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#RudeFood: Foodporn for a purpose

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The Internet is full of weird and wonderful things. Of course, we all know what is most frequently viewed and shared online. That’s right – food! Nonetheless, when celebrity chef Manu Fieldel posted a photo of his latest creation, it certainly made people look long and hard!

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Name this dish – I like to call it the ‘Cockembouche’ Does it remind you of anything in par-dick-ular? 🤣 It's bursting with flavour and with one bite, will melt in your mouth. I’m not just posting this for the laugh – I've created this #rudefood dish in support of @anzuptrials who work tirelessly conducting clinical trials to improve the treatment and outcomes of penile, testicular, bladder, kidney & prostate cancer these cancers are the ones that don’t make the headlines and people don’t want to talk about but we need to change that. Share your #rudefood – food porn with a purpose and use the hashtag #rudefood tagging @anzuptrials And let’s raise awareness for these cancers. #foodpornwithapurpose #cockembouche #anzup

A post shared by Manu Feildel (@manufeildelofficial) on

Soon it became clear that this naughty creation had a noble purpose – supporting a campaign to raise awareness of the so-called #BelowTheBelt cancers. While most people may have heard of prostate and bladder cancers, being relatively common, other #BelowTheBelt cancers such as penile and testicular cancers are rarer and relatively unknown. To make matters worse, these cancers affect men either exclusively or predominantly – and we all know how reluctant men can be to go to the doctors.

Hence, the #RudeFood campaign was developed by the Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group. ANZUP is the peak co-operative trials group for #BelowTheBelt cancers in Australia and New Zealand. ANZUP has and continues to develop and run many significant clinical trials, including the Enzamet and Enzarad trials for prostate cancer, the Phase III accelerated BEP trial for germ-cell tumours, the sequential BCG-mitomycin trial for bladder cancer and the Eversun and Unison trials in kidney cancer.

The week started with things heating up at ANZUP as they brought #RudeFood to the unsuspecting world!

Manu’s phallic creation was also matched by Ainsley Harriot, Sonia Meffadi and Monty Kulodrovic.

To counterpoint the raunch, there were also poignant personal connections from Simon Leong and Scott Gooding who both described family members who had suffered from prostate cancer.

Over the week, #RudeFood has certainly drawn some attention, including from media outlets such as Mamamia, news.com.au and GOAT. 

A poetic contribution on #RudeFood caught the eye of @UroPoet across the seas. Let us hope this campaign will also lead to greater awareness of #BelowTheBelt cancers and improved outcomes for those affected by them.

Shomik Sengupta is Professor of Surgery at the EHCS of Monash University and visiting urologist & Uro-Oncology lead at Eastern Health. Shomik has particular interests in prostate cancer, including open and robotic prostatectomy, as well as bladder cancer, including cystectomy with neobladder diversion. Shomik is the current leader of the UroOncology SAG within USANZ, and the past chair of Victorian urology training.  Shomik is a Board member and scientific advisory member of the ANZUP Cancer trials group and is heavily involved in numerous clinical trials in GU oncology.

Twitter: @shomik_s 

Science, technology and artificial intelligence

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As the year comes to a close, it is time to reflect fondly on the revolutionary reports in the world of scientific publishing. To me, the most exciting were the findings from the Cassini spacecraft diving within Saturn’s rings before destroying itself in its upper atmosphere. This so‐called ‘Cassini Grand Finale’ had begun with the launch of the spacecraft over 20 years ago with the hope of finding subsurface water and potentially habitable environments on Saturn’s moons [1]. Our search for intelligent life continues, driven by advances in new technology. Back on earth, modern microscopy can allow single molecules to be observed and genomes can be precisely manipulated by Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)‐mediated gene editing. The handling of the large data that are generated is likely to be enhanced by the ever‐evolving role of artificial intelligence (AI) [2]. Our New York Dedicated Servers come wіth a 100% network uptime SLA tо dеlіvеr a rеlіаblе dedicated ѕеrvеr hоѕtіng experience fоr уоur buѕіnеѕѕ. Get latest business updates at colabioclipanama2019 .

This is the year when we have heard more about AI within the surgical community than any other [3]. Most of us carry AI devices in our pockets in the form of our mobile phones. How can we use this to our benefit perhaps during the few minutes that we have between cases on a busy urological operating list? My usual trick is to ask ‘Siri’ (Speech Interpretation and Recognition Interface) on my iPhone® (Apple Inc., Cupertino, CA, USA) to play me a BJUI podcast, which provides me with a summary of a new paper without having to read any text. Many have told me that listening is becoming as fashionable as reading text, and this is one of our attempts at using AI to augment the BJUI experience.

We also set ourselves the target of becoming one of the first journals to embrace and embed AI. With this in mind, I requested Andrew Hung from California to join the BJUI as Consulting Editor for AI. Andrew has already been publishing novel and often paradoxical reports on surgical performance based on automated performance metrics. you can check our site rooftopyoga for latest updates. A team from Canada has found that machine‐learning (a subset of AI) algorithms can predict biochemical recurrence after radical prostatectomy more accurately than traditional statistical modelling [4]. While being excited by these results, Hung [5] reminds us that this needs to be validated externally in a larger patient population before it is ready for prime time. Next year we hope to report more from the world of AI and perhaps even surprise our readers with embedded technology within the BJUI itself.

With such rapid advances in science and technology comes the description of a new kind of education for our generation and the next. For part time quantity surveyor course in Singapore go through our site.  Joseph Aoun [6], who leads Northeastern University, describes this as ‘Humanics’ in his new book on higher education in the age of AI. It involves the fundamental difference between what machines and AI can do better than humans but equally what humans do better than machines. This book is a must‐read, as it describes the pillars of technological, data and human literacy. So much so that I have started advising my scientifically minded students and colleagues to consider participating in short boot camps on data science.

I wish you all, wherever you are and whatever the weather, much happiness and greetings of the season!

Prokar Dasgupta

Editor-in-Chief, BJUI

References

1 Dougherty MK, Cao H, Khurana KK et al. Saturn’s magnetic field revealed by the Cassini Grand Finale. Science 2018; 362: 5434

2 Mao S, Vinson V. Power couple: science and technology. Science 2018; 361: 864–5

3 Dasgupta P. New robots – cost, connectivity and artificial intelligence. BJU Int 2018; 122: 349–50

4 Wong NC, Lam C, Patterson L, Shayegan B. Use of machine learning to predict early biochemical recurrence after robot‐assisted prostatectomy. BJU Int 2018.

5 Hung A. Can machine learning algorithms replace conventional statistics? BJU Int 2019

6 Aoun JE. Robot‐Proof: Higher Education in the Age of Artificial Intelligence. Cambridge, MA: The MIT Press, 2017

Urofair 2018

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Urofair Congress Highlights – Singapore 2018

From 12-14 July, the Singapore Urological Association (SUA) welcomed 450 delegates from across Asia and further afield to sunny Singapore for Urofair 2018.

The theme was Integrating Scientific Knowledge, Technology and Clinical Urology, and the excellent scientific program crafted by the organizing chairman John Yuen and scientific chairmen Joe Lee and Terence Lim, certainly reflected this.

Continuing a fine tradition, the BJUI once again has supported this meeting with all accepted abstracts to be published in a special supplements issue.

Learn about healthy supplements at Amazon.com.

Pre-Urofair activities

Preceding the Urofair, was the Urology Residents Course (URC) and the European Basic Laparoscopic Urological Skills (E-BLUS). The revision of key concepts at URC followed by grounding of basic laparoscopic skills by great minimally invasive surgeons Christian Schwenter and Evanguelos Xylinas was truly beneficial for the residents, and primed them well for the latest updates they received at Urofair.

Urology Residents Course Class of 2018

Simulation and tutoring – Evanguelos Xylinas supervising a trainee on laparoscopic trainer at E-BLUS

Urofair 2018 started with a bang, with the ever popular live and semi-live surgery sessions at Tan Tock Seng Hospital. One of the highlights of the session was the masterful demonstration of retroperitoneal robotic assisted partial nephrectomy by James Porter (@JamesPorterMD). One of the attractions of live surgery is the anticipation of intraoperative problems and the thrill of watching experts manage them. This session was no exception, as Allen Sim of Singapore General Hospital showed calmness under pressure, as he showed how to deal with an inadvertent breach of the peritoneum and control of bleeding during a difficult retroperitoneal nephroureterectomy. The semilive demonstrations were no less educational, with Christopher Evans showing how he manages unusual anatomic variants during robotic radical prostatectomy.

One of the main highlights of this year’s Urofair was the launch of the inaugural KT Foo Lecture by the Father of Singapore Urology, Professor Foo, Keong Tatt who presented his life-long research work on the management of BPH. At the end of this tour de force, he was presented with the well-deserved SUA Life-time Achievement Award.

Lim Kok Bin (left), President of the SUA presenting the SUA Lifetime Achievement Award to Prof KT Foo (right)

 One of the goals of the SUA is to serve as a bridge between regional and international urological associations. Urofair 2018 reflected this goal with multiple joint sessions with our friends from the Malaysian Urological Association (MUA), European Urological Association (EAU), Urological Associations of Asia (UAA), Federation of Asean Urological Associations (FAUA) and Hannam Urological Association. Dr Tan Hui Meng delivered the MUA lecture on testosterone replacement therapy (TRT). He refuted some of the controversies regarding TRT, and cited the supporting data to defend its use. On a practical note, he shared his checklist for counselling and consent-taking before starting TRT in clinical practice. We were deeply honoured that the Secretary General of the EAU Professor Christopher Chapple(@ProfCRChapple) himself, delivered the EAU plenary on Substitution Urethroplasty. The management of urethral strictures is challenging due to the vast variability between patients, stricture aetiology, location and available tissue reconstruction. One key tip was that urethroscopy was useful to identify early stricture recurrence, which otherwise can be missed on uroflowmetry.

Hong Seok Shin from the Hannam Urological Association presented his unique presentation on Plastic surgery in collaboration with phẫu thuật gọt hàm, highlighting the importance of patient selection and counselling. The FAUA session was held concurrently with attendance of key office-holders of the various ASEAN urological associations. The theme of the session was on the development of MIS in Urology in the ASEAN countries discussion on “Cross-boundary Disease Management” with interesting clinical cases presented from different countries was lively. Koon Ho Rha delivered the UAA lecture on “The Role of Cytoreductive Prostatectomy in Advanced Prostate Cancer”, and showed in his series, that well selected patients with locally advanced disease, benefited from prostatectomy, which can be safely done robotically.

Multiple masterclasses ran concurrently on a range of subjects, including MRI-TRUS Fusion biopsies, Renal Transplantion, Andrology and Reconstructive Urology. The Robotic Surgery Masterclass chaired by Png Keng Siang was attended by a full house! The five expert robotic surgeons (Chris Evans, Koon Ho Rha, James Porter, Declan Murphy and Steve Chang) spoke on a range of topics from retroperitoneoscopic RAPN, to nerve-sparing techniques and complications of RARP to the use of different versions of robots (Si vs Xi) in robotic nephroureterectomy. The session ended with lively discussions between the panel and the audience in an interactive video session on trouble shooting challenging surgical aspects of RAPN and RARP.

The closing plenary was a “Glimpse into the Future”, covering topics from Precision Oncology and the role of Clinical Genetics for Urologic cancers, to the “The New Robots on the Block”.

Koon Ho Rha gave us a tour of the development of the ubiquitous Da Vinci, followed by the up and coming competitors, including one which has licensed and commercially available in Korea. Competition in this field can only make robotics in urology better and hopefully more cost effective.

Declan Murphy(@declanmurphy), Social Media Director of the BJUI shared his insights on the role of Social Media in Urology Practice. He highlighted the shift in the publishing paradigm, with videos and blogs of new findings peer reviewed on social media, before “traditional publication” by a journal, followed by amplification of the publication on social media.

Nurses are an integral part of the urological care, and they were certainly active at Urofair. The 180 strong audience at the Nursing Symposium were rapt with attention as Ms Helen Crowe shared her vast experience as Australia’s first Urology Nurse Practitioner on Prostate Cancer Nursing as well as expanding the role of Urology Nurses.

The Nursing Masterclass on the management of urinary incontinence was fully subscribed, and the practical hands on nature of the class was a big hit with the participants.

Physiotherapists conducting pelvic floor exercises with the Urology Nurses

 Our GP partners were not forgotten, and the 120 GPs who attended were treated to a great program. In this era of fake news, the standout lecture must have been “Google is not your friend”, where Lee Fang Jern shared the perils of medical fake news, and how medical practitioners can guide our patients to navigate the internet in search of reliable medical information.

The Gala Dinner was a fitting end to a fruitful Urofair, where everyone had a chance to strengthen and renew friendships over good food and wine.

Organising Chairman John Yuen is all smiles after the successful conclusion of Urofair

 The highlight of the Gala, was the rarely seen Bian Lian (变脸) performance. Bian Lian is an ancient Chinese dramatic art, where performers wear brightly colored costumes and vividly colored masks, typically depicting well known characters from the opera, which they change from one face to another almost instantaneously with the swipe of a fan, a movement of the head, or wave of the hand.

Bian Lian (变脸) performer

On a personal note, Urofair was a great opportunity to reconnect with Declan Murphy, who was my supervisor during my fellowship at the Royal Melbourne Hospital. I was honoured to have him and his son @cianblakemurphy (who is probably the youngest person to drive the Da Vinci) visit the National University Hospital where I work. Declan shared to a multispecialty group of robotic surgeons, his journey of expanding the adoption of robotics across multiple surgical disciplines at the Peter MacCallum Cancer Centre, and that the Da Vinci’s role in education, research and talent retention was key in surmounting concerns regarding cost.

On behalf of the SUA, we would like to thank all our international and local faculty for their efforts, and the delegates from near and far, for making Urofair 2018 a resounding success.

Finally, we are excited to announce Urofair 2019 will be held on 4-6 April 2019. Please save the date, and we look forward to welcoming you to Singapore.

Lincoln Tan

Consultant Urologist and Director of Urologic Oncology, National University Hospital, Singapore

Twitter: @LincolnRoboDoc

August 2018 – About the Cover

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This issue’s Article of the Month is the UK-ROPE study, a multicentre study with several authors from Southampton. The cover shows Southampton’s Calshot Castle, an artillery fort constructed by Henry VIII.

The development of Calshot castle as well as Cowes, Hurst and Netley castles along Southampton Water and the Solent, by Henry VIII in about 1540, meant that Southampton was no longer so dependent upon its fortifications.

 

© istock.com/kodachrome25

 

Residents’ Podcast: CUA 2018 review

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Jesse Ory and Andrea Kokorovic
Department of Urology, Dalhousie University, Halifax, NS, Canada

Dalhousie residents Jesse Ory and Andrea Kokorovic sum up the highlights of day 1 at the 2018 Canadian Urological Association annual meeting in Halifax

Song credits
Don’t fear the reaper: Blue oyster cult
Mute city: F Zero
Mortal Kombat Theme: The Immortals
Funky Suspense – Bensound.com

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

 

 

BAUS 2018 Highlights Day Two

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BAUS Day 2. The Multidisciplinary Team Debate. Which way are you headed?

BAUS is certainly a UK-centric meeting. But we all share most of the same challenges in healthcare, and as an international urologist in attendance, the learning experience is often gaining insight into how different health systems tackle common problems with solutions and evolutions.

During day 2 prime time, the agenda tackled the current and future situation with MDTs in cancer treatment—multidisciplinary team meetings. For the USA, we might use the term Tumor Board. At MD Anderson we just say, “Urological Multidisciplinary Case Conference.” So yes, MDT is much more efficient.

The goals are straightforward in principle: 1) increase the quality and standardization of care, 2) improve access to expert imaging/pathology, 3) provide a “group” decision which may be more experienced than any 1 person. In the United States, each center is left on its own how to organize and conduct MDTs, although there may be requirements for inclusion as an NIH designated comprehensive cancer center. In the UK, it appears that MDTs are more of a compulsory element. Another key decision is what patients will be presented—all or selected. In the UK, it appears the goal has been to present everyone.

The first speaker was Hashim Ahmed who showed how the “present everything” model has increasingly become impossible, as half of all cases are presented/discussed in < 2 minutes and few go beyond 3 minutes. A national strategy is being discussed and likely piloted in prostate cancer whereby “routine” cases might be listed as a statistic but not discussed; and time reserved for more complicated cases where discussion might be more fruitful. This model will require the MDT chair to spend more pre-meeting time triaging the meeting agenda.

Jo Cresswell expanded the topic by compiling the UK real world experience with MDTs in terms of what has worked well and where it has been lacking.

The “good” might include:

  • Building working relationships with colleagues
  • Mentorship interactions
  • Challenging old practices—evolving from eminence based to evidence based decisions
  • Calling out bad practice/minimize rouge decision making
  • Comforting patients that their case has been heard by a group—sort of a free 2nd opinion

The “bad” or “Pet Hates” list is interesting:

  • The cost of running the MDTs—actual and effort
  • Reduced ownership of the patient—notes where the plan just reads “refer to MDT”
  • Waiting on the MDT
  • MDT Tennis—i.e. referring back and forth between different MDTs
  • Fatigue—going through 120 cases in a session—is anyone awake at the end? Some providers have to attend multiple MDTs per week
  • Loud voices can overrule others (queue the photo of Trump)
  • Agenda effect—if you always present in the same order then whoever goes last on the agenda probably gets less quality discussion.

What is the best middle ground? Again,the concept of discussion reserved for complex cases, and routine cases are under the MDT but not given time.

The final speaker was Bill Dunsmuir. He started by challenging the assumption that the MDT make up of 10-20 experts in oncology will produce wiser decisions than any single provider. Case and point was the 1996 climbing expedition to Mount Everest where the group decision making of expert climbers led to the deaths of the many. Maybe group thinking is not so wise? Problems might include group thought with the same ideas, hierarchy that minimizes dissent, and false debates.

From the Emperor of All Maladies book, he channeled the similar questions, “What is Cancer, why does cancer kill?” One trainee responded in a survey “A cancer killed because they were unfortunate enough to have their cases discussed at an MDT.”   So why do we have MDTs?

His proposal was to consider MDTs as not only dedicated to group decisions, which may or may not always be right. Rather consider them as multidisciplinary professional education. As an example, if the group encounters a specific problem, there would be a pool of short video clips to review the evidence and guidelines—and then discussion could flow off of these standardized points. Ambitious for sure and would need funding and buy in.

In conclusion, this was a well-done session, and highlights the natural history, so to speak, of compulsory MDTs including all patients.   At MD Anderson, we went the other way: select presentations. Each case takes 10-20 minutes, so we usually only get through 3-5 in an hour session. Attendance is optional and there tends to emerge faculty personalities who like MDT interaction, and some who never go. Cases are nominated by a fellow or faculty and you would probably be criticized for presenting a patient where we already have a treatment protocol in placed, i.e. “put them on the protocol, next case.” As a fellow in 2001-2002 I observed there are 3 popular categories of MDT case presentation that are always worthwhile:

  1. I dare you to operate on this patient (co-morbidity, prior surgery, obesity etc.)
  2. How to manage multiple cancers
  3. Look what they screwed up on the outside. Now what?

Please use our comment section—where do you stand on MDTs at your center and what is in the future?

 

John W. Davis, MD, FACS

Associated Editor, BJUI

 

Figures: Slide highlights on current and future of MDTs

 

BAUS 2018 Highlights Day One

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Day one at BAUS gets started with society meetings and the John Blandy Prize and Lecture delivered by Editor Prokar Dasgupta.  The winner was from Pisano et al from Turin, Italy on “The role of re-transurethral resection in the management of high risk NMIBC (PMID 26469362).

But I had to miss this event as I was having my first patient encounter with the NHS.  I have 4 days of severe pain in my left foot after a lot of walking/running around as a tourist on a Baltic Sea cruise.  I went to the nearby NHS walk in clinic—there for an hour and saw the nurse practitioner and left with new scripts for NSAIDs, pain, etc.  And no bill?  Not in the USA!

So now that I can walk (sort of—but only with my running shoes—looks great with a suit) I made it to the teaching course on quality improvement (QI).  I am interested in the topic as I am a Quality Officer for Urology at MD Anderson Cancer Center.  One of our new directives has been to help with fellows organizing a new mandatory “quality improvement” initiative as part of their training.  From the course, I learned that the UK has similar programs but also similar challenges in implementation and standardization.  In the UK, it sounds like medical students are being taught quality improvement in the curriculum.  But if you are like me and finished school > 20 years ago, you likely missed this content.  A consensus opinion was that educational materials on quality improvement science will be created and hopefully will land on the BJUI Knowledge website.  This will help trainees but also trainers catch up on terminology, goals, and how to coach trainees on project development.

The next strong consensus was that quality improvement projects be listed on a website—likely BAUS—so that they could be indexed and searched.  Similar to clinicaltrials.gov or the PROSPERO website that catalog clinical trials and meta-analyses, respectively, the BAUS site could be searchable for projects that were successful as well as those that failed for some reason (perhaps with lessons learned).  Indexing could help with project selection as some QI ideas are unique to urology versus all specialties, and QI projects may emphasize different practice environments such as clinic, operating theatre, or diagnostic departments.

Overall, QI is an emerging field and we are struggling with the same barriers on both sides of the Atlantic.  Principle questions include 1) how to differentiate a clinical study from QI, 2) the role of statistics, evidence-based medicine principles, and ethics committees in QI, 3) how QI should be taught in medical school and post graduate programs, and 4) how QI projects can be published.  On the latter point the Journal of Clinical Urology has expressed interest in publishing QI projects.

The course was directed by Mr. James Green from Barts Health, and also taught by Prof. Nick Sevdalis.  Congrats to both on a job well done.  From my perspective, this field will continue to grow and for some young academic minded urologists will develop into a legitimate academic niche to go along with established pathways such as laboratory investigations, health services research, and surgical education.

Figure: My favorite slide—so may sources of inspiration for a Quality Improvement Projects

John W. Davis, Associate Editor.

 

The challenge with systematic reviews of non-randomised studies in urology

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In this issue, BJU International has made the conscious decision to publish a systematic review (SR) and meta-analysis (MA) by Guo et al. [1]to inform the question of whether patients undergoing nephrouretectomy for upper tract urothelial carcinoma are at increased risk of worse oncological outcomes. This question was also the topic of a similar review by Marchioni et al. [2] published earlier this year in this journal. Both studies were submitted around the same time and underwent independent, parallel peer review that resulted in different editorial decisions. Given their similarity in methodological quality they both deserved similar consideration for publication, which the journal is hereby honouring.

At the same time, this provides the unique opportunity to reflect on methodological developments in the field and BJU International‘s efforts to raise the bar of the methodological quality of SRs, which include the provision of an Assessment of Multiple Systematic Reviews (AMSTAR) rating [3]. AMSTAR is a validated tool to assess the components of a SR on an 11-point scale (0–11), with higher scores reflecting higher methodological rigor. An updated version of this tool has recently been provided, which offers greater clarity in interpretation [4]. Another related instrument that has become available is the Risk of Bias in Systematic Reviews (ROBIS), which assesses the study limitations in SRs (i.e., the relevance of the review, concerns with the review process, and potential bias introduced during the review) [5]. Meanwhile, while it would be premature to claim success, it is our impression that BJU International’s initiative to provide AMSTAR ratings is making a valuable contribution in raising awareness for such methodological issues and improving the transparency of published reviews.

As BJU International takes a lead in promoting high-quality SRs in urology, the journal has seen a considerable increase in the number of submissions, including SRs of non-randomised studies (NRS). Whilst much of what we practice on a day-to-day basis is based on evidence from NRS, studies of those designs have infrequently been included in the Cochrane Library, which has pioneered much of the underlying methodology. This is for a few reasons: First, the ‘garbage in–garbage out’ phenomenon; if the underlying individual studies only provide very low-quality evidence, combining these studies will rarely enhance the confidence we place in their results. Second, the need for methodological advances in the assessment and analyses of NRS. Third, when high-quality evidence from randomised controlled trials (RCTs) is available, it may be inefficient to review the NRS literature.

However, progress is being made on the methodology front. Members of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group are credited with having developed an approach for rating the quality or certainty of evidence from randomised and NRS to inform decision making [6]. While a body of evidence from RCTs, which starts as high-quality evidence, may be downgraded for study limitations, a body of evidence from NRS, which starts as low-quality evidence, may be upgraded for one of three reasons, most commonly for large magnitude of effect [7]. The underlying assumption is that, whilst we have to assume that bias is likely to be present in these studies, it is unlikely to explain the entire observed effect.

It nevertheless remains critical to assess the risk of bias of NRS. While the Newcastle-Ottawa scale (as used in both of these SRs) is a widely used instrument to evaluate risk of bias in NRS, it has critical limitations that the recently developed Risk Of Bias In Non-randomised Studies – of Interventions (ROBINS-I) seeks to overcome [8]. ROBINS-I evaluates NRS by using a standardised comparison to an RCT (i.e. target trial) [9]. In this way, ROBINS-I captures the bias inherent to studies without proper randomisation or allocation concealment, namely the lack of a balance of known and unknown confounders and selection of participants. ROBINS-I allows users to fundamentally start all studies at the same quality level, providing the transparency requested by some SR authors conducting SRs of NRS.

While ureterorenoscopy before nephroureterectomy may indeed increase the risk of intravesical recurrence as the authors suggest, additional exploration would be needed to make a statement about the causality of the relationship. Guo et al. [1] conducted sensitivity analyses to describe the potential for bias introduced by confounders of previous bladder tumour history and bladder-cuff management, thereby increasing our confidence that the observed effect may be closer to the truth. It seems equally important to note that Guo et al. found no increased risk in cancer-specific, recurrence-free or overall survival, which are other outcomes of potentially greater patient importance.

Understanding the inherent limitations of NRS, and placing their findings into appropriate clinical context are critical to the conduct of SRs. Moving forward, BJU International will continue to seek out the highest quality reviews that make use of the best, up-to-date methodology. We hope that these efforts will both serve as a beacon for the research community, but more importantly, result in improved evidence-based care for our patients.

Philipp Dahm*, Jae Hung Jung† and Rebecca L. Morgan‡
*Department of Urology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN, USA, †Department of Urology, Yonsei University Wonju College of Medicine,
Wonju, Korea and ‡Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada

 

References

 

1 Guo RQ, Hong P, Xiong GY et al. Impact of ureteroscopy before radical nephroureterectomy for upper tract urothelial carcinomas on oncological outcomes: a meta-analysis. BJU Int 2018; 121: 184-93

 

2 Marchioni M, Primiceri G, Cindolo L et al. Impact of diagnostic ureteroscopy on intravesical recurrence in patients undergoing radical nephroureterectomy for upper tract urothelial cancer: a systematic review and meta-analysis. BJU Int 2017; 120: 313–9

 

3 Dahm P. Raising the bar for systematic reviews with Assessment of Multiple Systematic Reviews (AMSTAR). BJU Int 2017; 119: 193

 

4 Shea BJ, Reeves BC, Wells G et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017; 358: j4008

 

5 Whiting P, Savovic J, Higgins JP et al. ROBIS: a new tool to assess risk of bias in systematic reviews was developed. J Clin Epidemiol 2016; 69: 225–34

 

6 Guyatt GH, Oxman AD, Vist GE et al. GRADE: what is “quality of evidence” and why is it important to clinicians? BMJ 2008; 336: 995–8

 

7 Guyatt GH, Oxman AD, Sultan S et al. GRADE guidelines: 9. Rating up the quality of evidence. J Clin Epidemiol 2011; 64: 1311–6

 

8 Deeks JJ, Dinnes J, D’Amico R et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003; 7: iii–x, 1–173

 

9 Sterne JA, Hernan MA, Reeves BC et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919

 

Highlights from the 6th International Alliance of Urolithiasis annual meeting 2017

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There is absolutely no doubt that #urolithiasis is a truly global disease. It is extremely rare in medicine to have a single disease entity with enough breadth and variety to generate such immense interest across the world that it merits a 3 days meeting on its own.

The International Alliance of Urolithiasis (IAU) was founded by Professor Zhangqun Ye, Professor Guohua Zeng (both from China), and Professor Kemal Sarica (Turkey, current chair of #EULIS) in 2010. The aim of the association is to provide a platform for urologists across the world to exchange knowledge on urinary tract stone disease, and to establish professional links for research.

Famous for the fine yellow rice wine produced in the region, Shaoxing in Southeast China was chosen as the host city of this year’s 6th IAU annual conference. This was our first time attending the IAU, and we were both honoured to be invited to speak at the conference. We must congratulate the association and the organising committee in putting together a truly excellent program, which included many thought-stimulating and inspiring talks by eminent local and international stone experts, provocative debates, and many live surgeries demonstrating latest endoscopic techniques in the management of challenging stone diseases.

Professor Guohua Zeng and @WayneLam_Urol

#IAU17 Day 1

#IAU17 started off with the Young Urologists sessions. These sessions not only provided an opportunity for young urologists from all over the world to present their work, but also set a stage for debates on controversial stone topics and a platform to interact with experienced and established eminent stone surgeons.

One of the first sessions were talks on #PCNL. All speakers agreed choice and accurate access is key to a successful and effective #PCNL. It is interesting to know that in China, the vast majority of punctures are performed by urologists. And with experience due to high prevalence of stone disease in particular in the southern part of the country, the practice of pure ultrasound-guided puncture has gained popularity in the past decade. Dr Zhiyong Chen and Dr Xiao Yu, both from China, provided some tips and tricks on pure ultrasound-guided puncture for access for #PCNL, in particular when treating patients with complex or staghorn stones. Both sagittal and coronal planes should be used to assess all major and minor calyces, and they also interestingly showed that the benefit of aiming stones with multiple branches as the most effective first puncture point in patients with complex or staghorn stones.

Position of #PCNL has been a regular debate in stone conferences, and few speakers in the young fellow sessions presented their findings and reviews on the topic. Both #supine and #prone positions have their pros and cons but all presenters agreed that surgeon’s preference to offer best chance of achieving best outcome is the most important determining factor.

Another eye-catching presentation of the day was a randomised study conducted in China comparing standard #PCNL against mini-PCNL in the management of 2-4cm renal stone. The study randomised 800 patients and demonstrated that mini-PCNL was superior in terms of reduced bleeding, post-operative pain, shorter hospital length of stay, and more patients were ‘tubeless’ after the procedure. It is a well-designed study that will add much-needed high-quality data to the argument on #PCNL sizing.

#Sepsis remains one of the most worrying complications during endoscopic surgery for urolithiasis. Optimal method of culture technique was discussed, with Dr Kremena Petkova of Bulgaria arguing that renal, pelvis, urine and stone cultures are more specific and sensitive in predicting post-op complications. Both are superior to #MSU, with higher concordance between pathogens and antibiotic sensitivities. However, their results are not often available pre-operatively, and it’s best to use them as guidance on choice of anti-bacterial treatment if sepsis develops post-operatively. However, in patients with high risk of post-operative sepsis despite peri-operative prophylaxis; renal, pelvis, urine and stone culture should be considered.

Another very interesting study was a randomised trial presented by Dr Wei Zhu from Guangzhou, China, on investigating dosage required for prophylactic antibiotics for patients undergoing retrograde intrarenal surgery for stones. Their study suggested that stone size is a determining factor of whether patients require prophylactic antibiotics, with risk of post-operative sepsis being low if <200 mm2.

In the stone prevention session chaired by Professor Hans-Goran Tiselius from Sweden, Dr Guohao Li from China presented a study on reduction of urinary oxalate. Diet in general contributes to urinary oxalate concentration, and they discovered the use of a mushroom powder is able to reduce oxalate contents by degradation in traditionally oxalate-rich things such as spinach and tea. Their study found that the mushroom product is able to reduce urinary oxalate in stone-formers by up to 33%!

@Mattbultitude, representing @BJUinternational, was invited to give a talk on tips for submitting manuscripts to the journal to maximise the chances of publication. An interesting fact was that China submitted more papers to @BJUinternational in 2016 than the UK, and came second only to the USA. There are now services from the Journal’s publisher,Wiley, to help improve fluency of manuscripts for papers written by authors whose first language isn’t English, and perhaps this may further increase acceptance rates from countries such as China in the future (https://wileyeditingservices.com/en/translation-service/).

Heavy weights in #urolithiasis closed the last session of the first day of #IAU17. Professor Pal from India, with over 30 years of experience in PCNL, offered tips to young urologists on a procedure not often talked about in textbooks. Short, straight puncture track through a papilla into the most peripheral calyx harbouring or leading to the stone is what we should be aiming for when performing the puncture, and he suggested that meticulous alignment of the C-arm is crucial to provide the spatial information to guide us to do that. This was followed by Professor Jean de la Rosette from the Netherlands, who gave a provocative but strong arguments on why he felt #MET should not be recommended. This discussion came as a heated debate has been going on with regards to the recent publication of a very large, multi-centre randomised controlled trial from China suggesting the use of MET is beneficial in patients with larger distal ureteric stones, and of course much debate was initiated after his talk amongst the audience and on social media (see The Drugs Don’t Work … Or Do They? https://www.bjuinternational.com/bjui-blog/drugs-dont-work/).

As we all know, 24-hour urine work-up is dreaded by most recurrent stone-formers.  It takes up a lot of the patient’s time and thus may result in incomplete collection or just simply be forgotten.  Professor Hans-Göran Tiselius described an abbreviated form of the 24-hour urine work-up that he uses in order to reduce patient inconvenience when collecting the urine samples. The first 16 hours are used to collect most of the common urine biochemistry of calcium, oxalate, citrate, etc while the last 8 hours are used to measure for urate and pH. Each portion is then extrapolated to achieve the final data. Through three examples, Professor Tiselius shows how it is easy to apply the results from the 24-hour urine to give specific dietary instructions and treatment to the patients in the prevention of stones.

One of the final talks of the day was presented by Professor Thomas Knoll from Germany on the use of miniaturised PCNL. Various high-quality comparative studies have demonstrated the benefit of miniaturised equipment for PCNL (in particular reduced morbidities), and interestingly the availability of miniaturised systems appeared to have increased the use of PCNL instead of using RIRS and ESWL for patients with renal stones.

This final session, with master stone surgeons sharing their experience and knowledge in the Young Urology Section, allowed the up-and-coming urologists a chance to pick the mind of the masters.  It set a great tone for the first day and created anticipation for the coming two days of the conference!

 

#IAU17 Day 2

Day 2 of the conference was full of exciting talks and live surgery, spanning over 12 hours from 07:50 in the morning to 20:00 in the evening!

This year @BJUinternational became an Affiliated journal of the IAU. To celebrate this, a virtual issue comprising the 10 best stone papers published in the journal over the past 2 years was published online (Best of Urolithiasis VI), and @mattbultitude, Consultant Urologist and head of stone unit at @guysurology, was invited to present these selected papers in the meeting.

Professor Alberto Trinchieri from Italy then provided an informative talk on the role of acid load in citrate excretion. Hypocitraturia is a common feature in up to 68% of calcium stone-formers. He argued that the acid load of the diet could decrease renal citrate excretion, and the LAKE score, could be a useful tool to be used as a food screener for acid load of diet.

The LAKE score by Professor Trinchieri.

He also argued that the use of oral alkaline citrate can potentially treat uric acid stones by dissolution and prevent calcium oxalate renal stones formation.

Dr Ravi Kulkani from the UK gave an interesting talk on the management of stones in the elderly population. He presented a study conducted at his institution of 60 patients with a median age of 84.6 years with low morbidity, post-op ITU stay and a median length of stay of only 1 day for the cohort. Complete stone clearance rate was still high in the elderly population studied. It is important to assess co-morbidity pre-operatively and optimise them before any surgical treatment, together with extensive anaesthetic input and assessment. Patient selection is crucial and a good outcome can still be achieved in the ever-growing geriatric population.

Following live surgery session demonstrating various tips and tricks of RIRS, the afternoon session on day 2 of #IAU continued to be comprehensive and informative. Professor Peter Alken from Germany gave a provocative talk on the underuse of chemolysis in treatment of patients with uric acid stones, of which most of the audience were in agreement. He argued that evidence suggests it is effective and should be recommended in the guidelines!

Professor Peter Alken from Germany on chemolysis for treatment of uric acid stone.

Professor Guohua Zeng, inventor of super-mini PCNL (SMP), gave a lecture on his experience using the second generation SMP. With the modified sheath enabling efficient irrigation-suction system, he found that the intrarenal pressure intraoperatively remained stably low, with shorter operative time and good stone clearance rate. Undoubtedly, SMP is useful in particular in the management of stones up to 3cm in size, and can be used as an adjunct to standard PCNL when multi-tracts are required. He has also presented his experience in using the technique in the paediatric population with good stone clearance rate and safe. (See The new generation super-mini percutaneous nephrolithotomy (SMP) system: a step-by-step guide)

 

Professor Guohua Zeng on the use of second generation SMP, with an improved
irrigation/suction system.

Another interesting study from Professor Gonghui Li revealed that post-endoscopic lithotripsy septic shock was heralded by a White Cell Count of <2.85 x 109/L at 2 hours post-operation, with sensitivity & specificity over 90%.  Stepping up the antibiotics and aggressive fluid resuscitation at this point could stave off significant hypotension or even mortality in his study.

Professor Gonghui Li of China on early detection of risk of septic shock post-surgery with White Cell Count at 2 hours post-op.

In the evening, the conference became heated with various debates. Management of calyceal diverticulum stones has always been challenging. Mr Simon Choong from UCLH in London, UK, presented good arguments in the use of PCNL with high success rates, but Dr Yi Zhang also showed good clearance rate in experienced surgeons’ hands. And in selective cases, both minimally invasive and open surgery may have a role, presented by Dr Gang Zhu from China and Dr Zinelabidine Abouelfadel from Africa.

Debate on optimal management of 1-2cm lower pole renal stone has been a hot topic for years. Brian Eisner (@BEendourology) from the USA argued that with experience, RIRS stone clearance rate is approaching that of PCNL but with lesser morbidity. However, seeing a live surgery of clearing a >3 cm stone with a miniaturised PCNL technique on day 3 of the meeting, with the patient left completely tubeless post-operatively, may have changed his mind!

 

#IAU17 Day 3

The final day of the conference included 13 live #PCNL surgeries, demonstrating various puncture techniques, tips on how to improve accuracy for access, and advanced surgical techniques including various miniaturised #PCNL by local and international experts.

Professor Guohua Zeng from Guangzhou Medical University First Affiliated Hospital in China demonstrated the treatment of a 3.5cm lower pole renal stone using the second generation super-mini PCNL (SMP), which he invented. With its innovative sheath, which provides effective irrigation and controlled suction, he completed the surgery within 20 minutes. It was bloodless and tubeless, with visually complete stone clearance. Stones were completely extracted via its suction system for stone analysis.

Professor Qu Chen of China demonstrated the use of ultra-mini-PCNL, effectively clearing a medium sized renal stone in a matter of minutes. Interestingly, many surgeons in China prefers to use the ureteric catheter as inflow for irrigation, which generates a flow pressure to help flush stone fragments out – great tip!

13 live stone surgeries were broadcasted to the audience on day 2 of IAU2017

Mr Matt Bultitidue @mattbultitide (left) with Professor Guohua Zeng (middle) and
Dr Christian Seitz @SEITZ_C_C (right)

We must congratulate the #IAU17 organisers’ incredible effort in making the conference an inspiring and valuable learning experience to all who attended. The short duration (8-15mins) of presentations ensured that all the meaty details were packed in with very little fluff!  It was also a great opportunity to build bridges to network and collaborate research in #urolithiasis. We thoroughly enjoyed it and would definitely recommend any urologist with an interest in #urolithiasis to attend its future meetings, and we very much look forward to #IAU18 in Istanbul!

 

 

Dr Wayne Lam

Assistant Professor in Urology, Queen Mary Hospital, University of Hong Kong

Twitter: @WayneLam_Urol

 

 

 

Dr Brian Ho

Associate Consultant in Urology, Queen Mary Hospital, University of Hong Kong

 

A Lifetime of Giving – Donald S Coffey (1932-2017)

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For those who knew Donald Coffey (the “Chief’”), the inquisitive smile says it all. Don spent his professional life sharing his knowledge, wisdom, humor, and encouragement to everyone that he encountered and mentored –and the list is very, very long. It would be difficult to measure the impact Don had on the field of urology and cancer research, given the countless clinicians and scientists that he mentored and inspired to pursue academic careers.

Born in Bristol, VA in 1932, his life story is not in the least traditional including chemist, engineer, laboratory director, prostate cancer researcher, and cancer center director. During college, he worked as a chemist for the North American Rayon Company and after attending King College in Bristol, Tennessee and the University of East Tennessee, Don worked as an engineer at the Westinghouse Electronic Corporation. He eventually decided that he wanted to spend his life working on cancer, and ended up at Johns Hopkins on the advice of a mentor, where he spent more than 50 years giving to others.

Don spent his early years at Johns Hopkins in the Brady Urology Research labs washing glassware for graduate students and taking classes. In 1959 when the Brady Urological Institute was chaired by William Wallace Scott, Don was named the director of the Urological Research Laboratory for 1 year to fill the spot of Charles Tesar who was on sabbatical. He impressed Dr. Scott who encouraged him to obtain a graduate degree. A year later he entered the biochemistry graduate program at Johns Hopkins University School of Medicine. He earned his PhD in physiological chemistry in 1964, and was named the director of the Brady Laboratory for Reproductive Biology in 1969. In 1974, the lab merged with the Brady Research Laboratory and Donald Coffey was made director of the merged laboratories, a position he held until 2004. Together with Patrick C Walsh, Coffey built what would be considered by many as the premier training ground for surgeon scientists, many becoming distinguished academic leaders in urology.

During his tenure at Hopkins he became the Catherine Iola and J. Smith Michael Distinguished Professor of Urology, Professor of Oncology, Pharmacology, and Pathology; and a member of the professional staff of the Applied Physics Laboratory. He was chair of the Department of Pharmacology having never taken a course in pharmacology, and he helped found the Cancer Center without an MD degree. Don was fond of saying that he flunked out of college and never took a course in a department where he was a full professor. He told this to mentees not bragging, but as encouragement that anything is possible with passion –a trait that he embodied to the very end of his life. He simply seemed never to tire of teaching and mentoring students, inspiring in them his passion and love for discovery and life in general. He was one of the most positive forces I have ever met, and his infectious enthusiasm characterized both his professional and personal life. Don Coffey was one of Johns Hopkins greatest teachers and in recognition of this he was the recipient of the Dean’s Distinguished Mentoring Award.

Dr. Coffey had many interests, but primary among them were his curiosity and fascination on the origins of human creativity and homo sapiens’ place in the world. His annual St. Patrick’s Day lecture on this topic was legendary at Johns Hopkins and was delivered to many audiences beyond Hopkins. Don’s early research involved descriptions of a nuclear scaffolding or matrix that was the organizational structure for DNA regulating genetic function. His research focus involved changes in the nuclear structure and shape that he believed could explain the biology of prostate cancer and provide markers of lethal disease.

Don Coffey achieved much during his life that most of us would regard as epaulets; President of the American Association for Cancer Research (AACR), Fuller Award and Lifetime Achievement Award from the American Urological Association, an American Cancer Society Distinguished Service Award from the American Cancer Society, the AACR Margaret Foti Award for Leadership and Extraordinary Achievements in Cancer Research. He minimized these accomplishments as natural fall out from pursuing his passion in life to “work on cancer.” But those who knew him well would agree that he would -without hesitation- say that his greatest award was witnessing the success of his colleagues and students.

Like all of his mentees and those fortunate enough to work with him, I spent countless hours with Don during a 2-year fellowship as an AUA Scholar. These sessions would go on for hours and could often devolve from science to the meaning of life, evolutionary biology, religion, relationships, etc; the one predictable was the unpredictable during an encounter with Don. They always ended the same way after hearing him say “and just one more thing and we are out of here”; have you eaten yet?” So off he would go with his student(s) in tow to enjoy a meal together and continue talking science.

It is difficult to capture in words the rich life that was Don Coffey over 85 years. Drs. Kenneth Pienta and Alan Partin probably said it best in written and spoken word; “For all of us who knew him and loved him, our grief is deep but our memories of the Chief bring joy that is boundless.”

To learn more about Donald Coffey’s life, take a look at the Donald Coffey story as told by his lovely and devoted wife Eula, his students, and himself (https://vimeo.com/122939259).

 

Bal Carter

Bernard L. Schwartz Distinguished Professor of Urologic Oncology, Johns Hopkins School of Medicine

 

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