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Here comes the sun

July 29, 2015/by Ben Challacombe

Sun, sea, sand and stones: BJUI on the beach.

Welcome to this month’s BJUI and whether you are relaxing on a sun-drenched beach or villa somewhere having a hard-earned break, or back at your hospital covering for everyone else having their time off, we hope you will enjoy another fantastic issue. After an action packed BAUS meeting with important trial results, innovation, social media and the BJUI fully to the fore, this is a great moment to update yourself on what is hot in urology. This is probably the time of year when most urologists have a little extra time to take the BJUI out of its cover or open up the iPad and dig a little deeper into the articles, and we do not think you will be disappointed with this issue, which certainly has something for everyone.

In the ‘Article of the Month’, we feature an important paper from Egypt [1] examining factors associated with effective delayed primary repair of pelvic fractures that are associated with a urethral injury. Do be careful whilst you are travelling around the world, as most of the injuries in this paper were due to road traffic accidents. They reported 76/86 successful outcomes over a 7-year period. When a range of preoperative variables was assessed, four had particular significance for successful treatment outcomes. The paper really highlights that in the current urological world of robotics, laparoscopy and endourology, in some conditions traditional open surgery with delicate and precise tissue handling and real attention to surgical detail are the key components of a successful outcome.

Whilst you are eating and drinking more than usual over the summer, we have some food for thought on surgery and metabolic syndrome with one of our ‘Articles of the Week’. This paper contains an important message for all those performing bladder outflow surgery. This paper by Gacci et al. [2] from an international group of consecutive patients clearly shows that men with a waist circumference of >102 cm had a far higher risk of persistent symptoms after TURP or open prostatectomy. This was particularly true for storage symptoms in this group of men and should influence the consenting practice of all urologists carrying out this common surgery.

Make sure you drink plenty of Drink HRW to stay well hydrated on your beach this August, as the summer months often lead to increased numbers of patients presenting to emergency departments with acute ureteric colic, so it seems timely to focus on this area.To this end I would like to highlight one of our important ‘Guideline of Guidelines’ series featuring kidney stones [3] to add to the earlier ones on prostate cancer screening [4]and prostate cancer imaging [5]. This series serve to assimilate all of the major national and international guidelines into one easily digestible format with specific reference to the strength of evidence for each recommendation. Specifically, we look at the initial evaluation, diagnostic imaging selection, symptomatic management, surgical treatment, medical therapy, and prevention of recurrence for both ureteric and renal stones. Quite how the recent surprising results of the SUSPEND (Spontaneous Urinary Stone Passage ENabled by Drugs) trial will impact on the use of medical expulsive therapy remains to be seen [6].

So whether you are sitting watching the sunset with a drink in your hand or quietly working in your home at night, please dig a little deeper into this month’s BJUI on paper, online or on tablet. It will not disappoint and might just change your future practice.

References

1 Koraitim MM, Kamel MI. Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome. BJU Int 2015; 116: 265–70

2 Gacci M, Sebastianelli A, Salvi M et al. Central obesity is predictive of persistent storage lower urinary tract symptoms (LUTS) after surgery for benign prostatic enlargement: results of a multicentre prospective study. BJU Int 2015;116:271–7

3 Ziemba JB, Matlaga BR. Guideline of guidelines: kidney stones. BJU Int 2015; 116: 184–9

4 Loeb S. Guideline of guidelines: prostate cancer screening. BJU Int 2014; 114: 323–5

5 Wollin DA, Makarov DV. Guideline of guidelines: prostate cancer imaging. BJU Int 2015; [Epub ahead of print]. DOI: 10.1111/bju.13104

6 McClinton S, Starr K, Thomas R et al. Use of drug therapy in the management of symptomatic ureteric stones in hospitalized adults (SUSPEND), a multicentre, placebo controlled, randomized trial of a calcium-channel blocker (nifedipine) and an a-blocker (tamsulosin): study protocol for a randomized controlled trial. Trials 2014; 15: 238

Ben Challacombe
Associate Editor, BJUI

When Not to be a Doctor

July 10, 2015/2 Comments/by Matthew Hayn

“Now you know. And knowing is half the battle.” As a child growing up in the 80’s, I heard this line at the end of every G.I. Joe cartoon show. But what if knowing doesn’t really help?

As a urologic oncologist, I (try) to know as much as possible about urology and urologic cancers. I counsel patients about their diagnosis, treatment, and prognosis. I give them facts and statistics, quote predictive nomograms, describe operations, draw pictures, and give them my expert opinion. I would like to think that I am being helpful.

But am I really helping? Do patients and family members really want all of that?

Twenty years ago, my mother-in-law had breast cancer. She had a lumpectomy, chemotherapy and radiation. She “cured” and went on with her life. Her cancer was mentioned occasionally, but only as a remote event. We mostly forgot about it.

Then, 4 years ago, she felt a lump next to her breast. Eventually it was biopsied – recurrent breast cancer. She saw the experts at my hospital. Bad news – the cancer had spread (in a big way) to her liver.

We were all devastated, especially my wife. After 10 years away, she had just moved back to New England. She was looking forward to spending more time with her mom and her family. Cancer had reared its ugly head, and turned that all upside down.

What did I do? I did what I thought would be helpful. Looked up treatment options. Looked up 5-year survival estimates. I gathered information. Lots of information. This turned out to be an unmitigated disaster. It did not help my wife. It made things worse.

In 2014, Paul Kalanithi, then a Neurosurgery resident at Stanford, wrote a great piece in the New York Times about his advanced lung cancer diagnosis.

His basic message – don’t obsess over the numbers. Live your life. Get on.

I had failed my wife in that moment by acting like “a doctor”. She didn’t want numbers or survival estimates. She wanted me to act like a husband and friend. She wanted sympathy, a hug, and a shoulder to cry on. She wanted me to acknowledge how much it sucked that her mom had cancer.

In the end, patients want both, and they need both. They need expert advice and “the numbers”. More importantly, they want and need compassion and empathy. Thankfully, my mother-in-law continues to do well to this day.

Communicating both of these effectively will make me a better doctor, a better husband, and a better person.

Dr Matt Hayn

Medical Direction, Genitourinary Cancer Program

Maine Medical Center

Portland, Maine

@matthayn

The BJUI at the Lindau Nobel Laureates meeting

July 3, 2015/by Prokar Dasgupta

Christina Sakellariou (BJUI Lindau Scholar), 64th Lindau Nobel Laureates Meeting, 2014.

Every year, Lindau, a south-eastern town and island of Germany, concentrates the greatest minds of science, representing the past, the present and the future. Nobel Laureates and young scientists from different disciplines, countries and backgrounds meet to ‘Educate, Inspire and Connect’ during talks and discussions given by the Laureates, social gatherings and an unforgettable boat trip to the garden-island of Mainau.

Last year, the BJUI became, to our knowledge, the first surgical journal to support one of the 600 young scientists to participate in the Lindau Physiology and Medicine meeting, and interact with 37 Nobel Laureates. It was the first time in the history of the meeting that the percentage of women participants was higher than that of the men!

Lindau is oriented to reach out to the future; the 5 days of the meeting were full of constructive and fruitful discussions between the Nobel Laureates and young scientists, sharing of experiences, knowledge and dreams, and inspirational and motivational moments, particularly those coming from the Laureates’ lectures. Drs Peter Agre and Roger Tsien shared some very personal moments and life experiences, while Oliver Smithies showed photographs of his 65-year-old laboratory book, leaving lasting impressions on the next generation.

As was highlighted in the opening ceremony, ‘what Brazil was for football, Lindau was for the Nobel Laureates and young scientists’. That week in Lindau provided our BJUI scholar the required strength, inspiration and motivation to continue answering questions through the highest quality of scientific research. This month the BJUI continues its Nobel theme with a fascinating paper on ‘tiny bubbles’ from Ramaswamy et al. [1], which the Editor-in-Chief first encountered at a meeting of the American Association of Genitourinary Surgeons (AAGUS).

The authors include Robert Grubbs who received the Nobel Prize for Chemistry in 2005. They have developed a minimally invasive technology to replace generated bubbles for shockwave lithotripsy (SWL) that can cavitate and fracture stones. Tagged microbubbles were self-assembled with a phospholipid surface and a perfluoronated carbon gas centre. These stable, short-lived microbubbles, were synthesised with bisphosphonate surface tags to facilitate selective attachment to the surface of stones. Ex vivo cavitation of microbubble-coated calcium urinary stones demonstrated excellent stone fragmentation. As the popularity of extracorporeal SWL diminishes, retrograde injection of ex vivo generated microbubbles may represent the next exciting frontier in minimally invasive stone surgery.

References

1 Ramaswamy K, Marx V, Laser D et al. Targeted microbubbles: a novel application for the treatment of kidney stones. BJU Int 2015; 116: 9–16

Prokar Dasgupta @prokarurol

Editor-in-Chief, BJUI

Christina Sakellariou

BJUI Lindau Scholar

While you slept: bad behaviour and recording in the operating room

June 25, 2015/2 Comments/by Mike Leveridge

A head-shaking story of operating room unprofessionalism has been making the rounds on news services and social media, as an unsuspecting patient inadvertently recorded audio during his colonoscopy, only to hear his person and personality belittled by the operating room staff while he was anaesthetized. The heat has fallen mostly on one anesthesiologist, but none has escaped rightful scrutiny.

The anesthesiologist of the day quipped to the newly asleep patient “after five minutes of talking to you in pre-op, I wanted to punch you in the face and man you up a little bit.” The OR team mocked a rash the patient had noted, alternately joking that it was syphilis or “tuberculosis of the penis”. “As long as it’s not Ebola”, remarked the surgeon. The case went to court and the patient was ultimately awarded $500,000US.

On reading the story and the clearly ghastly banter among the team, no doubt the first response would be along the lines of “they actually said those things?!”. I suspect, however, that more than a few surgeons’ gut reaction might have been “he heard what they were saying about him?!”, followed by squirming in one’s seat and the sudden recollection of a dozen blithe comments in one’s own ORs. This incident opens several proverbial cans of worms that merit some thought.

Clearly, this particular debacle is a no-debate-needed case of unacceptable behaviour, and the solution is simple: don’t do that! We have spent much energy in the past years establishing ground rules for online professionalism, but of course the rules of decorum have always applied in the material world as well. Recording or no recording, there is simply no place for mocking of patients, awake, asleep or in absentia.

As surgeons, and urologists perhaps in particular (with our warrant to investigate and operate on urogenital complaints), this provides a stark reminder about our own behaviour, when the audio isn’t being recorded. Ask yourself if you have openly lamented the challenges of operating within a morbidly obese patient’s pelvis or retroperitoneum, snickered or gasped at the enormity of a hydrocele or penile tumor, or glibly eulogized a torted or cancerous testicle.

A question then becomes, what is acceptable and unacceptable in the operating room? Are all off-topic conversations unacceptable? Given the intensity of surgery and the OR, is there room for joking and banter to decant some stress? My personal thought is that black-and-white dictates and zero-tolerance policies usually (read: usually) only serve to absolve us of having to actually think about issues, and that grey areas exist in most settings. Levity in the OR is no different, but caution and forethought are critical.

The other issue that clearly arises is that of recording within the OR during surgery. There are doubtless advocates of each extreme, from the sanctity of the theatre to full access to video and audio. We have all had patients bring recorders into the clinic room – does the Hawthorne effect improve our behaviour or our care, or does the added scrutiny lead to hedging, indecision or ambiguity on the part of the physician? You can see both sides play out in this post and its comments. Recording in the operating room is on a completely different level than clinic discussions, however. Aside from the content of conversation within the operating room, the complexities and individuality of each procedure and the thought of a second-by-second parsing of technical detail by non-expert patients seems to make this a totally unwieldy proposition. On the other hand, are the assumption of basic ethical standards and a post-op chat enough “data” for a patient to really understand all of the relevant details of their care? What about recording for skill development or assessment? Much has been written here as well.

The patient/plaintiff in this case was clearly subject to a debasement none of us deserves or would wish on ourselves. Reading and hearing this OR team’s contempt for their patient is a graphic reminder of what this behaviour can descend to unchecked, and hopefully a course-correction for surgeons, nurses and anaesthesiologists who hover on or over “the line”. As for its window into the merits of recording, the issue gets no clearer.

Mike Leveridge is an Assistant Professor in the Departments of Urology and Oncology at Queen’s University, Kingston, ON, Canada. @_TheUrologist_

Highlights from #BAUS15

June 24, 2015/by Rebecca Tregunna

#BAUS15 started to gain momentum from as early as the 26^th June 2014 and by the time we entered the Manchester Central Convention Complex well over 100 tweets had been made. Of course it wasn’t just Twitter that started early with a group of keen urologists cycling 210 miles to conference in order to raise money for The Urology Foundation.

Monday 15^th June 2015

By the time the cyclists arrived conference was well under way with the andrology, FNUU and academic section meetings taking place on Monday morning:

The BJU International Prize for the Best Academic Paper was awarded to Richard Bryant from the University of Oxford for his work on epithelial-to-mesenchymal transition changes found within the extraprostatic extension component of locally invasive prostate cancers.
Donna Daly from the University of Sheffield received the BJUI John Blandy prize for her work on Botox, demonstrating reductions in afferent bladder signaling and urothelial ATP release.

Professor Reisman’s talk on ‘Porn, Paint and Piercing’ as expected drew in the crowds and due to a staggering 44% complication rate with genital piercings it is important for us to try to manage these without necessarily removing the offending article as this will only serve to prevent those in need from seeking medical attention.
With the worsening worldwide catastrophe of antibiotic resistance, the cycling of antibiotics for prevention of recurrent UTIs is no longer recommended. Instead, Tharani Nitkunan provided convincing evidence for the use of probiotics and D-Mannose.

The afternoon was dominated by the joint oncology and academic session with Professor Noel Clarke presenting the current data from the STAMPEDE trial. Zolendronic acid conferred no survival benefit over hormones alone and consequently has been removed from the trial (stampede 1). However, Docetaxal plus hormones has shown benefit, demonstrated significantly in M1 patients with disease-free survival of 65 months vs. 43 months on hormones alone (Hazard ratio 0.73) (stampede 2). This means that the control arm of M1 patients who are fit for chemotherapy will now need to be started on this treatment as the trial continues to recruit in enzalutamide, abiraterone and metformin arms.

The evening was rounded off with the annual BAUS football tournament won this year by team Manchester (obviously a rigged competition!), whilst some donned the

lycra and set out for a competition at the National Cycle Centre. For those of us not quite so energetic, it was fantastic to catch up with old friends at the welcome drinks reception.

Tuesday 16^th June 2015

Tuesday kicked off bright and early with Professor John Kelly presenting results from the BOXIT clinical trial, which has shown some benefit over standard treatment of non-muscle invasive bladder cancer, but with significant cardiovascular toxicity.

The new NICE bladder cancer guidelines were presented with concerns voiced by Professor Marek Babjuk over discharging low-risk bladder cancer at 12 months given a quoted 30-50% five-year recurrence risk. Accurate risk stratification, it would seem, is going to be key.

The President’s address followed along with the presentation of the St. Peter’s medal for notable contribution to the advancement of urology, which was presented to Pat Malone from Southampton General Hospital. Other medal winners included Adrian Joyce who received the BAUS Gold Medal, and the St. Paul’s medal went to Mark Soloway.

A plethora of other sessions ensued but with the help of the new ‘native’ BAUS app my programme was already conveniently arranged in advance:

‘Heartsink Conditions’ included pelvic and testicular pain and a fascinating talk by Dr Gareth Greenslade highlighted the importance of early and motivational referral to pain management services once no cause has been established and our treatments have been exhausted. The patient’s recovery will only start once we have said no to further tests: ‘Fix the thinking’

Poster sessions are now presented as ‘e-posters’, abolishing the need to fiddle with those little pieces of Velcro and allowing for an interactive review of the posters.

Pravisha Ravindra from Nottingham demonstrated that compliance with periodic imaging of patients with asymptomatic small renal calculi (n=147) in primary care is poor, and indeed, these patients may be better managed with symptomatic imaging and re-referral as no patients required intervention based on radiograph changes alone.

Archana Fernando from Guy’s presented a prospective study demonstrating the value of CTPET in the diagnosis of malignancy in patients with retroperitoneal fibrosis (n=35), as well as demonstrating that those with positive PET are twice as likely to respond to steroids.

Wednesday 17^th June 2015

Another new addition to the programme this year was the Section of Endourology ‘as live surgery’ sessions. This was extremely well received and allowed delegates to benefit from observing operating sessions from experts in the field whilst removing the stressful environment and potential for risk to patient associated with live surgery. This also meant that the surgeon was present in the room to answer questions and talk through various steps of the operation allowing for a truly interactive session.
Wednesday saw multiple international speakers dominating the Exchange Auditorium:

The BJU International guest lecture was given by Professor Hendrik Van Poppel: a heartfelt presentation describing what he believes to be the superiority of surgery over radiotherapy for high-risk localised prostate cancer.
The Urology Foundation presented the Research Scholar Medal to Ashwin Sachdeva from Freeman Hospital, Newcastle for his work on the ‘Role of mitochondrial DNA mutations in prostate carcinogenesis’. This was followed by an inspiring guest lecture by Inderbir Gill on ‘Robotic Urologic Oncology: the best is yet to come’ with the tag line ‘the only thing that should be open in 2015 is our minds’
Robotic Surgery in UK Urology: Clinical & Commissioning Priorities was a real highlight in the programme with talks from Jim Adshead and Professor Jens-Uwe Stolzenburg focussing on the fact that only 40% of T1a tumours in the UK were treated with partial (as opposed to radical) nephrectomy, and that the robot really is the ‘game-changer’ for this procedure. Inderbir Gill again took to the stage to stress that all current randomised trials into open vs. robotic cystectomy have used extracorporeal reconstruction and so do not reflect the true benefits of the robotic procedure as the dominant driver of complications is in the open reconstruction.

These lectures were heard by James Palmer, Clinical Director of Specialised Commissioning for NHS England who then discussed difficulties in making decisions to provide new technologies, controlling roll out and removing them if they show no benefit. Clinical commissioning policies are currently being drafted for robotic surgery in kidney and bladder cancer. This led to a lively debate with Professor Alan McNeill having the last word as he pointed out that what urologists spend on the robot to potentially cure cancer is a drop in the ocean compared with what the oncologists spend to palliate!

Thursday 18^th June 2015

The BJU International session on evidence-based urology highlighted the need for high-quality evidence, especially in convincing commissioners to spend in a cash-strapped NHS. Professor Philipp Dahm presented a recent review in the Journal of Urology indicated that the quality of systematic reviews in four major urological journals was sub-standard. Assistant Professor Alessandro Volpe then reviewed the current evidence behind partial nephrectomy and different approaches to this procedure.

Another fantastic technology, which BAUS adopted this year, was the BOD-POD which allowed delegates to catch-up on sessions in the two main auditoria that they may have missed due to perhaps being in one of the 21 well designed teaching courses that were available this year. Many of these will soon be live on the BAUS website for members to view.

The IBUS and BAUS joint session included a lecture from Manoj Monga from The Cleveland Clinic, which led to the question being posed on Twitter: ‘Are you a duster or a basketer?’The audience was also advised to always stent a patient after using an access sheath unless the patient was pre-stented.

The updates session is always valuable especially for those studying for the FRCS (Urol) exam with far too many headlines to completely cover:

Endourology: The SUSPEND trial published earlier this year was a large multi-centre RCT that showed no difference in terms of rates of spontaneous passage of ureteric stone, time to stone passage or analgesic use between placebo, tamsulosin and nifedipine. There was a hot debate on this: should we be waiting for the meta-analysis or should a trial of this size and design be enough to change practice?
Oncology-Prostate: The Klotz et al., paper showed active surveillance can avoid over treatment, with 98% prostate cancer survival at 10 years.
Oncology-Kidney: Ellimah Mensah’s team from Imperial College London (presented at BAUS earlier in the week) demonstrated that over a 14-year period there were a higher number of cardiovascular-related admissions to hospital in patients who have had T1 renal tumours resected than the general population, but no difference between those who have had partial or radical nephrectomy.
Oncology-Bladder: Arends’s team presented at EAU in March on the favourable results of hyperthermic mitomycin C vs. BCG in the treatment of intermediate- and high-risk bladder cancer.
Female and BPH: The BESIDE study has demonstrated increased efficacy with combination solifenacin and mirabegron.
Andrology: Currently recruiting in the UK is the MASTER RCT to evaluate synthetic sling vs. artificial sphincter in men with post-prostatectomy urinary incontinence.

Overall BAUS yet again put on a varied and enjoyable meeting. The atmosphere was fantastic and the organisers should be proud of the new additions in terms of allowing delegates to engage with new technologies, making for a memorable week. See you all in Liverpool!

Rebecca Tregunna, Urological Trainee, West Midlands Deanery @rebeccatregunna

Dominic Hodgson, Consultant Urologist, Portsmouth @hodgson_dominic

The Social Media Revolution in Chinese Urology

June 23, 2015/5 Comments/by Wei Wang

It is well known that Twitter, Facebook and YouTube, the most popular social media platforms available in the West, are not easily accessible in China. It is also clear that urologists in the West have embraced these social media platforms (Twitter in particular), not just for personal interaction, but also for professional engagement, and journals such as BJUI have enthusiastically encouraged the use of social media for urologists through their use of Twitter, blogging, YouTube etc.

So what then of Chinese urology? Are we missing out on all this? Not at all! In fact, as a recent BMJ blog observed, China is among the most heavily connected populations on earth, and the smartphone revolution has seen this connectivity grow very rapidly in recent years, more than in many Western countries. The lack of access to Western websites has just meant that a host of home-grown websites have cropped up to allow the insatiable appetite for connectivity to be met. Therefore sites such as RenRen (like Facebook), Sina Weibo (like Twitter), and Youku (like YouTube). The BMJ have blogged about this and have highlighted the huge volume of activity on Chinese social media sites.

Figure from “Your quick guide to social media strategy in China”

At present, the most popular platform among Chinese urologists is WeChat. WeChat, (similar to WhatsApp), is connecting more than a half billion Chinese people now. Apart from free chat, video and voice call, group chat is perfect for professional online discussion. There are several major urological discussion groups. Each group has many hundreds of participants. It is estimated that more 3000 urologists (1/4) in China have been involved in one or more online discussion group. Earlier this month, Prof. Declan Murphy’s lecture slides were uploaded to our urology major discussion group after his presentation at the Asia Urology Prostate Cancer Forum in Shanghai.

More than 2000 Chinese urologists (1/6) watched his slides on smartphones that weekend and shared feedback using the app. Prof Murphy, one of the world’s foremost leaders in social media, even joined WeChat and engaged in dialogue with the discussion group.

At present, the top two most famous discussion groups are called scope art and Hippocrates group. A talented young urologist, Dr. QIan Zhang, set up scope art two years ago. More than 500 urologists from across the country were invited to join the group. New knowledge, case discussion and meeting information can be arranged in the group. Recently, the Top 10 WeChat urologists has been selected thorough WeChat vote platform system. More than 20,000 WeChat users voted for their favorite social medial stars. Several discussion groups were built based on the different specialties (stone disease, andrology etc.). Several leading uro-oncologists, urologists, pathologists, radiologists and related experts also built an MDT discussion group to discuss interesting uro-oncology cases to help select the best options for patients.

We are now also seeing these online discussions develop a physical presence. Recently, a WeChat integrated Hippocrates urological meeting was held in Jiaxing. When each speaker starts to talk, the slides were uploaded to the WeChat discussion group, allowing the entire membership of the discussion group to attach their comments and questions during the presentation. All the questions and comments are projected to the separate screen in the meeting hall. The speaker can discuss with all the members, wherever they are.

WeChat meeting in action in Jiaxing

As these examples demonstrate, social media significantly helps Chinese urologists communicate more effectively, especially in such a large country with a huge population. We are very keen to embrace these new communication platforms and to engage more with our colleagues in the West!

Dr. Wei Wang

Consultant Urologist, Beijing Tongren Hospital, Capital Medical University, China

WeChat ID: medtrip

Give the pill, or not give the pill. SUSPEND tries to end the debate

June 22, 2015/1 Comment/by Christopher Bayne

June 2015 #UROJC Summary

News of a landmark paper on medical expulsive therapy (MET) for ureteric colic swirled through the convention halls on the last day of the American Urological Association’s Annual Meeting in New Orleans, Louisiana. I watched the Twitter feeds evolve from my desk at home: the first tweets just mentioned the title, then the conclusion, followed by snippets about the abstract. As time passed and people had time to read the manuscript, discussion escalated. Without data to prove it, there seemed to be more Twitter chatter about the SUSPEND trial, even among conference attendees, than the actual AUA sessions.

Robert Pickard and Samuel McClinton’s group utilized a “real-world” study design to publish what many urologists consider to be the “best data” on MET. The study (SUSPEND) randomized 1167 participants with a single 1-10 mm calculi in the proximal, mid, or distal ureter across 24 UK hospitals to 1:1:1 MET with daily tamsulosin 0.4 mg, nifedipine 30 mg, or placebo. The study’s primary outcome was the need for intervention at 4 weeks after randomization. Secondary outcomes assessed via follow-up surveys were analgesic use, pain, and time to stone passage. Though the outcomes were evaluated at 4 weeks after randomization, patients were followed out to 12 weeks.

Some of the study design minutiae are worth specific mention before discussing the results and #urojc chat:

Treatment allotment was robustly blinded. Participants were handed 28 days of unmarked over-encapsulated medication by sources uninvolved in the remaining portions of the study
Medication compliance was not verified
The study protocol didn’t mandate additional imaging or tests at any point
Participants weren’t asked to strain their urine
Secondary outcomes assessed by follow-up surveys were incomplete: 62 and 49% of participants completed the 4- and 12-week questionnaires, respectively

The groups were well balanced, and the results were nullifying. A similar percentage of tamsulosin- , nifedipine-, and placebo-group patients did not require intervention (81%, 80%, and 80%, respectively). A similar percentage of tamsulosin-, nifedipine-, and placebo-group participants had interventions planned at 12 weeks (7%, 6%, and 8%). There were no differences in secondary outcomes, including stone passage. There was a trend toward significance for MET, specifically with tamsulosin, in women, calculi >5 mm, and calculi located in the lower ureter (see image taken from Figure 2).

The authors concluded their paper was iron-clad with results that don’t need replication.

“Our judgment is that the results of our trial provide conclusive evidence that the effect of both tamsulosin and nifedipine in increasing the likelihood of stone passage as measured by the need for intervention is close to zero. Our trial results suggest that these drugs, with a 30-day cost of about US$20 (£13; €18), should not be offered to patients with ureteric colic managed expectantly, giving providers of health care an opportunity to reallocate resources elsewhere. The precision of our result, ruling out any clinically meaningful benefit, suggests that further trials involving these agents for increasing spontaneous stone passage rates will be futile. Additionally, subgroup analyses did not suggest any patient or stone characteristics predictive of benefit from MET.”

Much of the early discussion focused on the trend toward benefit for MET in cases of calculi >5 mm in the distal ureter:

Journal Club participants raised eyebrows to the use of nifedipine and placebo medication in the trial:

A few hours in, discussion shifted toward the study design, particularly the primary endpoint of absence of intervention at 4 weeks rather than stone passage or radiographic endpoints. The overall consensus was that that this study was a microcosm of “real world” patient care with direct implications for emergency physicians, primary physicians, and urologists.

The $20 question (cost of 4 weeks of tamsulosin according to SUSPEND) is whether or not the trial will change urologists’ practice patterns. Perhaps not surprisingly, opinions differed between American and European urologists.

We owe SUSPEND authors Robert Pickard and Sam McClinton special thanks for their availability during the discussion. In the end, the #urojc banter for June 2015 was the largest and most-interactive monthly installment of International Urology Journal Club to date.

Christopher Bayne is a PGY-4 urology resident at The George Washington University Hospital in Washington, DC and tweets @chrbayne.

Further Randomised Controlled Trials are needed….No! say something original.

June 12, 2015/11 Comments/by Ben Challacombe

“As we all know, prostate/kidney/bladder cancer is a common disease…” aaargh!!! Of course it is, that’s why you are writing about it and trying to get this piece of work into this journal and why everyone who reads it might be interested; because it is so important and common! If we all know it anyway why are you bothering to tell us this whilst wasting time and your word count and not getting on with presenting the actual research? Anyone who doesn’t know that prostate cancer is pretty common isn’t a doctor let alone a urologist. This is found more often than I can stand and got me thinking about all the other scientific catchphrases and tactics that serve more to irritate than inform.

As the BJUI associate editor for Innovation and one of the triage editors, I read around 600 BJUI submissions each year as part of my role. This is not to mention the additional manuscripts I formally review for this journal and others and there are certain phrases and statements that really just make my blood boil. Time and time again the same statements come up that are put into medical papers seemingly without any thought and which add nothing other than serving to irritate the editor, reviewer and reader.

The throwaway statement that “further randomised trials are needed” is often added to the end of limited observational and cohort studies, presumably by young researchers and almost never adds anything. Anyone who has ever been involved with a surgical RCT will know how challenging it is to set one up and run one, let alone recruit to one which is why so few exist and why so many have failed. Just saying more RCTs are needed without thought to why they haven’t already been carried out just frustrates the reader and shows a lack of true comprehension of the subject. Suggesting an valid alternative to an RCT however might actually get people thinking.

So what else is in the wastebucket of things that cause journal irritation? Well conclusions that have no basis in the results that have been shown; such as XXX is a safe and generally acceptable procedure after 3 cases, of which one had a 2 litre blood loss; or we advise everyone to switch to our technique on the basis of this uncontrolled retrospective cohort. Another is YY is the “Gold Standard” even though this is just opinion that is usually very outdated and this way of doing things was really only the standard approach 20 years ago!

Failure to acknowledge the study limitations is another area that particularly winds me up especially when the authors did a procedure one way 500 times then subsequently did it 50 times in a subtly different way and state that the second is better without mentioning that they might have learnt a fair bit from the previous huge number of cases!

So please let me know what irritates you in a paper so I can watch out for it and makes sure never to use it myself

Ben Challacombe
Associate Editor, BJUI

Learning from The Lancet

June 12, 2015/by admin Z.9

The Lancet, established in 1823, is one of the most respected medical journals in the world. It has an impact factor of 39, and therefore attracts and publishes only the very best papers. Like most journals that have evolved with modern times, it has an active web and social media presence, particularly based around Twitter.

On a Monday morning, last autumn, the Editor of the BJUI had a meeting with the Web Editor of The Lancet at Guy’s Hospital. There was a mutual interest in surgical technology, particularly as Naomi Lee had been a urology trainee before joining The Lancet full-time. The topic of discussion was robot-assisted radical cystectomy with the emergence of randomised trials showing little difference between open and robotic surgery, despite the minimally invasive nature of the latter [1, 2]. Thereafter, The Lancet kindly invited the BJUI team to visit its offices in London. The location is rather bohemian with a mural of John Lennon on the wall across the street! Here is a summary of what we learnt that day.

1. Democracy – what gets published in The Lancet after peer review is decided at a team meeting, where editors of the main journal and its sister publications gather around a table to discuss individual articles. Most work full-time for The Lancet, unlike surgical journals that are led by working clinicians. No wonder that >80% of papers are immediately rejected and the final acceptance rate is ≈6%. Interesting case reports are still published and often highly cited because of the wider readership.

2. Quality has no boundaries – it does not matter where the article comes from as long as it has an important message. The BJUI recently published an excellent paper on circumcision in HIV-positive men from Africa [3]; the original randomised controlled trial had appeared some 7 years earlier in The Lancet [4].

3. Statisticians – the good ones are a rare breed and sometimes rather difficult to find. While we have two statistical editors at the BJUI, sometimes, it is difficult to approach the most qualified reviewer on a particular subject. The Lancet occasionally faces similar difficulties, which it almost always overcomes due to its’ team approach.

4. Meta-analysis and systematic reviews – they form a significant number of submissions to both journals. It is not always easy to judge their quality although a key starting point is to identify whether the topic is one of contemporary interest where there are significant existing data that can be analysed. Rare subjects usually fail to make the cut.

5. Paper not dead yet – this is certainly the case at The Lancet office, where its editors gather together with paper folders and hand-written notes. We are almost fully paperless at the BJUI offices, and are hoping to be completely electronic in the future. A recent live vote of our readership during the USANZ Annual Scientific Meeting in Adelaide, Australia, indicated that the majority would like us to go electronic in about 2–3 years’ time; however, ≈30% of our institutional subscribers still prefer the paper version and are reluctant to make the switch.

The BJUI and The Lancet are coming together to host a joint Social Media session at BAUS 2015, which will provide more opportunity to learn from one of the best journals ever. We hope to see many of you there.

References

1 Messer JC, Punnen S, Fitzgerald J, Svatek R, Parekh DJ. Health-related quality of life from a prospective randomised clinical trial of robot- assisted laparoscopic vs open radical cystectomy. BJU Int 2014; 114: 896–902

2 Lee N. Robotic surgery: where are we now? Lancet 2014; 384: 1417

3 Kigozi G, Musoke R, Kighoma N et al. Male circumcision wound healing in human immunodeﬁciency virus (HIV)-negative and HIV-positive men in Rakai, Uganda. BJU Int 2014; 113: 127–32

4 Gray RH, Kigozi G, Serwadda D et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 657–66

Prokar Dasgupta @prokarurol

Editor-in-Chief, BJUI

Scott Millar

Managing Editor, BJUI

Naomi Lee

Web Editor, The Lancet

Men’s Health – Driving the Message Home

June 3, 2015/9 Comments/by Brian Stork

Gentlemen, Start Your Engines

Over the past couple of years, we have seen a growing number of fun and exciting ways to help raise awareness for prostate cancer and men’s health. Movember, for example, has become increasingly popular across the globe. This summer, a couple of high-octane, awareness and fund-raising events are taking place on both sides of the Atlantic. I encourage you to check out both of these events and consider participating – jump in and fasten your seat belts, we’re going for a ride!

The Drive for Men’s Health

Electron Powered

For the second straight year, American urologists Dr. Jamin Brahmbhatt and Dr. Sijo Parekattil have organized the Drive for Men’s Health. Last year, the team drove an all-electric powered TESLA from Clermont, Florida, to Manhattan, New York.

This year, on Thursday, June 11th, the Drive for Men’s Health will again start in Clermont, Florida. However, once they arrive in Manhattan, they’ll take a sharp left turn and head West to Los Angeles, California. The 6,000 mile journey is expected to take nine days to complete. Along the way, the team will need to stop over 60 times to plug in and recharge.

Putting a Plug In for Men’s Health

Over the course of the drive, the urology duo will host live webcasts, on a variety of men’s health topics, including the topic of home health care provided by our partners at www.oxford-healthcare.com/tulsa-home-care-services/, all this with the help of over 200 speakers from around the world. The drivers hope the car, and technology used during the drive, will function as a magnet to pull men and their loved ones into further discussions about healthy living, as well as knowing when to request respite care Tinton NJ once aware of what this kind of care entails. This year’s Drive for Men’s Health coincides with National Men’s Health Week in the United States.

The Banger 3K Rally for Prostate Cancer

Putting the Pedal to the Metal

As summer approaches, auto racing heats up in Europe. In July, amateur hockey player Adam Clark (Clarky) and his friend Robert Lamden (Lambo) will strap themselves into a 28-year-old Toyota MR2 Mk1 for the 2015 Banger Rally Challenge. The race is similar to the Gumball 3000 Rally, but with old cars that cannot be worth more than £350. These old cars needs to be modified with Remapping stages for better performance.

In England, an old car is referred to as “an old banger”. It’s not going to be easy by any stretch of the imagination, and we hope not to break down.” – Adam Clark, “Clarky”

Over the course of ten days, the team will attempt to drive 3,000 miles across France, Switzerland, Monaco, Italy, and thru the Alps. The purpose of the event is to raise awareness and money for Prostate Cancer UK, the largest men’s health charity in the UK, dedicated to helping men survive prostate cancer, and enjoy a better quality of life.

It’s a lighthearted race, but being the first one to the finish line does not mean you have won. There are lots of challenges along the way that need to be completed – and we have no idea what they are yet as it is all secret! It’s very much a social activity, many laughs, great memories. It will be competitive, but I think everyone will be happy just to get to the finish line without breaking down! – Adam Clark, “Clarky”

A Shot and a Goal

Clarky and Lambo have already raised nearly £9,000 for Prostate Cancer UK by selling sponsorship spaces on the car, and from donations. When the team finally arrives back home in London, England, Clarky will wrap up the fundraising event on the ice, as assistant captain, playing for Team Prostate in an All-Stars Charity Ice Hockey Tournament at the home of British ice hockey, Sheffield Arena.

Driving the Message Home

Every man has a unique set of interests. Some men respond to technology under the hood, while others enjoy the screeching of tires on pavement, or the excitement of a shot and a goal. When it comes to men’s health, this summer offers something for just about everyone.

Please consider giving a shout out to Jamin and Sijo on Twitter or Facebook as they drive across America, and/or consider donating to Clarky and Lambo who you can follow on Instagram and Twitter, and for updates along the Banger 3K, please “friend” on Facebook.

By donating and supporting the boys, you will not only help shift men’s health into high gear, but also help keep our patients and our friends out of the penalty box and firing on all cylinders.

Dr. Brian Stork is a community urologist who practices in Muskegon and Grand Haven, Michigan, USA. He is a member of the American Urological Association’s Social Media Workgroup, and is the Social Media Director at StomaCloak. You can follow Dr. Stork on Twitter @StorkBrian.