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The professional benefits of USANZ trainee week 2015

November 30, 2015/by Sanchia Goonewardene

I landed on a bright sunny Brisbane morning for the Urological Society of Australia and New Zealand (USANZ) Trainee Week 2015 – an annual, 5 day, comprehensive, bi-national conference specifically for trainees. I have much to be grateful for including sponsorship from BAUS, TUF, USANZ and SURG. All these organisations had realised international organisation inter-working is required to foster a higher level of teaching for trainees.

Later that day, I had opportunities to meet trainees from all over Australia and New Zealand (ANZ). The quality of training given is truly remarkable. When looked at in detail, the ANZ system focuses on general surgery training initially, prior to moving to urology as a separate speciality. The result of this are that they are superb open surgeons. This is often a dying art and difficult to gain.

Our first day started with a chance to observe mock FRACS stations. The standard of the candidates was incredibly high, despite it being a mock exam. As part of this, an overview of the FRACS exam was given by one of the FRACS senior examiners, Mr. Neil Smith. The day concluded with meetings of trainees for each region within ANZ – again another fantastic way to support the trainees. I have never seen anything quite like this. This also ensures trainees are receiving adequate training as concerns and issues are relayed directly to the training board chair. The evening concluded with a Welcome reception and barbeque at Brisbane Surf club.

The next day started with a series of lectures on bladder cancer, led by Mr Shomik Sengupta (Melbourne) and Mr. Roger Watson (Brisbane). There were many learning points for trainees to take away, including case based management discussions, role of cystoprostatectomy and role of bladder preservation (Dr Tanya Holt, Brisbane).

Also covered were the roles of neoadjuvant vs adjuvant chemotherapy, (Dr. Niara Oliveira, Brisbane), the pros and cons of urinary diversion (Dr. Sarah Azer), and LND (Dr. Jonathan Chambers, Brisbane). After lunch the most amazing teaching was given on uro radiology, with a focus on nuclear medicine and also on pathology. The FRACS exam is very different from any other end of training exam, as there will be both radiology and pathology stations.

The next day dawned bright and early, with a whole morning of paediatric urology. I can think of many registrars, who would love a whole morning of teaching on this subject- it is not often easy to get access to paediatric urology. Testicular embryology and maldescent were very nicely covered by Mr. Peter Borzi, (Brisbane). Both normal and abnormal conditions were discussed including reasons for orchidopexy with maldescent. Former USANZ President, David Winkle then spoke on translation care. Mr Pete McTaggart, then covered Adolescent voiding dysfunction, a profoundly difficult subject to manage, given the age of the patient and the disease involved.

The next focus was on the adrenal including functions of the adrenal, management of the adrenal mass and investigations and phaeochromocytoma. This again, is another area, which is not often covered or encountered in clinical practice.

The morning concluded with a Board of Urology update addressed by Mr Richard Grills, Board Chair, covering the training programme for urologists. Also covered were training policies and involvement of RACS in governing this. Most impressively, USANZ has negotiated membership for all of its’ trainees with EAU, SIU and AUA. A good step forward regarding international working and fellowship.

The next day started with a breakfast meeting, on how to pass the FRACS exam. This session was chaired by Dr. Matt Winter. Big congratulations also went out to Dr. Tim Smith, who had had a baby the day before and still attended to teach. Topics covered were perspectives of preparing emotionally, physically, and psychologically. This recognised how difficult it can be to prepare. All tips and tricks were given by former trainees, who had passed the exam. Further mock practice also occurred, being taken through a pathology exam.

A whole session was dedicated to renal cancer covering topics such as active surveillance, partial and radical nephrectomy, RFA and cryotherapy. A really fantastic lecture was given by Mr. Simon Wood on management of RCC and cyotreductive nephrectomy, followed by oncological management of metastatic RCC. This is an area, which unless you are in a renal fellowship, may not see.

The next session involved teaching on upper tract and transplant. This was absolutely brilliant at covering donor assessment, management of transplant ureter and assessment of renal function and prognosis. Unless a transplant job were done, this knowledge would not be gained. All of this contributes to making a far better surgeon.

The afternoon focused on mastering difficult interactions with colleagues. Lastly, the day ended, with case based discussions, focused on FRACS viva practice. After having gone through that, I have a greater respect for all candidates going through post graduate exams. The evening was completed by a lovely boat ride through Brisbane and farewell dinner.

The next day, started with a bang, with Prof Samaratunga (Brisbane) talking on prostate grading. It is wonderful to have a lady professor. It shows the forward thinking of the Australia medical field, clearly ahead of others. Next, very valuable teaching was received from Dr. Peter Swindle (Brisbane). This was followed by teaching on PSA screening by Dr John Yaxley (Brisbane). PSMA PET was then covered by Dr. Rob Clarke (Brisbane), and its role in detection of prostate cancer. A fantastic presentation on management of elevated PSA was covered via a balloon debate- much loved by all and a different way of learning.

The conference ended with a quiz- Masters of the Uroverse. Teams from different regions of Australia battled it out for the title. It ended the conference is a very fun and unusual way. After having been to this meeting, my knowledge base has grown.

Our thanks go to Ms. Deborah Klein, the star organiser who is Education and Training Manager of USANZ, the Convener Mr. Stuart Philip and Mr. Richard Grills Chair, Board of Urology for hosting a thoroughly enjoyable event. Also to all the trainees and consultants who made us incredibly welcome.

Sanchia Goonewardene, University of Warwick, UK. @survivorshipuk

Worldwide Live Robotic Surgery 24-Hour Event 2015

October 15, 2015/4 Comments/by admin Z.9

For the first WRSE24 we had over 2500 unique viewers registered from 61 countries (58 on the day).

This time we want you the global audience to get involved and participate online

In the Worldwide Robotic Surgery Event

Register now for free

In February 2015, with EAU approval, ten robotic centers from 4 continents planned to stream live surgery continuously for 24hrs.

Viewing of live surgery was limited to medical professionals using password protection, following registration. LiveArena ™ provided the infrastructure and technological support. All surgeries were completed without incident and we have submitted our outcome data to the EAU live surgery committee, who are supporting our next planned event. Further details can be found at www.wrse24.org

Following previously published EAU Policy on Live Surgery Events (LSE’s), whilst ongoing live surgery at conferences is assured, there remains debate as to how best we can optimise this form of training. The EAU panel reached >80% consensus view that performing live surgery from home institutions may be safer, identifying several issues with a ‘‘travelling surgeon’’. A BJUI poll related to the first WRSE24 found that 76% of respondents would ‘attend’ a streamed virtual surgical conference rather than travel if accreditation were the same, further indicating the potential for uptake into training and education events.

The outcome from the first event surpassed many of our expectations. Registrants came from 61 countries. 1390 unique viewers visited the www.WRSE24.org website during the live 24 hours and this number increased to 2277 over the next 6 days.

The event was well received by industry and the project was a finalist in the category of “Innovative Technology for Good Citizenship” at the prestigious Microsoft Partnership awards held in July 2015, which received over 2,300 nominations from 108 different countries.

We are also delighted to announce that the forthcoming WRSE24 will involve surgeons from 2 more continents making it the first live urological conference to have contributors from 6 continents.

As well as all the surgeons previously involved we will be joined by 5 new surgeons including 2 additional robotic centres: Clinique St Augustin (Dr Richard Gaston and Professor Thierry Piechaud) and Sao Paulo University Hospital (Dr Rafael Coelho). Benjamin Challacombe will be operating from Guys Hospital, London and Ketan Badani will be operating from Mount Sinai, New York. Our aim is to stream live surgery from 12 leading robotic centres, a list of whom can be seen below. Finally we will have a live teleconference link via Skype between Professor Hassan Abol-Enien from the world famous Mansoura University Hospital and Professor Peter Wiklund at Karolinska.

The second event will also see the 24hour studio sessions split into six 4hour sessions. The contributing centres are Karolinska Stockholm, OLV Aalst, Guys London, Mt Sinai New York and Keck USC, Los Angeles.

The first event was primarily focused on providing access to live streamed HD video of world leading surgeons operating in their normal working day, with their expert teams. The second event plans to build on this format with more audience participation utilizing social media. We are working with LiveArena™ and Microsoft™ to optomise this aspect. There will be improved opportunities to ask questions to the surgeons utilizing a Microsoft Yammer ™ app that will be integrated into the WRSE24 site or via twitter using #wrse24. Although the concept of a Twitter backchannel at educational events has become familiar, future approaches may be able to improve on ways of communicating within a global audience. Our aim for the 2^nd WRSE24 is to enliven virtual participation, widening access to a fuller, interactive, experience for the online audience, with an emphasis on conversation, connection and crowd sourcing of opinions. To highlight the benefits of crowd sourcing of opinions we are planning an ambitious project to have an interactive live debate between Mansoura University Hospital and Karolinska University Hospital. This will include polling technologies available via Yammer™, so that the second part of this planned live discussion will potentially be guided by the opinions of the global audience. A research-group at Stockholm University, with a specialist interest in Social Media are also working closely with WRSE24 to help interpret this data, so that we can learn from this event.

For more details on this worldwide event and the complimentary activities that are planned please visit www.wrse24.org

Controversies in management of high-risk prostate and bladder cancer

October 12, 2015/by Stacy Loeb

Recently, there has been substantial progress in our understanding of many key issues in urological oncology, which is the focus of this month’s BJUI. One of the most substantial paradigm shifts over the past few years has been the increasing use of radical prostatectomy (RP) for high-risk prostate cancer and increasing use of active surveillance for low-risk disease [1,2].

Consistent with these trends, this month’s BJUI features several useful articles on the management of high-risk prostate cancer. The ﬁrst article by Abdollah et al. [3] reports on a large series of 810 men with D’Amico high-risk prostate cancer (PSA level >20 ng/mL, Gleason score 8–10, and/or clinical stage ≥T2c) undergoing robot-assisted RP (RARP). Despite high-risk characteristics preoperatively, 55% had specimen-conﬁned disease at RARP, which was associated with higher 8-year biochemical recurrence-free (72.7% vs 31.7%, P < 0.001) and prostate cancer-speciﬁc survival rates (100% vs 86.9%, P < 0.001). The authors therefore designed a nomogram to predict specimen-conﬁned disease at RARP for D’Amico high-risk prostate cancer. Using PSA level, clinical stage, maximum tumour percentage quartile, primary and secondary biopsy Gleason score, the nomogram had 76% predictive accuracy. Once externally validated, this could provide a useful tool for pre-treatment assessment of men with high-risk prostate cancer.

Another major controversy in prostate cancer management is the optimal timing of postoperative radiation therapy (RT) for patients with high-risk features at RP. In this month’s BJUI, Hsu et al. [4] compare the results of adjuvant (≤6 months after RP with an undetectable PSA level), early salvage (administered while PSA levels at ≤1 ng/mL) and late salvage RT (administered at PSA levels of >1 ng/mL) in 305 men with adverse RP pathology from the USA Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry. At 6.2 years median follow-up, late salvage RT was associated with signiﬁcantly higher rates of metastasis and/or prostate cancer-death. By contrast, there was no difference in prostate cancer mortality and/or metastasis between early salvage vs adjuvant RT. A recent study from the USA National Cancer Data Base reported infrequent and declining use of postoperative RT within 6 months for men with adverse RP pathology, from 9.1% in 2005 to 7.3% in 2011 [5]. As we await data from prospective studies comparing adjuvant vs early salvage RT, the results of Hsu et al. [4] are encouraging, suggesting similar disease-speciﬁc outcomes if salvage therapy is administered at PSA levels of <1 ng/mL.

Finally, this issue’s ‘Article of the Month’ by Baltaci et al. [6] examines the timing of second transurethral resection of the bladder (re-TURB) for high-risk non-muscle-invasive bladder cancer (NMIBC). The management ofbladder cancer at this stage is a key point to improve the overall survival of bladder cancer. Re-TURB is already recommended in the European Association of Urology guidelines [7], but it remains controversial as to whether all patients require re-TURB and what timing is optimal. The range of 2–6 weeks after primary TURB was established based on a randomised trial assessing the effect of re-TURB on recurrence in patients treated with intravesical chemotherapy [8], but it has not been subsequently tested in a randomised trial. Baltaci et al. [6], in a multi-institutional retrospective review of 242 patients, report that patients with high-risk NMIBC undergoing early re-TURB (14–42 days) have better recurrence-free survival vs later re-TURB (73.6% vs 46.2%, P < 0.01). Although prospective studies are warranted to conﬁrm their results, these novel data suggest that early re-TURB is signiﬁcantly associated with lower rates of recurrence and progression.

References

1 Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA 2015; 314: 80–2

2 Loeb S, Berglund A, Stattin P. Population based study of use and determinants of active surveillance and watchful waiting for low and intermediate risk prostate cancer. J Urol 2013; 190: 1742–9

3 Abdollah F, Klett DE, Sood A et al. Predicting pathological outcomes in patients undergoing robot-assisted radical prostatectomy for high- risk prostate cancer: a preoperative nomogram. BJU Int 2015; 116: 703–12

4 Hsu CC , Paciorek AT, Cooperberg MR, Roach M 3rd, Hsu IC, Carroll PR. Postoperative radiation therapy for patients at high-risk of recurrence after radical prostat ectomy: does timing matter? BJU Int 2015; 116: 713–20

5 Sineshaw HM, Gray PJ, Efstathiou JA, Jemal A. Declining use of radiotherapy for adverse features after radical prostatectomy: results from the National Cancer Data Base. Eur Urol 2015; [Epub ahead of print]. DOI: 10.1016/ j.eururo.2015.04.003

6 Baltacı S, Bozlu M, Yıldırım A et al. Signiﬁcance of the interval between ﬁrst and second transurethral resection on recurrence and progression rates in patients with high-ris k non-muscle-invasive bladder cancer treated with maintenance intravesical Bacillus Calmette-Guerin. BJU Int 2015; 116: 721–6

7 Babjuk M, Bohle A, Burger M et al. European Association of Urology Guidelines on Non-Muscle-Invasive Bladder Cancer (Ta, T1, and CIS). Available at: https://uroweb.org/wp-content/uploads/EAU-Guidelines- Non-muscle-invasive-Bladder-Cancer-2015-v1.pdf. Accessed September 2015

8 Divrik RT, Yildirim U, Zorlu F, Ozen H. The effect of repeat transurethral resection on recurrence and progression rates in patients with T1 tumors of the bladder who received intravesical mitomycin: a prospective, randomized clinical trial. J Urol 2006; 175: 1641–4

Stacy Loeb – Department of Urology, Population Health, and the Laura and Isaac Perlmutter Cancer Center, New York University, New York City, NY, USA

Maria J. Ribal – Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain

A Medical Voyage of Discovery

October 9, 2015/by Jim Duthie

I am still getting used to being able to stretch out in bed. For the last two weeks my nights were spent in a wooden bunk designed for trainee Japanese fishermen, none of who apparently exceeded 175cm in height. Or 50cm in width during any point in their nocturnal contortions. Combined with a roaring generator, constant motion, four roommates, and another person in the same situation on the other side of the thin plywood wall from me getting up for their daily four o’clock watch, nights were not a highlight on the ship. The ship was the Pacific Hope, a (mostly) refurbished training trawler with a new career in humanitarian outreach.

My day job as a Urological Surgeon mostly involves lasers and robots, but for this two-week period the peak technology available was a blood pressure cuff. I had not looked in an ear since I was an undifferentiated junior doctor, or taken anyone’s blood pressure, or diagnosed knee arthritis. One thing that I was confident of, was that I was better than no doctor at all for the inhabitants of Ambrym Island, Vanuatu. In the event I enjoyed the collegiality of an Irish Junior doctor who was hard working, quick to learn, and most importantly hilarious company. Between us we solved most problems, and had the bail out option of referral to Port Vila hospital for blood tests or imaging if we were completely baffled. As well as tuberculosis, a yaws, and an elephantiasis, we were saddened by how widespread hypertension was becoming, thanks to the introduction of low quality, high-salt canned beef to the islands. I managed to rescue a man with a rotten diabetic leg, sepsis, and uncontrolled blood glucose (no insulin) with a bedside debridement and urgent transfer to the mainland. We followed up a week later and surprisingly, it looked like he wouldn’t need an amputation. I couldn’t do anything for a woman with early Parkinson’s disease, as medication would never be reliably available for her. I even saw one case of BPH, but didn’t have any alpha-blockers.

It was a cheerful, positive environment, with grateful patients and hard working team mates. There were no managerial reviews, waiting lists, or funding approval involved in treating the patients. We didn’t order unnecessary tests to rule out the miniscule possibility of an alternative pathology, as we knew no one would sue us for trying to help them.

I swam a lot, ate coconuts, had no phone or internet access on ship, and the world still turned. I won’t get any publications out the trip, and had to pay for the privilege of working, but it was actually a privilege to do the work.

I climbed a mountain and looked into a lava lake, watched dolphins play and flying fish fly, swung off a 10 metre high crane into the ocean, and walked an hour through jungle to do a house call. I don’t usually get to do these things as part of my job.

The Pacific is an area of high medical need that is comparatively safe and accessible for a third world region. Most of us train to be doctors because we want to make people better, and volunteering is a way of really feeling like you are achieving this. Taking two weeks off work will make little difference to my career development, was good for my mental health, and allowed me to stare at the horizon more than I otherwise would have. As doctors, we have portable skills; our tools are our hands and brains, and they work well in remote areas. Have you been finding work a bit “samey” lately?

I’m going back next year.

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

TUF Cycle India

September 17, 2015/88 Comments/by Roger Kirby

The Urology Foundation Cycle Challenge in Rajasthan

19 – 28 November 2015

In memory of Professor John Fitzpatrick

After the gruelling cycling challenges in Sicily, Malawi, Madagascar, Patagonia, and most recently South Africa, which together have raised many hundreds of thousands of pounds for The Urology Foundation (TUF), our next Challenge is a 500 Km ride through Rajasthan, India. We now have 50 intrepid cyclists signed up and ready to participate in this exciting, but very demanding, ride. Some grizzled veterans, such as Roger Plail and Andrew Etherington (80 years old next year!) will be joining us again. Peter Rimington, who led the South African challenge, will be there, but is replaced as “local knowledge team captain” by Abhay Rane, who has done a great job in recruiting and motivating participants this year. Our wonderful CEO Louise de Winter will be bravely accompanying us on the ride, as she did in Africa.

The ride commences in Bharatpur – the eastern gateway to Rajasthan. It is most famous for the Keoladeo Ghana National Park, a world heritage site and one of the finest water-bird sanctuaries in the world. On the first morning we will have a chance to visit the specacular Taj Mahal in Agra, one of the true wonders of the world.

From there, we start our adventure by cycling through the National Park. Our first day’s cycling takes us to the Bhanwar Vilas Palace in Karauli. The following day we will ride to the famous Ranthambore National Park, which is famous for its tigers; the conservation project there is popular with wildlife buffs and professional photographers from right across the world. With luck we may encounter some of the animals to be found in the park including sambar, cheetah, wild boar, leopard, jackal and hyena. We will overnight at the famous “Tiger Den”.

From here on it is just toil, sweat and tears, together with the ever-present risk of “Delhi Belly”! We will no doubt, just as we did before before, rise to the challenge and press on relentlessly to our final destination, the famous “pink city” Jaipur. Here the “Amber Fort” and a well-earned celebration awaits us.

I am very much hoping that many of you will support our endeavours with a donation, and participants themselves will add their own comments, stories and photographs to this blog. TUF is such a worthy cause, and really does an amazing job in supporting and promoting urology, not only throughout the British Isles, but in Africa and beyond. Do watch (and especially contribute to) this space! We will be posting updates to let you know how we get on.

Click here to see a short video on the challenges the TUF cyclists faced https://trendsinmenshealth.com/video/tuf-cycle-india-2016/

Roger Kirby, The Prostate Centre, London

Functional urology is coming to you!

September 11, 2015/by Dirk De Ridder

This month’s edition features three interesting papers in the field of functional urology. Overactive bladder (OAB) syndrome has a prevalence of 14%, prostatitis symptoms have a prevalence in the male population of 8.2% and a substantial number of all men undergoing radical prostatectomy will remain incontinent. These are clinical entities that every urologist encounters in his daily practice.

The treatment of refractory OAB symptoms with anticholinergics, can be optimized by adding mirabegron in a flexible dose scheme. This has been nicely shown in a Japanese population by Yamaguchi et al. [1]. Despite the fact that Japanese health authorities recommend starting with a lower dose of 2.5 mg of solifenacin or 25 mg of mirabegron, these data can be extrapolated to other populations as well, where 5 mg of solifenacin and 50 mg of mirabegron are used as standard doses.

Chronic bacterial prostatitis and chronic pelvic pain syndrome are difficult to deal with. As there is a lack of well-designed prospective randomized controlled studies in this field, Rees et al. [2] used the Delphi consensus methodology to draw up experience- and science-based consensus guidelines. Their Delphi panel included 58 participants consisting of GPs, urologists, pain specialists, nurse specialists, physiotherapists, cognitive behavioural specialists and sexual health specialists. The guidelines give a well-structured overview of the diagnostic and therapeutic possibilities for chronic bacterial prostatitis and chronic pelvic pain syndrome.

Post-radical prostatectomy incontinence varies widely from 3 to 87%. Artificial sphincters are still the main treatment for this complication. While the results in non-irradiated patients might be good in the long term, it remains unclear how external beam radiotherapy would affect the outcome of artificial sphincters in post-radical prostatectomy incontinence. Bates et al. [3] performed a meta-analysis on the complications occurring after the implantation of an artificial sphincter after radical prostatectomy and radiotherapy. The combination of radical prostatectomy and external beam radiotherapy increases the risk of infection and erosion and urethral atrophy and results in a greater risk of surgical revision compared with radical prostatectomy alone. Also persistent urinary incontinence is more common in this population.

These three papers highlight important and relevant problems in urology. It is clear from these papers that we need more insight and more research into the underlying mechanisms of these highly prevalent entities. With an ageing population that wants to remain active as long as possible, we need to invest more time, people and money in this field to improve the quality of life of these patients. Basic science and clinical science need to work together to improve our knowledge and understanding.

Functional urology is coming to you! You will not escape from this growing population.

References

1 Yamaguchi O, Kakizaki H, Homma Y et al. Safety and efﬁcacy of mirabegron as ‘add-on’ therapy in patients with overactive bladder treated with solifenacin: a post-marketing, open-label study in Japan (MILAI study). BJU Int 2015; 116: 612–22

2 Rees J, Abrahams M, Doble A, Cooper A. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int 2015; 116: 509–25

3 Bates AS, Martin RM, Terry TR. Complications following artiﬁcial urinary sphincter placement after radical prostatectomy and radiotherapy: a meta-analysis. BJU Int 2015; 116: 623–33

Dirk De Ridder

Department of Urology, University Hospitals KU Leuven, Leuven, Belgium

The Urological Ten Commandments

September 7, 2015/3 Comments/by Jonathan Glass

“It is my ambition to say in ten sentences what others say in a whole book.” – Friedrich Nietzsche

The EAU guidelines on lower urinary tract symptoms have been published recently. These contain 36,000 words. It was pointed out to me that the American declaration of independence contained 1300 words and The Ten Commandments just 179 words.

The challenge was therefore to write ten commandments for urology in 179 words. The rules I set were that I should write them whilst keeping the spirit of the structure of the decalogue as closely as possible. (It may be worth rereading the original before reading on). So here goes.

1) I am a logical specialty. Thou shall investigate thoroughly prior to undertaking intervention for I am a specialty that avoids surprises.
2) Though interested in the whole of medicine thou will perform no other procedures other than urological.
3) Thou shalt not base intervention on old imaging for the clinical situation could have changed.
4) Remember that 80% of diagnoses can be made with history alone. Thou shalt listen carefully to your patient to this end.
5) Honour sound surgical principles. Urological tissue is forgiving but anastamoses under tension will not heal.
6) Thou shall not ignore haematuria.
7) Thou shall not leave a stent and forget it has been placed.
8) Thou shall not adopt new technology without proper clinical evaluation unless it is part of a trial.
9) Thou shall not fail to see the images yourself in assessing the patient before you.
10) Thou shall not fail to assess the potential for harm before embarking on a surgical procedure. If you would not do it to your family, your neighbour or friends, you will not do it to the patient who is in your clinic.

I put these out for discussion. Other offerings please.

Jonathan M. Glass @jonathanmglass1

The Urology Centre, Guy’s Hospital, London, UK.

[email protected]

Clever surgeons and challenging study endpoints

August 18, 2015/by John Davis

Intraoperative in vivo tracking of a periprostatic nerve with multiphoton microscopy in rat model.

In the last 6 months, the BJUI editorial team has evaluated an average of 59 urological oncology papers per month with an average acceptance rate of 16%. We receive additional papers for our ‘Translational Science’ section. Studies with high-quality methods are given the highest priority. Other papers compete well if they are highly applicable to clinical practice (i.e. comparative, multicentre, multi-surgeon design) and/or show us new ideas in surgical technique, re-designed study endpoints, or explore new sources of data. For translational science, the best candidates are studies that look at new diagnostic tests in humans and beyond simple immunostaining techniques. We want to evaluate biomarkers likely to be validated and translated into a clinical test. Clinical impact will be even higher if a biomarker is linked to a therapy outcome rather than just a risk estimate. We want our papers to guide us to better outcomes for our patients, hopefully control healthcare costs, and, yes, be well-cited in the literature.

Our review process is tough but fair, and we congratulate and highlight three authorship groups for acceptance into this month’s issue of BJUI. The theme of ‘clever surgeons and challenging study endpoints’ is well illustrated by all three groups. Zargar et al. [1] report on an exclusive database of high-volume minimally invasive surgeons who have tackled the partial nephrectomy option for small renal masses. The comparison is simple in concept and retrospective in design, but what they have done is to significantly increase the outcome measures into a ‘trifecta’ concept in perioperative outcomes (previously reported) with an even more stringent ‘optimal outcome’ endpoint that includes renal function preservation. With a database of 1185 robotic and 646 laparoscopic cases, the robotic procedures showed superior trifecta results (70% vs 33%), complication rates (14.8% vs 20.9%), positive surgical margin rates (3.2% vs 9.7%), and warm ischaemia time (18 vs 26 min). The optimal outcome endpoint included a minimum 90% estimated GFR (eGFR) preservation and no chronic kidney disease upstaging. Only the robotic cohort had sufficient data available and the rate was 38.5%. The latter figure is an interesting challenge, as defining such a high threshold for success challenges surgical technique and allows more room to identify incremental advancement. This may be the largest study of its kind, but non-randomised and with limitations discussed in peer review such as the learning curve influence, use of eGFR as an endpoint with two kidneys, and incomplete data. The definitions used are of interest and the field could use some uniformity moving forward in measuring perioperative and long-term benchmarks of quality.

Durand et al. [2] give us a glimpse into the future of surgery, a science fiction world of prostate surgery where nerves and prostatic glands can be colour coded and seen at a microscopic level in real time. The pictures stand for themselves, especially Fig. 1. If such imaging can be integrated into technique decisions, and perhaps future instrument designs, then perhaps we will have a whole new wave of studies possible on linking surgical technique to improved functional and oncological outcomes after radical prostatectomy. The paper has a nice depth in detail, methods, results, as well as narratives in solving technical problems with novel technology.

This issue’s ‘Article of the Month’ by Gavin et al. [3] is a different look at the question of morbidity after localised prostate cancer treatments, specific to long-term care at >2 years from treatment. The database is from a cancer registry and they have an impressive 54% response rate from a population that is 2–18 years from diagnosis. Rather than Likert-like scales of symptom severity, they simply look at ‘current’ vs ‘ever had’ symptoms and look at the total burden including multiple/overlapping symptoms. Although this may not be as robust and validated as the Expanded Prostate Cancer Index Composite (EPIC) instrument, the simple phrasing of ‘current’ vs ‘ever had’ is probably capturing a very high proportion of symptoms rather than dismissing them if minor or in the past. Again, we see more erectile dysfunction after radical prostatectomy and radiation with hormonal therapy, and more bowel symptoms after radiation therapy. Hormone therapy patients have hot flashes and fatigue, and watchful-waiting patients have some advantages but are certainly not free of symptoms. The burden of symptoms is interesting, nine of 10 reported at least one of seven key symptoms at some point and three of four are current. Therefore, as the authors indicate, ≈75% of prostate cancer survivors will have ongoing symptoms needing follow-up care. This is a significant database resource adding to our understanding of long-term outcomes of patients with prostate cancer and supporting the significance of the Durand et al. [2] study that may show the way forward towards reducing such burdens of disease treatment.

References

1 Zargar H, Al laf ME, Bhayani S et al. Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study. BJU Int 2015; 407–14

2 Durand M, Jain M, Aggarwal A et al. Real-time in vivo periprostatic nerve tracking using multiphoton microscopy in a rat survival surgery model: a promising pre-clinical study for enhanced nerve-sparing surgery. BJU Int 2015; 478–86

3 Gavin AT, Drummond FJ, Donnelly C, O’Leary E, Sharp L, Kinnear HR. Patient-reported ‘ever had’ and ‘current’ long-term physical symptoms after prostate cancer treatments. BJU Int 2015; 397–406

John W. Davis, MD
Associate Editor, BJUI

#pass4prostate gears up for Rugby World Cup

August 17, 2015/by Declan Murphy

Here is a fun campaign which should appeal to anyone interested in rugby or prostate cancer for that matter. The 2015 Rugby World Cup kicks off in England and Wales next month and as part of their warm up schedule, Australia are playing USA Rugby in a friendly match at Soldier Field in Chicago on the 5th of September. As part of their sponsorship of this fixture, Astellas are supporting a social media campaign called #pass4prostate which will directly raise funds for prostate cancer research in both the USA and Australia.

As part of their support, Astellas will donate $5 to prostate cancer research and advocacy organizations for every qualifying #pass4prostate submission posted to Twitter, Facebook, or Instagram, up to a maximum contribution of $125,000 in the USA and a further $40,000 in Australia. At socialboost you will get the best review of the instagram traffic boosting tools. Therefore to make sure we maximize this commitment, we need to drive lots of traffic using the #pass4prostate hashtag! You can see examples of Australian and US rugby players supporting the campaign below by throwing around special blue rugby balls, but the campaign is encouraging people to make videos supporting the campaign and throwing anything blue around (in a rugby style of course!).

The campaign will run up to the match on 5^th September, and there be lots of activity at the 2^nd Prostate Cancer World Congress which takes place in sunny Far North Queensland, Australia, from 17-21^st August 2015. Follow #pcwc15 or #pass4prostate to get involved!

For full details, please visit the pass4prostate website.

Declan Murphy

Melbourne, Australia

@declangmurphy

That’s what’s wrong with you and your ‘Star Wars’ generation

August 10, 2015/2 Comments/by Nathan Lawrentschuk

Just a few years ago whilst operating, I was curious to find out about one of our unit’s patients on the ward. We still had a bit of time to go in the current case, a retroperitoneal lymph node dissection. There was a chance the patient on the ward would require surgery and being at that time of the day an earlier ‘heads up’ is always best. One of the theatre staff kindly paged our resident. It was 5.05pm. No response. The other resident who was scrubbed directed them to get the resident’s mobile phone and call direct. This did not seem unreasonable – perhaps they were tied up. Maybe the phone could rouse him? Ring ring… Finally an answer. It’s the urology team wanting an update from the ward. “Sorry I’m in the car”. Have you rounded yet? Sort of. Is there a handover? Silence. We’ll call you back later!’

I was astounded at two things – the resident having clearly left without giving a handover in person (or verbally) and the fact that they appeared to have left without the customary afternoon ward round being conducted. I grumbled and sent the other resident up to check on the patient. Was I becoming one of those ‘grumpy old surgeons ‘ whining at the ‘youth of today’? I didn’t think so as what was expected was probably the minimum expected.

Fast forward two weeks. Same time being 5.05pm and the same resident actually appears in person to give handover (were they learning?) I couldn’t miss the chance to poke at him “What a surprise – you’re still here and it’s after 5pm!” The scrub nurse and registrar and Anaesthetist all laughed having been there when he was in the car on the prior occasion. Clearly smarting he quipped “That’s what’s wrong with you and your ‘Star Wars’ generation”… “What do you mean? what’s wrong?” I quizzed. He thought… then responded: “You all think you are the only ones who have worked hard and that all Gen Y doctors are lazy… You guys shoe-box all of us… .”. I pointed out I was miffed that he had left without handover. He claimed all was fine with the ward and had no real excuse for not giving handover but no ill effects happened and the patient in question avoided theatre. “Only just” I added.

All the while the ‘Star Wars’ jibe had gotten under my skin. His blatant and underhand use of the name of a movie that was perhaps the “God amongst Gods” being a classic tale of good and evil that had delivered many new words and ideas and music to at least one generation…

I took my time. So wanting to get it out of my system I chose my words carefully: “So you say ‘I’m part of the ‘Star Wars’ generation’ so that must make you… part of the ‘Avatar’ generation?” He paused… “That’s right – you are exactly right”. This was potentially going to be fun.

OK. “So remind me, who were the lead characters on Avatar? The female lead Avatar?” Deafening silence…. “What about the actors’ names?” … Silence…… I then pointed out it was embarrassing given one was Australian and I couldn’t help but point out the other I quickly recalled being Sigourney Weaver!

Maybe I was being a bit hard – “OK, what was the mineral they were mining on their planet?” Silence …….”unobtainium!” I yelped… “Who could forget that? Alright give me a line from the movie, any line?” Silence …. “Alright hum me the ‘Theme to Avatar'”… Again, silence.

I paused, then in a friendly way with a wry smile, I stated: “May the force be with you!” and gleefully hummed the well known Star Wars theme… as he ducked off….

So was this reinforcing the stereotypes that Gen Y is all flash and glamour with No Substance?

Probably not, but it teaches us that one generation is not that far from the next (the other resident a Gen Y knew more about Star Wars than I did!!). And subsequently I have had some of the best residents ever. So it is all about attitude and understanding what is required. The resident really lifted their game after this, which was excellent and they ended up with a great report – having taken on board the veiled but constructive “criticism”.

Honesty and communication is the best policy, sometimes laced with humour and by doing this “Help them, you will”.

Nathan Lawrentschuk @lawrentschuk

University of Melbourne, Department of Surgery and Ludwig Institute for Cancer Research, Austin Hospital and Peter MacCallum Cancer Centre, Department of Surgical Oncology, Melbourne, VIC, Australia