Helen Nicholson

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The Surgical Spectacle: Blurred Lines

October 14, 2013/4 Comments/by Helen Nicholson

October’s #urojc discussion marks a number of important milestones– not only the 1^st anniversary of the online, international Twitter-based Journal Club, but this month we reached 1000 followers on Twitter – an achievement indeed! We also saw a record number of participants in demonstration of the #urojc concept going from strength to strength.

Fittingly, this month’s paper “The Surgical Spectacle: A Survey of Urologists Viewing Live Case Demonstrations” by Elsamra et al, with free online access provided by BJUI for the duration of the discussion, looks not so much at advances in our theoretical knowledge but rather at the way technological advances are changing our ability to obtain surgical ‘know-how’.

Elsamra et al undertook a survey of all those who attended the live surgery sessions at the Atlanta AUA Meeting in 2012 and the 2013 Paris 3^rd International Challenges in Endourology Meeting, to gauge the perceived educational benefits of live case demonstrations (LCD) particularly when compared with taped case demonstrations (TCD). There were a number of problems highlighted in the paper itself:

David Chen won the best Tweet Prize, free registration at EAU 2014, kindly donated by @EUPlatinum, with the following:

Interestingly, while 78% of survey respondents felt that LCDs were ethical and only 26% that interactive discussion may lead to distraction of the surgeon and potential morbidity, only 58% would allow themselves or a family member to undertake their own surgical management as an LCD.

Live case demonstrations are by no means a new concept – they have been undertaken since the advent of surgery for the purpose of education and learning.

Recent innovations have seen a blowout in the size of the viewing audience, with live streaming to conference audiences and potentially worldwide viewers, live tweeting and more recently, as pointed out by Dr Brian Stork, the use of Google Glass for both live surgery and the purpose of remote assistance. LCDs have become the drawcard of many surgical conferences, are often the most packed sessions, arguably for the educational benefit and more importantly for the buzz and thrill of seeing ‘the masters’ deal with difficult situations in real time… while answering questions from the audience simultaneously… “so that bleeding sir, where is it coming from exactly?!?!”

It seems that there is no argument that case demonstrations are of great educational benefit and there are some perceived advantages of live vs taped sessions, as summarized by Amrith Rao in a recent BJUI blog.

The vast majority of those involved in this #urojc discussion, however, seemed to suggest that it was hard to argue that the benefits of LCD outweighed those of TCD. Are we simply promoting a surgical circus? Does the perceived stress of operating to a live large audience have a potential negative impact on patient outcomes? Declan Murphy has already blogged about his own personal experience with LCD.

As for the ethical conundrum regarding the patient?

As suggested by Henry Woo:

In 2012 the EAU released guidelines with respect to the use of live case demonstrations within its own jurisdiction. Importantly, this has highlighted the need for regulation by means of submitting outcomes to a data registry, so as to provide a means of analyzing complications and patient safety outcomes.

Position statements or guidelines have also been released by the Royal College Surgeons (UK), American Urological Association and the Royal Australasian College of Surgeons, to name a few.

Where to from here? Will we continue the trend for ‘reality TV’?

There is certainly evidence out there to suggest that recording of basic operations and comparing with peers is potentially a useful means of assessing surgeon proficiency.

I think it very much remains a case of watch this space!

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

Bladder Cancer: a stagnant foe?

July 15, 2013/6 Comments/by Helen Nicholson

This month’s topic for the Twitter-based International Urology Journal Club #urojc was bladder cancer, with a paper titled ‘Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades’ by Zehnder et al, published online in July 2013. Open access to the paper was kindly provided by the BJUI.

Zehnder and colleagues undertook a retrospective analysis of the University of Southern California cohort and identified 1488 patients with muscle invasive bladder cancer who underwent radical cystectomy and extended pelvic lymph node dissection between 1998 and 2005. They also included 190 patients from the University of Bern cohort to determine outcomes in patients with clinical N0 disease who were upstaged on pathology to node positive disease. Analysis, performed based on decade of intervention, showed no significant difference in overall survival (OS) or recurrence free survival (RFS) over the three decades. 10-year RFS was 78-80% for organ confined, lymph node negative, 53-60% in locally advanced, LN –ve and 30% in LN positive patients.

Firstly, it has certainly been suggested that the overall survival and cancer free survival outcomes are not as good in broader population based studies (Ontario Cancer Registry). Why?

Analysis of the SEER database has shown that cancer specific survival and overall mortality has not improved for any clinical stage of bladder cancer and in fact suggests that the incidence is increasing in the United States.

And of course, we must always look at the study design and determine whether the outcomes are reflective of the patient populations that we see in practice.

The roles of neo- and adjuvant chemotherapy were discussed at length. Only 6% of patients received neoadjuvant chemotherapy, with worse OS and RFS in multivariate analysis. The use of adjuvant chemotherapy actually almost doubled from the 80’s to 90’s, stable in the 00’s at 29%.

If neoadjuvant chemotherapy is so widely recommended, why has its use failed to take off?

Jim Catto suggested an excellent clinical pathway for the implementation of neoadjuvant chemotherapy.

If indeed bladder cancer is the poor cousin of prostate cancer, why has progress stagnated and what can we change?

So what are my humble take home messages from the discussion surrounding this month’s #urojc paper?

Current data suggests that we have made no significant progress in bladder cancer outcomes over the past 30 years
Early referral and diagnosis coupled with timely intervention key; be wary of progression in context of high grade NMIBC
Both surgeon volume and hospital volume are thought to be independent predictors of overall survival. Patie nts do best at a high volume facility under the care of a high-volume Uro-oncologist in a multidisciplinary context
Neoadjuvant chemotherapy, despite randomized controlled trial evidence in favour of its use, has poor uptake in a real world setting. Advances in dense dose regimens (MVAC and Phase III GC underway) with resultant improvement in progression free survival, lower toxicity profile and fewer dose delays make for an attractive partner to radical cystectomy and extended pelvic lymph node dissection.

To finish with the words of the self-proclaimed Urology King of Twitter, Dr Ben Davies:

Winner of the best tweet prize for July’s #urojc was Mike Leveridge from Queens University, Canada – he was certainly a little frustrated with the apparent lack of progress we have made. The July #urojc Best Tweet Prize was kindly supported by the Nature Journal “Prostate Cancer Prostatic Diseases” which is edited by Dr Stephen Freedland and will be a complimentary 12 month online access to the journal.

Do join us for the August #urojc which commences on Sunday 4^th/Monday 5^th depending on your time zone.

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

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A beer a day keeps stones away

June 10, 2013/5 Comments/by Helen Nicholson

This month the Twitter-based International Urology Journal Club #urojc made a bold move away from cancer to discuss kidney stones. The paper entitled ‘Soda and other beverages and the Risk of Kidney Stones’ by Ferraro et al. was published online on 15^th March 2013. Open access to the article was generously provided by the Clinical Journal of the American Society of Nephrology. The lead author, Pietro Manuel Ferraro, was kind enough to actively participate within the Twitter discussion.

This particular study looked at a total of 194 095 participants amalgamated from the Harvard-based Health Professionals Follow-Up Study and The Nurses Health Studies I and II. These individuals all filled in biennial questionnaires regarding their diet, general health and kidney stone pain for a median follow up period of 8 years. It is interesting that the event rate was relatively low with only 4462 cases identified, however it is important to note that the study looked only for new stone formers and persons who had previously had a kidney stone were excluded from the trial. At the outset this begs the question as to whether these results are in any way applicable to the recurrent stone former population.

So what did they find? The referent is the consumption of less than one drink per month, so with respect to daily consumption of one or more sugar sweetened colas there was a 23% increased risk in the incidence of renal calculi. Other beverages to show a statistically significant increased risk of stones included:

Sweetened non-cola soft drinks	33% increased risk
Artificially sweetened non-cola soft drinks	17% increased risk (p=0.05)
Punch (sugar sweetened fruit drink)	18% increased risk

And what decreases your risk?

% risk reduction

Coffee	26%
Decaffeinated coffee	16%
Tea	11%
Red Wine	31%
White Wine	33%
Beer	41%
Orange Juice	12%

Missing my poison of choice, diet cola? While there was a trend towards a decreased risk, this was not found to be statistically significant. But not an increased risk….so I may just keep drinking it for the time being. I am not alone.

There were certainly more than one of the so called Urological ‘Twitterati’ who seemed delighted that the study findings justified their habits:

There are undoubtedly limitations with any cohort questionnaire analysis. The authors have acknowledged that while they tried to control and adjust for variables including age, BMI, diabetes, race, BP and dietary intake, there are variables that simply cannot be accounted for on the basis of a simple questionnaire. Fructose, for example, is purported to be a potential contributor to the increased risk of stones by increasing calcium, oxalate and uric acid excretion. There are many other dietary sources of fructose, including fruits, cereals and processed foods and sauces that are not accounted for and are potential confounders. Along the same lines, coffee is a relatively broad category of beverage. When one compares an espresso with a teaspoon of sugar to a Starbucks Frappuccino the difference in sucrose, and thus fructose, content is extraordinary. The caffeine content of these beverages, while purported to decrease the risk of stones through diuresis, is variable and thus also a potential confounder.

Manuel Ferraro importantly acknowledged that the study observed ‘associations, not causal effects’. Harder evidence such as 24 hour urines, stone analysis and imaging data would be useful to draw more significant conclusions as to causality.

The population studied was also somewhat limited. As mentioned by Jason Lee, Henry Woo and Matt Bultitude the study included male health professionals and female nurses, who were generally white, an older population with a relatively low BMI and potentially prone to dehydration. There was also limited control of comorbidities.

As suggested by Christopher Bayne, the only evidence as yet in randomized controlled trials is that water consumption as reflective of hydration status and urinary volume is the only substance known to reduce the risk of stone formation.

An astute observation by one of my fellow Australian trainees Janice Cheng noted the relatively dehydrated status of the study subjects.

This won the best Tweet prize, kindly donated by European Urology @EUplatinum.

Increased water intake has been reviewed on the Cochrane Database in 2012, however the consensus drawn was that there is currently insufficient evidence that increased water intake specifically, as opposed to other fluids, prevents the formation of urinary calculi.

So what conclusions should we draw? A patient with his first presentation kidney stone actually asked me yesterday whether he could keep drinking his favourite drink….beer. I simply replied that there was no current evidence that this would increase his risk of stones, however that moderation was key. We must remember that many of these calorific drinks have significant impact on comorbidities outside of the world of kidney stones. #a(lotof)wateradaykeepstheurologistaway

The overall participation in #urojc continues at a solid rate, with 39 participants and 178 total tweets over the 48 hour period. The next #urojc will be on the first Sunday or Monday of July (depending on your time zone).

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

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