Jonathan Makanjuola

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West Coast Urology: Highlights from the AUA 2016 in San Diego… Part 2

May 12, 2016/1 Comment/by Jonathan Makanjuola

By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

The AUA meeting was starting to hot up with the anticipation of the Crossfire sessions, PSA screening and the MET debate that appeared to rumble on. We attended the MUSIC (Michigan Urological Surgery Improvement Collaborative) session. It is a fantastic physician led program including >200 urologists, which aims to improve the quality of care for men with urological diseases. It is a forum for urologists across Michigan, USA to come together to collect clinical data, share best practices and implement evidence based quality improvement activities. One of their projects is crowd reviewing of RALP by international experts for quality of the nerve spare in order to improve surgical outcomes.

The MET debate continues to cause controversy. In the UK there has been almost uniform abandonment of the use of tamsulosin for ureteric stones following The Lancet SUSPEND RCT.

The MET crossfire debate was eagerly awaited. The debate was led by James N’Dow (@NDowJames) arguing against and Philipp Dahm (@EBMUrology) in favour of MET. Many have criticised the SUSPEND paper for lack of CT confirmation of stone passage. Dr Matlaga (@BrianMatlaga) stated that comparing previous studies of MET to SUSPEND is like comparing apples to oranges due to different outcome measures. He recommended urologists continue MET until more data is published. More conflicting statements were made suggesting that MET is effective in all patients especially for large stones in the ureter. The AUA guidelines update was released and stated that MET can be offered for distal ureteric stones less than 10mm.

In a packed Endourology video session there were many high quality video presentations. One such video was a demonstration of the robotic management for a missed JJ ureteric stent. Khurshid Ghani (@peepeeDoctor) presented a video demonstrating the pop-corning and pop-dusting technique with a 100w laser machine.

One of the highlights of the Sunday was the panel discussion plenary session, Screening for Prostate Cancer: Past, Present and Future. In a packed auditorium Stacy Loeb (@LoebStacy), gave an excellent overview of PSA screening with present techniques including phi, 4K and targeted biopsies. Freddie Hamdy looked into the crystal ball and gave a talk on future directions of PSA testing and three important research questions that still needed to be answered. Dr. Catalona presented the data on PSA screening and the impact of the PLCO trial. He argued that due to inaccurate reporting, national organisations should restore PSA screening as he felt it saved lives.

There was a twitter competition for residents and fellows requiring participants to tweet an answer to a previously tweeted question including the hashtag #scopesmart and #aua16. The prize was Apple Watch. Some of the questions asked included; who performed the 1st fURS? And what is the depth of penetration of the Holmium laser?

UK trainees picked up the prizes on the first two days.

The British Association of Urological Surgeons (BAUS) / BJU International (BJUI) / Urological Society of Australia and New Zealand (USANZ) session was a real highlight of day three of the AUA meeting. There were high quality talks from opinion leaders in their sub specialities. Freddie Hamdy from Oxford University outlined early thoughts from the protecT study and the likely direction of travel for management of clinically localised prostate cancer. Prof Emberton (@EmbertonMark) summarised the current evidence for the role of MRI in prostate cancer diagnosis including his thoughts on the on going PROMIS trial. Hashim Ahmed was asked if HIFU was ready for the primetime and bought us up to speed with the latest evidence.

The eagerly awaited RCT comparing open prostatectomy vs RALP by the Brisbane group was summarised with regards to study design and inclusion criteria. It is due for publication on the 18th May 2016 so there was a restriction of presenting results. Dr Coughlin left the audience wanting more despite Prof. Dasgupta’s best effort to get a sneak preview of the results! We learnt from BAUS president Mark Speakman (@Parabolics) about the UK effort to improve the quality of national outcomes database for a number of index urological procedures.

Oliver Wiseman (@OJWiseman) gave us a flavour of outcomes from the BAUS national PCNL database and how they are trying drive up standards to improve patient care. A paediatric surgery update was given by Dr Gundeti. The outcomes of another trial comparing open vs laparoscopic vs RALP was presented. There was no difference in outcomes between the treatment modalities but Prof. Fydenburg summarised by saying that the surgeon was more important determinant of outcome than the tool. Stacy Loeb closed the meeting with an excellent overview of the use of twitter in Urology, followed by a drinks reception.

It was not all about stones and robots. The results of the Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment (ROSETTA) trial results were presented. Botox came out on top against neuromodulation in urgency urinary incontinence episodes over 6 months, as well as other lower urinary tract symptoms.

The late breaking abstract session presented by Stacy Loeb highlighted a paper suggesting a 56% reduction in high-grade prostate cancer for men on long term testosterone. This was a controversial abstract and generated a lot of discussion on social media.

It has been an excellent meeting in San Diego and we caught up with old and met new friends. It was nice to meet urologists from across the globe with differing priorities and pressures. There was a good British, Irish and Australian contingent flying the flag for their respective countries. It was another record-breaking year for the #AUA16 on twitter. It surpassed the stats for #AUA15 with over 30M impressions, 16,659 tweets 2,377 participants. See you all in Boston for AUA 2017.

West Coast Urology : Highlights from the AUA 2016 in San Diego… Part 1

May 10, 2016/3 Comments/by Ben Challacombe

By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

The 2016 AUA returned to the beautiful city of San Diego set on the shores of the Pacific in an excellent conference centre located in the centre of the town adjacent to the Gaslamp district. For a change the wifi was excellent and allowed enhanced levels of social media interaction and urological discussion. Opening these interactions were 2 key sessions which provoked much debate. Firstly the announcement that after over 10 years of trying the FDA has approved HIFU treatment although it seemed to get there through a slightly “de novo” pathway. Apparently the FDA approved it as an ablation tools but not for prostate cancer.

Although not directly approved for use in prostate cancer, that is exactly what it is going to be used for. A packed house saw a debate with evidence from both sides. Dr Nathan Lawrentschuk promoted the 4 Ds of HIFU. His key point was that 56/101 had a post treatment biopsy of which 51 where biopsy positive!

The second big session focussed on the AUA/SAR consensus statement document on prostate cancer diagnostics. This recommended a “High Quality” MRI should be strongly considered if patient has a rising PSA with a previous negative biopsy, has persistent clinical suspicion for prostate cancer or is undergoing a repeat biopsy. There was no mention of MRI for all at the pre-biopsy stage which many had hoped for and only 2 lines on trans-perineal biopsy as an option. This is of course related to health resources and the outpatient office-based nature of most USA urologists.

A welcome innovation was the Crossfire Sessions which pitted 2 well known advocates of one treatment against 2 with the opposite views. It was hardly debating of the Oxbridge variety but none the less did provoke some useful discussions. Topics included radical prostatectomy vs radiotherapy, endoscopic vs nephro-ureterectomy management of upper tract TCC, and enucleation at partial nephrectomy vs formal resection. Standing room only at the back of the halls but no real audience interaction or voting which was a shame.

The session which really woke everyone up was Rene Sotalo’s wonderful complication horror show. Bleeding, bleeding and more bleeding in a variety of ways. How would you handle this he asked? Pray I thought! But this and similar sessions clearly show the benefits of recording all cases and reviewing these DVDs if something goes wrong. The cause of some complications were only identified by review of the intra-operative tapes. Some clinical titbits learn’t included using only a horizontal incision for the camera port at RARP to reduce hernias and turning off pneumocompression stockings if there is a major venous injury to prevent excessive venous bleeding.

From a SoME perspective there was both good and bad. One poster showed that 40% of graduating US residents had publicly accessible unprofessional content on social media. Food for thought at the consultant interview no doubt, but on the other side SoMe ranks third in the acquisition of urological knowledge (and climbing…). One hack produced this tweeting guideline for all to reflect on.

Prof Prokar Dasgupta had the honour of presenting the widely anticipated session on emerging robotic technology . At last there appears to be some real competition to Intuitive’s dominance on the way. There are at least 3 credible robotic systems on the way. He finished with an intriguing slide on Dr Google being the most powerful doctor in the world!

Despite Europe and Asia moving towards the use of PMSA PET , the USA is not moving in this direction due to reimbursement issues if the PMSA molecule.

There was a lot of interest in a packed auditorium to see live surgery for a single use disposable fURS “Lithovue” with some reporting superior vision , optics and deflection.

There were some sceptics amongst the stone community with the environmental impact and cost effectiveness a concern.

With the popular Gaslamp district a stones throw away many delegates went after the conference for a meal and drinks. The local baseball team San Diego Padres was a popular destination with may watching baseball for the 1st time whist others had gone for a run along the harbour and even caught a sighting of some seals!

Headline news: “Doctors and nurses may face jail for neglect”?

December 5, 2013/3 Comments/by Jonathan Makanjuola

It has been an important few weeks in for doctors in the United Kingdom, sensationalist headlines have been on the front pages of many of the national newspapers: “Doctors and nurses may face jail for neglect”

This has all stemmed for the publication of the Francis report and Berwick review into patient safety. They detail recommendations on how the National Health Service (NHS) can learn and improve the standard of patient safety. The Berwick report was led by Professor Don Berwick, an international expert and former adviser to US president Barack Obama, in patient safety. He was asked by the British Prime Minister David Cameron to carry out the review following the publication of the Francis Report into the breakdown of care at a Mid Staffordshire NHS Foundation Trust Hospital.

Stafford Hospital is an NHS hospital in the West Midlands area of England where hundreds of hospital patients died as a result of substandard care and staff failings between January 2005 and March 2009. The Mid Staffordshire Trust failed to provide safe care in the wards, people lay starving, thirsty and in soiled bedclothes. Decisions about which patients to treat were left to receptionists, inexperienced junior doctors were put in charge of critically-ill patients, and nurses switched off equipment because they did not know how to use it. The culture of the hospital Trust was one of secrecy and defensiveness. The inquiry highlights a whole system failure.

Both reports highlight the main problems affecting patient safety in some hospitals in the NHS and makes recommendations on how to address them. It says that the health system must, amongst many things, recognise the need for wide systemic change by abandoning blame as a tool and trust the goodwill and good intentions of the staff. The use of quantitative targets must be approached with caution and they should never displace the primary goal of better care.

The main headline grabbing item was the recommendation that the UK Government should create a new general offence of willful or reckless neglect or mistreatment applicable both to organisations and individuals.

Organisational sanctions might involve removal of the organisation’s leaders and their disqualification from future leadership roles, public reprimand of the organisation and, in extremis, financial sanctions but only where that will not compromise patient care.

Individual sanctions should be on a par with those in Section 44 of the Mental Health Capacity Act 2005 in UK law, which states that a person can be found guilty of an offence if he ill-treats or willfully neglects a person who lacks capacity and if convicted could be sentenced to imprisonment for a term not exceeding 5 years or a fine or both.

So does this affect us as urologists?

As doctors our first duty of care is towards our patients and patient safety should be our number one priority. However, in light of the report there is the possibility of a custodial sentence to individual(s) where the standard of care falls far short of expectations and blatant neglect is proven. In the age of clinical teams, proving that one individual was at fault is very difficult.

There has been a recent case in the UK press in which a surgeon has been jailed for two and a half years for manslaughter for gross negligence of a patient.

In another case in Australia a 63-year-old American surgeon working in a hospital in Queensland faced complaints from hospital staff that he had botched operations, misdiagnosed patients and used poor surgical techniques. He was arrested in the US in 2008 and extradited to Australia to stand trial. He was jailed for seven years in 2010 after being convicted of criminal negligence leading to the deaths of three patients.

These are two isolated cases but both demonstrate that the days when problematic surgeons were quietly retired are over. Our actions will be scrutinised by an ever demanding public with complications not just being discussed in mortality and morbidity meetings locally but in some cases publicly and in extreme situations in the courts.

My question to the readers is: what happens to clinical staff in your individual countries when clinical negligence and neglect is accused? Is jail time a possibility if proven?

Jonathan Makanjuola is a Urology Trainee, Innovator and techie based at King’s College Hospital, London, United Kingdom. @jonmakUrology

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