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Fluorodeoxyglucose positron-emission tomography (FDG PET)/computed tomography (CT) in bladder cancer
In this month’s issue Mertens et al. [1] present a retrospective analysis of the clinical impact of fluorodeoxyglucose positron-emission tomography (FDG PET)/CT in 96 patients with muscle-invasive bladder cancer. Muscle invasion is present in ≈30% of patients presenting with bladder cancer and is associated with a higher incidence of nodal and metastatic disease than non-muscle-invasive tumours [2]. Accurate staging in this patient group will influence management decisions to proceed to local therapies, to instigate neoadjuvant treatment before local therapy, or to offer palliative chemotherapy where there is imaging evidence and subsequent confirmation of metastatic disease [2].
While there have been a few previous studies investigating FDG PET or FDG PET/CT for staging bladder cancer [3-7], with reported sensitivities and specificities ranging from 60 to 81% and 67 to 94% respectively, to date there are few data describing the impact on clinical management. A recent FDG PET/CT study of 57 patients with bladder cancer [3] reported that management was changed in 68% of cases after PET suggesting that FDG PET/CT has a substantial impact on the management of these patients. However, most patients in that study underwent FDG PET/CT for a suspected recurrence (72%) and the remainder for initial staging (21%) or post-treatment monitoring (chemotherapy or radiotherapy; 7%); 44% of patients had metastatic disease.
In the study reported by Mertens et al. [1], clinical data obtained in 96 patients during the patients’ clinical pathway were reviewed retrospectively. FDG PET/CT staging with standard contrast-enhanced CT was discordant in 22% of cases (21 patients), where PET/CT predominantly upstaged patients, consistent with the previous reports [3, 4]. After PET/CT, the treatment recommendations changed in 13.5% (13 patients) due to disease upstaging. In seven of the 13 patients treatment recommendations altered from local to palliative, due to the presence of metastatic disease, and in the remaining six of the 13 patients, neoadjuvant treatment was recommended in addition to planned local therapy. In another four patients management changed as a consequence of detecting other incidental primary tumours with FDG PET/CT.
However, the final clinical impact of FDG PET/CT may be less. When actual treatment changes were recorded, in only eight of these 13 patients were the recommendations implemented, due to patient co-morbidity or patient wishes in the remainder, e.g. FDG PET/CT changed actual treatment in only 8% in this study (eight of 96 patients). Including the four patients in whom incidental other primary tumours were discovered, the management impact of FDG PET/CT was 12.5%.
There is no doubt that from current published data and supported by this study by Mertens et al. [1] that FDG PET/CT improves staging in bladder cancer due to its higher sensitivity for metastatic disease. However, the actual change in management is relatively low and more prospective data will be required to confirm its clinical and cost effectiveness in terms of outcome, both in a single and multicentre setting.
Vicky Goh*‡ and Gary Cook*†
*Division of Imaging Sciences and Biomedical Engineering, King’s College London, ‡Department of Radiology, and †Clinical PET Imaging Centre, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
References
October’s #urojc discussion marks a number of important milestones– not only the 1st anniversary of the online, international Twitter-based Journal Club, but this month we reached 1000 followers on Twitter – an achievement indeed! We also saw a record number of participants in demonstration of the #urojc concept going from strength to strength.
Fittingly, this month’s paper “The Surgical Spectacle: A Survey of Urologists Viewing Live Case Demonstrations” by Elsamra et al, with free online access provided by BJUI for the duration of the discussion, looks not so much at advances in our theoretical knowledge but rather at the way technological advances are changing our ability to obtain surgical ‘know-how’.
Elsamra et al undertook a survey of all those who attended the live surgery sessions at the Atlanta AUA Meeting in 2012 and the 2013 Paris 3rd International Challenges in Endourology Meeting, to gauge the perceived educational benefits of live case demonstrations (LCD) particularly when compared with taped case demonstrations (TCD). There were a number of problems highlighted in the paper itself:
David Chen won the best Tweet Prize, free registration at EAU 2014, kindly donated by @EUPlatinum, with the following:
Interestingly, while 78% of survey respondents felt that LCDs were ethical and only 26% that interactive discussion may lead to distraction of the surgeon and potential morbidity, only 58% would allow themselves or a family member to undertake their own surgical management as an LCD.
Live case demonstrations are by no means a new concept – they have been undertaken since the advent of surgery for the purpose of education and learning.
Recent innovations have seen a blowout in the size of the viewing audience, with live streaming to conference audiences and potentially worldwide viewers, live tweeting and more recently, as pointed out by Dr Brian Stork, the use of Google Glass for both live surgery and the purpose of remote assistance. LCDs have become the drawcard of many surgical conferences, are often the most packed sessions, arguably for the educational benefit and more importantly for the buzz and thrill of seeing ‘the masters’ deal with difficult situations in real time… while answering questions from the audience simultaneously… “so that bleeding sir, where is it coming from exactly?!?!”
It seems that there is no argument that case demonstrations are of great educational benefit and there are some perceived advantages of live vs taped sessions, as summarized by Amrith Rao in a recent BJUI blog.
The vast majority of those involved in this #urojc discussion, however, seemed to suggest that it was hard to argue that the benefits of LCD outweighed those of TCD. Are we simply promoting a surgical circus? Does the perceived stress of operating to a live large audience have a potential negative impact on patient outcomes? Declan Murphy has already blogged about his own personal experience with LCD.
As for the ethical conundrum regarding the patient?
As suggested by Henry Woo:
In 2012 the EAU released guidelines with respect to the use of live case demonstrations within its own jurisdiction. Importantly, this has highlighted the need for regulation by means of submitting outcomes to a data registry, so as to provide a means of analyzing complications and patient safety outcomes.
Position statements or guidelines have also been released by the Royal College Surgeons (UK), American Urological Association and the Royal Australasian College of Surgeons, to name a few.
Where to from here? Will we continue the trend for ‘reality TV’?
There is certainly evidence out there to suggest that recording of basic operations and comparing with peers is potentially a useful means of assessing surgeon proficiency.
I think it very much remains a case of watch this space!
Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN
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I am sure that many of you will recall the shocking images which went around the world in the aftermath of the devastating earthquake in Haiti in 2010. The scale of the devastation was quite shocking, even for a world that is getting used to scenes of terrible destruction following natural disasters. Over 100,000 people died and over 3 million were seriously affected. For those of us working in the region, the devastation is felt all the more, and long after the news crews and journalists have departed, we must pick up the pieces and try and rebuild our lives and those of our patients again. Three years later, over 250,000 people still live in tents following the earthquake and all of the aid money has been spent.
One of the practical issues for those of us working in healthcare in such a region is the rebuilding of infrastructure following such a calamity. The Caribbean Urological Association [CURA] is a very small player amongst the major organisations that seek to offer support to the Third World and most immediately to post-earthquake-ravaged Haiti. The purpose of our involvement is to ensure that each patient receives appropriate help. We may not be able to offer this help but we seek to provide the means that will provide help and we certainly need help in trying to achieve this.
Following lessons learned in the Haiti Hurricane, we suggest the following structured steps in managing such a recovery on a regional scale:
Level 1 – Basic beginner-level urology, better started on the ground in Haiti. Use of symptoms scores etc. Manage urgent conditions e.g. acute urinary retention etc.
Level 2 – Develop confidence with greater experience. Introduction to endoscopic techniques etc.
Level 3 – Experienced senior urologists to staff Haitian tertiary centres.
A next level development is to look at workshops, tele-mentoring and telemedicine as electronic services become available, along with trips to overseas centres.
CURA can offer level II training in San Fernando, Trinidad. Candidate selection is done by the Haitian fraternity. Funding has to be sought for the six month training periods – SIU, AUA, BAUS, EAU and BJUI. Provide a certificate on completion of training and a basic urological kit for each trainee to be used in the public health sector. Request six month progress reports from each candidate.
CURA can also help with workshops if these are thought helpful. Trinidad is not far from Haiti as the crow flies. However, airlines have not learnt from crows.
The simplicity of this model places the people of Haiti and their care givers in the centre. International donor groups are placed peripherally with regional associations in the middle delivering help as required. International donor groups are an essential component since resources need to be sought here – human resources, equipment, access for tertiary training etc. The model can also be applied to other disadvantaged regions when faced with huge destruction following natural disaster.
Today it is Haiti, tomorrow who knows.
Haitian girl three years after quake.
The annual meeting of CURA is planned for October 25th – 27th 2014 in Trinidad. One or two papers have been accepted from Haitian urologists. The distinguished foreign faculty includes David Quinlan of BJUI, Richard Santucci of SIU, Arthur Burnett of Johns Hopkins, Josh Woods of IVU/Med, Grannum Sant of AUA. We hope to have an in depth discussion of the way forward for the Haiti/CURA relationship.
Dr Deen Sharma, Georgetown, Guyana
The work of Verdi et al. [1] published in this issue, shows the continuing quest to find a cellular substrate suitable for producing a tissue engineered replacement for detrusor smooth muscle. This study has identified the regenerative ability of endometrium and with the use of myogenic culture media has sought to differentiate stem cells of endometrial origin to produce the desired smooth muscle cells. The ultimate objective is to produce a functional organ replacement that improves on the current methods of tissue replacement. The current standard for bladder replacement is bowel, both large and small, in various eponymous configurations. All cystoplasties have the potential for long-term consequences including metabolic derangement, UTI, stone formation and mucus secretion [2]. They also suffer the limitation that they will not contract, thus between 10% and 75% will need to self-catheterise. However, many patients do very well after reconstruction with bowel, thus it is important that any substrate designed to replace the current standard matches and improves on that which bowel can offer.
The complex interactions required to achieve a functional bladder replacement are discussed by many authors and include that with urothelium [3], nerve growth and angiogenesis. Despite considerable ingenuity only some of these concerns are solved by previous approaches that have, for example, seeded urothelium onto a vascularised, de-epithelialised flap [4]. The attempt to generate a true composite bladder using cultured urothelium and muscle generated from their native source has been through animal and some clinical exposure but thus far have not gained widespread acceptance and usage – suggesting continued limitations [5, 6].
The pluripotent stem cell approach is attractive, as tissue can be generated from a source distant from the organ needing regeneration, thus bypassing any inherent disease process. The creation of an environment that pushes cellular differentiation along the desired path is the premise by which this works.
The authors of the current work [1] have analysed the population of generated cells using immunohistochemistry, scanning electron microscopy, gene expression analysis and Western blotting. From this we can learn that the cells are reproducible, viable and appear to exhibit characteristics of the desired smooth muscle cell. That said, all of the current models lack the most desirable of goals – that of controlled, functional similarity to the native bladder. The authors of this paper make the inference that the presence of α-smooth muscle actin suggests that the cells will be contractile. The experiments presented here may imply that but do not confirm it.
The field of tissue engineering remains exciting and authors such as these and others are to be congratulated on continuing to seek innovative approaches to solve a complex problem. The goal is organ replacement and clinical application. Each step along the path to that achievement is valuable but researchers working in the field need to ensure that they remain true to that aim. Cellular markers are only one part of a picture and future work must link them with function in novel cell populations. Once linked with function the means by which function is then controlled becomes important. Before we can safely apply this technology to patients, we must be clear about the functional abilities and limitations of the tissue created, this should be by evidence and not implication. Whilst those undertaking the research convey an optimistic view, the ability to understand the long-term viability and cellular stability remain significant unknowns.
Dan Wood
Adolescent and Paediatric Urology, University College London Hospitals, London, UK
References
Recently, I encountered, and indeed I actually caused, a complication of robot-assisted radical prostatectomy (RARP) which was new to me, and one which I felt that I should share with other surgeons.
PM, a 60-year old teacher, underwent a completely routine RARP, which took less than 2 hours to perform on a Saturday morning. During Sunday night he developed severe abdominal pain and distension. By Monday morning he was in distress with rebound tenderness and marked tachycardia. A CT scan was requested, which revealed a caecal volvulus. A laparotomy by a general surgeon confirmed the diagnosis and an urgent right hemicolectomy was undertaken. The patient made an uneventful recovery and, I am pleased to say, is still speaking to me. Histology confirmed an ischaemic caecum twisted on its rather thickened mesentery, with no perforation present. The prostate itself contained a Gleason 3+4=7 adenocarcinoma, without evidence of extra-prostatic extension.
Although robotic assistance provides the benefits of very precise, virtually bloodless surgery, with 10 times magnification and 3D vision, it also carries the risk of a specific set of complications. These need to be dealt with promptly and efficiently and can usually be completely resolved. Failure to recognise post-operative problems, such as bowel injury, intra-abdominal bleeding or port-site hernia, however, can place the patient in severe and increasing jeopardy. We recently published an article in the BJUI entitled “Lessons Learned from 1000 robot-assisted radical prostatectomy” in which we discussed how many of the problems could be avoided, and, if they occur how they can be best dealt with. One key message is the importance of an early CT scan to diagnose the nature of a post-operative problem, rather than crossing fingers and hoping things will settle.
I am hoping that this blog, and the BJUI article mentioned above, will stimulate other surgeons to discuss openly and frankly the problems that they themselves have encountered, either with regular laparoscopy or with the da Vinci robot, and how they dealt with them. Learning the lessons, not only from one’s own errors and omissions, but also from those of others, seems the best way to become, and continue to be, a safe and successful surgeon.
Roger Kirby, The Prostate Centre, London
Time waits for no man St. Marher, 1225Urology is arguably the leading technology driven surgical specialty. This is no accident. As surgeons we have always looked towards minimal invasion to reduce the trauma of access to our patients. One would have thought that the advent of drugs for BPH and OAB would perhaps reduce our hunger for technology.You can visit One Click Power if you are always hungry for knowing trends in technology. On the contrary, many urologists have moved on to effective alternatives to TURP such as HoLEP and having learnt the lessons from previous unproven over enthusiasm, relied on the results of high quality randomised trials before accepting the results.
The BJUI has a long history of publishing innovative manuscripts in the fields of basic science, imaging and therapeutics. We aim to bring the readership entire new paradigms in surgical diagnostics and treatment. Indeed while we enjoy #ERUS13 in sunny Stockholm, the autumn sunshine reminds us of the role played by robotics in the steady rise of technological innovation. This “sub specialty” has become so prominent that the EAU are soon accepting ERUS and its committee as an integral part of the European Association of Urology. The randomised trials, meta analysis and health technology assessments are gradually appearing in contemporary literature such that it is no longer true to say that robotics is just a fad backed up by little or poor evidence. Robotics remains one of the most highly cited parts of the BJUI and therefore together with laparoscopy has its own dedicated section. We were pleased to publish the novel method of suprapubic catheterisation as an alternative to the urethral route after robotic prostatectomy [1] which led to much conversation on the BJUI twitter page. Our readers ultimately decide whether to adopt a particular technique or technology and are now able to vote via the BJUI Poll.
Last month, Mahesh Desai demonstrated microPCNL in London. The technology is truly breathtaking. It is hard to believe that light and image transmission as well as stone disintegration can be effectively achieved via a needle so thin! We almost stopped doing robotics and were thinking of re-training to become stone surgeons. Mahesh and his team went on to back up the technology with a randomised comparison against flexible ureterorenoscopy [2]. It should come as no surprise that such an article should come from the sub-continent where stone disease is endemic.
And the technological innovations in the BJUI continue. This month we present three rather different articles for your reading pleasure. The first is an international collaboration demonstrating the ideal dose and safety of photodynamic TOOKAD therapy (a light-activated vascular occluding agent) in localised prostate cancer. Nearly 80% of patients had negative biopsies at 6 months [3]. Next we evaluate the role of PET CT in bladder cancer patients undergoing cystectomy. With almost a 20% greater pickup than standard imaging, we may be able to save a number of patients a morbid operation in the presence of metastasis. Advanced imaging may also allow better stratification of patients for neo-adjuvant chemotherapy [4]. Finally, we have an exciting paper from Iran on the use of endometrial derived stem cells for creating bladder replacements and alternatives to meshes in prolapse surgery. The immuno and scanning electron micrographic images in this paper are just stunning [5].
The BJUI intends to continue leading technological innovation in urology. We will bring our readers early phase safety data on new technologies in addition to long-term results to truly judge their efficacy and durability. We hope you enjoy reading, citing and interacting with these articles online at bjui.org and ultimately translate them to your own clinical practice.
Prokar Dasgupta, Editor in Chief, BJUI
Ben Challacombe, Associate Editor, BJUI
King’s Health Partners
References
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Image from Liu et al. BJUI 2013; 112: 271–275
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15 years ago, many people reading this blog won’t have even had a mobile phone! Fast forward to today and we wouldn’t leave home without it. Not content with just having a phone, we now crave the multimedia functionality of smartphones which dominate the market. With this ability to spread and share information so easily comes medico-legal dangers, not only for individuals but also hospitals concerned about patient confidentiality for which they are corporately responsible.
Not long ago, taking a picture of a medical condition for any purpose was a major effort. Contacting the medical photography department of the hospital would take an age and often the moment would be lost. Things began to change with affordable digital cameras although images were usually stored in one location on that camera, often locked away. This situation has altered completely with mobile phone now offering cameras capable of extremely high quality photography (I don’t own one but the Samsung Galaxy S4 possesses a 16MP lens offering far greater resolution than my digital SLR which is only a few years old and Nokia have just released a 41MP cameraphone!). Here you will get the brief idea about the wired vs wireless security system. Suddenly if we see an interesting condition, we can whip our phones out, take a picture and immediately send it round the world on social media platforms. Even if the photos are just stored on the phone, with these being such desirable objects for thieves, this poses a significant risk to loss of that data and potential breach of patient confidentiality. It used to be that CCTV cameras were all that was required to ensure that things ran well in terms of security within a business. Tough circumstances, on the other hand, necessitate even harder measures, which necessitate the installation of detection and alarm systems. The fact that these commercial access control systems are available in a number of models is the nicest part about them.
So where am I going with this ? Well, I read with interest a recent article on “Clinicians and their Cameras” in Australian Health Review 2013. In this survey of one hospital in Australia, one fifth of clinicians reported using their personal mobile phones for medical photography. The authors describe as “endemic” the non-compliance with policy requirements for written consent for these images. Only 6% disposed of the images according to hospital protocol. What is scary is that I suspect the use of personal mobile phones may be under-reported!
There are many benefits to being able to immediately take a medical image in an appropriately consented patient. It may allow a condition to be tracked e.g. serial photographs of cellulitis; or allow discussion with a senior doctor where the most salient image e.g. the infected wound or an x-ray could even be sent to the consultant at home to review. These moments require spontaneity or the chance is lost.
Many hospitals, certainly in the NHS in the UK, completely ban the use of mobile phones for photography. This is an understandable corporate response to the problem which includes consent, confidentiality, appropriate use, storage and disposal.
Medical staff clearly need to be aware of the ethical issues and regulations regarding the use of medical images. The European Commission has found that collection of medical data and maintenance of medical records fall within the sphere of Article 8 of the European Convention on Human Rights. Thus failure to comply with regulations not only contravenes policy from your employer and regulatory body but also breaches the patients human rights. In the UK the Data Protection Act states that all organisations have a legal obligation to protect personal data which would include an individual taking images on any device and thus non-compliance also breaks the law.
The General Medical Council (GMC) in the UK has guidance on visual and audio recordings of patients. This makes clear the following points:
But what about the unexpected finding in the middle of a case? The GMC guidance is clear: In this situation “you must not make recordings for secondary purposes without consent”. So you need it in advance if you are going to do it.
This study suggests that the use of mobile phones for photography in hospitals is commonplace and local protocols are not met. This is likely to be a widespread problem in hospitals in many countries. In my hospital the policy is clear: NO PHOTOGRPAHY ON PHONES OR PERSONAL DEVICES IN THE HOSPITAL. Any breach of this is a disciplinary offence. This prompted the following response from one of my colleagues: “This is ridiculous on many fronts. Bad for patient care, bad for education”. From a managerial perspective I can understand this. From a clinician’s point-of-view, I find this very sad with multiple opportunities lost for improving patient care and medical education. In a highly regulated workplace these rules are likely here to stay and we must all ensure we are compliant with them to avoid potential disciplinary action. I would be interested in the experiences and opinions of readers from other hospitals and countries.
Matthew Bultitude
BJUI Associate Editor