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West Coast Urology : Highlights from the AUA 2016 in San Diego… Part 1

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By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

 

The 2016 AUA returned to the beautiful city of San Diego set on the shores of the Pacific in an excellent conference centre located in the centre of the town adjacent to the Gaslamp district. For a change the wifi was excellent and allowed enhanced levels of social media interaction and urological discussion. Opening these interactions were 2 key sessions which provoked much debate. Firstly the announcement that after over 10 years of trying the FDA has approved HIFU treatment although it seemed to get there through a slightly “de novo” pathway. Apparently the FDA approved it as an ablation tools but not for prostate cancer.

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Although not directly approved for use in prostate cancer, that is exactly what it is going to be used for. A packed house saw a debate with evidence from both sides. Dr Nathan Lawrentschuk promoted the 4 Ds of HIFU. His key point was that 56/101 had a post treatment biopsy of which 51 where biopsy positive!

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The second big session focussed on the AUA/SAR consensus statement  document on prostate cancer diagnostics. This recommended a “High Quality” MRI should be strongly considered if patient has a rising PSA with a previous negative biopsy, has persistent clinical suspicion for prostate cancer or is undergoing a repeat biopsy. There was no mention of MRI for all at the pre-biopsy stage which many had hoped for and only 2 lines on trans-perineal biopsy as an option. This is of course related to health resources and the outpatient office-based nature of most USA urologists.

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A welcome innovation was the Crossfire Sessions which pitted 2 well known advocates of one treatment against 2 with the opposite views. It was hardly debating of the Oxbridge variety but none the less did provoke some useful discussions. Topics included radical prostatectomy vs radiotherapy, endoscopic vs nephro-ureterectomy management of upper tract TCC, and enucleation at partial nephrectomy vs formal resection. Standing room only at the back of the halls but no real audience interaction or voting which was a shame. 

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The session which really woke everyone up was Rene Sotalo’s wonderful complication horror show. Bleeding, bleeding and more bleeding in a variety of ways. How would you handle this he asked? Pray I thought! But this and similar sessions clearly show the benefits of recording all cases and reviewing these DVDs if something goes wrong. The cause of some complications were only identified by review of the intra-operative tapes. Some clinical titbits learn’t included  using only a horizontal incision for the camera port at RARP to reduce hernias and turning off pneumocompression stockings if there is a major venous injury to prevent excessive venous bleeding.

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From a SoME perspective there was both good and bad. One poster showed that 40% of graduating US residents had publicly accessible unprofessional content on social media. Food for thought at the consultant interview no doubt, but on the other side SoMe ranks third in the acquisition of urological knowledge (and climbing…). One hack produced this tweeting guideline for all to reflect on.

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Prof Prokar Dasgupta had the honour of presenting the widely anticipated session on emerging robotic technology . At last there appears to be some real competition to Intuitive’s dominance on the way. There are at least 3 credible robotic systems on the way. He finished with an intriguing slide on Dr Google being the most powerful doctor in the world!

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Despite Europe and Asia moving towards the use of PMSA PET , the USA is not moving in this direction due to reimbursement issues if the PMSA molecule.

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There was a lot of interest in a packed auditorium to see live surgery for a single use disposable fURS “Lithovue” with some reporting superior vision , optics and deflection.

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There were some sceptics amongst the stone community with the environmental impact and cost effectiveness a concern.

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With the popular Gaslamp district a stones throw away many delegates went after the conference for a meal and drinks. The local baseball team San Diego Padres was a popular destination with may watching baseball for the 1st time whist others had gone for a run along the harbour and even caught a sighting of some seals!

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May Editorial: The Current Hot Topics in Functional Urology

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BJUI-May-2015-cover_smallFor some time, the challenge represented by managing the overactive bladder (OAB) has been dominant in functional urology research. The introduction of new therapies has galvanised the area, with mirabegron showing strong promise for many patients as a monotherapy. In addition, the potential for combined therapy using mirabegron with established antimuscarinics has recently been reported for urgency urinary incontinence [1]. Now that the place of onabotulinum-A injections in refractory cases is firmly established, management options have clearly taken a step forward in recent years. However, there remain people for whom even the more comprehensive current options are inadequate or intolerable. The need for basic science research remains a priority, in the hope of translation into clinical options. In this month’s BJUI, Aizawa et al. [2] report responses in an animal model to an inhibitor of fatty acid amide hydrolase, showing how exploiting the endocannabinoid pathway might be a translational focus for entirely new approaches in OAB. They consider an issue that is very important in developing clinical options, which is that the systems regulating bladder function are also fundamental in other organs, such as the CNS. As the compound they studied does not cross the blood–brain barrier, the potential generation of CNS adverse effects is reduced, which would be important for its potential as a new therapy.

OAB is a symptom syndrome based on storage-type LUTS [3]. Increasingly the field of functional urology is recognising the large number of people who present with voiding and post-micturition LUTS yet do not have BOO. Currently, there are no satisfactory treatment options for affected people and the symptoms can have considerable impact. Frustratingly, current diagnostic methods rely on urodynamic testing to establish whether the presence of detrusor underactivity explains voiding LUTS in an individual patient. Recently, the profession has established a move towards using symptoms to categorise the clinical need in patients [4]. Accordingly, the International Continence Society has established a working group to generate terminology for underactive bladder (UAB), which will report this year, including a symptom-based definition. A symptomatic diagnosis would be very helpful to enable therapy development to proceed without the need for urodynamic testing. Also, in this month’s BJUI, Kajbafzadeh et al. [5] report a clinical trial in UAB using transcutaneous interferential electrical stimulation in children. The treatment was delivered in the context of the rather laborious process currently required for managing this difficult problem, namely diet and fluid manipulation, scheduled voiding, toilet training, and pelvic floor and abdominal muscles relaxation training. The electrical stimulation was demonstrably beneficial, and included responses for the highly troublesome symptom of nocturnal enuresis. The comparatively straightforward nature of this therapeutic approach potentially makes it a valuable tool for dealing with a notoriously difficult problem.

Marcus J. Drake, Senior Lecturer
School of Clinical Sciences, University of Bristol, Bristol, UK

 

References

 

1 Drake MJ, Chapple C, Esen AA et al. Efficacy and safety of mirabegron add-on therapy to solifenacin in incontinent overactive bladder patients with an inadequate response to initial 4-week solifenacin monotherapy: a randomised double-blind multicentre phase 3B study (BESIDE). Eur Urol 2016; [Epub ahead of print]. DOI: 10.1016/j.eururo.2016.02.030

 

2 Aizawa N, Gandaglia G, Hedlund P et al. URB937, a peripherally restricted inhibitor for fatty acid amide hydrolase, reduces prostaglandin E2-induced bladder overactivity and hyperactivity of bladder mechano-afferent nerve fibres in rats. BJU Int 2016; 117: 821–8

 

3 Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub- committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167–78

 

4 Chapple CR, Osman NI , Birder L et al. The underactive bladder: a new clinical concept? Eur Urol 2015; 68: 351–3

 

5 Kajbafzadeh AM, Sharifi-Rad L, Ladi-Seyedian SS, Mozafarpour S. Transcutaneous interferential electrical stimulation for the management of non-neuropathic underactive bladder in children: a randomised clinical trial. BJU Int 2016; 117: 793–800

 

Trainee Jobs: Pot Luck or Picking Teams in Gym Class?

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Fardod O Kelly FI“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is most adaptable to change…” (C. Darwin; ca.1857)

 

On Friday 18th March 2016, U.S. medical school students and graduates participated in the National Resident Matching Program (NRMP) with 42,370 registered applicants attempting to match into 30,750 PGY-1 and PGY-2 positions. This was preceded the same day by the Irish Higher Surgical Training (HST) Urology interview held in the RCSI in Dublin for a smaller number, but just as eager candidates endeavoring to secure their future in their own field. Thousands of candidates, in the pursuit of a career that they have so far, only dreamed about. Thousands of candidates, all with one thing in common: Not one of them knew where they were going to end up if they were somehow successful.

The British Medical Journal (BMJ) on their careers website explaining to core trainees how they might perform better in interviews, outline a roadmap of 12 key components from extra courses to leadership skills, but not once mention visiting the various deanery sites in order to assess whether the place represents a good fit for your own ambitions, learning objectives and style of management.

Prof. Adrian Joyce provided an editorial on the BJUI blogs site in 2013, highlighting the need to devise a better means of training “The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD… The challenge therefore is to devise innovative ways of training within the limit of fewer hours and training, not service, must become the priority for trainees and for those surgeons, departments and hospitals that train them…”

Therefore, we have two health systems on these islands, with the UK National Health Service (NHS), and the Irish Health Service Executive (HSE), both acknowledging the mandatory requirements of the European Working Time Directive (EWTD) to shorten working hours, and the need to fulfill service commitments within the health sector, and the need to allow for postgraduate training to ensure a steady workforce into the future, but also to balance the requirements of the Specialist Advisory Committee (SAC) and the Joint Commission on Surgical Training (JCST) as well as the Royal Colleges to ensure that training is to a satisfactory level. In order to achieve this, hospitals and trusts are allocated a number of trainees who have gone through the above selection process and have accumulated years of experience, qualifications and debts to fill a very complex role within a volatile system.

However, when did a “one-size-fits-all” approach become acceptable to trainers and trainees who need to work alongside each other within these environments filled with stress, litigation, and variable relationships with managerial types within the system? We all see patients, break bad news, manage expectations, provide treatment options, and above all know that each patient is different. They handle information, make choices, adhere and respond to treatment in a myriad of ways depending on a huge number of variables and confounders (not to mention the relatives). We have developed nomograms to try to communicate outcomes and risks to patients for disease like prostate cancer, such that entering the keywords “prostate cancer” and “nomogram” into PubMed will in excess of 900 hits. So, the hospital environment is complicated, and patients are complicated, but what about the lowly figure of the surgical trainee who has successfully demonstrated the aptitude and the background to progress to higher training?

Sullivan et al. demonstrated in 2013 that despite the reduction in trainee hours in the USA, resident attitudes, and program location were most frequently associated with voluntary attrition, with “the personal cost of training” (p<0.001; HR2.89) playing a major role in leaving a program. Bell et al. elegantly demonstrated in 2012 that despite the abundance of information on particular candidates, many of the fundamental qualities that are associated with success for the surgical trainee cannot be identified by review of the applicants’ grades, scores, letters of recommendation, personal statement, or even from the interview process. Therefor only by meeting trainees, in order to identify unique behavioral, motivational and personal talents that applicants bring to the program, allowed the authors to determine applicants who were a good match for the structure and culture of that particular program.

The standard interview process, whilst objective, does not allow trainers and institutions the luxury of getting a feel for the candidate, and applying instinct and acumen as to whether and how the trainee will fit into the overall scheme of things. The exact statement can be played in reverse.

All the innate instinctual abilities and skills that we prize in being able to quickly assess measure patients have been denied to us in choosing some of our closest junior colleagues on whom we rely on so heavily.

From a trainee urologist’s perspective, and one that would apply to nearly any other profession, one of the greatest predictors of your happiness and productivity at work is your relationship with your senior colleague. This is therefore intuitively important when considering new post, on order to know how you’ll get along with your new boss. This can be hard to assess in an interview when one is attempting to masquerade an unbridled sympathetic response and trying to demonstrate one’s one appointability, but it’s crucial to evaluate the panel as well. What sorts of questions should you ask to understand their management style? Should one try to talk with other people who have previously rotated through the post? Are there red flags you should watch out for? Will it even matter?

There are a number of healthy checklists in the business world which lend themselves to translation in surgery:

  • Trust your instincts: Ask yourself whether this is the training post you want and the consultant you want to work for. Did you get a good feeling from the person? Is she someone you can imagine going to with problems? Or someone you could have a difficult conversation with? This is especially important when the stakes are high
  • Do your homework: One of the greatest faux pas one can make is to incompletely prepare. You should try to gather as much information on the unit/post as possible including the history of the department, publishing record of the consultants, theatre logbooks from other trainees, inter-personal relationships, red flags. Google each consultant and check out the social media presence of the unit (#SoMe) as a proxy of their willingness to engage with social technology and communication
  • Meet your colleagues: Spend time with future colleagues in the unit independent of the interview. Take some time to chat to nursing and clerical staff as well as other trainees. More information can be acquired about a unit over a cup of coffee with future colleagues than any other approach

In this time of flux within health service systems, trust, collegiality and communication as key. Things that sound apt are not always what they seem. The quotation attributed above to Darwin, is often one that is misquoted, and although seems appropriate, there is no evidence that he ever made that statement. In the same way, trainees can no longer be seen to be but from the same cloth. Their own lives and careers are unpredictable and multi-faceted, and the answers and applications relied on at interview do not guarantee a good correlation coefficient when plotted on a graph belonging to a particular unit i.e. not a “good fit”. Perhaps it is time to trust our own instincts when appointing a trainee to a particular unit by taking the time to meet candidates and assessing – in addition to applications and CVs – how they might slot into a department – so that when it comes to tackling overcrowding, waiting lists, theatre slots, emergencies, call, research, audit, management and teaching, at least they can be met with the strongest team possible.

 

“…it’s better in fact to be guilty of manslaughter than of fraud about what is fair and just…”  (Plato, The Republic and Other Works)

 

Fardod O’Kelly is a Specialist Registrar in Urology at AMNCH, Tallaght, Dublin 24, Ireland. Twitter @FardodOKelly

 

April #UROJC: The Surgeon Scorecard – Merits of Publicly Reported Surgical Outcomes

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The April 2016 International Urology Journal Club on Twitter (#urojc) hosted a discussion on our paper, “Comparing Publicly Reported Surgical Outcomes with Quality Measures from a Statewide Improvement Collaborative”. Published in JAMA Surgery on March 16, 2016, the paper was authored by Gregory Auffenberg MD, David Miller MD, Khurshid Ghani, Zaojun Ye, Apoorv Dhir, Yoquing Gao. I contributed as a member of MUSIC.

It was an honor to have the paper selected for a #urojc discussion, and the authors would like to thank JAMA Surgery for providing open access during the discussion period. This post serves as an overview, and the entire #urojc transcript is available for reading courtesy of Symplur

For those not familiar, the #urojc Twitter chat is a 48-hour asynchronous conversation amongst urologists around the world on Twitter on a selected journal paper, taking place on the first Sunday/Monday of every month.

 

The ProPublica Surgeon Scorecard

The subject of our research centered on the online U.S. surgeon ratings compiled for ProPublica’s Surgeon Scorecard. ProPublica is an investigative journalism organization that was given exclusive access to U.S. Medicare data for the years 2009 to 2013.

“Reporters Olga Pierce and Marshall Allen studied almost 75 million hospital visits billed to Medicare looking for eight common, elective surgeries. They then looked to see whether the same person returned to the hospital for what appeared to be complications from the surgery. Their full methodology is spelled out here.”

 

The Michigan Urological Surgery Improvement Collective

Specifically, our research paper looked at ProPublica’s ratings for only one procedure – results on radical prostatectomy (RP) for prostate cancer – and correlation to reporting by MUSIC, the Michigan Urological Surgery Improvement Collaborative. MUSIC is a state-specific quality initiative in the U.S. in which I am a participating surgeon. Participation in MUSIC is voluntary, over 85 percent of urologists in the State of Michigan participate in the collaborative.

 

 

April #UROJC

As our paper states, the recent release of the Surgeon Scorecard accelerated debate around the merits of publicly reporting surgical outcomes. Surgical outcomes assessment is not a new concept, even dating back to 1860 as this tweet by @mattbultitude surfaced.


What does our community of urologists think about public reporting? Does greater transparency correlate with better outcomes? What are the benefits of a collaborative method like MUSIC? What methods are used in other parts of the world?

 

The #urojc discussion found that many urologists outside the U.S. were not familiar with the ProPublica ratings or debate. Some were not surprised that we did not find a correlation between our MUSIC outcomes data and the ProPublica data, thereby validating the need for quality outcomes data.

 

 

If the Surgeon Scorecard is flawed, what needs to be done to create an acceptable public reporting system?

 

Is public reporting of surgical outcomes taking place in Australia, UK, Canada & elsewhere?

 

 

How are ‘outliers’ identified by this study handled by MUSIC?

 

Do ratings lead to cherry-picking of patients?

 

According to New York cardiologist, Sandeep Jauhar, MD via Medscape, 63 percent of cardiac surgeons acknowledged accepting only relatively healthy patients for heart bypass surgery owing to report cards in New York State.

 

Moving Surgical Outcomes Forward 

On behalf of the authors of the paper and the entire MUSIC collaborative, I would like to thank our #urojc colleagues around the world for their thoughts, insights, criticisms and questions about the paper.

The ProPublica Surgeon Scorecard has generated significant and serious discussion in the U.S. about the challenges and merits of the public reporting of surgical outcomes. In an increasingly connected world, it’s difficult to imagine how this can remain simply an American debate.

Urologists by their very nature are leaders. Personally, I see this debate as yet another opportunity for us to develop and implement systems and strategies that reassure the public and advance patient care.

MUSIC JAMA Paper

 

Publons: Giving Credit For Peer Review

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NL Blog PicPeer reviewing of journal articles may be one of the most unheralded and feel at times as the least rewarded of continuing medical activities we do. People give time, expertise and judgement to make articles of a higher scientific standard and are crucial to the nature of medical publishing. As an Associate Editor of the BJUI, I am aware of the significant contribution reviewers make. I also review myself for many journals. For me it is one of the best forms of learning we have available to us. This was made even more apparent at the recent peer-reviewing workshop just prior to the EAU in Munich, where reviewers were delighted to learn of the possibility of a verifiable metric of reviewing.

Most journals provide recognition of peer-review work by publishing lists of reviewers, often collating CME credits and points or even the ability to provide a letter of reference when asked.

Third-party collation and recognition of peer-review work has until recently been lacking. This means to ‘prove’ one has indeed reviewed for a journal we would have few options apart from possibly saved emails thanking us for our good work. Publons has many aims but chief is to do just that – provide a platform where there is authenticity and recognition for peer review.

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How to do it?

  1. Go to www.publons.com
  2. Register (free)
  3. Upload a photo, short biography and your academic affiliations (Figure 1 and 2)
  4. Enter in your editorial board positions (the Journals you have reviewed for will be added by Publons once verified – Figure 3)
  5. Add reviews

IMG_8980The final point of adding reviews has been made relatively easy – it is automated and quick.

The official emails you have received over the years (which of course you carefully filed away…) stating “thank you for your review of the journal article entitled … Manuscript number …‘ just need to be forward to [email protected]

This will then, within a few days, be placed into the system. You will get an email notification. The partner publishing organizations (e.g. Nature publishing group) have their logo which makes it look all the more official (Figure 3)

 

IMG_8981Now for those of us who have not kept all of the ‘thank you’ emails, a second way is to go to each journal you have reviewed for, log in to the reviewers dashboard. Take screenshots and send as a JPEG (be careful to include your name as part of screenshot for verification). This may take a small fiddle to cut and paste to a word document if you have multiple shots. You can then send as PDF or photo etc. Again email the attachment to [email protected]. The website has provided rules on the types of proof or verification they will accept but they are pretty open to suggestions if there is an issue.

The review records are collated (Figure 4) and then a chance to upload your review. This type of open access is only in its infancy and not mandatory.

 

IMG_8982To make it more interesting there are award merits, which are a nice touch. Each review gets you three merits. Prizes are awarded quarterly and displayed on your profile page (Figure 1). They are categorical or may be within your country or university. Remember in this environment everyone doing peer review is represented so you are up against engineers, theologians and the like in some categories. The opening of reviews with ‘extra merit points’ available, although noble, is unlikely at this stage to have uptake. The peer-review process is fragile enough and this may need to be reworked. Perhaps “open review” bonus merit points could be separated out as it seems unfair to penalise reviewers as most are single or double blinded in any case and will not wish to open. Publons goals of promoting discussion and interaction are fine but after having spent time doing the reviews and not getting remuneration, it is somewhat counterintuitive to want to take more of your valuable time on a review – but it may suit some (read more on history of Publons here)

In time it is likely that Publons will become the Pubmed for peer reviewers. Relationships will form with publishers and hopefully it may become a network for peer reviewers and a tool for handling editors. Overall a wonderful initiative and a great step to recognize and hopefully enhance peer review, which is a sacrifice many of us make – but for the good of medicine!

 

Nathan Lawrentschuk, University of Melbourne, Australia

@Lawrentschuk

 

The 4th BJUI Social Media Awards

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As you may know, we alternate the occasion of the BJUI Social Media Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Our first awards ceremony took place at the AUA in San Diego in 2013, followed by the EAU in Stockholm, and a really fun evening at AUA in New Orleans last year. This year, we descended on Munich, Germany to join the 13,000 or so other delegates attending the EAU Annual Meeting and to enjoy all the wonderful Bavarian hospitality on offer. More about that in our blog posts from #eau16.

1.1On therefore to the Awards. These took place on Sunday 13th March 2016 in the roof garden bar of the beautiful Bayerischer Hof hotel. Over 70 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2016 BJUI Social Media Awards. Individuals and organisations were recognised across 46 categories including the top gong, The BJUI Social Media Award 2016; awarded to an individual, organization, innovation or initiative that has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her exceptional individual contributions, and in 2015 by the #UroJC twitter-based journal club. This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, Mike Leveridge, and Henry Woo, as well as BJUI Managing Editor Scott Millar whose team in London drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions. As befits the fast-moving nature of social media, we decided to omit a couple of previous categories and add two new ones.

One of these was the “Best #EAU16 Selfie” competition which we launched on the eve of this year’s EAU Annual Meeting to encourage some fun among congress attendees.

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We had dozens of enthusiastic entries which betrayed the social side of urology conferences today – see examples on our Awards Prezi.

 

The full list of awardees, along with some examples of “best practice” in the urology social media sphere can be found in the Prezi. The winners are also listed here:

  • Most Read Blog@BJUI – “The drugs don’t work”. Dr Matt Bultitude
  • Most Commented Blog@BJUI – “The Urology Foundation Cycle India” – 87 comments. Accepted by Dr Ben Challacombe, on behalf of Prof Roger Kirby, London, UK
  • Most Social Paper (new category) – “Twitter response to the USPSTF recommendations against screening with PSA”. Published in BJUI 2015. Accepted by Stacy Loeb on behalf of Dan Makarov and other co-workers.
  • Best BJUI Tube Video – “Extended PLND – creating the spaces”. Accepted by Declan Murphy on behalf of John Davis, MD Anderson, USA.
  • Best Urology Conference for Social Media – #AUA15 – The American Urological Association Annual Meeting 2015. Accepted by Dr Stacy Loeb on behalf of the AUA.
  • Best Urology App – The “British Association of Urological Surgeons Emergency Urology App”. Accepted by BAUS President Mark Speakman on behalf of BAUS and Dr Nick Rukin
  • Innovation Award 2016 – “Urology Ontology Tag Project”. Accepted by Dr Jim Catto and Dr Henry Woo (Dr Alex Kutikov not present)
  • #UroJC Award – Dr Rustom Manecksha, Dublin, Ireland
  • Most Social Trainee (new category) – Kari Tikkinen
  • Best Selfie – Khurshid “Macgyver” Guru
  • Best Urology Journal for Social Media –Journal of Sexual Medicine. Accepted by Associate Editor for Social Media, Mikkel Fode
  • Best Urology Organisation – European Association of Urology. Accepted on behalf of EAU by European Urology Editor-in-Chief, Jim Catto.
  • Best #EAU16 Selfie (new category) – Maria Ribal with special mentions to Morgan Roupret and Inge van Oort
  • The BJUI Social Media Award 2016 – #ilookllikeaurologist. Accepted on behalf of female urologists all over the world by Dr Stacy Loeb, New York, USA

Most of the Award winners were present to collect their awards themselves, including Dr Stacy Loeb who received our top gong for her work in driving the #ilooklikeaurologist campaign. The Awards Committee had identified this wonderful social media campaign from early on as a stand-out example of how social media (Twitter in particular), can be deployed to drive a really important social message. The #ilooklikeasurgeon campaign had already caught the imagination of all of us who identified with the message that female surgeons were undervalued in our specialty, and the #ilooklikeaurologist campaign really brought a welcome focus on our female urology specialists and trainees. The tweet that first used the hashtag was sent by Stacy in August 2015 in reply to a tweet from Rustom Manecksha:

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Since that time, over 1000 tweets have been sent using this hashtag, most featuring great pictures of our female urologists at work or at play. See plenty of examples on our Prezi or just search the hashtag #ilooklikeaurologist.

A special thanks to our outstanding BJUI team at the Editorial Office in London, Scott Millar and Max Cobb, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Boston for #AUA17 where we will present the 5th BJUI Social Media Awards ceremony!

Declan Murphy, Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor – Social Media, BJUI

@declangmurphy

 

 

 

 

Divided by more than a common language

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CaptureAt its simplest, hypogonadism manifests as (abnormally) low testosterone levels, which require effective clinical intervention; however, there is little or no consensus on the definition, diagnosis and treatment of the condition. Indeed, at least in the USA, the issue of the (ab)use of testosterone replacement has been under the microscope because of a hypothesis, albeit flawed, linking it to increased cardiovascular risk. The need for consensus on the management of hypogonadism is increasing almost in front of our eyes as a result of the link with the metabolic dysfunction associated with the increase in diabetes and/or obesity in the general population. With this background, an international panel representing the disciplines involved in the management of hypogonadism was convened; the output of the group, in terms of definition and patient management, is reported in this month’s issue of BJUI [1].

Apparently, the need for effective intervention is more critical than one would necessarily assume. Not only is there a hypogonadism ‘epidemic’, linked to the fattening of our population, but there is no globally approved treatment for secondary hypogonadism (2HG) i.e. that form not associated with testicular failure. Epidemiologists warn that 2HG is in fact the predominant clinical representation, being roughly six times as common as primary hypogonadism.

The conclusions of the recent consensus panel are neither more nor less appropriate nor scholarly than those of other groups, e.g. the Endocrine Society, BAUS, AUA or SMSNA, but their value is as a timely reminder that unless there is clinical consensus on the disorder it is practically impossible to design regulatory authority-proof clinical trials to ensure drug approval. Ironically the most effective treatment strategy in many instances would be lifestyle intervention, but we all know how compliant men are when diet and exercise are recommended.

Returning to drug treatment, the panel does emphasize the critical importance of distinguishing between the different aetiologies of primary hypogonadism and 2HG. Although testosterone replacement therapy is usually appropriate in the treatment of primary hypogonadism, it may be inappropriate in the treatment of 2HG. Because of negative feedback in this situation testosterone replacement can reduce spermatogenesis and testicular function. This clinical phenomenon is exemplified by the phase III data from two clinical trials presented by Kim et al. [2] in this issue of BJUI. Compared with placebo, testosterone replacement produced substantial reductions in spermatogenesis and testicular function. Bearing in mind that many men with androgen deficiency may well wish to preserve fertility, testosterone replacement could therefore in fact be counterproductive. The trials by Kim et al. also showed that, by comparison, the selective, centrally active, oestrogen antagonist, enclomiphene, could normalize testosterone levels while maintaining testicular function and spermatogenesis.

In many ways, assuming eventual regulatory approval, enclomiphene could represent the optimum therapy for 2HG, preferably as an adjunct to lifestyle modification, i.e. dietary manipulation and exercise. Unfortunately, at least in the USA, the regulatory authority appear not to recognize 2HG as a condition that merits treatment. Pressure from the clinical community could influence this attitude.

Michael G. Wyllie, BJUI Consulting Editor, Sexual Medicine
Stratton House, Shenington, Banbury, Oxfordshire, UK

 

References

 

1 Dean J, Maggi M, de Boer J-B et al. Diagnosing secondary hypogonadism: important consequences for fertility and reversibility. BJU Int 2016; 117: 551–4

 

2 Kim ED, McCullough A, Kaminetsky J. Oral enclomiphene citrate raises testosterone and preserves sperm counts in obese hypogonadal men, unlike topical testosterone: restoration instead of replacement. BJU Int 2016; 117: 677–85

 

March #urojc: Radiotherapy for Prostate Cancer – Is it a gift that keeps on giving?

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The International Urology Journal Club on Twitter is now well into its 4th year.  The subject for the March 2016 discussion was a paper published in the BMJ entitled “Second Malignancies after radiotherapy for prostate cancer: systematic review and meta-analysis”.

Lead and senior authors, Chris Wallis and Rob Nam were kind enough to  make themselves available to participate in this discussion.  Rob Nam made use of the  #urojc guest twitter account.

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The literature was searched using Medline and Embase and the method of review was the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational studies in Epidemiology (MOOSE) guidelines for reporting of this systematic review and meta-analysis.

Chris Wallis provided an excellent TL:DR summary with the following tweet.

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It is well recognized that secondary malignancies following radiation exposure could take many years to become apparent.

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The responses were fairly predictable but nevertheless an important point to explore.

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Early in the discussion, there was also relevant reminder of the issue of differences in odds ratios and absolute risk.  That said, consideration needs to be given to the ‘big ticket’ nature of secondary malignancy where even a small absolute risk drives a great deal of interest in this subject matter.

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An interesting finding from the study was that the risk of secondary malignancy was less with brachytherapy compared with external beam radiation.

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Further to this, is it possible that there could be a difference between HDR and seed brachytherapy?  An interesting thought although not specifically covered in the paper.

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A more controversial aspect to the discussion was whether the risk of secondary malignancy would justify screening or surveillance. The following exchange was worthy of note.

Whilst there is nothing in the way of documented guidelines or actual evidence to demonstrate a benefit of surveillance, it seems something worthy of consideration for future practice guidelines –  in other words, recommendations one way or the other.

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Rob Nam refers to a third paper on radiation outcomes in the context of previous surgery.  This BJC paper, the Lancet Oncology paper (previous discussed at a #urojc in 2014) and now the current paper could cheekily be called the Nam Trilogy – make note that you heard this term here for the first time.

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To what extent should we be counseling our patients on the risk of secondary malignancy if they are to undergo radiation for prostate cancer?  Is this just another factor to encourage surgery over radiotherapy?  Will there be no change in practice, particularly in the US where many lucrative radiation oncology services are actually owned by urological surgeon private practice groups?

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The state of radiation oncology practice is different outside the US and my own personal thoughts on the matter are that the Nam Trilogy of papers will create a series of well cited ‘evidence’ that will further shift the weight of opinion towards surgery over radiotherapy as a primary treatment for localized prostate cancer.

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Anybody who followed the March installment of the #urojc would have been impressed by the high level of interaction by the authors Chris Wallis and Rob Nam.  A particular mention should be given to Sabin Motwani who as a radiation oncologist, provided valuable input to the discussion.

Please do join us for the April installment of the #urojc and I encourage you all to email, tweet or DM your suggestions for papers to be discussed.  Please also, feel free to volunteer to write up a monthly summary for publication on the BJUI blogs.  I would also like to acknowledge the contributions of Rustom Manecksha who was the winner of the 2016 BJUI SoMe Award for #urojc – a reflection to the quality of his participation and support for this online educational activity.

 

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney.  He is the coordinator of the International Urology Journal Club on Twitter.

EAU 2016 Congress Day 3

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Das bringt mich weiter! While the sun was shining in Munich, the 3rd day of the 31st EAU Annual Congress continued with very well attended plenary and poster sessions. And that is no wonder because the EAU Scientific Committee had created such an attractive program, including amazing plenary sessions during the morning and a plethora of informative poster sessions in the afternoon.

 

Professor Hendrik Borgmann (@HendrikBorgmann) has already covered highlights of the opening days 1 and 2 of this year’s Congress in his BJUI blog. We will give you some highlights of Day 3 and highly recommend you to take a look on EAU congress website, Day 3, which has archived a huge amount of material to allow you to catch up on sessions you may have missed. Indeed, lots of webcasts are available!

 

We focused on non-oncology plenary morning sessions and oncology poster sessions afternoon. Here are some of our highlights:

SURGERY IN THE ELDERLY – As our urological patients become older and older, surgery for octogenarians, or even nonagenarians, is increasingly common. The morning session covered various aspects on diagnosis and treatment of benign prostatic hyperplasia and other urological conditions in the ageing patient.

Professor Cosimo De Nunzio began the morning with “Highlights” on lower urinary tract symptoms and prostatic disease presented during this year’s EAU congress. Also this year, as many as every third abstract was on either prostate cancer or prostatic hyperplasia.

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Indeed, the plenary session on Day 3 also covered prostatic disease.

Professor Alexander Bachmann talked about surgery for BPO in the elderly. He pointed out that in elderly (high-risk) patients we do not need a complete anatomical tissue removal, we do not need a (very) long-term follow-up and that we do not need tissue for prostate cancer diagnosis. Instead, we need a safe and efficient operation with individual adaptation of the technique and preferably feasibility in an ambulatory setting or local anaesthesia.

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Professor Bachmann further emphasized that it would be preferable if surgery for the elderly would be performed by experienced surgeons, and that age per se is not a reason to not operate. There are several new minimally invasive operations available, and especially for elderly less is often more.

HOW AND WHEN TO STOP ANTICOAGULATION – Managing perioperative thromboprophylaxis for patients who already receive anticoagulants remains a challenge. Associate professor Daniel Eberli and Professor Per Morten Sandset covered many of these aspects in their helpful presentations.

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Dr. Eberli told us that bridging therapy (options for stopping or not stopping anticoagulation in the above figure) is eminence-based, as no papers exist showing benefits. He also presented data from the recent NEJM trial (BRIDGE study; see Table below), which showed that stopping anticoagulation without bridging was non-inferior to perioperative bridging for the prevention of arterial thromboembolism and decreased the risk of major bleeding.

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Dr. Eberli gave us all a take home message to discuss and question our local bridging guidelines as new evidence is very likely not supporting them (concluding slide below).

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Professor Sandset recommended that during the perioperative period only use aspirin in high-risk patients, that is, those with recent thrombotic event or extensive coronary heart disease. He also informed us that stopping antiplatelet therapy 5 days before surgery (figure below) is often the way to go, and agreed with Dr. Eberli regarding bridging therapy statements.

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Professor Sandset also gave helpful information regarding use of direct oral anticoagulants (DOACs) in urological surgery:

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There were numerous poster sessions available on Day 3, as usual, many of them on prostate cancer. We have selected some of the highlight abstracts presented.

PROSTATE CANCER – On Day 3, prostate cancer presentations dominated once again in a number of poster, abstract and thematic sessions but also kidney, bladder, testicular and penile cancer sessions, which provided new interesting data.

Molecular markers, genomic profiling and individualized risk and treatment assessments were presented and discussed in poster session 58, and summarized by Stacy Loeb (@LoebStacy). Further advances in prostate cancer biomarkers in prostate cancer were presented in poster session 84. These new tools are moving from bench to bedside and urologists can hopefully incorporate these new tools to cancer care sooner rather than later.

In sessions on prostate cancer diagnostics, more advanced risk profiling tools were highlighted. For instance, STHLM3 test combines history of the patient, clinical parameters, biochemical markers and genetic markers. It was presented earlier in the congress and on Day 3 further health, economic and clinical evaluations were presented in Thematic session 12. It is one example of the tests showing promising results to potentially decrease the number of prostate biopsies needed. Other similar risk profiling tools were also presented during the congress. In addition to PSA only, evaluation of the smart use of already available clinical and biochemical parameters and the combination of genetic markers may bring individualized risk assessment of prostate cancer to the next level.

In poster session 62 on Day 3, diagnostic proceedings in prostate cancer with co-morbidity evaluation, biopsy strategies and MRI imaging were presented.  A combination of molecular markers and imaging may be the way to proceed in future. These aspects were covered nicely in Thematic session 12.

MRIs have been heavily integrated in prostate cancer diagnostics during recent years. Image guidance in prostate biopsies seem to be making a breakthrough in prostate cancer diagnostics. Targeted biopsies with cognitive or MRI-TRUS fusion imaging were shown to be the way to enhance the results and reliability of biopsies and cut down the number of biopsies. However, as biopsies are still needed in prostate cancer diagnostics, use of the pre-biopsy MRI protocols were suggested to be done only in clinical trial setting. Many aspects of MRI diagnostics of prostate cancer were elegantly summarized in Thematic session 11.

New sophisticated imaging technologies in addition to MRI were present in several sessions during the meeting. Diagnostic enhancement has been seen also in metastatic prostate cancer. PSMA-PET seems to be replacing choline-PET-TT in evaluation of relapsing and metastatic prostate cancer (e.g. Thematic session 10). More reliable diagnostics and imaging of prostate cancer are also enhancing the treatment decision and treatment choice of patients with local prostate cancer. Finding the right patients for the active surveillance protocols is also being helped with advanced diagnostics. Indeed, finding only patients who need treatment for prostate cancer should be the ultimate goal for enhanced diagnostics as discussed in poster sessions 66 and 75 on Day 3. There are also high expectations on focal therapy (e.g. poster session 66), which at the moment is still experimental but will likely be a real option for patients with low volume prostate cancer verified by imaging.

The role of quality of life evaluations and patient reported outcomes measured were heavily discussed during the congress in all treatment modalities of both local and advanced prostate cancer. Survivorship issues are an increasingly important issue when more effective treatments both in local and advanced prostate cancer are available.

In metastatic disease, the use of early chemotherapy in combination with hormonal treatment has been implemented very rapidly to clinical use after the results of the CHAARTED and STAMPEED studies. Further evaluation of early chemo in metastatic disease is still needed and the patient selection needs still clarification. Hormonal therapy still has a very marked role in metastatic prostate cancer and new advances can also be found in new strategies of using castration therapy as presented in poster session 67. Urologists should actively follow the changing landscape of the medical treatment of metastatic prostate cancer and be active in treatment planning and treatment of these patients. At the same time with poster session 62 novel drugs and new forms of isotope radiation therapy in castration resistant prostate cancer were discussed in poster session 61. These open new possibilities for potential treatments.

The clinical and scientific content of the program of the Day 3 was of a very high standard, and reflective of the breadth of contemporary research in many areas within urology. Besides this session, it was our pleasure to meet old and new urological friends worldwide. The annual EAU meeting remains a highly effective method of knowledge translation and provides the opportunity for collaboration between surgeon scientists and other researchers in the field. As always in big congresses, there are so many interesting sessions going on at the same time, that it is hard to pick up and follow everything you would like to. We hope that this report provides some memories and take home messages of the Day 3 to the readers of the BJUI and BJUI blogs.

We look forward to future BJUI and EAU happenings!

 

Kari Tikkinen

Urology resident, adjunct professor of clinical epidemiology

Helsinki University Hospital, Helsinki, Finland

@KariTikkinen

 

Mika Matikainen

Chief of urology, adjunct professor of urology

Helsinki University Hospital, Helsinki, Finland

 

 

Rehumanising

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james-duthieWe live in a dehumanizing world. Out of a need for efficiency, convenience, and reassurance, we both dehumanize and are dehumanized routinely in our commerce and relationships. We are not a three-dimensional human being of unique genetics and experience, forte and frailty, preferences and peculiarities to our bank, public library, or insurance company. Out of necessity, these structures diminish us to a number or barcode. We are grouped by age and demographic, measured by our internet clicks, targeted according to our income by corporations.  To those profiting from our consumption our individuality is irrelevant; the big money is in exploiting groups. Whether you support a free Tibet does not concern the people selling cheeseburgers, unless enough people agree with you that some marketing leverage can be generated from this fact. In medical research we reduce people to “female between 40 and 75 years with chemotherapy naïve metastatic ovarian carcinoma”. Not “Julie, mother of three boys (one with cerebral palsy), who put up with her vague abdominal symptoms for too long because she was preoccupied by supporting her younger sister out of an abusive relationship”.  While logistical limitations do not allow for the statisticians to enter into every individual story, we reassure ourselves that the depersonalized and homogenized data from these studies is for the greater good. Indeed, sometimes it just isn’t any of our business.

We can accept that on this macro level there are faceless amoral corporations that care only about how to alter our spending patterns, but on an interpersonal level we can be equally guilty of dehumanizing attitudes. Thanks to the heuristics developed by our ancestors, which I for one am grateful for, the human brain is very efficient at mentally grouping things under such headings as “dangerous” and “delicious”. This has allowed our continued survival. Having a general suspicion of things that looks like snakes means a reduced risk of envenomation. Being suspicious of strangers by default means that we are less likely to be on the back foot if someone pulls a spear on us. It would be nice to think that we have largely put this simplistic cognitive process behind us, but we tend to fall back on bad habits. Every time we mentally label a person we are trimming their humanity in order to fit them into a pre-existing cognitive category. When we think “young hoodlum”, “old codger”, “drug addict”, “liberal”, or “health nut”, we are in fact extracting what we deem to be the most salient point of person and making it the sum total of their identity. There is obviously expedient for us, as we continue to do it. It makes it easier to ignore the “derelict” on the street, and not feel too bad about the “foreigners” affected by natural disasters. Our bias is routinely exploited by our leaders, especially in times of war. We are not killing  people very similar to ourselves, we are fighting “scum”, “heretics”, “commies”. While studying for a degree in psychology I came across a study that demonstrated that people attribute more negative characteristics to people groups if they are referred to by nouns rather than adjectives. People were more mistrustful of others described as “Poles” or “Jews”, rather than “Polish” or “Jewish”. The objective label nudges people into a category, with the adjective reminds us that these are complex individuals, who happen to have a given ethnicity or faith.

We have a reflexive discomfort at being dehumanized ourselves. We don’t like being treated like cattle by airlines or sports stadiums. We despise being written off as nothing more than the town we came from, the school we went to, the era we grew up in, or our gender. We know from personal experience that we are unique, and attribute value to this, at least in ourselves.

Surgery is dehumanizing. We take frightened people, anaesthetize them so that they cannot resist, and then disassemble them. The intention is to reassemble them in an improved way, but we are reducing people to a collection of organs and meat in a way that strips them of usual dignity. Until the Renaissance, disassembling the dead was considered too shameful to tolerate. Indeed, to begin with only executed criminals, considered sub-human (already dehumanized), were considered suitable candidates for anatomical dissection.  It was too much to imagine a person opened up for the world to see their insides, their dignity stripped in an extreme form of nudity. I have already written about how not entering into the full experience of every human drama is what makes surgery a viable career (https://www.bjuinternational.com/bjui-blog/surgery-is-not-normal/), and I don’t think it is helpful to focus on the bigger picture beyond the operating theatre while focusing on the technical steps of an operation, but a few points are worth considering.

Firstly, those of us who have had human dissection as a part of our training tend to share a common experience. While in the thick of a dissection, occasionally rewarded with the discovery of a familiar structure, it is normal to forget that the prosection was once the residence of a functioning person. Typically it is the glimpse of a uniquely human feature; the face, feet, hands that triggers a moment of shock at what is going on. I still recall looking down to see that our cadaver had painted toenails. Instead of being a learning resource, it struck me that this woman had spent time days before her death, tending to her toenails fastidiously, unaware of what was to come. This placed her in a room in her home, at a time of day, perhaps before leaving to attend a social event. The full experience of her humanity was infinitely greater than the tutorial aid she had been reduced to. The strict procedures governing the use of human tissue made sense, lest we forget the gift of the donor.

One of the more moving experiences I have had in a hospital is watching Intensive Care nurses managing comatose patients. My observation is that these patients are treated more gently than necessary, and there is a constant one-way conversation from the nurses explaining that now, they are going to reposition the legs. They are going to brush teeth. They are adjusting the pillow. Calling the patient by their name, as their words fall on deaf ears. While logically this makes no difference to medical treatment, it protects the nurse from dehumanizing the patient, making them more than an oxygen trace on a screen.

Ultimately, the effort to re-humanize is what makes us fully human. The unconscious patient or cadaver is not affected by our attitude towards them, but we sacrifice our own humanity whenever we revert to applying broad heuristics to other people. A cat knows to be frightened of snakes, but it takes human intelligence and will to deliberately consider that a person is more than something to fear, ignore, or desire. It is an act of overcoming base instinct. When we apply the appropriate reverence for a person as we prepare them for surgery, care for them in their unconsciousness, our respectfully use their dead body to improve the treatment of future patients, we affirm our own humanity. It is more for us than for them.

 

Jim Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Tauranga, New Zealand. @Jamesduthie1

 

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