateaued after 400–500 and 200–300 cases, respectively [2]. Although improvement is likely, it is not clear how much these performances might improve with further extension of the caseload. 

Taken together, those data suggest that even with robotic assistance, a high volume of cases is strongly associated withimproving oncological and functional outcomes after RARP. This is not an extraordinarily original concept, but implies that the daVinci platform, by itself, cannot guarantee excellent surgical quality and that the relevance of the surgeon is as high as ever. 

Limited data are available on other major robotic procedures, such as RAPN and robot-assisted radical cystectomy (RARC). Specifically, 20–75 cases are thought to be needed to observe a plateau in warm ischemia time (WIT) during RAPN, which is in line with our previous findings demonstrating a continuous decrease in WIT during the first 50 cases [3]. Similarly, 20–30 cases are supposed to be needed to achieve acceptable operating times, lymph node yields and PSM rates after RARC; however, those findings do not take in account the burden of robotic experience achieved with RARP before embarking in RARC, which is clearly a major issue [4]. 

Considering that the improvements in performances along the learning curve exceeded any effect sizes we might reasonably expect from a novel drug [5], it is clear that any attempt to centralise treatments for complex procedures in high-volume centres with high-volume surgeons should be attempted. Obviously, that is a very critical target, which is hard to achieve in many realities. In parallel, interventions to improve the performance of surgeons in order to,reduce the learning curve are mandatory. For example, fellowship-trained RARP surgeons have been shown to outperform experienced open or laparoscopic surgeons moving to RARP without specific training [6,7]. For those surgeons for whom fellowship is unfeasible or unpractical, structured courses with integration of simulation, dry laboratory, wet laboratory and da Vinci modular training, for example, using the model of the recently concluded European Robotic Urology Society Pilot Study, can significantly ease the first steps of the learning curve, reducing patients risk. In parallel, intensive courses focused on specific procedures could help those surgeons who had completed the initial steps of their learning curve to master the specific technical details necessary to improve outcomes.

Read the full article

Alexander Mottrie*† and Giacomo Novara†‡

*OLV Vattikuti Robotic Surgery Institute and † Department of Urology, OLV Hospital Aalst, Aalst, Belgium and ‡ Department of Surgery, Oncology and Gastroenterology, Urology Clinic University of Padua, Padua, Italy

References

1 Abboudi H, Khan MS, Guru KA et al. Learning curves for urological procedures: a systematic review. BJU Int 2014; 114: 617–29

2 Thompson JE, Egger S, Böhm M et al. Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective single-surgeon study of 1552 consecutive cases. Eur Urol 2014; 65: 521–31

3 Mottrie A, De Naeyer G, Schatteman P et al. Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours. Eur Urol 2010; 58: 127–32

4 Hayn MH, Hellenthal NJ, Hussain A et al. Does previous robot-assisted radical prostatectomy experience affect outcomes at robot-assisted radical cystectomy? Results from the International Robotic Cystectomy Consortium. Urology 2010; 76: 1111–6

5 Vickers AJ. What are the implications of the surgical learning curve? Eur Urol 2014; 65: 532–3

6 Kwon EO, Bautista TC, Jung H et al. Impact of robotic training onsurgical and pathologic outcomes during robot-assisted laparoscopicradical prostatectomy. Urology 2010; 76: 363–8

7 Leroy TJ, Thiel DD, Duchene DA et al. Safety and peri-operative outcomes during learning curve of robot-assisted laparoscopicprostatectomy: a multi-institutional study of fellowship-trainedrobotic surgeons versus experienced open radical prostatectomysurgeons incorporating robot-assisted laparoscopic prostatectomy. J Endourol 2010; 24: 1665–9

 

What’s the Diagnosis?

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Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

This image is from a recent paper by Hefermehl et al on lateral temperature spread by different robotic instruments.

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