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Have the days of ADT Monotherapy for Hormone Sensitive Prostate Cancer Come to an End? STAMPEDE in the June #urojc

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The much awaited results of the STAMPEDE study of abiraterone for hormone naive prostate cancer was simultataneously presented at #ASCO17 and published ‘on line ahead of print’ in the NEJM. The formal title of the study was “Abiraterone for Prostate Cancer Not Previously Treated with Hormone Therapy”.

Briefly, the study randomised 1917 men with locally advanced or metastatic hormone naive prostate cancer  to receive either ADT alone or ADT in combination with abiraterone and prednisolone.  significantly higher rates of overall and failure-free survival than ADT alone.We were privileged to have the lead author Professor Nick James join us for the June #urojc.  He posted the following video which is a lovely summary about STAMPEDE.  All of us could benefit from watching this and it is a useful link for our patients.

The data from the study is clear and it was not surprising that the majority of the discussion surrounding this paper was not going to be a dissection of the methodology or dataset and its analysis but rather how these results might impact upon urological practice.

There was a somewhat provocative start to the discussion with:-

To turn the question around, we saw the following tweet:-

But @urogeek came out swinging

But he was not alone in these thoughts.

But lets be fair, these responses are from urologists immersed in clinical trials experience and highly academic centers.  The following tweet perhaps brought out what many were thinking.

But perhaps the onus is upon us to make that extra effort to learn. As has been mentioned, we manage one of the most toxic agents competently in the form of intravesical BCG for bladder cancer.

Naturally, there was bound to be some discussion about cost of treatment.

For a bit of light hearted banter, there was the following exchange which we hope nobody took too seriously.

The twitter account of the journal Prostate Cancer and Prostatic Diseases posted a poll which was responded to by 117 participants with only 10% choosing the ADT alone option.  Whilst far from scientific, does this represent a significant change in thinking?  It was not long ago where we could have predicted that almost all respondents would have chosen the ADT alone option.

And to finish up, a question answered by Nick James as follows:-

A big thanks to all who participated in the June #urojc discussion. A special thanks to lead author Nick James for his insightful comments that really added to the discussion.  We will be back for another installment of the #urojc in July.  See you then.

Henry Woo (@drhwoo) is the Director of Uro-Oncology and Professor of Robotic Cancer Surgery at the Chris O’Brien Lifehouse in Sydney, Australia. He is also Professor Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney.

 

The 5th BJUI Social Media Awards

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It’s hard to believe that we have been doing the BJUI Social Media Awards for five years now! I recall vividly our inaugural BJUI Social Media Awards in 2013, as the burgeoning social media community in urology gathered in the back of an Irish Bar in San Diego to celebrate all things social. At that time, many of us had only got to know each other through Twitter, and it was certainly fun going around the room putting faces with twitter handles for the first time. That spirit continues today as the “uro-twitterati” continues to grow, and the BJUI Awards, (or the “Cult” Awards as our Editor-in-Chief likes to call them), remains a fun annual focus for the social-active urology community to meet up in person.

As you may know, we alternate the Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Last year, we descended on Munich, Germany to join the 13,000 or so other delegates attending the EAU Annual Meeting and to enjoy all the wonderful Bavarian hospitality on offer. This year, we set sail for the #AUA17 Annual Congress in Boston, MA, along with over 16,000 delegates from 100 different countries. What a great few days in beautiful Boston and a most welcome return for the AUA to this historic city. Hopefully it will have a regular spot on the calendar, especially with the welcome dumping of Anaheim and Orlando as venues for the Annual Meeting.

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On therefore to the Awards. These took place on Saturday 13th May 2017 in the City Bar of the Westin Waterfront Boston. Over 80 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2017 BJUI Social Media Awards. We actually had to shut the doors when we reached capacity so apologies to those who couldn’t get in! Individuals and organisations were recognised across 12 categories including the top gong, The BJUI Social Media Award 2017, awarded to an individual, organization, innovation or initiative who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her outstanding individual contributions, and in 2015 by the #UroJC twitter-based journal club. Last year’s award went to the #ilooklikeaurologist social media campaign which we continue to promote.

This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, John Davis, as well as BJUI Managing Editor Scott Millar whose team in London (Max and Clare) drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions.

The full list of winners is as follows:

Most Read Blog@BJUI – “The optimal treatment of patients with localized prostate cancer: the debate rages on”. Dr Chris Wallis, Toronto, Canada

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Most Commented Blog@BJUI – “It’s not about the machine, stupid”. Dr Declan Murphy, Melbourne, Australia

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Most Social Paper – “Novel use of Twitter to disseminate and evaluate adherence to clinical guidelines by the European Association of Urology”. Accepted by Stacy Loeb on behalf of herself and her colleagues.

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Best BJUI Tube Video – “Combined mpMRI Fusion and Systematic Biopsies Predict the Final Tumour Grading after Radical Prostatectomy”. Dr Angela Borkowetz, Dresden, Germany

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Best Urology Conference for Social Media – #USANZ17 – The Annual Scientific Meeting of the Urological Association of Australia & New Zealand (USANZ) 2017. Accepted by Dr Peter Heathcote, Brisbane, Australia. President of USANZ.

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Best Urology App – The EAU Guidelines App. Accepted by Dr Maria Ribal, Barcelona, Spain, on behalf of the EAU.

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Innovation Award – BJUI Urology Ontology Hashtags keywords. Accepted by Dr Matthew Bultitude, London, UK, on behalf of the BJUI.

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#UroJC Award – Dr Brian Stork, Michigan, USA. Accepted by Dr Henry Woo of Brian’s behalf.

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Most Social Trainee – Dr Chris Wallis, Toronto, Canada

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Best Urology Journal for Social Media –Journal of Urology/Urology Practice. Accepted by Dr Angie Smith, Chapel Hill, USA, on behalf of the AUA Publications Committee.

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Best Urology Organisation – Canadian Urological Association. Accepted by Dr Mike Leveridge, Vice-President of Communications for CUA.

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The BJUI Social Media Award 2017 – The Urology Green List, accepted by Dr Henry Woo, Sydney, Australia.

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All the Award winners (except Dr Brian Stork who had to get home to work), were present to collect their awards themselves. A wonderful spread of socially-active urology folk from all over the world, pictured here with BJUI Editor-in-Chief, Prokar Dasgupta.

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A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar, Max Cobb and Clare Dunne, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Copenhagen for #EUA18 where we will present the 6th BJUI Social Media Awards ceremony!

 

Declan Murphy

Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor, BJUI

@declangmurphy

March 2017 #urojc summary: Pelvic Lymph Node Dissection with Radical Prostatectomy – Is there enough evidence for and against?

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The twitter-based international urology journal club @iurojc #urojc is back with a splash after a brief hiatus. For the March 2017 #urojc, a lively discussion takes the theme of pelvic node dissection (PLND) on radical prostatectomy (RP) reviewing a timely article by Nicola Fossati et al. The paper was made available open access courtesy of European Urology @EUplatinum.

A systematic review of the literature was performed including all comparative studies of both randomized and non randomized studies, with at least one experimental and one control arm. This summarised 66 studies including more than 250.000 patients with particular focus on different extents of pelvic lymphadenectomy as proposed by the European Association of Urology. Outcome measures studied included oncological features of biochemical recurrence, development of metastases, cancer-specific survival, and overall survival. Adverse events were covered under secondary outcomes, both intra- and postoperatively observed. Finally, quality of PLND was addressed in terms of total number of nodes and total number of positive nodes. Risk of bias was assessed for all studies judging on basis of specific confounders.

The journal club ran for 48 hours from Sunday 5th march. The central question addressed is balance of benefits and drawbacks of lymph node dissection. The corresponding author of the manuscript, Steven Joniau from the University Hospitals of Leuven, Belgium highlighted the role of lymph nodes in prostate cancer recurrence.

However despite this idea, the benefit of PLND is heavily scrutinized from the start. Long term data from a single centre  suggested limited benefit.

 

However PLND has since earlier times been employed as a diagnostic tool, where an optimal template (presacral in addition to extended LND) may be optimal for staging and removal of lymph nodes.

Despite the current state of evidence, PLND is frequently mentioned in the various guidelines available for prostate cancer. However the exact situations when to employ them is questioned by some participants.

The various therapeutic options for lymph node metastases also coloured the discussion.

The discussion further continued to the important issue of morbidity, and the associated question of performing an extended PLND (ePLND).

Despite the current state of evidence, PLND is frequently mentioned in the various guidelines available for prostate cancer. However the exact situations when to employ them is questioned by some participants.

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The discussion further continued to the important issue of morbidity, and the associated question of performing an extended PLND (ePLND).

The increasing use of PSMA PET/CT provided other spread pattern data to be considered. And finally temporal changes in PSA testing is observed to affect the need for LND.

 

From the poll which ran during the discussion, about half responders would perform extended PLND for staging, while the rest were divided almost equally between therapeutic benefit and adherence to guideline recommendations.

Probably all participants of the discussion agrees for the need of a proper randomised study addressing role of PLND.

At the end of a busy 48 hours, the discussion had been joined by top experts in the field of prostate cancer, generated more than 200 tweets and reached more than 700 thousand impressions the world over.

Yodi Soebadi (@yodisoebadi) is an Indonesian urologist, trained at Universitas Airlangga, currently pursuing doctoral research at KU Leuven in Belgium.

 

Introducing The Urology Green List

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henry-wooThe world of predatory scientific publishing had a major ‘win’ when Jeffrey Beall’s blog “Scholarly Open Access” was suddenly emptied of content in January 2017. Beall was tireless in his attempts to expose the unscrupulous behaviour of predatory open access journals whose objective was nothing other than to extract author publication charges (APCs) from unwitting academics. His blog was very much the “go to” site if one wished to check the legitimacy of a particular open access journal. In a confusing publishing landscape, it was an essential guidance on which open access journals were to be avoided. The growth of this predatory publishing industry has been exponential and clearly a reflection of the enormous amount money that is there to be made. Beall was constantly under attack from predatory publishers including threats of litigation. Beall has gone to ground and this normally vocal bastion of transparency has provided no reason for the sudden deletion of content from the Scholarly Open Access blog.

You can’t help to ask the following questions about the predatory publishing industry. How do these journals make such inroads into academia? How do they manage to outwit highly intelligent individuals to support their journal either through the submission of manuscripts or editorial board duties?  The answer is quite simple.  They prey on the naivety, vulnerability and egos of academics.

Spam email casts a wide net. Cast it wide enough and somebody is bound to get caught.  The standards required to publish articles in good journals has never been so high and the pressure to publish weighs heavy in the minds of academics.  These emails will always find an email inbox of a researcher on the rebound after the rejection of a manuscript from a reputable journal.  The language of the emails use flattery and an expert sales pitch to appeal to the recipient into submitting an article and then later discovering excessive APCs. If payment is refused, the article is published in any case; as a result of this action, they are deprived of the opportunity to submit their work elsewhere.

The same language is used to appeal to urologists to become members of editorial boards. Those accepting these roles unwittingly allow these journals to trade on their good name as well as the good name of their institutions to prop up their otherwise shonky image. These academics inadvertently contribute to the flow of manuscripts to these journals as a result of researchers associating the credibility of editorial board members with the credibility of the journal.

Beall’s focus was very much on where not to publish. The recent events suggest that a change in direction is needed. Accordingly, the Urology Green List has been created. The focus is all about good journals, both subscription and open access, where it is considered safe for the urological community to send their research for publication.  Beall demonstrated that it was a never ending task trying to keep up with an exponential growth in the numbers of predatory journals. It is far more practical to maintain a list of journals where it is safe to publish.

Absence from the list does not mean that a journal must be avoided – absence is nothing more than a red flag suggesting that there be appropriate due diligence in establishing the authenticity of the journal and to ask colleagues, friends and mentors for advice.

The Urology Green List will be a living on line document.  Visitors will be encouraged to make suggestions on which journals should be added to the list and which journals should be removed from the list.  In the near future, an International Editorial Board will be established to assist with providing opinion and review of journals that are for inclusion or exclusion from the Urology Green List.

In the longer term, a project will be to develop objective criteria for which journals on the Urology Green List may be assessed and graded.  In the future, it is hoped that researchers can be provided with guidance to understand the ‘best fit’ venue for their research amongst the journals that reside on the Urology Green List.

Please come and visit the Urology Green List.  It is here to support the urological community. Feedback is always welcome.

 

https://urologygreenlist.wordpress.com/

 

 

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Henry Woo is a urological surgeon.  He is Professor of Surgery (Urology) at the Sydney Adventist Hospital Clinical School of the University of Sydney. He is also the Director of Uro-Oncology and Professor of Robotic Cancer Surgery at the Chris O’Brien Lifehouse cancer service in Sydney. @drhwoo

 

March #urojc: Radiotherapy for Prostate Cancer – Is it a gift that keeps on giving?

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The International Urology Journal Club on Twitter is now well into its 4th year.  The subject for the March 2016 discussion was a paper published in the BMJ entitled “Second Malignancies after radiotherapy for prostate cancer: systematic review and meta-analysis”.

Lead and senior authors, Chris Wallis and Rob Nam were kind enough to  make themselves available to participate in this discussion.  Rob Nam made use of the  #urojc guest twitter account.

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The literature was searched using Medline and Embase and the method of review was the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational studies in Epidemiology (MOOSE) guidelines for reporting of this systematic review and meta-analysis.

Chris Wallis provided an excellent TL:DR summary with the following tweet.

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It is well recognized that secondary malignancies following radiation exposure could take many years to become apparent.

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The responses were fairly predictable but nevertheless an important point to explore.

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Early in the discussion, there was also relevant reminder of the issue of differences in odds ratios and absolute risk.  That said, consideration needs to be given to the ‘big ticket’ nature of secondary malignancy where even a small absolute risk drives a great deal of interest in this subject matter.

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An interesting finding from the study was that the risk of secondary malignancy was less with brachytherapy compared with external beam radiation.

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Further to this, is it possible that there could be a difference between HDR and seed brachytherapy?  An interesting thought although not specifically covered in the paper.

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A more controversial aspect to the discussion was whether the risk of secondary malignancy would justify screening or surveillance. The following exchange was worthy of note.

Whilst there is nothing in the way of documented guidelines or actual evidence to demonstrate a benefit of surveillance, it seems something worthy of consideration for future practice guidelines –  in other words, recommendations one way or the other.

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Rob Nam refers to a third paper on radiation outcomes in the context of previous surgery.  This BJC paper, the Lancet Oncology paper (previous discussed at a #urojc in 2014) and now the current paper could cheekily be called the Nam Trilogy – make note that you heard this term here for the first time.

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To what extent should we be counseling our patients on the risk of secondary malignancy if they are to undergo radiation for prostate cancer?  Is this just another factor to encourage surgery over radiotherapy?  Will there be no change in practice, particularly in the US where many lucrative radiation oncology services are actually owned by urological surgeon private practice groups?

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The state of radiation oncology practice is different outside the US and my own personal thoughts on the matter are that the Nam Trilogy of papers will create a series of well cited ‘evidence’ that will further shift the weight of opinion towards surgery over radiotherapy as a primary treatment for localized prostate cancer.

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Anybody who followed the March installment of the #urojc would have been impressed by the high level of interaction by the authors Chris Wallis and Rob Nam.  A particular mention should be given to Sabin Motwani who as a radiation oncologist, provided valuable input to the discussion.

Please do join us for the April installment of the #urojc and I encourage you all to email, tweet or DM your suggestions for papers to be discussed.  Please also, feel free to volunteer to write up a monthly summary for publication on the BJUI blogs.  I would also like to acknowledge the contributions of Rustom Manecksha who was the winner of the 2016 BJUI SoMe Award for #urojc – a reflection to the quality of his participation and support for this online educational activity.

 

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney.  He is the coordinator of the International Urology Journal Club on Twitter.

Urologists in the Yellow Submarine – a Periscope to the World

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henry-woo_smOver the last few weeks, there has been a lot of chatter about a new Social Media platform. Just when you thought that we had exhausted all possible ways that people could interact online, live video streaming is the talk of the town.

Last month, two competing live video streaming apps were launched.  Meerkat initially gained popularity quite rapidly, particularly through Twitter, given the ease and immediacy of being able to share your live video streaming with twitter followers. Twitter acquired its competitor, Periscope, and Meerkat’s access to the twitter followers was cut off no sooner than it had began. Already there are arguments as to which of the two platforms are better but I can already sense from user reactions and expert opinion, that Periscope will be the one that will prevail. The might of Twitter will be very difficult to compete with.

Why on earth would urologists be interested in live broadcasts? The obvious application is live streaming of events such as conferences. The default option is perform a public broadcast and this will have particular value when there is an advocacy focus. There is also an option to broadcast privately only to followers of the Periscope account performing the broadcast. The latter may well be the best option for more sensitive material but there are still issues that need to be sorted out.  In particular, there is no simple mechanism to determine which followers should be permitted to follow the broadcasting account in order to see a private live stream. It is inevitable that this will be simplified in the future, as it would be logical for this platform to find a mechanism to attract business users.

As things are at present, one needs to have a twitter account in order to sign on to broadcast using Periscope. This platform is designed for the mobile user – this is both for broadcasting and for watching the live stream.  Attempting to do this on a desktop or laptop website is cumbersome and clumsy from my initial attempts to do so whereas the iOS App was straightforward and intuitive, particularly for those already familiar with the Twitter app.

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Note the similarity of the iOS Periscope App with the Twitter App interface.

It is my belief that the first ever Periscope live stream broadcast from a medical conference was performed on Sunday 12 April 2015 at the Urological Society of Australia and New Zealand’s (USANZ) Annual Scientific Meeting. Declan Murphy used Periscope to broadcast a message from Prokar Dasgupta, Editor-in-Chief of the BJUI Journal.   The video from the Periscope live stream is below. This first, at least for a urological conference, was tweeted by Declan Murphy.

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A couple of hours later, I performed a live video stream from the Social Media session when Imogen Patterson gave an excellent presentation on managing our online reputations. During the feed, observers are able to make comments as well as to demonstrate their approval by tapping their screens to trigger a flow of hearts from the bottom right hand corner of the screen.

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This is a screenshot from an unrelated live video feed. From the bottom left, the user is notified of those joining the observation of the feed as well as comments. From the bottom right, hearts float upwards in response to positive taps of the screen by watchers.

There are a few issues with Periscope as it is right now. The feed is only available for 24 hours before disappearing from the Periscope platform, however, a video recording minus the comments and hearts, can be stored in the photo stream on your mobile device. As mentioned before, you must have a twitter account to broadcast although you do not need one to view a broadcast. Thirdly, directed broadcasting should be simplified.

Social media platforms come and go but the ability to live stream is an exciting new development. For Periscope, it is my belief that the potential application for a use in medical education seems boundless. Live broadcasting is no longer the exclusive domain of television and cable networks.

 

Henry Woo (@drhwoo) is Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney. He is the Editor-in-Chief of BJUI Knowledge, an innovative on-line CME portal that launches this year.

 

You may have heard it on the grapevine, but UroVine is now here

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UroVinePic3I was first introduced to Vine by my good friend Dr Fernando Gomez Sancha over a very enjoyable dinner in Milan during the European Association of Urology meeting in March 2013.  I thought that the concept was interesting and signed up on the spot.

Vine is a relatively new social media platform that allows users to create and share 6 second videos loops.  It brings out amazing creativity with the very restrictive maximum 6 second video duration. It is not dissimilar to the Twitter where users have to work within the content limits of the platform where one only has a 140 character to make a point. However, Twitter is probably a lot easier than trying to create 6 second video content.

Although signed up to a Vine account, I did not use it very much initially.  I was still a little unsure as to how I was going to be able make use of it either for personal or professional use.  Gradually over time, I started playing around and making some personal Vine clips, mainly at concerts or at sports events.  They were not particularly well thought out Vines and certainly of limited interest. I also tweeted a few of these Vines and I was impressed by the integration of Vine videos on the Twitter platform.  I should not have been surprised since Twitter owns Vine.

On Twitter, one can watch a Vine loop video without having to click a link out of the App or website as is the case for say YouTube. Additionally, the short Vine clips were a perfect match for Twitter users who wanted small bite sized content in this time poor world. I then became fascinated with Vine having this repetitious loop – it is almost captivating to the extent that you cannot help but to watch at least 3 or more loops. The first loop is like “what was that”, the second loop is like “I think it’s what I thought I saw” and third loop is like “I get it” and the fourth loop is because you could not work out exactly when the third loop ended and accidentally watched it for an additional time. Have a look some Vine clips and you will then understand what I mean.

This repetition had me thinking about how can we find a medical education application to this platform. The answer was really in Twitter. The best way was to use Twitter and Vine together. If a specific Twitter account were to be created to link to specific Vines, we could create a powerful medical education tool. The repetitious nature of the video loop enables us to reinforce a learning point.

On 3 February 2015, #UroVine was established using the account @UroVine. Vine clips have already been tweeted associated with key learning points. I would love to hear your feedback and to have your Vines submitted for tweeting.

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Making a Vine is very simple. It does not have to be HD or have cinema ready professional production. The simplest thing to do is to take your mobile phone with the Vine App and to shoot selected video running off your laptop. More important is that there needs to be clear learning point that needs to reinforced.

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The combined use of Twitter and Vine specifically for medical education has the potential to be a very powerful tool. With recent provision of Twitter Activity metrics for each tweet and Vine loop data, there is the potential for some interesting analysis. It is my belief that this is a first and once again a demonstration that Urology is leading the way with innovation in medical education and social media. I hope you will join us.

Henry Woo (@drhwoo) is Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney. He is the Editor in Chief of BJUI Knowledge, an innovative on-line CME portal that launches this year.

 

One year on and “The International Urology Journal Club on Twitter” still going strong

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November marked the first anniversary of the International Urology Journal Club on Twitter. As far as we are aware, our #urojc was the first journal club on Twitter using the asynchronous format. Prior to our commencement and unknown to us, a very successful real time journal club had been established with great success. Our major challenge was to enable engagement from our global community and clearly the way forward was to use the asynchronous chat format. This has since proved to be the innovation that has enabled true global participation. Other specialties have since followed our model.

When we started, we were fortunate to be in a specialty group where there were already significant numbers on Twitter and we were able to rally up the troops for the first #urojc discussion in November 2012. In the first month of our existence, we had around 50 followers and since then there has been a steady growth in those following the #urojc account and as we reached our one year anniversary, we had hit the magic 1000 follower mark.

Before all is relegated to faint memory, it is important to acknowledge the supporters and Best Tweet (Hall of Fame) winners over the past 12 months.

A couple of the novel prizes, were not sur‘prize’ingly from Urology Match.

Thanks to all of you who have supported this project as participants and followers of the #urojc discussions. A shout out to BJUI for allowing us to have the audience of the BJUI Blogs to communicate and publicize our activities. Thank you to the supporters of the Best Tweet Prizes and the journals who have kindly allowed open access of articles discussed. A special thanks to authors who have been kind enough to make themselves available for the discussion – having author insights adds a special touch that is simply not possible with any other journal club format.

We have been off to a strong start for our second year and look forward to the continued success of this novel form of CME by social media.

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

UroLift Takes Off From Down Under. The Potential Rewards When Engineers Bring You Into Their Inner Circle

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At the American Urological Association meeting in San Antonio in May 2005, I was introduced to a four engineers from a small start up company called NC2 (New Company 2).  It had at that time been recently spun off from the medical device incubator company Exploramed.  They had no product and not even a prototype of a product that could possibly be used in humans but what they did have was a passion to make a difference, incredible ideas and a laptop computer. 

They had thought about the failings of existing mechanical treatments for LUTS/ BPH and the first that comes to your mind is prostatic stents.  No stent conforms perfectly to the shape of the prostatic urethra and there were the issues of encrustation of any elements of stent material that were exposed to the urine.  Rather than throw the baby out with the bathwater, they harnessed what was good about stents, which was the potentially immediate effects they could have on urinary function without associated destruction of tissue and that perhaps tailoring the radial expansion to just a few critical points rather than the entire length of the prostatic urethra could do the trick.

The original idea was that some sort of metallic disc could be placed outside the prostate capsule and one on the urethral side and between them, a non absorbable suture could be placed under tension and therefore draw open the prostatic urethra and defined sites.  How these engineers were to find a way of designing a delivery tool to do this had me a little skeptical at first but there seemed to be no doubt in their minds, even thought they had not yet worked it out, were going to find a way.  Their confidence, intellect and enthusiasm was infectious and you just felt like you wanted to be a part of this project.  It so turned out that the metallic discs would be replaced by linear metallic tabs which logically make for easier delivery.

So why involve Australians?  It is difficult to keep things under the radar and one way of doing so is to take the idea where it is less likely to be visible. Additionally, the data needed to be trustworthy and in a place where strong ethic committee governance structures exist. We make no illusion that for once, being Australian, gave us a clinical research opportunity from a company based in the US that would rarely be directed our way.

My Australian colleague, Dr Peter Chin was also brought in on the project.  Over the next few months, we did not hear anything but there was then an urgent call that ‘California was the place we ought to be’ so we literally dropped everything and headed over to Silicon Valley where we had the opportunity to use the first prototype of the device on human cadavers.  Whilst our travel costs were covered by NC2, we received no payment for our time spent during these exercises but remuneration was the last thing on our minds given the exciting path that the idea could potentially take.  Simultaneously, animal studies were being conducted and these demonstrated that the internal metallic tabs of the prosthesis would become covered by urothelium and in combination with the cadaveric work, provided a convincing argument to move forward with human clinical trials.

Putting on a brave face doing the first human Urolift case at Westmead Hospital in Sydney in December 2005

By December 2005, we were ready to conduct the first human trials.  We measured everything that could possibly move and it probably took close to 2 hours to perform the first case.  The initial prototype device used looked like it was literally built in somebody’s garage workshop but it was functional and confirmed proof in principle that a transurethral delivery system could deploy metallic tabs on the capsular side of the prostate and within the urethra that was connected by a tensioned suture. Through this, it created mechanical alteration to the anatomy of the prostatic urethra with positive influence on lower urinary tract symptoms.  From here, multiple clinical trials have been performed by the company that became known as Neotract Inc and as of 13 September 2013, the device received FDA approval.

It is enormous privilege to have played a role in product development from inception of an idea through to FDA approval.  These opportunities are rare and whilst healthy skepticism and caution should be applied to all ideas presented to you, if you are offered such an opportunity to take a side project, it could be a rewarding diversion from your daily clinical practice.  Financially, you will never recoup your time investment but the rewards of making a difference is priceless.

Shared passion for a project can go a long way.   This experience emphasizes the value of engineers interacting with clinicians to achieve a desired outcome and there is certainly room for of such interactions. Opportunities to embrace these relationships are out there and perhaps a good place to start is to become active in the Engineering and Urology Society which as a section of the Endourological Society meets each year at the AUA Annual Meeting.

 

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

Disclosure: Henry Woo has formerly been an investigator and advisor to Neotract Inc. He holds a small stock investment in the company.

No Classical Music In My Operating Room Please

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For as long as I have been operating independently, music has been an essential part of my operating theatre environment. If there is no music playing in the background, it is to me as if there is a missing component of the “time out” check list that is carried out by surgical teams prior to each procedure.

For many years, I was trapped in the 70s and 80s with my choice of music. Bowie, Stones, R.E.M. and Pink Floyd were some of the artists that were on high rotation. It provided education to the growing numbers of nurses and medical students who had never heard of classic albums such as Dark Side of the Moon. These days I am lucky to find a medical student who can volunteer the names of the four Beatles – I don’t even bother asking if they know anything about Pete Best who was ousted in favour of Ringo. Sometimes they almost believe my suggestion that the next Pope will be named John Paul George Ringo I, which of course is a perfectly reasonable suggestion. The music played in my theatre therefore actually has an important educative role that makes up for parenting deficiencies with the failure to teach their children about classic rock acts of the 70s and 80s.

 

Over the past couple of years, I have been encouraged to explore contemporary music, which has led to a change in the music played in my operating theatre to performers such as the XX, The Vaccines, First Aid Kit, The Hives, Regina Spektor, Mumford & Sons and Laura Marling just to name a few. This has been a positive move in that I not only have come to appreciate some of the great new music that will one day become classic material, but it also receives a high approval rating from other staff within the operating room. I do admit that I have the latest David Bowie album on order in the vinyl format though an EBay seller.

Why am I telling you all about this? This month, a systematic review by authors Moris and Linos was published in the journal Surgical Endoscopy entitled Music meets surgery: two sides to the art of “healing”. Using fairly limited search terms, a literature search identified 28 relevant articles that were included for review. These papers covered a mix of subject matter including effects of music in the operating theatres on patients, surgeons and theatre staff.

As a surgeon, I will leave discussion of effects of music on patients to our anaesthetic colleagues and it is for them to debate whether there is any beneficial effect of music on induction and upon waking up. Our interaction with music occurs when the patient is asleep so our interest as surgeons lies primarily with its effects on ourselves and other members of staff in the operating room.

Having your anaethetist ‘on board’ with your attitude to music is essential. In the private sector, this is unlikely to be an issue given that you will generally choose to work with somebody who has some compatibility with your own personal tastes. The public sector can at times be challenging where the anaesthetist feels equally entitled and at times more entitled to determine the choice of music or even absence of music in the operating room– this requires tactful negotiation. The principle reason I tend to back off from a fight over this type of issue is that I hate going into an operation feeling cranky. The only time I may make a stand is when classical music is being played – the swings between the calms and storms of some pieces are a little too stressful for my liking.

So what do operating room staff prefer to listen to? Only a couple studies examined this but the bottom line is that classical music is not a clear majority choice – in one study it was favoured amongst 1.2% of respondents and in another it was 45%, they prefer to listen to a type of music that’s a bit more fun . With the latter, my personal inclination is that they were asking non-urologists who are no way as cool as urologists in general. My thoughts, as you may have gathered, are to drop the ‘al’ and choose classic music over classical music.

 

Summary of relevant studies extracted from Table 1 of the Moris study published in Surgical Endoscopy.

 

I am not sure I entirely agree with one conclusion of the review, which states: “With regard to its effect on surgical staff, music is thought to be distracting, reducing the staff’s ability to cooperate and coordinate”. Only one retrospective study is insufficient to reach the general conclusion about the effects of music on staff in operating theatres. My admittedly biased perspective has been in total agreement with the second conclusion that states “From a surgeon’s point of view, music facilitates achievement of higher speed and accuracy of task performance.”

 

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

 

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