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AUA 2014 – Monday, Tuesday, Wednesday: “The Tweeter’s Congress”

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Thanks to @rmehrazin and @uroncdoc for a great summary of the first three days of #AUA14. This year’s meeting has been a phenomenal success, especially with regards to Twitter use during the Congress and the dissemination of content surrounding the meeting. You know how it goes – ‘sorry I can’t catch your session because I have to be somewhere else’. Well not anymore. Keep the #AUA14 search feed on your Twitter app, and the stream of information on posters/podiums or plenary was tremendous! One could be at multiple sessions at the same time. Indeed, Twitter use compared to last year’s meeting has increased by over 100%. Just as Tony Blair coined the term ‘the people’s Princess’ for Princess Diana – I am calling #AUA14 ‘the Tweeter’s congress’. In honour of that, I have created ‘Twitter-grams’ around themes. As the conference has too much to cover, I will concentrate on the big plenary sessions.

Twitter-gram 2: PCNL

Further plenary included the EAU lecture by Mr Marcus Drake on the management of LUTS. He announced the protocol of a European RCT enrolling 800 patients assessing invasive urodynamics versus noninvasive tests in men undergoing surgery for bladder outlet obstruction. This was followed by Dr Quentin Clemens, from @umichurology and Chair of the multidisciplinary approach to the study of chronic pelvic pain (MAPP) network. The objectives of this impressive multi-institutional study are to address underlying disease pathophysiology and natural history utilizing patient cohorts, biospecimens and animal models, as well as provide new information to inform patient management and future clinical trial design. More details can be found here.

The plenary then wrapped up with a discussion of the new AUA guidelines from Dr Morey on urotrauma and Dr Pearle on medical management of stone disease. Both can be viewed here:

Urotrauma
Medical management of kidney stones

Some important points from the urotrauma guidelines:

  1. Imaging is necessary – immediate and delayed
  2. Indications for renal trauma imaging include gross hematuria, microscopic hematuria and systolic blood pressure <90, or mechanism of injury suggest high index of suspicion.
  3. Stable patients be managed non-invasively
  4. For renal injuries Grade 4 or greater – follow-up imaging is advised
  5. For ureteral trauma, immediate repair is indicated if complete injury and recognized in the operating room
  6. In unstable patients, ureteral trauma can be managed with temporary urinary drainage
  7. In presence of gross hematuria and pelvic fracture – patient must have cystography

Some important points from the medical management guidelines:

  1. Thiazides are indicated in patients with recurrent calcium stones and hypercalciuria
  2. Potassium-citrate therapy should be offered to patients with hypocitraturia and recurrent calcium stones
  3. In patients with recurrent calcium stones and absence of metabolic abnormalities, both thiazides and potassium citrate should be offered
  4. Allopurinol should be prescribed to patients with recurrent calcium stones elevated urinary uric acid and normal urinary calcium. It should not routinely be prescribed as first line therapy for patients with uric acid stones
  5. In terms of follow-up, a 24 hour urine collection should be performed within 6 months of initiating treatment and at least annually thereafter

Monday – Townhall session

The ‘townhall’ session this year contained urology and non-urology experts who were questioned by the audience via text messages (but not Twitter! @AmerUrological). This session was moderated by Dr Inderbir Gill, and included experts from Hollywood on 3D imaging, a neuroscientist, molecular imaging scientists and surgical simulation pioneers. The session began with a talk on tissue level imaging in 3D, followed by Dr Tewari (@nycrobotics) introducing us to his research on visualizing nerves during robot-assisted radical prostatectomy. Dr Narula, Editor of the Journal of Cardiovascular Imaging, then gave a fascinating talk on “Who gets the Heart Attack? Imaging from Bench to Bedside and from Mummies to Population”. At the end of his talk, I had a strong urge to get my cholesterol checked as well as demand a CT angiogram. The simulation debate was entitled – “The giants of the past don’t need no stinkin’ simulators” – and was between Dr Carl Olsson (Against simulation) and Dr Robert Sweet (For). Dr Olsson was the man with all the right jokes, while Dr Sweet’s slides malfunctioned; although it was clear to the audience that in this era of reduced hours training, simulated surgical training is becoming the norm. Finally, only at the AUA meeting can you get the team behind 3D rendering for Hollywood provide an insight into the methodology of rendering. We all put on 3D glasses and watched a short clip of the film “Need for speed” in glorious 3D.

Tuesday – plenary

The morning began with a panel discussion between some very well known urologists on robotic vs. open robotic cystectomy. First on, Dr Hautmann argued against robotic cystectomy: “Optimal function was more important than the length of the incision or time to flatus”. He also argued there was a selection bias in robotic series, with healthier patients tending to be selected for robotic surgery. He closed by quoting Einstein: “make things as simple as possible but not simpler than that”.

Next was Dr Pruthi, an expert on robotic cystectomy. He felt the benefit of a robotic intracorporeal diversion was fewer GI complications, readmissions, and the potential to reduce ureteral stricture because of less ureteral mobilization with the robotic approach. While the ileal conduit robotically was simple and straightforward, he admitted he was unsure of robotic neobladders as this was more complex. The session closed with a frank statement by Dr Jay Smith, “It is unlikely any substantial difference in outcome will emerge between robotic vs open cystectomy”. However, he felt robotics was here to stay, as it was doubtful if the next generation of urologists would have the skills to obtain high-level open cystectomy results.

The plenary then resumed with the theme on PSA testing, and started with a panel discussion on tests to distinguish aggressive from non-aggressive prostate cancer before biopsy. Dr John Wei (@jtwei88) from @umichurology, spoke about the Michigan Prostate Score (MiPS) – a composite score consisting of three tests: PSA, urine T2:ERG gene fusion, and urine PCA3 level. Later on, to a jam jam-packed hall, Dr Penson (@urogeek), from Vanderbilt, delivered a state-of-the-art lecture on PSA testing guidelines. This excellent talk generated lots of Twitter traffic, which is illustrated in the Twitter-gram.

Wednesday – take home messages and wrap-up

The final day was not as busy as the other days as most delegates and all exhibitors had left. I too had to get back to work, but I was still able to catch up with #AUA14 via the twittersphere (thanks @chrisfilson). The best of the tweets from this last day are depicted in the final twitter-gram. I also recommend @cbayneMD for his top 5 conference highlights.

[caption id=”attachment_15430″ align=”alignnone” width=”1024′ label=’ Twitter-gram 4: final day

Overall, #AUA14 has been a fantastic conference, where records were set for Twitter participation and engagement in a urological meeting. I am still recovering!

Khurshid Ghani
University of Michigan, Ann Arbor, USA
@peepeeDoctor

Social media traffic broke all records at #AUA14 with over 1100 participants sending over 10,000 tweets and making almost 14 million digital impressions.

 

Dusting vs. Fragmentation and other highlights from WCE 2013

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I am in the beautiful city of New Orleans for this year’s World Congress of Endourology (#WCE2013). The city indeed has a charm and vibe that is different to any other in the U.S. You feel it in the air the moment you touch down. Of course, of late it gained much infamy as the epicenter of Hurricane Katrina. The taxi driver who took me to the Sheraton Hotel where the conference is being held, tells me everything is now fixed – new roads, stronger levees. Even the Superdome looks magnificent in the night sky (now rebranded with a giant Mercedes-Benz logo). A far cry from the devastation and havoc reeked on it during Hurricane Katrina.

The meeting began with an inauguration by the local hosts – Dr Benjamin Lee and Dr Raju Thomas from Tulane University. The tagline for this meeting is ‘innovate, cultivate, celebrate’. Dr Lee did a good job in reminding us that this conference really is a multicultural success. This year’s meeting has 1900 delegates from 93 countries with 300 faculty offering a diverse mix of plenary, poster and video sessions, live surgery, courses and industry sponsored events.

Dr Mahesh Desai, President of the Endourological Society, then welcomed us, and had the unusual honor of being introduced by a live Jazz band playing to the tune of “when the Saints go marching in”. 

Dr Desai showed a picture of Raju Thomas performing retrograde renal surgery in Gujarat, India, in 1998, reminding us that this meeting is built on the hallmarks of globalization and spirit of collaboration. It is pleasing to know that the Endourology Society paid for 23 scholars from less developed nations to attend this meeting.

The plenary session kicked off with a debate on the merits of laparoscopic vs. robotic partial nephrectomy (PN) by Dr Inderbir Gill from USC and Dr Louis Kavoussi from LIJ, New York.

It was good to hear Dr Kavoussi elegantly state how important it is in medicine to assess new technologies with a critical eye. Science has progressed against this background of debate and discourse. Indeed, this week’s The Economist’s lead editorial is on the alarming lack of critical data analysis in modern science. Although I got the feeling the audience was on the side of robotic PN, it was nice to see a healthy debate on this subject by two titans of laparoscopic urology.

The plenary then moved on to a crowd favorite – difficult cases with scary videos! There was a nice presentation of a Weck clip that was stuck on a renal vein tributary during laparoscopic radical nephrectomy (LRN) with a panel discussion on how to get out of such tricky situations. Dr Rimington from the UK, discussed a case of postoperative bleeding after laparoscopic nephroureterectomy and the difficulty in deciding where to make an incision – where was the bleeding coming from: upper or lower tract? (The patient was too unstable to have a CT scan). Dr Landman from UC Irvine presented his personal agonies in the management of a patient with persistent chylous leak after LRN which failed conservative management. He reluctantly explored the patient laparoscopically many weeks later only to find a leaking lymphatic that was clipped and dealt with. I found these cases and this type of session extremely informative. One gets to hear competing arguments for case management and learn a great deal, in an environment that may be safer than the live case demonstration (LCD). The latter has been the subject of much interest in a recent BJUI blog. @JYLeeUroSMH from University of Toronto also thought so. 

The Keynote Imaging Lecture, by Dr Joseph Liao from Stanford University, was on optimal imaging technologies for urothelial carcinoma, and in particular the role of confocal endomicroscopy – a technique where images reminiscent of H&E slides are produced using small probes in contact with the urothelial mucosa. Although in its infancy, it is able to distinguish between low and high-grade lesions and provide a diagnostic imaging atlas.

Another highlight of the opening plenary was a debate on the role of renal biopsy for small renal masses. Chaired by Adrian Joyce from the UK, the pro-camp was presented by Dr Stuart Wolf, from @UMichUrology and Chairman of the AUA Guidelines Committee. The anti-camp was presented by Jens Rassweiler from Germany. Interesting facts: 25% of renal masses are benign, and of those that are malignant, 25% are indolent. Dr Wolf stated the seeding rate from a biopsy was 0.01% and the major complication rate <1%. A recent study from the University of Michigan found the sensitivity and specificity to be 96% and 100% respectively. Dr Wolf’s feeling was that it helped avoid intervention in benign or non-aggressiveness cases, and even change the treatment plan in aggressive cases (i.e. do a radical nephrectomy, not a PN). Dr Rassweiler’s thoughts were that modern day imaging was so good at diagnosing malignancy, the endpoint being surgical excision did not change with a biopsy. Mr Joyce put the outcome of the debate to the audience and the clap-o-meter favored ‘no biopsy’. I wonder what the clap-o-meter will sound like in 5 years time?

There was a presentation by Duke Herrell on imaging guidelines from the AUA for the follow-up of localized RCC. This is essential reading and can be viewed online. Finally, to end the first day’s plenary, Prof Ralph Clayman spoke about the art of innovation and his journey with laparoscopic nephrectomy. He identified six aspects that had to be fulfilled in order for a new technique to be successful: there had to be a desired future, purpose and urgency. Practically there had to be time/energy, in an appropriate environment with stewardship. It’s amazing to know that the first LRN was performed in an 85 year old patient! 

Another feature of this conference has been the “unedited videos session”. I went to one on flexible ureterorenoscopy chaired by Dr Preminger.

While the video of the case is played, both the surgeon and panel are able to have an extensive discussion on the nuances of technique. In my opinion, this is a far safer environment than the LCD. Also of value have been the various industry sponsored practical courses. One on ureteroscopy by Dr Timothy Averch @Tdave from University of Pittsburgh, was standing room only. 

Other highlights of the conference included:

A unique demonstration of the use of an iPad to help plan percutaneous access by Dr Rassweiler. 

Dr Stephen Nakada introduced a new quality of life instrument for stone patients – the Wisconsin Stone QoL tool.

A fantastic debate on “Dusting” vs. “Fragmentation” by Dr Breda from Spain and Dr Traxer from France. Dr Olivier Traxer is known for his high quality HD videos and he did not disappoint in showing great clips of endoscopic stone surgery. Take home message: Dusting settings are usually kept at 0.2 J x 20-30 Hz. Fragmentation is better with lower frequency and higher energy (i.e. 0.8 J x 6 Hz). For large stones, dust first then fragment.

Watching a live robotic partial nephrectomy by Dr Ariel Shalhav from the University of Chicago.

A great overview on the latest developments in RARP by Prof Francesco Montorsi @F_Montorsi.

Another session dedicated to renal mass biopsy (get the hint?) – and an excellent demonstration by Dr Landman on how urologists can do renal biopsies themselves in the clinic using ultrasound.

A session on innovation, and a beginners guide to patents; Dr William Roberts from @UmichUrology spoke on how to secure funding with venture capitalists. He is part of a team behind a new medical device using “histotripsy”, a noninvasive image-guided therapeutic form of ultrasound. 

Video session on “nightmares” in robotic urology: want to know what a rectal injury at RARP looks like? Or what a Weck clip applied to an obturator nerve looks like? And how to deal with these complications?

As Elspeth McDougall from USC Irvine, said during the session on simulation and training – “A smart man learns form his mistakes, but a wise man learns from the mistakes of others”.

So on that note: I feel wiser to have attended this conference. It indeed was innovate, cultivate and celebrate!

Khurshid Ghani
Clinical Assistant Professor, University of Michigan, Ann Arbor, MI
@peepeeDoctor

 

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