How time flies! It seems like only yesterday that I was appointed the 10th Editor‐in‐Chief of a 90‐year old major surgical journal. We assembled a dynamic team with a clear, modern vision and strategy. As we say goodbye, it is time to reflect fondly on our achievements.
The most read surgical journal on the web?
Of the many ways to measure this, one is the number of downloads of BJUI articles from our publisher Wiley Online Library. This has increased steadily every year, reaching 3 million downloads in 2019 alone. In addition to this we are regarded as pioneers of web‐based publishing and social media. The BJUI itself and its editorial team have a large, devoted following especially on Twitter. Our infographics, podcasts, picture quizzes, polls and videos were deliberately designed to grab an audience with limited time and short attention spans. The BJUI blogs have often been read more than the articles themselves, bringing immediacy, wider engagement and sensible debate. The most visited blog on the death of Nobel Laureate Tagore from prostatic enlargement was read nearly 110 000 times.
To increase the impact of the BJUI
Our impact factor has steadily increased since 2012, reaching the highest in its history and is as close to 5 as it ever has been. This has been achieved by decreasing the acceptance rate to 10% without any form of manipulation. This means that the BJUI papers are now “returnable” to any research excellence exercise of which many exist worldwide. As a clinician–scientist I could not accept anything else in academic circles. The BJUI is the only surgical journal to be rated in the Altmetric top 50 reaching a score of 1469 [1], compared to an average Altmetric score of 3. It is a testament to the hard work of our team above and beyond the impact factor. I suspect that with more fully open access journals such as the BJUI Compass , driven by Plan S, the importance of the impact factor as it now stands, may gradually diminish over time. We have also led on bringing innovation such as Artificial Intelligence [2] into our journal and making science accessible to a clinical audience through our “science made simple” section.
Quality without boundaries
While many of our papers come from the UK, USA and Australia, we have also published the best articles from Uganda, China, Japan, Iran, Korea, India, Pakistan and Peru. We are and remain a global journal, associated with 10 international societies. The NICE guidelines have been well cited over the last 3 years [3] as have the papers in our Trials section and the ever‐popular Guideline of Guidelines [4]. We have managed to co‐publish a number of high‐quality Cochrane reviews including the only one with a maximum AMSTAR score of 11 out of 11 comparing laparoscopic, robotic and open radical prostatectomy [5].
In this issue of the BJUI , we have published the protocol and curriculum development of the SIMULATE study – the world’s first and only multi‐centre randomised controlled trial of surgical simulation. What started as a BAUS study, expanded worldwide and recruited 1400 cases to see if simulation made better surgeons and improved patient outcomes [6].
The BJUI also brought innovative design from the fashion industry into academic publishing through the Glass magazine. As a parting gift, I therefore thought it fitting to publish a photograph of the courtyard of King’s College London where the SIMULATE trial first started. It was taken on a sunny day on my iPhone with no one in sight because of the pandemic. We have seen the viral crisis as an opportunity to learn from other nations and published a critical review to guide urological care for our colleagues, residents and patients [7].
I take this opportunity to thank a loyal group of friends at the BJUI Editorial offices, our trustees, the Associate and Consulting Editors, our wider editorial team of authors and reviewers and our publisher Wiley. I am proud to hand over the BJUI to my friend Freddie Hamdy in the best state of academic health and creativity.
Professor Dasgupta at his desk in his first month as BJUI Editor‐in‐Chief.
Urologist & Director of Genitourinary
Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
Twitter: @declangmurphy
The 3rd Advanced Prostate Cancer Consensus Conference (APCCC) took place in Basel in late August 2019, and the subsequent manuscript was published in European Urology just recently. We delayed posting this blog until now as the recommendations were under embargo until the manuscript went online. As with the previous two APCCC events (which took place in St Gallen; the so-called “St Gallen meetings”), this “Basel meeting” and its resultant recommendations are certain to provoke discussion due to the contentious nature of the topics which feature. Indeed, much of the raison d’etre of the meeting is to create recommendations from key opinion leaders to help guide decision-making in prostate cancer, particularly in areas where confusion exists, and where traditional guidelines are not clear.
The format is as follows:
The meeting takes place every two years and includes two full days of plenary sessions from world leaders, and one half-day of voting to try and achieve consensus on hot topics
72 of the world’s leading experts in prostate cancer are invited to deliver plenary addresses, and more than 750 delegates from 65 different countries
Ten areas of controversy are featured in the plenary sessions, and invited experts participate in a live vote on the final day to see if consensus can be reached. More than 120 questions are selected by the panel over the previous few months.
The level of consensus was defined as follows: answer options with 75% agreement were considered consensus, and answer options with 90% agreement were considered strong consensus.
The results are published in a detailed manuscript (40 pages!) in European Urology
The meeting is convened by Dr Silke Gillessen and Dr Aurelius Omlin who are world-renowned experts in prostate cancer. One of the unique and most enjoyable aspects of the APCCC is the unashamed Swiss-ness which Silke and Aurelius bring to the meeting. The meeting is conducted in a very relaxed manner with excellent interaction between the Faculty which is part of the high value of the meeting. Of course, one would expect a meeting in Switzerland to run efficiently, and Silke and Aurelius wield a goat’s bell for the one minute warning; if you hear the cow bell, then the time is up!
As before, the invited panel is a truly global gathering of world experts in prostate cancer:
A truly global gathering of world leaders in prostate cancer
The ten areas of controversy for #APCCC19 are as listed below, followed by a summary of some of the notable areas of consensus, along with some areas of non-consensus.
Locally advanced prostate cancer
Biochemical recurrence of prostate cancer after local therapy
Management of the primary tumour in the metastatic setting
Management of newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC), including oligometastatic prostate cancer
Management of nonmetastatic (M0) castration-resistant prostate cancer (CRPC)
Management of metastatic CRPC (mCRPC)
Bone health and bone metastases
Molecular characterisation of tissue and blood
Interpatient heterogeneity
Side effects of hormonal treatments and their management
It was interesting to note the proportion of voting panellists by discipline as listed below, in particular the healthy proportion of urologists in a meeting focussed on advanced prostate cancer:
And also by region as listed below.
Obviously a massive amount of territory gets covered during this meeting, but I have highlighted some of the key recommendations within each of the ten areas of controversy below:
Locally advanced prostate cancer:
This section featured plenary addresses on node-positive prostate cancer from myself and radiation oncologist Dr Mack Roach. There was strong consensus that some sort of loco-regional treatment with surgery or radiation (RT) should be offered to men with node-positive prostate cancer, combined with androgen deprivation therapy (ADT) for men undergoing RT. The impact of PSMA PET/CT in defining N1 disease was considered and was recommended for accurate staging (pending the read out of the proPSMA trial which had not yet been published). Regarding duration of ADT, there was no consensus with answers ranging from six months to three years.
Biochemical recurrence (BCR) of prostate cancer after local therapy:
One of the stand-out themes of this year’s APCCC was the impact of PSMA PET/CT for imaging prostate cancer, and Lu-PSMA theranostics as a treatment for mCRPC. I am pleased to say that much of the focus of this was on data from here in Australia, and there was much favourable comment on how Australia has led in this area. It is fair to say there was a reasonable amount of envy also for how much access we have to PSMA PET/CT compared to many other parts of the world. In one of the opening plenaries, Professor Ian Davis did a terrific job overviewing this, and did introduce some cautionary tones about the management impact of novel imaging.
There was consensus that PSMA PET/CT should be used for the assessment of BCR following radiation or surgery. This is a new recommendation compared with the previous meeting, and is in line with the most recent EAU Prostate Cancer Guidelines. What PSA level should we image at? Most discussion centred around a PSA of 0.2ng/mL or greater following surgery.
For patients undergoing salvage RT, there was consensus that this should be accompanied by a short period (4-12 months) of ADT. 83% of panellists voted in favour of offering salvage RT before PSA reaches 0.5ng/mL, with 37% offering RT before PSA reaches 0.2ng/mL. There was consensus that ADT alone should not be used for the majority of patients with rising PSA and no evidence of metastases following prior local therapy.
Management of the primary tumour in the metastatic setting
This was certainly a hot topic. There was much discussion around the role of RT to the primary in men presenting with metastatic prostate cancer (in addition to lifelong ADT), and the most recent data from STAMPEDE led to a strong (98%) consensus for the use of RT in men presenting with low-volume metastatic prostate cancer. Volume was defined based on conventional imaging using classic CHAARTED criteria. The recommended dose was 55Gy over four weeks as per STAMPEDE.
Should we extrapolate from this data and offer surgery as local therapy in the same group of patients? There was 88% consensus that we SHOULD NOT offer surgery, other than within a clinical trial. There was also consensus that patients with N1 disease should be offered RT to the nodes in addition to the primary.
Management of newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC), including oligometastatic prostate cancer
This is clearly one of the fastest moving areas in advanced prostate cancer and there was much new data to consider. The panellists reached consensus on 12 areas of mHSPC including:
Nomenclature – there was 77% consensus that we should avoid the term “castration”, although there was not consensus on what other term we should use! In describing treatment-naïve men, it is easy as we can use the term mHSPC. However, when treatment resistance emerges, we are still left with mCRPC (87% consensus).
I must say there was an outstanding intervention from patient advocate, Mr Millman, after the initial round of voting on this topic, saying how much patients detest the use of the term “castration”. I could not have agreed more. This led to the convenors calling for a repeat vote with subsequent vote in favour of avoiding the use of the term.
95% consensus for obtaining histological evidence of prostate cancer in men suspected of having M1 disease; 96% consensus that ADT could be initiated prior to biopsy.
Most striking – 100% of panellists voted for ADT combined with something else (docetaxel or an androgen receptor (AR) pathway inhibitor) in patients with de novo high-volume mHSPC. There was much discussion about which combination should be offered, but there was no consensus. The decision can be individualised based on patient factors and local registration and reimbursement status. In Australia that means docetaxel for most patients while we awai tregistration/reimbursement for agents such as abiraterone, enzalutamide and apalutamide.
There was also consensus for combination approaches in men with de novo low-volume mHSPC, with 85% voting in favour of some additional systemic therapy in addition to ADT, and 80% supporting RT to the primary.
Similarly, in men with relapsing high-volume or low-volume mHSPC, there was consensus to offer combination systemic approaches, with no consensus on which therapy to offer in addition to ADT.
There was consensus (78%) that in men with mHSPC diagnosed with conventional imaging, that no additional imaging (ie PSMA PET/CT) should be utilised. That horse has already bolted in Australia where it is not unusual for men to be diagnosed with M1 disease using PSMA PET/CT in the first instance.
Regarding oligometastatic disease, there was consensus that if metastasis-directed therapy (MDT) is to be considered, that the extent and location of disease should not be defined using conventional imaging (79%), but should be defined using more sensitive imaging such as PSMA PET/CT (75%). There was also strong consensus that a distinction should be made between lymph node-only disease, and M1 disease involving other sites. Systemic therapy should be used in addition to local therapy to all local sites of disease (75%). I must say that I was pretty surprised that consensus was reached on this point, as guidelines still suggest that MDT approaches should still only be offered within clinical trials.
Management of nonmetastatic (M0) castration-resistant prostate cancer (CRPC)
What even is M0 CRPC? Once again, PSMA PET/CT dominated the conversation. Although there is a relatively recently accepted definition of high-risk M0 CRPC (castrate levels of testosterone; PSA doubling time of </= 10 months; M0 based on conventional imaging), it is fair to say that there was much interest in the role of PSMA PET/CT in this population of patients. Data about to be published at the time of the meeting reported that 98% of patients in this setting will have identifiable disease on PSMA PET/CT despite being M0/N0 on conventional imaging. There these patients are actually mCRPC, rather than M0 CRPC, albeit based on novel imaging with a lead-time bias. Nonetheless, following various overviews of the recent pivotal data showing improvements in metastasis-free survival (MFS, conventional imaging) in patients with M0 CRPC receiving enzalutamide, apalutamide or darolutamide, the panel voted 86% in favour of using one of these agents in this population of high-risk M0 CRPC. We also voted 86% in favour of NOT extrapolating this data to M0 CROC patients with PSA doubling time of greater than 10 months.
Management of metastatic CRPC (mCRPC)
Another huge area with much data to consider. Although much of this had been considered at the previous APCCC and indeed, there were many areas where consensus was not reached eg which agent to use for first-line mCRPC (docetaxel vs AR pathway inhibitor). Despite general enthusiasm for molecular profiling/precision medicine approaches (and some outstanding talks on these areas), there was 85% consensus that we should not use AR-V7 status when considering mCRPC patients for abiraterone or enzalutamide. There was consensus that a steroid dose of prednisone 5mg bd should be used when starting mCRPC patients on abiraterone, and an 86% consensus that a tapering course of steroids should be used when discontinuing abiraterone or docetaxel.
There was considerable interest in the role of reduced dose abiraterone (250mg with food, instead of 1000mg without food), based on a phase II study, and the panel voted 86% in favour of a reduced dose regimen when there are resource or patient constraints on receiving the full dose.
One of the standout talks of the meeting was delivered by Prof Michael Hofman on the role of Lu-PSMA in progressive mCRPC as he presented data from the phase II trial at Peter Mac published in Lancet Oncology (to date, the only prospective data on Lu-PSMA), and on the TheraP randomised controlled trial from Australia which will read out at ASCO in June this year. For patients with PSMA imaging-positive mCRPC who have exhausted approved treatments and cannot enrol in clinical trials, 43% of panellists voted for Lu-PSMA therapy in the majority of patients, and 46% voted for it in a minority of selected patients. For selecting patients for 177Lu-PSMA therapy, 64% of panellists voted for PSMA PET/CT plus FDG PET/CT with or without standard imaging, 21% voted for PSMA PET/CT plus standard imaging, and 15% voted for PSMA PET/CT alone. Although consensus was not reached on this issue, it was clear that the panel were very influenced by Michael’s excellent presentation on this topic, highlighting observations in the Peter Mac phase II trial that the use of FDG PET/CT in addition to PSMA PET/CT led to enhanced patient selection for Lu-PSMA therapy.
Bone health and bone metastases
There was 77% consensus in favour of routine screening for osteoporosis risk factors (e.g. current/history of smoking, corticosteroids, family history of hip fracture, personal history of fractures, rheumatoid arthritis, 3 alcohol units/day, and BMI), in patients with prostate cancer starting on long-term ADT. There was 86% consensus that mCRPC patients with predominantly bone disease and without visceral metastases, should be considered for radium-223 therapy, although this hardly applies to Australia where radium-223 is difficult to access and not reimbursed (plus Lu-PSMA available).
Molecular characterisation of tissue and blood
The plenaries on this topic were some of the most stimulating of the whole meeting. Truly outstanding talks from the pre-eminent leaders in the world. Among the consensus areas were:
90% support for the assessment of germline BRCA1/2 status in M1 prostate cancer patients at some stage of the disease
94% consensus that mismatch repair status (MSI high) should be assessed at some stage in M1 disease, most likely in mCRPC.
96% consensus that PD-1 inhibition should be considered for MSI high patients at some stage in the disease course
Strong consensus (93%) for PARP inhibitor or platinum therapy at some point during the disease course in patients with a deleterious germline BRCA1/2 mutation
Genetic counselling and/or germline DNA testing for patients with newly diagnosed metastatic (M1) castration-sensitive/naïve prostate cancer: consensus (84%) for genetic counselling and/or germline DNA testing for the majority of patients with newly diagnosed metastatic prostate cancer.
Interpatient heterogeneity
There were some terrific talks on heterogeneity in prostate cancer, including ethnic and regional diversity, and the assessment and management of older patients. This year’s meeting expanded on this section compared to previously to acknowledge the diversity of prostate cancer around the world, and the fact that much of the data used to make recommendations is based on particular patient cohorts. The panel did reach consensus (76%) for the extrapolation of efficacy data to patients older than the majority of patients enrolled in a trial.
Side effects of hormonal treatments and their management
Professor Mark Frydenberg was one of the invited plenary speakers in this session and did a terrific job overviewing the management of hot flushes. I have not seen this topic discussed better anywhere in the world. There were also terrific talks on strategies to mitigate other side-effects. The panel reached strong consensus (94%) for the use of resistance and aerobic exercise to reduce fatigue in patients receiving systemic therapy for prostate cancer (apart from therapy dose reduction if possible).
Need more detail?
If you are interested in more detail, please download the manuscript from European Urology (open access), or visit Urotoday where the plenary lectures are available, along with exclusive interviews with many of the invited experts.
Finally, the 4th APCCC will take place from 7-9th October 2021. It will take place in the beautiful city of Lugano towards the Italian side of Switzerland. I encourage anyone with a strong interest in prostate cancer to consider attending. It will be a most stimulating and enjoyable few days immersed in the world of prostate cancer, and conducted with wonderful Swiss hospitality once again by the fabulous Silke Gillessen and Aurelius Omlin.
As the BJUI is a Global journal, we felt that we could learn from our global friends amidst a global infectious disease. I asked my colleagues Guohua Zeng from Guangzhou, China, KH Rha in Seoul, Korea and Riccardo Campi from Florence, Italy as to what they had been doing as urologists. Their texts are below but please also listen to these twopodcastsfrom Italy by Andrea Gavazzi and Riccardo Campi.
How are they dealing with outpatient clinics? Have they stopped elective operating What about the management of cancers? What about emergencies such as ureteric stones, trauma and torsion? Are urologists learning how to treat critically ill patients
I was recently in India as Visiting Professor moving between Mumbai – Vellore – Kolkata. While at Vellore I received the news that a confirmed COVID case had been found near our lab at KCL. My personal assistant took precautionary isolation and I warned my team to await further instructions from Public Health England and the university. I was debating whether to myself travel from Vellore to Kolkata on the final leg of my tour as I did not want to come into contact with my elderly parents in their 80s. Thankfully my handwritten scribbles in my diary confirmed that I had been in my lab area 14 days prior to detection of the case as above. Since I had no symptoms at all, the advice from the hospital in Kolkata that I was visiting was to continue with my travel as planned.
A few days later I left Kolkata for London via New Delhi by Air India. At the Indian capital, I was screened just like all other international passengers and given clearance to travel. I am told that at New Delhi airport this is now routine and crowding at immigration and luggage counters is being minimised to avoid close contact between travellers. While it is impossible to be certain about what happens next, COVID-19 infection in India seems lower than most other countries.
While the response of each nation will be slightly different depending on scientific advice and their local population, here is what our colleagues elsewhere have been doing. Hopefully we can learn and adapt for the weeks and months ahead.
Prokar Dagupta BJUI Editor-in-Chief
Italy
From: Dr. Riccardo Campi, resident in Urology and PhD student at the Department of Urology and Renal Transplantation, Careggi University Hospital in Florence, Italy.
I am grateful for the opportunity to share with you my perspective on the coronavirus epidemic in Italy and its impact on Urological practice at my Institution.
Prof Dasgupta and Dr Campi, Florence, Italy
As of 15th March 2020, the number of laboratory-confirmed cases in Italy was 24 747. Of these, 1809 patients died.
In Italy the coronavirus epidemic has led to profound repercussions from social, healthcare, economic and political perspectives and unfortunately it appears we are still living its rising phase. Thus, we are striving to manage this complex scenario day by day, learning from real-life experience, joining our forces and doing our best to minimize further infection of the population while ensuring effective care of COVID patients.
To tackle the rapidly spreading coronavirus infection, in the past weeks the Italian Government has released several orders that progressively led to the complete closure of schools, universities, commercial activities, as well as to strict recommendations toward social lockdown.
This is now a really challenging scenario, far more serious than most of us thought just a few weeks ago while watching at a distance the worrying reports from China.
Soon after the explosion of the Covid-19 epidemic in China, the Northern Regions of Italy were hit by the coronavirus with the highest strength, putting a strain on the healthcare human and logistical resources, progressively raising concerns on the availability of qualified professionals, as well as on patient selection criteria for admission to Intensive Care Units (ICU), also from an Ethical perspective. Notably, there have been recent orders by the Italian Government that allow Residents in their final years of training to be hired with temporary contracts in hospitals that lack healthcare professionals to face the emergency.
Importantly, all hospitals across the country had to quickly re-modulate their internal logistics to increase the availability of resources in ICUs. To do so, many hospital services, including Surgical Departments, have been discontinued or reshaped to ensure sufficient numbers of available beds for patients requiring intensive care.
Both doctors and nurses are working tirelessly without breaks to guarantee effective care of COVID patients, especially those requiring long, highly demanding hospitalization periods in ICUs.
There still remains a certain degree of heterogeneity in decision-making regarding both the logistics and the internal politics across Italian hospitals and regions regarding the management of services, wards and ICUs, the remodulation of responsibilities among healthcare professionals, as well as the security practices and the operating room schedules.
Nonetheless, it is important to highlight that there has been a significant proactive spirit of participation, solidarity, and commitment among Italian healthcare professionals from all regions.
In this regard, thanks to the potential of social media and technology, it has been possible for all doctors working on the front-line to share a tremendous amount of information, experiences and recommendations on clinical management of COVID patients as well as correct application of preventive measures in relatively short timeframes.
In this scenario, Careggi University Hospital in Florence, a high-volume referral centre with >1200 beds, >45 operating rooms and >110 000 visits at the Emergency Department per year, has entirely reorganized the Emergency Service logistics to ensure a separate, specific diagnostic pathway for patients with suspected coronavirus infection.
Moreover, the logistics of available ICUs have been remodeled in order to concentrate all suspected or laboratory-confirmed cases in one ICU, leaving the others available for “COVID-free” patients.
The organization and logistics of the Internal Medicine, Infectious Diseases, Surgery and Radiology Services have been also significantly revised to ensure maximal availability of healthcare professionals and resources in the most critical departments in case of need.
At the Department of Urology and Renal Transplantation of Careggi University Hospital, directed by Prof. Sergio Serni and Prof. Marco Carini, several critical modifications of the operating room schedule and of the activities of the outpatient clinic have been ordered in the past two weeks.
Firstly, all elective medical visits and procedures in the outpatient clinical setting have been canceled, including Extracorporeal Shock Wave Lithotripsy, circumcisions, cystoscopies for benign diseases, and follow-up visits for non-urgent reasons. The only exceptions are represented by prostatic biopsies, cystoscopies for suspected bladder cancer and/or hematuria, and first visits for patients requiring urgent urological consultation after a screening phone interview.
Overall, there has been a reduction in the number of operations that are allowed to be performed in the urological operating rooms, with a subsequent reduction in the number of beds of the Inpatient Clinic.
In particular, all elective urology operations for benign conditions (such as TURP, Holep, RIRSs, PCNL, pyeloplasty, surgery for pelvic organ prolapse or urinary incontinence, as well as andrological surgery) have been canceled. In addition, renal transplantation from living donors is currently suspended.
Urological emergencies, including ureteric stones, are currently being performed in our ORs, as needed, provided adequate preventive measures for both patients and staff are in place, and after careful evaluation of the individual case.
Interventions for genitourinary cancers are currently being performed according to their priority. Cancer operations scheduled with the maximal priority (priority “A”) are currently performed according to the waiting list. These operations include TURB, radical cystectomy, partial nephrectomy, radical nephrectomy/nephroureterectomy, ureterectomy, orchiectomy, retroperitoneal lymph node dissection, penectomy, and radical prostatectomy for intermediate-high risk prostate cancer.
Cancer operations scheduled with a lower priority (priority “B”), such as radical prostatectomy for low-risk prostate cancer, are currently being postponed.
Finally, renal transplantation from deceased donors is currently being performed without restrictions, provided that the donor was negative for coronavirus infection.
To date, both residents in urology and consultant urologists at Careggi University Hospital are not being trained to treat critically ill patients with COVID infection.
Overall, the decision to allocate Urologists into ICUs in support of anesthesiologists and intensive care physicians to help cope with the emergency related to the coronavirus infection depends on several factors, including the particular hospital’s scenario, internal politics, needs and available resources.
I do hope that this information might be of value for healthcare professionals and decision makers involved in the management of the COVID epidemic in UK, and that the Italian example might be taken into consideration to prevent further spread of the infection across Europe and worldwide.
Thank you again for the opportunity to share my perspective with all of you,
Best wishes
Riccardo Campi, MD
– Resident in Urology, Dept. of Urology, Careggi University Hospital, Florence (Italy) – Ph.D. student, Doctoral Program in Clinical Sciences, Dept. of Experimental and Clinical Medicine, University of Florence, Florence (Italy) – Member of the EAU Young Academic Urologists – Renal Cancer Working Group – Associate Member of the EAU Section of Oncological Urology – Twitter: @Ric_Campi
How to deal with urological patients during coronavirus epidemic?
1. First of all, we recommend that our new or old patients use online services or telephone medical advice. In my department, most of the consultants are using an online APP for free consultation during the coronavirus period. We therefore reduce the number of visiting patients remarkably.
2. For those who have to come to the hospital in person, they need to make an appointment online first. A questionnaire needs to be completed to clarify their epidemic history within the last 2 weeks. If a patient has positive epidemic history, fever, respiratory symptoms, he/she will be assigned to the designated hospital for isolation and treatment. If not, he/she could see a urologist in the temporary outpatient clinic. In the temporary shelter clinic, wearing masks and single room occupancy are obligatory. Urologists are asked to wear examination gloves, isolation gowns, surgical masks, eye protection and disposable hat and shoe covers in a single room for face to face consultation. Negative complete blood count, chest CT and oropharyngeal swab DNA test are compulsory prior to inward admission or day surgery.
Guangzhou, China
3. One patient-one room policy was obligatory for inpatients. Urological treatment was implemented as routine as long as the patient was proved to be coronavirus free.
4. For coronavirus-infected urinary patients, they were referred to a designated hospital in Guangzhou. A negative pressure stretcher was used for transportation all the way along. Grade 3 protection strategies are required for all relevant staff including surgeons, scrub team, anesthetists, technicians and cleaners during the whole period of treatment.
5. In my institute, the fast track of the coronavirus screening usually needs about 6 hours: 6 hours for the swab DNA test, 2 hours for chest CT scan, 1 hour for CBC. Therefore, for emergent and urgent urological situations, such as kidney rupture needing resuscitation or testes torsion needing exploration, patient will be sent to the designated hospital in the first place. For other non-life-threatening situations such as renal colic or urinary retention, patients were allowed to stay in the temporary shelter clinics waiting for the result of coronavirus screening before they are admitted.
Guohua Zeng
-Dr and Prof in Urology -Vice-President, the First Affiliated Hospital of Guangzhou Medical University -Chief, Guangdong Key Lab of Urology -President, Urological Society of Guangdong Province -Vice-Chairman, Urolithiasis section of Chinese Urological Association -Co-chairman and General Secretary, International Alliance of Urolithiasis(IAU)
Professor Guohua Zeng
South Korea
From: Professor KH Rha, Department of Urology at Yonsei University Medical School
To update you on the Corona story in Korea: we had a massive outbreak in Daegu stemming from a religious gathering about a month ago and the medical community put all-out effort to contain this within the region which seems quite successful (different from the Taiwan model where they stopped all international traffic).
Seoul, South Korea
There have been no cancellations of elective operations; rather there are layers of entrance evaluations. More importantly everyone wears a protective mask to prevent any inadvertent transmission of the virus. (This aspect is different from US/European protective guidelines which time will tell…)
Urologists are not handling critically ill patients but we take turns in screening centers and other preventive measures.
To increase awareness of the magnitude of the disease, the Korean Society of Laboratory Medicine has prepared a massive screening program since 2017 after MERS-Coronavirus attack in Korea which had 39 casualties. We can do >15 000 tests a day with more than 200+ institutions. Also every patient’s whereabouts is posted on the web and text messages are used to avoid spread. They are unsung heroes.
I think there seems to be a period of 3 weeks of spread.
KH Rha
-Professor, Department of Urology at Yonsei University Medical School -Director of planning; Chief Operating Officer of Severance Hospital, Seoul, Korea -Consulting Editor, BJUI -Associate Editor, Korean Journal of Urology -Editor-in-Chief, Asian Journal of Urology
The Article of the Month for March 2020 – Guideline of guidelines: social media in urology – was written by Drs Stacy Loeb and Jacob Taylor, who are based in New York City. The cover features the Manhattan skyline as seen from New Jersey, famous for its skyscrapers, which have been built there on bedrock left over from the last ice age at ever-increasing heights since the 1890s, and the song by Norwegian band A-ha. The skyline was dominated by the 1930s-built Empire State and Chrysler buildings until the 1970s when the World Trade Center was completed. The new One World Trade Center is now the tallest building in the city at 1776 feet (541 m) but since the 2000s nine towers over 1000 feet have been built with 16 more being planned. This is partly fuelled by a desire for high city living but also by technological advances meaning thinner bases can be used to support the structures.
In January 2019, the National Institute for Clinical Excellence (NICE) and British Association of Urological Surgeons (BAUS) published new guidance on the management of Acute Ureteric Stones. This guidance suggests that primary definitive treatment should be the goal for all symptomatic ureteric stones, via either ureteroscopy (URS) or extra-corporeal shock wave lithotripsy (EWSL), and should be undertaken within 48 hours of acute presentation.
This is in stark contrast to current practice in the UK: Getting It Right First Time evidence suggests 20% (2-49%) of acute stones are currently treated in this way with only 8% treated primarily with URS and just 2% with primary ESWL.
It has been shown that primary definitive treatment of acute stones within 48 hours has superior outcomes to secondary definitive treatment after stenting; including a higher chance of achieving a stone free state, lower chance of needing retreatment, reduced exposure to general anaesthetic and associated complications, and avoidance of stent-associated symptoms.
However, due to the nature of current emergency surgery provision in UK NHS Trusts, primary definitive treatment is often impossible. Procedures are performed on pressured CEPOD lists which may not be set up for laser treatment (lacking suitable equipment and trained scrub staff) and are often incredibly time-pressured, necessitating ureteric stenting as a faster and simpler option.
Whilst the upfront investment required to provide sufficient resources and training is expected to be recovered downstream by reducing costs associated with stent use and the need for multiple procedures, NHS Trusts are reluctant to make these upfront investments unless incentivised.
We propose a potential solution in the form of Best Practice Tariffs (BPTs).
Traditionally, NHS Trusts receive their income from Clinical Commissioning Groups (CCGs) on the basis of a ‘Payment by Results’ (PbR) system. Under this system, tariffs are calculated based on the national average cost for clinically similar treatments (grouped together into healthcare resource groups; HRGs) and Trusts can retain additional income by keeping costs below this national average. However, this can lead to wide variations in the standards of care. Lord Darzi’s 2008 ‘High Quality Care For All – NHS Next Stage Review’ report suggested that a revised payment system be used, where payment depended on compliance with best-known practice; a best-practice tariff (BPT).
BPTs have now been rolled out across more than 50 diseases and procedures including cholecystectomies, strokes/TIA and NSTEMIs and are recognised as an effective tool for changing practice in an acute setting.
One of the earliest examples was in the management of fractured neck of femurs (NOFs). The base tariff was halved and an additional BPT of £1,335 was made available if seven key ‘best practice’ criteria were met. A dramatic improvement in adherence to national guidelines for management of NOF fractures was seen after introduction of this BPT as shown in Figure 1 (Royal College of Physicians; 2014).
Of particular relevance here was the BPT criteria that required a ‘time to surgery within 36 hours from arrival in A&E to the start of anaesthesia’. The overall median time reduced from 44 hours pre-BPT to 23 hours post-BPT (p<0.005) and the proportion of patients being operated on within 36 hours of admission increased from 36% pre-BPT to 84% post-BPT (p<0.005).
BPTs have the most potential utility for high volume procedures with large variations in national practice and where there is a strong evidence base regarding what constitutes best practice. Renal stones are high volume, affecting 12.5% of the population and resulting in 18,000 URS procedures a year. There is significant national variation in management and there is strong evidence on best practice.
Therefore, if we truly believe that the BAUS and NICE guidelines are in the best interests of patients, BPTs should be considered as a tool to prompt a rapid paradigm shift and make the gold standard, of primary definitive treatment within 48 hours, the new norm.
This blog marks the launch of the British Journal of Urology 90 years ago. Since then the Journal has undergone many changes as urology and the publishing environment have changed. The first Editors outlined their vision in the Foreword of the first issue, which includes an introduction to the speciality, the locations and opening hours of Urology Clinics and a plea for peace:
From the outset, the Editors placed emphasis on seeking collaboration and contributions internationally. From 1929 up to 1942 there was even a section in the Journal advising urologists visiting London where to find details of urological clinics which they could visit.
“This time-table is published in each number of the Journal for the guidance of travelling medical practitioners who may wish to visit Urological Clinics.
Visitors to London are advised to call at No.1 Wimpole St, W.1, where daily bulletins of operations and lectures issued by the Fellowship of Medicine are available for inspection….”
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A sample of the advertisements included in the first edition shows the kit available at the time.
Articles
The first two pages of the very first article are reproduced here and can be accessed via Wiley Online. Note the detailed hand-drawn diagrams. It is also interesting to note the lack of articles on prostate cancer – very different from a urological journal of today.
Collaboration
In 1946 the Journal included a report on “… the Inaugural Scientific Meeting of the British Association of Urological Surgeons and acknowledged the importance of taking on “…the role of official organ of the B.A.U.S….”
The Journal is proud to continue to be an official journal of BAUS and to be the official journal of, or to be affiliated with, many urological associations around the world including:
The Journal was, of course, solely a paper-based one from inception until 1994 when content was made available on CD ROM. This innovation was soon superseded by the advent of the internet and the Journal was first published online in 1997. This signal event resulted in a transformation of the procedure for submitting and processing papers through peer review from a paper-based, postal one to an online one. All articles published in the Journal since 1929 have been digitised so that they are accessible online. Over the last two decades, the demand for print subscriptions has waned.
In 1999 the name of the Journal was changed to BJU International, reflecting the Journal’s British heritage and the importance of the contributions from the UK and internationally.
BJUI Editors 1929-2019
Responsibility for the Journal has been held by a succession of Editors and their Editorial Teams. There have been 10 editors during the first 90 years, some of whom served as co-editors (early version of a job-share?).
Thanks to Jonathan Goddard for the photos of the editors
Our current Editor-in-Chief, Prokar Dasgupta, is supported by an internationally based teamof Associate Editors and Consulting Editors. In August next year, he will hand on the Editorship to Freddie Hamdy.
Thank you to our Editorial Teams, authors and peer reviewers for all their hard work in contributing to the success of the Journal.
IP4- CHRONOS is open! CHRONOS is a phase II randomised control trial, that will review the outcomes (including oncological, functional, quality of life and cost-effectiveness) of focal therapy against those from radical therapy, in men with newly diagnosed localised clinically significant prostate cancer.
All men newly diagnosed with low-intermediate risk prostate cancer, confined to the prostate, with a life expectancy of at least 10 years will be screened for eligibility. Men must be well enough to undergo the interventions outlined in the trial prior to being enrolled.
Men will then have a choice of enrolling into CHRONOS A or CHRONOS B. CHRONOS A will randomise men to having radical whole gland treatment (radiotherapy, brachytherapy or prostatectomy), or focal therapy (HIFU or cryotherapy). CHRONOS A will answer the question, ‘is focal therapy equivalent in cancer control as radical therapy?’ CHRONOS B will randomise men to having focal therapy with or without additional neoadjuvant treatment and will answer the question: ‘can the success of focal therapy be improved by using neoadjuvant treatment?’ Randomisation will be stratified by disease characteristics.
All men will undergo intervention as they would within the NHS, however by doing so in a trial setting, we can directly compare the results of such treatments against each other. As the follow up mimics that of standard of care, the extra burden of treatment within the trial is minimal.
60 men will be recruited into both CHRONOS A and CHRONOS B (total 120) over a 1-year period, during the pilot, and if recruitment is successful the aim is to continue to a larger study assessing 2450 patients over 5 years, with a minimum follow up of 3 years. The primary outcome measures will be progression free survival in CHRONOS A, and failure free survival in CHRONOS B. The CHRONOS pilot will open in 12 UK hospital sites, aiming to open across the UK and Europe within the larger study.
CHRONOS is entirely funded by the Prostate Cancer UK charity, and available on the NIHR CRN portfolio. If you would like to join the main phase of CHRONOS as a site, please contact Miss Deepika Reddy ([email protected]) or visit our website for further information www.imperialprostate.org.uk/CHRONOS
Prof Hashim U. Ahmed (CHRONOS PI&CI)
Mr Taimur T. Shah (CHRONOS sub-investigator, Urology SpR & Research Fellow)
Miss Deepika Reddy (CHRONOS Clinical Research Fellow)
The Indonesian Urological Association Annual Scientific meeting was held at The Golden Tulip Hotel, Banjarmasin – 3-5 October 2019.
The main conference was preceded by pre-congress workshops at the University of Indonesia Medical Education and Research Institute (IMERI) in Jakarta.
Masterclass with Consultant Urologist Mr Brian Chaplin
Furthermore, the BJUI held a plenary lecture entitled: High Risk Non-Muscle-Invasive Bladder Cancer : The Promise of New Therapies by Consultant Urologist Miss Jo Cresswell, also from the South Tees Hospitals NHS Foundation trust in the UK.
[caption id=”attachment_40134″ align=”aligncenter” width=”243′ label=’Promoting knowledge: Miss Jo Cresswell at the Masterclass
The conference also featured the increasingly popular 10 and 5 Km Uroruns and a Urowalk starting at 6 and 7am on the Saturday morning.
A taster week is a training opportunity offered to UK doctors in their first two years of clinical practice to try a new specialty. They are an important learning experience for doctors at this stage, who will have experienced working in six different specialties at most. While taster weeks are only five days long, they offer a unique insight into a new specialty, as well as the chance to network with registrars and consultants.
During medical school I was interested in transplantation, as I found the combination between surgery and immunology interesting. This led me to complete a Master of Research in Transplantation while at medical school. During this degree, I looked at urinary tract infection in transplant patients and this started my interest in urology.
In the UK, the majority of trainees enter the field of transplantation following training in General Surgery. In clinical practice, it is good to have urologists with an active interest in Renal Transplantation for the betterment of these patients but there are few centres where this can be learnt. However, the Freeman Hospital in Newcastle, UK offers a one to two-year fellowship in renal transplantation which can be completed at the end of urology training. I contacted one of the urology and renal transplant surgeons and organised a week’s visit to the Freeman Hospital.
During my taster week I had the opportunity to shadow a urology and renal transplant surgeon. I joined urology and transplant ward rounds, including a renal transplant grand round, and I also attended a transplant nephrology clinic where I saw the long-term management of patients who had received kidney transplants. I observed theatre lists in both urology and transplant and saw the wide variety of operations that urology and transplant surgeons are involved in, such as renal access surgery for dialysis and robotic partial nephrectomy for renal cancer.
I also had a chance to attend multi-disciplinary team meetings about new transplant recipients as well as an x-ray imaging meeting concerning live kidney donors.
Speaking to urology and renal transplant surgeons was an invaluable experience and helped me plan the next steps in my career as well as solidify it as a preferred career choice.
The highlight of my taster week was attending regional surgical teaching. I spent a day in one of the few world-class cadaveric training laboratories in the UK and learnt how to perform an orchidopexy for testicular torsion and vascular anastomosis; two operations that are no doubt necessary for a urology and renal transplant surgeon.
I am very glad I completed a taster week in urology and renal transplantation. It allowed me to experience the variety of work involved in this niche specialty. It was an experience that would have only been available much later in my career otherwise, which would be at a point too late for a career change.
by Matthew Byrne
Matthew Byrne recently completed two years as an Academic Foundation Doctor in Cambridge, UK. He graduated MBBS from Newcastle where he also completed a Master of Research in Transplantation. He is now a Urology Clinical Fellow in Cambridge, UK.
