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What gets Indy Gill REALLY excited?

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Dr Indy Gill, as everyone knows, has always been a pioneer of minimally invasive surgery, and has continued to push the boundaries of this over the past 20 years. Some of this progress has been seriously exciting, both for us mere mortals who have visited his operating room or viewed his live surgery, and also for Dr Gill as he has continued to reinvent what is possible.   Tackling a Level II/III caval thrombus using robotic surgery, exploring nephron-sparing surgery with anatomically extreme tumours, and now zero ischaemia – all of this progress has been very thrilling indeed.

But last week, I realised that there is something that is capable of getting the great Dr Gill REALLY excited, and I thought I would share that with you.

It started after Indy accepted an invitation from myself and my colleague, Daniel Moon, to join our international faculty at the National Bladder and Kidney Cancer Symposium which we convene here in Melbourne. Our faculty already included Dr Mike Stifleman (NYU), Dr Colin Dinney (MD Anderson), Dr Simon Horenblas (National Cancer Institute, The Netherlands), Dr Nick James (University of Birmingham), and Dr Maha Hussein (University of Michigan), as well as an excellent faculty from around Australia and New Zealand. This symposium is convened at the world famous Melbourne Cricket Ground (MCG), one of the world’s greatest sporting arenas, and one of the most famous cricket grounds in the world. It recently broke the world record for attendance at an international test cricket match when over 91,000 people attended the Australia versus England “Ashes” match on Boxing Day.

I was aware that Indy receives about 1000 emails per day and we wanted to catch his eye as we planned the program. I therefore emailed him with the subject heading, “Opening the batting at the MCG?”, in the certain knowledge that as a self-confessed “cricket tragic”, he might just respond! And here is his response:

  

Apologies to those (me included) who do not understand “cricket-speak”! However one can tell that Indy, like everyone else I know from the sub-continent, is a big cricket fan. The stage was therefore set: our Symposium would benefit from Indy presenting a spectacular overview of advances in nephron-sparing surgery with the wonderful backdrop of one of the world’s greatest sporting arenas and a mecca for cricket lovers.

What we did not know was that by chance, one of the greatest cricketers of all time, legendary leg-spin bowler Shane Warne, was hosting a private charity cricket match in aid of The Shane Warne Foundation on the hallowed turf during our Symposium. As soon as we realised, we started plotting to see if we could arrange for the Urology Legend to meet the Cricket Legend. A few phone calls later and it had been agreed- “Warney” would meet Indy at 08:30 the next morning.

Put simply, I have never seen anybody so excited in my entire life. I don’t think Indy slept very much as he looked forward with child-like amazement to his encounter with one of the greatest cricket players of all time. He paced up and down somewhat nervously (I would say considerably more nervous than he would be before performing one of his live surgery spectaculars to a gigantic audience), as we waited for our escort to bring us to the home team changing room at the MCG. He seemed somewhat breathless, he was speaking terribly quickly, his eyes scanning nystagmus-like as he looked like someone having a supraventricular tachycardia.

Meanwhile in the auditorium upstairs, Indy’s colleague Dr Mihir Desai, another cricket tragic, was broadcasting a live robotic cystectomy from the University of Southern California to our auditorium. When we explained that Indy was a little delayed as he was meeting Shane Warne downstairs, this was met with an audible sigh along with some muttering from Dr Desai’s robot console as he clearly would much prefer to have been in Melbourne than in California at that particular moment. “Stop the procedure” he pleaded in vain, “if I leave now I can be there in 15 hours”.

And then the big moment arrived – Shane Warne, cricket legend, taker of over 700 Test wickets, deliverer of the “Ball of the Century”, and one of only five of Wisden’s Cricketers of the 20th Century, walked over to the star-struck urology legend and shook hands.

They chatted for about 10 minutes about various great cricketing moments and about mutual friends in Indian cricket. They both seemed to be thoroughly enjoying themselves and one could tell that Indy was relishing every moment he was spending in the company of true cricket royalty. Shane then happily signed an Australian cricket jersey before we finally dragged Indy back to the Symposium upstairs. I don’t think it is unreasonable to say that he was somewhat starstruck:

  

The moment was shared by Daniel Moon on Twitter using the official meeting hashtag #bkcs14:

Social media metrics supplied by Symplur at that time showed healthy activity for a sub-specialist uro-oncology meeting with about 250 delegates:

However, when Shane Warne re-tweeted us to his 1.46 million followers, the meeting statistics went through the roof! We had gone from 37,000 digital impressions to almost 1,500,000 impressions:

In the twisted world of social media statistics, #bkcs14 has become one of the biggest scientific meetings in the world this year!

Indy then returned to the relatively mundane world he normally inhabits by showing footage of a robotic-assisted partial nephrectomy with zero ischaemia for a 10cm interpolar tumour in a solitary kidney (including vascular reconstruction of a feeding vessel), followed by a super-human robotic resection of a kidney tumour with level II caval thrombus done as part of a live surgery broadcast to 1000 people. Interesting for sure, but not what gets him really excited.

Declan Murphy
Urologist and Associate Editor (Social Media), BJUI
Melbourne, Australia
Twitter: @declangmurphy

 

Video: Why the Melbourne Statement?

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The Melbourne Consensus Statement on the early detection of prostate cancer

Declan G. Murphy1,2,3, Thomas Ahlering4, William J. Catalona5, Helen Crowe2,3, Jane Crowe3, Noel Clarke10, Matthew Cooperberg6, David Gillatt11, Martin Gleave12, Stacy Loeb7, Monique Roobol14, Oliver Sartor8, Tom Pickles13, Addie Wootten3, Patrick C. Walsh9 and Anthony J. Costello2,3

1Peter MacCallum Cancer Centre, 2Royal Melbourne Hospital, University of Melbourne, 3Epworth Prostate Centre, Australian Prostate Cancer Research Centre, Epworth Healthcare Richmond, Melbourne, Vic., Australia, 4School of Medicine, University of California, Irvine, 5Northwestern University Feinberg School of Medicine, Chicago, IL, 6Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, 7New York University, 8Tulane University School of Medicine, Tulane, 9The James Buchanan Brady Urological Institute, Johns Hopkins University, USA, 10The Christie Hospital, Manchester University, Manchester, 11Bristol Urological Institute, University of Bristol, Bristol, UK, 12The Vancouver Prostate Centre, 13BC Cancer Agency, University of British Columbia, Vancouver, Canada, and 14Erasmus University Medical Centre, Rotterdam, The Netherlands

Read the full article

• Various conflicting guidelines and recommendations about prostate cancer screening and early detection have left both clinicians and their patients quite confused. At the Prostate Cancer World Congress held in Melbourne in August 2013, a multidisciplinary group of the world’s leading experts in this area gathered together and generated this set of consensus statements to bring some clarity to this confusion.

• The five consensus statements provide clear guidance for clinicians counselling their patients about the early detection of prostate cancer.

 

Editorial: Three robotic surgery training methods: is there a clear winner?

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All training adds value. A craft-based specialty such as surgery has always recognised this. The advent of advanced minimally invasive surgical technology and techniques has provided both new challenges and new opportunities for surgical performance and for the delivery of training. Conceptually, we have moved from the Halstedian model of ‘See one, do one, teach one’ [1] to an environment where skills are acquired away from the operating room in simulator, inanimate and in vivo (animal) laboratory training sessions. Increased scrutiny of credentialling and medico-legal aspects of robotic surgery have reinforced the importance of training and have led to a number of papers outlining pathways to facilitate this [2, 3].

In the present paper, Hung et al. evaluate the construct validity of three standardised training methods (inanimate, simulator and in vivo) and also compare the three different platforms for cross-method training value. As others have shown, the latest generation of robotic surgery simulators have high face, content and construct validity [4, 5] and the present paper confirms the value of both inanimate and simulator training for novice surgeons. In addition, the authors confirmed the construct validity of a simple in vivo exercise using the daVinci© surgical system by demonstrating that experts outperformed novices. Using Spearman’s rank correlation coefficient, the authors compared the three training methods under evaluation and concluded that they were strongly correlated for construct validity between exert and novice surgeons. While construct validation of these exercises may be established, are they useful for experts? Until realistic virtual reality surgical simulations are available, only a novice, an inexperienced or an occasional robot-assisted surgeon may benefit from virtual reality exercises.

What are we therefore to conclude from this? For certain, the advent of excellent surgical simulators and structured inanimate exercises has provided tools for novice surgeons to acquire console skills in a safe and structured environment. This will enhance their operating performance and reduce aspects of the learning curve such as operating time; however, the lack of availability of in vivo training opportunities greatly limits the applicability of this method of surgical training. In many countries (including Australia and the UK), this type of training is illegal or not available. The robotic surgery industry has strongly recommended that in vivo training should be undertaken in one of their official training facilities before surgeons are given the credentials to use this technology; however, even in the USA where most of these facilities are located, key leaders within the AUA have called for the awarding of credentials for robotic surgery ‘not to be an industry driven process, but one that is a result of a standardized, competency based, peer evaluation system’ [2]. Notably, the current AUA Standard Operating Practices (guidelines) for the awarding of credentials for robotic surgery list in vivo training as being optional.

Our view is that although all training has value, there is not enough evidence that in vivo training (particularly on an animal with a rudimentary prostate), which requires international travel and considerable expense, adds sufficient value to be mandatory in any credentialling process. In fact, we have dropped the requirement to complete in vivo training from our requirements at major robotic surgery centres in Australia in favour of structured Mini-Fellowship training [6]. Hung et al. have confirmed what we already knew, which is that all training adds value; however it is likely that only simulator and inanimate training adds enough value to be incorporated into standardised training in robotic surgery.

The multi-disciplinary ‘Fundamentals of Robotic Surgery’ (FRS) curriculum being created by Dr Richard Satava and associates is working on psychomotor skills tasks that include inanimate models as well as corresponding virtual reality exercises. Multi-institutional validation of the FRS or similar curricula will allow the establishment of training milestones and proficiency benchmarks. We must continue to strive for further development of robotic and surgical simulation to change the training paradigm so that surgical training does not need to be at the expense, however minor, of increased operating time or adverse patient outcome.

Declan G. Murphy*† and Chandru P. Sundaram‡
*Peter MacCallum Cancer Centre, Division of Cancer Surgery, University of Melbourne, †Australian Prostate Cancer Research Centre, Epworth Richmond Hospital, Melbourne, Australia, and ‡Department of Urology, Indiana University, Indianapolis, IN, USA

Read the full article

References

  1. Halsted WS. The training of the surgeon. Bull Johns Hop Hosp 1904; XV: 8
  2. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialing. J Urol 2011;185: 1191–1197
  3. Zorn KC, Gautam G, Shalhav AL et al. Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons. J Urol 2009; 182: 1126–1132
  4. Finnegan KT, Meraney AM, Staff I, Shichman SJ. da Vinci Skills Simulator construct validation study: correlation of prior robotic experience with overall score and time score simulator performance. Urology 2012; 80: 330–335
  5. Abboudi H, Khan MS, Aboumarzouk O et al. Current status of validation for robotic surgery simulators – a systematic review. BJU Int 2013; 111: 194–205
  6. Melbourne Uro-Oncology Training Program. Robotic surgery training. Available at: https://www.declanmurphy.com.au/training. Accessed 28 February 2013

Conference Report – ERUS 2013 – live surgery spectacular in Stockholm

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When it comes to live surgery meetings, one of the biggest and best of them all is the EAU Robotic Urology Section (ERUS) Congress (formerly the European Robotic Urology Symposium). The 10th edition of ERUS took place in Stockholm this week and continued the tradition of spectacular live robotic assisted surgery, along with scientific sessions dealing with issues around robotic assisted surgery. Following discussions with the EAU over the past two years, ERUS has now become an official section of the main EAU Organisation and future scientific and educational activity will be co-ordinated under that esteemed banner. In his welcoming address at this weeks meeting, EAU Secretary General and proud Swede Per-Anders Abrahamsson, warmly welcomed ERUS into the EAU family. He also highlighted the mission statement of ERUS, “to support science and education in the field of robotic urology”.

Over 750 delegates gathered from around the world (including a healthy delegation from Australia, South America and the USA), giving this meeting a truly global footprint. The programme featured 12 live surgical procedures performed by some of the world’s leading robotic surgeons and broadcast in full 3-D from Karolinska Hospital.

 

This meeting has showcased many advances in roboticsurgery over the past 10 years and this year was no exception. The audience seemed most interested in extended public lymph node dissection during radical cystectomy and prostatectomy, as well as intra-corporeal urinary diversion and complex partial nephrectomy. This year’s starring surgeons included Alex Mottrie, Peter Wiklund, Magnus Annerstedt, Geoff Coughlin, Hubert John, Aldo Bocciardi, Jean Palou, Carl Wijburg, Craig Rogers, Jim Porter, Tim Wilson, Vip Patel and Abi Hosseini. An outstanding line-up of surgeons from all over the world.

Of note, this Section has led the development of ethical guidelines around the conduct of live surgery and these have been fully endorsed by the EAU. We have previously blogged about this issue and I have blogged about my own experience of doing live surgery at ERUS 2012 in London.  As part of the live surgery ethical governance, Convener of ERUS 2012, Ben Challacombe (London), presented an update on the outcome of all patients who underwent live surgery as part of last years meeting.

The main scientific meeting was preceded by the Junior ERUS Section, the Nursing Course on Robotics, and five master classes led by experts and dealing with various aspects of robotic assisted surgery.  The Junior ERUS Prize was awarded to Khan et al who presented a poster on behalf of the International Robotic Curriculum Group entitled, “Towards a Standardised Training Curriculum in Robotic Surgery”. There were also a number of parallel meetings dealing with education and scientific activity within ERUS/EAU, in particular, the development of structured robotic training and a robotic surgery curriculum across Europe and beyond. The BJUI Editor in Chief Prokar Dasgupta, a well-known robotic surgery innovator and also an expert in simulation and education, is playing an active role coordinating development of this curriculum. European Urology Editor in Chief Jim Catto, was also present at ERUS 2013 and delivered a podium presentation outlining some of the exciting changes which the Platinum Journal will undertake once he takes over in January 2014. What is clear is that robotic surgery is an important part of the content for both of these leading journals.

Of course, this meeting has a particular reputation as being a friendly and sociable event (a point repeatedly mentioned by many of the Intercontinental visitors). The local organising committee pulled out all the stops with the official social events by hosting the welcome reception at the Stockholm City Hall, home of the famous Nobel Prize banquet each year. The gala dinner was in the spectacular Vasa Museum, surely one of the world’s most spectacular maritime museums.

We were treated to a tour of this spectacular, fully intact 17th century warship, followed by dinner in the shadow of this huge exhibit, notorious for capsising in Stockholm harbor only 15 minutes into her maiden voyage.

As we have seen at all major urology meetings this year, social media played a prominent role in expanding the reach of the meeting and in enabling engagement from within the audience and from around the world. The conference organisers placed a Twitter feed on the panellists monitors so that questions could be directed via Twitter to the expert panels and to the operating rooms.

 As if the spectacular multiple source 3-D display was not providing enough content, social media guru Carl Wijburg was busy tweeting “backstage” photos from Karolinska as he waited to perform a meticulous extended pelvic lymph node dissection.

 

 The final data from Symplur showed just how enthusiastically delegates from all over engaged with the meeting through Twitter.

 

Congratulations go to the organisers and scientific committee of #ERUS13 led by Alex Mottrie (Belgium), Peter Wiklund (Stockholm) and Magnus Annerstedt (Copenhagen) who did an outstanding job putting on this complex congress.

We are already looking forward to ERUS 2014 which takes place in beautiful Amsterdam from 17- 19th September 2014, led by Chair of the Local Organising Committee, Henk van der Poel. A must-attend for anyone interested in robotic surgery.

 

Declan Murphy BJUI Associate Editor

Follow Declan on Twitter @declangmurphy

 

The Melbourne Consensus Statement on Prostate Cancer Testing

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The final, peer-reviewed version of this Consensus Statement has now been published in BJUI. You can find it here. The full citation is Murphy, D. G., Ahlering, T., Catalona, et al. (2014), The Melbourne Consensus Statement on the early detection of prostate cancer. BJU International, 113: 186–188. doi: 10.1111/bju.12556

A consensus view on the early detection of prostate cancer, led by experts at the Prostate Cancer World Congress, Melbourne, 7–10th August 2013

Recent guideline statements and recommendations have led to further confusion and controversy regarding the use of Prostate Specific Antigen (PSA) testing for the early detection of prostate cancer. Despite high-level evidence for the use of PSA testing as a screening tool, and also for its role as a predictor of future risk, the U.S. Preventive Services Taskforce (USPSTF) has called for PSA testing to be abandoned completely [1], and many men are therefore not given the opportunity for shared decision-making. Other groups such as the American Urological Association, National Comprehensive Cancer Network , and European Association of Urology support a role for PSA screening but with somewhat conflicting recommendations. The majority of guideline statements have endorsed the role of shared decision-making for men considering PSA testing.

To address these somewhat conflicting and confusing positions, a group of leading prostate cancer experts from around the world have come together at the 2013 Prostate Cancer World Congress in Melbourne and have generated the following set of consensus statements regarding the use of PSA testing. The goal of these statements is to bring some clarity to the confusion that exists with existing guidelines, and to present reasonable and rational guidance for the early detection of prostate cancer today.

1.        Consensus Statement 1: For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer. In the European Randomized Study of Screening for Prostate Cancer (ERSPC), screening reduced metastatic disease and prostate cancer-specific mortality by up to 30% and 21% respectively in the intent-to-treat analysis, with a greater reduction after adjustment for noncompliance and contamination[2,3]. In addition, the Goteborg randomized population-based randomized trial showed a reduction in metastatic disease and prostate cancer mortality with screening starting at age 50 [4]. The degree of over-diagnosis and over-treatment reduces considerably with longer follow-up, such that the numbers needed to screen and numbers needed to diagnose compare very favourably with screening for breast cancer. The boob reduction in Tri-Cities procedures are one among the very best rated and most valued cosmetic procedures among woman (and some men) within the Tri-Cities, TN area.  High patient satisfaction ratings for this procedure should come as no surprise, given the quantity of relief the operation provides to those that suffer from heavy or large breasts. With years of experience, and a diary of positive patient outcomes, Dr. Jim Brantner, M.D. can help improve your overall wellness, comfort, and confidence through a secure and effective breast reduction procedure. Breast reductions, otherwise referred to as Reduction Mammoplasties, are often a relief for thousands of men and ladies . If your breasts are causing pain or other health issues, then you’ll wish to think about a breast reduction. In a breast reduction, our surgeon improves a patient’s health by removing a predetermined amount of breast tissue, skin, and fat. This reduces the patient’s breast size overall and helps improve their neck, shoulder, back, and overall health. If you would like to understand what the procedure evolves in additional detail, please read subsequent paragraph. If you discover you are feeling squeamish, be happy to scroll to subsequent section. To remove the surplus breast tissue, your surgeon will make an incision around your nipple then downward over your breast — consider a keyhole. Our expert team will remove excess skin, tissue, and fat before adjusting your nipple for cosmetic purposes. Your surgeon may have to use drainage tubes before your incision site is sutured. Our team will then wrap your breasts during a special gauze; your doctor may recommend a surgical bra, as well. While routine population-based screening is not recommended, healthy, well-informed men in this age group should be fully counseled about the positive and negative aspects of PSA testing to reduce their risk of metastases and death. This should be part of a shared decision-making process. According to a study, it is also revealed that not every time you need a surgery, breast cancer can be also be treated easily. With the advancement of the technology, Botox injection and dermal filler injection can be used by patient of breast cancer. But for this an expert recommendation is required.  Visit the dermal fillers melbourne expert to know more.

 2.        Consensus Statement 2: Prostate cancer diagnosis must be uncoupled from prostate cancer intervention. Although screening is essential to diagnose high-risk cases within the window of curability, it is clear that many men with low-risk prostate cancer do not need aggressive treatment. Active surveillance protocols have been developed and have been shown to be a reasonable and safe option for many men with low-volume, low-risk prostate cancer [5,6]. While it is accepted that active surveillance does not address the issue of over-diagnosis, it does provide a vehicle to avoid excessive intervention. Active surveillance strategies need standardization and validation internationally to reassure patients and clinicians that this is a safe strategy.

 3.        Consensus Statement 3: PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection. PSA is a weak predictor of current risk and additional variables such as digital rectal examination, prostate volume, family history, ethnicity, risk prediction models, and new tools such as the phi test, can help to better risk stratify men. Prostate cancer risk calculators such as those generated from the ERSPC ROTTERDAM, the Prostate Cancer Prevention Trial (PCPT) , and from Canada , are useful tools to help men understand the risk of prostate cancer in these populations. Further developments in the area of biomarkers, as well as improvements in imaging will continue to improve risk stratification, with potential for reduction in over-diagnosis and over-treatment of lower risk disease.

4.        Consensus Statement 4: Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer. Although these men were not included in the two main randomized trials, there is strong evidence that this is a group of men who may benefit from the use of PSA testing as a baseline to aid risk stratification for their likely future risk for developing prostate cancer [7], including clinically significant prostate cancer. Studies have shown the value of PSA testing in this cohort for predicting the increased likelihood of developing prostate cancer 25 years later for men whose baseline PSA is in the highest centiles above the median [8,9]. For example, those men with a PSA below the median could be spared regular PSA testing as their future risk of developing prostate cancer is comparatively low, whereas those with a PSA above the median are at considerably higher risk and need closer surveillance. The median PSA for men aged 40–49 ranges from 0.5–0.7 ng/ml, with the 75th percentile ranging from 0.7–0.9ng/ml. The higher above the median, the greater the risk of later developing life-threatening disease. We recommend that a baseline PSA in the 40s has value for risk stratification and this option should be discussed with men in this age group as part of a shared decision-making process.

 5.        Consensus Statement 5: Older men in good health with over ten year life expectancy should not be denied PSA testing on the basis of their age. Men should be assessed on an individual basis rather than applying an arbitrary chronological age beyond which testing should not occur. As life expectancy improves in many countries around the world (men aged 70 in Australia have a 15 year life expectancy), a small proportion of older men may benefit from an early diagnosis of more aggressive forms of localised prostate cancer, just as it is clear that men with many competing co-morbidities and less aggressive forms of prostate cancer are unlikely to benefit irrespective of age. Likewise, a man in his 70s who has had a stable PSA at or below the median for a number of years previously is at low risk of developing a threatening prostate cancer and regular PSA screening should be discouraged.

An important goal when considering early detection of prostate cancer today, is to maintain the gains that have been made in survival over the past thirty years since the introduction of PSA testing, while minimizing the harms associated with over-diagnosis and over-treatment. This is already happening in Australia where over 40% of patients with low-risk prostate cancer are managed with surveillance or watchful waiting [10], and in Sweden where 59% of very low risk patients are on active surveillance. This is also reflected in current guidelines from the EAU, NCCN and other expert bodies, and in a comment from AUA Guideline author Dr Bal Carter in the BJU International.

Abandonment of PSA testing as recommended by the USPSTF, would lead to a large increase in men presenting with advanced prostate cancer and a reversal of the gains made in prostate cancer mortality over the past three decades.

However, any discussion about surveillance is predicated on having a diagnosis of early prostate cancer in the first instance. As Dr Joseph Smith editorialized in the Journal of Urology following the publication of the ERSPC and PLCO trials, “treatment or non-treatment decisions can be made once a cancer is found, but not knowing about it in the first place surely burns bridges” [11]. A key strategy therefore is to continue to offer well-informed men the opportunity to be diagnosed early, while minimizing harms by avoiding intervention in those men at low risk of disease progression. This consensus statement provides some guidance to help achieve these goals.

 
Signatories:

A/Professor Declan G Murphy, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia

Professor Tony Costello, University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia

Dr Patrick C Walsh, The James Buchanan Brady Urological Institute, Johns Hopkins University, USA

Dr Thomas Ahlering, University of California, Irvine, School of Medicine, USA

Dr William C Catalona, Northwestern University Feinberg School of Medicine, USA

Dr Oliver Sartor, Tulane University School of Medicine, USA

Dr Tom Pickles, British Columbia Cancer Agency, Canada

Dr Jane Crowe, Australian Prostate Cancer Research Centre, Australia

Dr Addie Wootten, Royal Melbourne Hospital, Australia

Ms Helen Crowe, Royal Melbourne Hospital, Australia

Professor Noel Clarke, Manchester University, The Christie Hospital, Manchester, UK

Dr Matthew Cooperberg, University of California San Francisco, Helen Diller Family Comprehensive Cancer Centre, USA

Dr David Gillatt, University of Bristol, Bristol Urological Institute, Bristol, UK

Dr Martin Gleave, University of British Columbia, The Vancouver Prostate Centre, Vancouver, Canada

Dr Stacy Loeb, New York University, USA

Dr Monique Roobol, Erasmus University Medical Centre, Rotterdam, The Netherlands

Footnote:

The median PSA for men aged 40–49 ranges from 0.5–0.7ng/ml. The 75th percentile ranges from 0.7–0.9ng/ml.

This blog was originally published on 7th August 2013 and was updated on 13th August 2013.

References:

[1] Moyer VA, Force USPST. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120–34.

[2] Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med. 2012;366:981–90.

[3] Schroder FH, Hugosson J, Carlsson S, Tammela T, Maattanen L, Auvinen A, et al. Screening for prostate cancer decreases the risk of developing metastatic disease: findings from the European Randomized Study of Screening for Prostate Cancer (ERSPC). Eur Urol. 2012;62:745–52.

[4] Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11:725–32.

[5] Bul M, Zhu X, Valdagni R, Pickles T, Kakehi Y, Rannikko A, et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol. 2013;63:597–603.

[6] Bangma CH, Bul M, van der Kwast TH, Pickles T, Korfage IJ, Hoeks CM, et al. Active surveillance for low-risk prostate cancer. Crit Rev Oncol Hematol. 2012.

[7] Loeb S. Use of baseline prostate-specific antigen measurements to personalize prostate cancer screening. Eur Urol. 2012;61:875–6.

[8] Vickers AJ, Ulmert D, Sjoberg DD, Bennette CJ, Bjork T, Gerdtsson A, et al. Strategy for detection of prostate cancer based on relation between prostate specific antigen at age 40-55 and long term risk of metastasis: case-control study. BMJ. 2013;346:f2023.

[9] Lilja H, Cronin AM, Dahlin A, Manjer J, Nilsson PM, Eastham JA, et al. Prediction of significant prostate cancer diagnosed 20 to 30 years later with a single measure of prostate-specific antigen at or before age 50. Cancer. 2011;117:1210–9.

[10] Evans SM, Millar JL, Davis ID, Murphy DG, Bolton DM, Giles GG, et al. Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011. Med J Aust. 2013;198:540–5.

[11] Smith JA, Jr. What would you do, doctor? J Urol. 2009;182:421–2.

Social media @BJUIjournal – what a start!

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When Prokar Dasgupta assumed the role of new Editor-in-Chief of the BJUI in January 2013, he outlined his vision and some of the major changes that the Journal would make as it transitioned to a new editorial team. After 10 years of progress under John Fitzpatrick, it was clear that we are now working in a much-changed publishing landscape, one which will change even more in the next few years. In particular, the way in which medical professionals receive information and interact with colleagues, patients, journals and other professional groups is unrecognisable from what it was just 2 or 3 years ago.

Social media is the driver of much of this change. It has transformed the way in which the current generation of trainees interact—Facebook, Twitter, YouTube, LinkedIn, Urban Spoon, Expedia, Trip Advisor, Instagram – all of these platforms are key conduits for how Generation Z experiences life. This generation will find the idea of a printed journal arriving in the post every month to be anathema. In a world with an ever-increasing amount of content being produced, and much competition for our limited attention span, Gen Z live their lives through mobile platforms capable of delivering the precise content they want, immediately to their devices. Not just that, this content, whether that be breaking news via Twitter, friend status updates on Facebook, job opportunities via LinkedIn, is delivered through vibrant media that allows them to engage and respond by liking, sharing, favourite-ing, re-tweeting and commenting, even as the content reaches them. All of this activity is done through convenient and increasingly pervasive mobile platforms while on the train to work, while queuing for a coffee, between cases in theatre, during a lecture, first thing in the morning, last thing at night. Gen Z will not seek out this type of content – it will seek them out and be delivered straight to their timeline/twitter-feed.

The BJUI is the first surgical journal to introduce an Associate Editor for Social Media. The aim is to devise and implement a strategy to ensure that the BJUI evolves in this new world; to ensure that the next generation of trainees find us a meaningful organisation to engage with and be informed, educated and entertained by. Our fellow Associate Editor, Matt Bultitude (Web) plays an important role here as do our publishers, our Executive team and Editor-in-Chief.

 

Our social media platforms

So what have we done? If you are on Twitter or Facebook you will have noticed that BJUI has come to life on these key social media platforms.

Between January and April 2013, our followers on Twitter have grown from by one third to over 1300, and continue to grow at over 100 followers per month. Through Twitter alone, we have generated huge traffic back to our website with over 3500 link clicks from the hundreds of interactions we have had during this period.

 

 

Advanced social media metrics allow us to measure all of this activity against other organisations active in urology. For example our Klout score has increased from 46 to 55 with a corresponding increase in our Peerindex rating. We are leading the field across all of the key domains we have targeted to date and continue to make progress as we introduce further changes at www.bjui.org in 2013.

Our Facebook site is now highly engaging and is constantly updated with news and content from our website.

 

 

We have recorded over 133 000 page impressions by 23 000 Facebook visitors in the first 3 months of 2013, a huge rise from previously, and all of this traffic gets directed back to content at www.bjui.org, whether that be a Journal article, blog, picture quiz or our new ‘Poll of the Week’.

 

 

Our YouTube site is updated with videos from authors and other multimedia content to complement citable articles published in the Journal. You will see a lot more content added here in coming months.

 

Blogs@BJUI

But perhaps the most talked-about area we have introduced is Blogs@BJUI. And although we are the first mainstream urology journal to introduce a blog site, other journals have done so with great success. In September, we visited the social media team at the BMJ to get some tips on how they had developed their social media strategy into the very successful multi-platform spectacular, which they now oversee. Juliet Dobson, Blogs Editor and Assistant Web Editor at the BMJ offered some excellent advice to help us get up and running and their former Editor, Richard Smith, remains one of the bloggers we most admire. BMJ Blogs is well worth a visit for aspiring bloggers to read some of the best.

We launched our new web journal on the 2 January 2013 to coincide with the new Editor taking the helm, and also published our first blog that day. From then until April 2013, Blogs@BJUI has featured the following:

  • 51 blogs contributed by 25 authors on three continents
  • 193 comments from all over the world, including opinion from some household names in academic urology
  • 16 editorial blogs from our specialty Associate Editors
  • 4 blogs from major urology conferences
  • Multidisciplinary contributions from both authors and comment-leavers

The topics have included everything from urology humour, through the European Working Time Directive, reality TV and an eminent urologist describing his recent personal experience of robotic radical prostatectomy. Our contributors have included many of the key opinion leaders in social media in urology, many of whom are rising stars or already established in academic urology. Also established urology opinion-leaders who are rather new to social media but enjoying the challenge! Other contributors are young trainees who have proved themselves to be talented bloggers already. Blogs@BJUI has been highly successful at driving traffic to the Article of the Week as improving quality remains our main objective.

Also of note is the impact that social media has made at urology conferences in the past few months. As part of a planned strategy, the BJUI social media team has been very active posting updates on Twitter, Facebook and YouTube from major urology conferences, thereby increasing the reach of these meetings to a much larger audience and also allowing those following on social media to engage pro-actively with the conference. This has been a very successful strategy; social media metrics confirm that the BJUI team has been leading the social media revolution at this year’s Annual European Association of Urology (EAU) Congress:

 

 

We had set a target that by the end of the first quarter we would have 1000 readers per month visiting Blogs@BJUI. By the end of the February, we had already had over 9000 visits to our blog site! Each reader spent over 3.5 min reading the web journal and many of them left comments or pushed out links using Twitter or Facebook. We have had many comments posted by readers from every corner of the world and have enjoyed some very humorous posts. For us, social media is all about engagement. We want to use these platforms to allow readers to passively engage with us by liking, sharing, tweeting content that they enjoy whether that is a full paper in the BJUI, a blog post, YouTube video, weekly poll or Picture Quiz of the Week. And for those who want to engage more actively, we strongly encourage you to join the conversation and add a comment.

So we have had a great start to our social media push at the BJUI. And there will be a lot more to come in the coming months. For those of you who are new to social media, we encourage you to dip your toes in by reading a blog or two and adding a comment. Before you know it you will have downloaded the Twitter app to your smartphone and you’ll be off and running! For the Twitterati, we thank you for all your enthusiasm in helping us get social media up and running at the BJUI and we look forward to your blogs, mentions, re-tweets and podcasts over the coming months. Social media is all about engagement – join the conversation @BJUIjournal.

Declan G. Murphy and Marnique Basto

Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia


Declan Murphy is Associate Editor for Social Media at the BJUI.
Follow him on Twitter @declangmurphy

The BJUI Social Media Awards 2013

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The BJUI has been very pleased with the large amount of social media activity we have seen across our various platforms since January 2013 when the new-look Journal was introduced. Editor-in-Chief, Prokar Dasgupta, has decreed that he wants the BJUI to be “the most-read surgical journal on the web”, and has recognised the key role that social media plays in realizing this ambition. At the same time, the social media revolution that has engrossed Gen Y and Gen Z and which has transformed the way in which news is communicated, has now taken a foothold in scientific publishing and is evolving.

To recognise the rapidly growing interest in social media in urology, and also to acknowledge those who have played a major role in advancing social media in urology at the BJUI and elsewhere, we this year inaugurated the BJUI Social Media Awards, presented for the first time at the AUA recently. Individuals and organisations were recognised across 20 categories including the top gong, The BJUI Social Media Award 2013, awarded to an individual or organization who has made an outstanding contribution to social media in urology in the preceding year.

This year’s Awards Ceremony was held in the Dublin Square Irish Bar in San Diego during the AUA Annual Meeting. Sixty of the World’s leading social media enthusiasts (the “Uro-Twitterati”), gathered to meet up in person and to see who would be recognised. Sort of like the Oscars but without the wardrobe malfunctions. Yours truly played the role of MC. While most of the awards recognised genuine achievements in social media, there were a few “special” categories which recognised some reasonably strange activity propagated through social media channels!

Todd Morgan and Alex Kutikov, the brains behind Draw MD Urology and Urology Match who won the top award of the evening.

We were delighted to have recipients from all categories present at the ceremony including representatives from the AUA and EAU. The BJUI Social Media Awards Ceremony was competing with the European Urology Cocktail Reception a couple of blocks away but in the spirit of conviviality which we encourage, we welcomed European Urology Editor-in-Chief elect, Dr Jim Catto, and managing editor Cathy Pierce, who popped in for a drink and to collect the EAU awards.

A special thanks to my research fellow Dr Marni Basto who organised this year’s awards, and to Scott Millar and Helena Kasprowicz at BJUI in London who manage our social media and website activity.

For more pictures from the evening, please visit BJUI Associate Editor John Davies Flickr page.

 

Declan Murphy is Associate Editor for Social Media at BJUI. He is a uro-oncologist in Melbourne, Australia

Follow Declan on Twitter @declangmurphy 

 

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The BJUI and BAUS join forces at AUA in San Diego

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For the first time, the BJUI and our friends at the British Association of Urological Surgeons (BAUS), joined forces at the Annual Meeting of the American Urological Association to stage a satellite session focusing on some interesting areas of urology. While both BAUS and BJUI have long had strong relations and have worked together on many occasions, this was the first time we had an opportunity to present a full afternoon of plenary content at the AUA.

This year’s AUA took place in beautiful San Diego, a very popular destination for delegates, even those travelling all the way from the UK. The convention centre is very conveniently located and is state-of-the-art. The adjoining Marriott hotel hosts many of the satellite events and it was here on Sunday 5th May 2013 that the joint BAUS/BJUI session took place. We attracted over 200 delegates in the face of tremendous competition from parallel sessions and had a wonderful atmosphere all afternoon.

Prokar Dasgupta excited about this session at AUA Annual Meeting 2013

Part one was chaired by BAUS President Adrian Joyce and featured state-of-the-art lectures from Prof Tony Mundy, Dr Tamsin Greenwell, Dr Craig Rogers, Mr Ben Challacombe, Mr Simon Brewster , Dr Philippa Cheetham and Prof Mark Emberton.

The second session was opened by BJUI Chairman Dr David Quinlan who gave a great introduction before handing over to BJUI Editor-in-Chief Prokar Dasgupta who Chaired the session. This was a fascinating session which combined state-of-the-art addresses from well known BJUI editors/contributors Dr John Davis, Dr Peter Gilling and Dr David Ralph, along with an exciting overview of social media and digital publishing by Prokar Dasgupta, Casey Ng and myself. The future of publishing is certainly not in paper and attendees at this session were given a wonderful preview of how urology publishing might look in the future.

The joint session finished with the presentation of the BJUI Coffey–Krane Prize, which was accepted by Dr Christian Pavlovich on behalf of his team for their paper Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching. The Prize was presented by the great Dr Coffey who gave a humorous overview after his warm introduction by Dr Quinlan.

Dr Christian Pavlovich receives the Coffey–Krane Prize 2013 from Dr Donald Coffey,
Prof Prokar Dasgupta and Mr David Quinlan

Attendees enjoyed socializing over drinks following the session and toasted the strong relationship between BAUS, the BJUI and the AUA.

We look forward to similar conjoined events in the future and are particularly looking forward to the BJUI supporting the forthcoming BAUS Annual Meeting in Manchester from 17–20th June 2013.

 

Declan Murphy BJUI Associate Editor

Follow Declan on Twitter @declangmurphy

 

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EAU Annual Meeting 2013 – Final thoughts

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The BJUI team was most impressed with this year’s EAU Annual Congress which has just concluded in Milan. The scientific content was excellent – topical plenary sessions from key opinion leaders; lively poster sessions; superb video sessions and very high-quality courses run by the European School of Urology. The EAU are to be congratulated on consistently raising the bar with the quality of this meeting which is reflected in the huge delegate numbers again this year.

The last two days had a number of highlights, some of which we summarise here:

  • The Plenary on lower urinary tract symptoms – management of side-effects included a wide variety of presentations including an specific talks on new potential drug treatments which certainly wouldn’t be considered main-stream at the moment. It will be interesting to monitor how trials with beta-3 agonists, botulinum toxin and PDE5 inhibitors go over the next few years for this potentially huge market. Professor Marberger finished the session discussing if TURP remains the gold standard for BPO. The answer may be that it is not, although it remains the ‘reference’ to which all other treatments must match. It is interesting to see how delegates reacted to this on Twitter such as Dr GomezSancha who tweeted to his 251 followers:

 

We are not sure if all would agree but we do enjoy seeing the debate bouncing around the Twittersphere!

  • Prevention of infections – chaired by T.E. Bjerklund Johansen, this plenary updated us on resistance to antibiotics which is increasingly a problem and has led the lay press to describe this as an Apocalypse and more recently as big a risk as terrorism. Dr Kahlmeter then discusses the implications for urology in this video interview with the EAU. This is a highly topical area and we are pleased to see key urology meetings showing leadership here to address these broad concerns.
  • Urological Surgery in Renal Transplant Patients – this session was very emlightening for urologists who work alongside bust renal transplantation services. The transplant population have many challenging urological issues and Dr Jon Olsburgh from Guy’s & St Thomas’ in London provided an excellent overview of some of these. He outlined very nice strategies for stones in patients who have received an allograft and also for those considering kidney donation. A summary can be found in the EUT Newsletter from Day 3.
  • There were many poster sessions throughout each day – too many to be honest for us to keep track of.  Fear not though – keep an eye on the BJUI blogs for the Best of the Best Posters coming soon. We would also direct you to Twitter where you will find some excellent commentary from the many active Tweeters who attended various poster sessions. Just search under the #eau13 hashtag. Watch out in particular for tweets from the Montreal/Detroit group who presented much work and were particularly active on Twitter (@qdtrinh, @peepeedoctor, @jdsammon, @maxinesun and others).
  • Souvenir Session and EAU Guidelines on Live Surgery: The last day featured an excellent souvenir session which overviewed some of the key messages for the meeting. European Urology Editor-in-Chief Elect , Jim Catto, reviewed Urothelial cancers and observed that PET scanning has most value for evaluating distant disease rather than pelvic lymphadenopathy when compared to CT scanning. The management of small renal masses, a dominant topic this year, also . The highly-anticipated EAU Guidelines on Live Surgery were presented very nicely by Section Chairman Keith Parsons and were very well received. There are sometimes competing goals here and these guidelines will ensure that the best interests of patients are maintained while maximising the educational value of these very popular sessions.
  • Breaking News: this final session had a number of headlines, one of which was data from Peter Wiklund’s group in Sweden which suggested that long-term cancer outcomes for localised prostate cancer patients are better for those who underwent surgery rather than radiotherapy. Also data from Bertrand Tombal showing a greater than 50% reduction in cardiovascular morbidity for patients on the GnRH antagonist degarelix when compared with those on GnRH analogues. Further detail of this are awaited.

Lastly, we would again like to congratulate EAU and all the active Tweeters who contributed so much to the social media side of this year’s meeting. The final data from Symplur show huge activity which greatly expanded the reach and engagement of this meeting:

We are also very pleased that the BJUI team dominated the metrics for key influencers of #eau13 which reflects well on the strong social media strategy which we have put in place since January 2013. We were delighted to visit the busy EAU Communications back-office on the last day of the meeting to congratulate Communication Manager Evgenia “Zhenya” Starkova and her talented team who did a fantastic job running the Congress and EAU websites, twitter, facebook, video interviews etc and who we enjoyed interacting with through the week. Zhenya’s team kept tweeters engaged by awarding a “Tweet of the Day”:

EAU Official Tweets of the Day for the conference:

Friday –  “Small renal masses, debate continues: surveillance vs biopsy vs partial vs radical neph. Individualised care is key.” @HamidAbboudi

Saturday – “#eau13 this is not just the European meeting now. It is the world meeting! What an event.”
@benchallacombe

Sunday – “It’s going to be a tough act for Stockholm to follow! Great congress so far! #eau13”@SJGore

Monday – “I suspect #eau13 will be remembered as 1st major urology meeting to do social media seriously. It’s been great fun!”@MattBultitude

So we look forward to EAU Annual Congress 2014 which takes place in Stockholm from 11-15th April 2014. We wish Scientific Chair Arnulf Stenzl and the team at EAU Central Office all the best with planning for next year’s meeting!

We will be back with more conference coverage from the Urological Society of Australia and New Zealand Annual Scientific Meeting that takes place in Melbourne next month (#usanz13).

 

Declan Murphy & Matt Bultitude
BJUI Associate Editors

 

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Day 3 at EAU Annual Meeting

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Day 3, St Patrick’s Day, saw the Irish trying to lift their spirits having been beaten by Italy in the Six Nations rugby tournament the evening before. Cathy Pierce from European Urology donned a shamrock for the day but declined Declan’s suggestion to serve Guinness instead of champagne for the Platinum Journal’s cocktail hour.

Our day started with the BJUI Editorial Board Meeting hosted by new Editor-in-Chief, Prokar Dasgupta. There was much enthusiasm for the new-look of the Journal and for the return to a once-monthly print edition. The new web interface is receiving huge traffic and the close integration with our social media platforms has proved very popular to date. It is clear that the future for urology journals will require a much broader vision than the production of a print journal and we are excited by the suggestions made by our learned editorial board members for how we might achieve that.

The main plenary on day 3 addressed contentious issues involving the upper urinary tract. Prof Pilar Laguna opened the packed session by overviewing challenges in diagnosis of upper tract tumours and the role of new technologies in improving diagnostic strategies here. Tim O’Brien moderated a debate on surgical approaches for upper tract TCC, which featured some stunning video from Dr Traxer. Key messages from this session (summarized very nicely by EUT Congress News) included:

  • Dr Shariat: “Treatment is more and more based primarily on the risk of the tumour and efficacy of therapy rather than practical limitations; role of LND during segmental ureterectomy remains to be evaluated.”
  • Dr Brausi: “Lymphadenectomy (LND) improves disease staging and helps in selecting patients who can benefit from chemotherapy; several retrospective studies suggest the potential therapeutic role of LND during nephronureterectomy for transitional cell carcinoma of the upper urinary tract.”
  • Dr Traxer: “Regarding endoscopic treatment, flexible URS (ureterorenoscopy) for diagnosis is recommended, and new tools for better detection are needed such as narrow band imaging (NBI).

One other highlight from the plenary was provided by Dr Shahrokh Shariat who presented evidence to support the use of partial ureterectomy instead of nephroureterectomy for patients with upper tract TCC. In a large, retrospective, multi-institutional study, using matched-pair analysis, they reported that segmental ureterectomy provided similar oncological and renal functional outcomes when compared to nephro-ureterectomy.

Three back-to-back poster sessions on stone disease covered the topics from basic science to ESWL, ureteroscopy and PCNL. Olivier Traxer’s group presented their comprehensive series of classifying complications in flexible uretero-renoscopy using the modified clavien grading system. They reported on over 1000 patients and this data will provide a contemporary benchmark for us to advise our patients on the expected incidence of these complications. Dr András Hoznek reported a new online programme (also available from the Apple AppStore) for the metabolic work-up of stone disease.

This is an area that traditionally urologists have done poorly and it is hoped that innovations such as this will ensure a standardisation of investigations and it is hoped that future developments will allow patients to analyse their diet and fluid intake to make individual recommendations (personal communication O.Traxer). There was much debate about the use of simulators for PCNL and Mahesh Desai chairing the session commented that this is surely where the future lies in training young urologists. Finally, Lucarelli et al. reported on functional renal loss after iatrogenic injury causing obstruction to the upper urinary tract. They confirmed 1970s animal experiments that there was a clear benefit to dis-obstruction within 2 weeks compared with delayed treatment using both eCrCl and MAG-3 renograms.

Continuing a recurrent theme for this year’s EAU Annual Meeting, Dr Inderbir Gill and Dr Mike Jewitt debated the role of surveillance versus surgery for the management of small renal masses. Clearly there is a role for surveillance here, especially in older patients, but until there is more certainty about the precise nature of these masses based on better imaging and biopsy strategies, then partial nephrectomy will remain the standard here. This image of Dr Gill tweeted out by @hendrikborgmann shows him somewhat impressed about the idea of not doing surgery!

Watch out for more contention today as Dr Gill debates Dr Alex Mottrie over laparoscopic versus robotic-assisted partial nephrectomy. We have already seen much minimally-invasive partial nephrectomies at this year’s meeting thanks to the various video and live surgery sessions. Ben Challacombe was not happy with the blood loss during conventional laparoscopy on show yesterday and clearly thinks the robot is the answer!

Social media continues to grow significantly at #eau13 with significant growth in Twitter traffic:

(Statistics courtesy of www.symplur.com)

After resolution of some teething issues with the complimentary wifi that EAU provide at the meeting, delegates and those watching from further afield really got the conversation going throughout the day and there was a constant stream of commentary and humour streaming out using the #eau13 hashtag. Organisers of major urology meetings should take note of the fact that social media will be increasingly embraced and having good wifi access (complimentary please) throughout the venue will be considered essential by smart-device-wielding delegates.

More from the team tomorrow!

Matt Bultitude – BJUI Associate Editor (Web)
Declan Murphy – BJUI Associate Editor (Social Media)

 

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