Matthew Bultitude

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The Drugs Don’t Work … Or Do They?

November 16, 2017/4 Comments/by Matthew Bultitude

The Verve made millions out of the hit single “The Drugs Don’t Work” … I doubt they would have made any money if they called it “The Drugs Don’t Work … Or Do They ?” but that is where we are in 2017 with medical expulsive therapy (MET) for ureteric stones.

In 2015, “The Drugs Don’t Work” was the most read blog of the year and for that won the “Best Blog of the Year” award at the BJUI Social Media awards. And it was all about SUSPEND. The trial that changed everything. We had been giving MET out like smarties. We loved it. Patients loved it. But many of us had doubts. The evidence was weak. “Large randomised trials are needed to confirm” the authors of small trials said. And so we did it in British Urology and it did change practice for many people. Doubts crept in around the world. More trials confirmed this. The Furyk study … MET doesn’t work in Australia (apart from a small advantage on small subgroup analysis). It doesn’t work in America either. Silodosin … promising but little benefit. But wait … the NIH are doing a trial. This will confirm once and for all. And as I was about to debate John Hollingsworth at the Rock Society at #AUA17 – thrown into the lion’s den of believers – it was released, a late breaking abstract – The STONE study and NO BENEFIT TO MET. Game over … MET is dead. Even non-believers were convinced in another debate with John in Vancouver at #WCE17.

So imagine the surprise as this month in European Urology, the largest study ever conducted was released. 3450 patients. A good quality double-blind placebo-controlled RCT. The headline … Overall MET does work (86% vs. 79%). And this was judged on a fairly hardcore follow-up schedule of CT scans weekly for 4 weeks – how many people do that in their practice? On subgroup analysis stones >5mm show greatest benefit (87 vs. 75% stone passage). Stones ≤ 5mm showed no benefit (88% vs 87%) although there is some advantages for time to passage (148 vs.249 hours), colic episodes (1.9 vs.9.4%) and analgesia requirements (89 vs.236mg). So what do we do now? Firstly I suspect this has just cemented the current position of the 2017 #EAUGuidelines which already states “the greatest benefit might be among those with large (distal) stones”. I do also feel this trial requires greater scrutiny – does this really change everything again?

Some facts: 3296 patients included in the analysis. Only 15 patients declined entry to the study – that is amazing! Recruited in 30 centres in China over 2 years which finished in 2013. The inclusion criteria was for distal ureteric stones from 4-7mm (interestingly a fact not expressed in the abstract). Not 3mm; not 8mm; 4-7mm only. So a narrow window which probably represents the potential target benefit for MET. There are lots of exclusion criteria – diabetes, previous stone on that side, previous ureteroscopy on that side and ‘severe hydronephrosis’. So if the emergency departments are to follow this study they need to select stones of 6 or 7mm in longest diameter, only in the distal ureter and without “severe hydronephrosis” whatever that means. I’m not sure I totally know and I’m a urologist. Good luck to the ED docs with that one!

I need to ask, why has it taken 4 years for this to be published? There is no long-term follow-up required in this study. Outcomes should be known within 28 days. With such international controversy surely this should have been a priority to publish? Only the authors can answer this question but such delayed publication suggests to me some issue with the data. This was a company sponsored trial – so why weren’t they pushing for publication? Only they know. Company involvement to me automatically introduces a degree of murkiness about the outcomes in any trial – just look at the problem with oncology trials. Even more so when they are “involved with preparation of the manuscript”. That gives them a controlling interest in the publication of the outcomes and that really concerns me. It probably shouldn’t … the results are the results … but it still concerns me. It’s one thing supplying the medications for a trial but having control of the manuscript? What data is missing? For example, how many people in each group complied with the imaging protocols? We don’t know. How many patients didn’t undergo any follow-up imaging at all? We don’t know. How many patients did not attend (DNA) for follow-up at each stipulated week (as DNA rates are often high for colic patients)? We don’t know. Any small differences between the groups might explain the differences in final outcome. How many returned the analgesia and pain questionnaires? We don’t know. What were the compliance rates with medication? We don’t know. Importantly, why were the side-effects the same in both groups in such a big sample? That worries me a lot. This trial is powered to show small differences and even the most ardent MET supporters will concede that MET comes with a tolerable increase in side-effects – other studies have clearly shown that. That concerns me. Is that actually a surrogate marker of quality for this study?

Don’t get me wrong, other studies definitely have their limitations as well. Furyk – underpowered for larger stones. STONE – confounded by small stones? SUSPEND – real-life follow-up without mandated imaging. There is no doubt this trial will shift the balance in the debate. I thought MET was dead but, as per the EAU guidelines, MET may confer benefit for stones >5mm but in reality only those measuring 6 or 7mm – an absolute benefit of 12% for that specific group. It definitely doesn’t help stone passage for ≤ 5mm stones. It is interesting that whilst SUSPEND was criticised for having such high stone passage rates of ~ 80% – that is exactly what is seen in this paper and in a more select larger stone group. That is curious. Placebo did very well again. It’s a shame we can’t prescribe that!

What will I do? I might use MET a bit more for the carefully selected and counselled “larger stone” – I did anyway – but I certainly don’t feel we are back to giving this out to everyone who walks through the door.

Matthew Bultitude

Consultant Urologist, Guy’s and St. Thomas’ Hospital

Associate Editor, BJUI

RSM Urology Winter Meeting 2017, Northstar, California

February 17, 2017/6 Comments/by Niyati Lobo

This year’s Annual RSM Urology Section Winter Meeting, hosted by Roger Kirby and Matt Bultitude, was held in Lake Tahoe, California.

A pre-conference trip to sunny Los Angeles provided a warm-up to the meeting for a group of delegates who flew out early to visit Professor Indy Gill at the Keck School of Medicine. We were treated to a diverse range of live open, endourological and robotic surgery; highlights included a salvage RARP with extended lymph node dissection and a robotic simple prostatectomy which was presented as an alternative option for units with a robot but no/limited HoLEP expertise.

On arrival to Northstar, Dr Stacy Loeb (NYU) officially opened the meeting by reviewing the social media urology highlights from 2016. Next up was Professor Joseph Smith (Nashville) who gave us a fascinating insight into the last 100 years of urology as seen through the Journal of Urology. Much like today, prostate cancer and BPH were areas of significant interest although, in contrast, early papers focused heavily on venereal disease, TB and the development of cystoscopy. Perhaps most interesting was a slightly hair-raising description of the management of IVC bleeding from 1927; the operating surgeon was advised to clamp as much tissue as possible, close and then return to theatre a week later in the hopes the bleeding had ceased!

With the promise of beautifully groomed pistes and stunning views of Lake Tahoe, it was hardly surprising that the meeting was attended by a record number of trainees. One of the highlights of the trainee session was the hilarious balloon debate which saw participants trying to convince the audience of how best to manage BPH in the newly inaugurated President Trump. Although strong arguments were put forward for finasteride, sildenafil, Urolift, PVP and HoLEP, TURP ultimately won the debate. A disclaimer: this was a fictional scenario and, to the best of my knowledge, Donald Trump does not have BPH.

The meeting also provided updates on prostate, renal and bladder cancer. A standout highlight was Professor Nick James’ presentation on STAMPEDE which summarized the trial’s key results and gave us a taste of the upcoming data we can expect to see in the next few years.

We were fortunate to be joined by prominent American faculty including Dr Trinity Bivalacqua (Johns Hopkins) and Dr Matt Cooperberg (UCSF) who provided state-of-the-art lectures on potential therapeutic targets and biomarkers in bladder and prostate cancer which promise to usher in a new era of personalized therapy.

A personal highlight was Tuesday’s session on learning from complications. It was great to hear some very senior and experienced surgeons speaking candidly about their worst complications. As a trainee, it served as a reminder that complications are inevitable in surgery and that it is not their absence which distinguishes a good surgeon but rather the ability to manage them well.

There was also plenty for those interested in benign disease, including topical discussions on how to best provide care to an increasingly ageing population with multiple co-morbidities. This was followed by some lively point-counterpoint sessions on robot-assisted versus open renal transplantation (Ravi Barod and Tim O’Brien), Urolift vs TURP (Tom McNicholas and Matt Bultitude) and HOLEP vs prostate artery embolization for BPH (Ben Challacombe and Rick Popert). Professor Culley Carson (University of North Carolina) concluded the session with a state-of-the art lecture on testosterone replacement.

In addition to the excellent academic programme, delegates enjoyed fantastic skiing with perfect weather and unparalleled views of the Sierra Nevada Mountains. For the more adventurous skiiers, there was also a trip to Squaw Valley, the home of the 1960 Winter Olympics. Another highlight was a Western-themed dinner on the shores of Lake Tahoe which culminated in almost all delegates trying their hand at line dancing to varying degrees of success! I have no doubt that next year’s meeting in Corvara, Italy will be equally successful and would especially encourage trainees to attend what promises to be another excellent week of skiing and urological education.

Miss Niyati Lobo
ST3 Urology Trainee, Brighton and Sussex University Hospitals NHS Trust

@niyatilobo

The Drugs Don’t Work

May 19, 2015/12 Comments/by Matthew Bultitude

For those pop enthusiasts amongst you, “The drugs don’t work” – the year was 1997; The band: The Verve. For those more urologically minded, you will immediately be thinking of the recent publication in the Lancet reporting on the use of tamsulosin and nifedipine vs. placebo for the medical expulsive therapy (MET) of ureteric stones. Current national (BAUS) and international (EAU guidelines) recommend the use of MET, usually with an alpha blocker – and often tamsulosin, and it has certainly become common practice in most Emergency and urology departments certainly across the UK and likely worldwide.

There have however always been doubts regarding the use of these with many small heterogenous studies with variable inclusion/exclusion criteria, various blinding protocols and suspicion of publication bias when only positive trials get published. Regardless, the clear outcome from the Hollingsworth meta-analysis was that both alpha blockers and calcium channel blockers are effective for helping stone passage and so they crept into routine clinical use. This trial should change all of that with headline results:

No change in spontaneous stone passage at 4 weeks for either drug vs. placebo or compared against each other
No difference when analysed by stone size or location
No difference in analgesic use or time to stone passage

Aren’t those all the reasons we prescribe them? The first question of course is whether this trial is accurate. It certainly is a large trial with 1167 patients, randomised to the three double-blind arms in 24 centres in the UK. The trial (like many modern studies) is described as pragmatic. This has pros and cons. The advantages are that it replicates real life clinical practice allowing for variations in decision making (e.g. follow-up imaging in this paper) thus making it generally applicable. The downside of course is the lack of precision that this can introduce with stone passage possibly being only patient reported, or based on ultrasound, plain x-ray, IVU or CT. I guess we have to decide which type of trial we prefer, although it would be very difficult to mandate CT follow-up, with concerns about radiation safety, in this trial if that isn’t part of routine practice. Thus maybe this study is actually applicable to the vast amount of units around the world.

Secondly did it include the right type of patient? Well the current guidelines suggest using MET for any stone measuring up to 1cm in any part of the ureter … and that is what this trial did. And this is thus a strength given that it didn’t just focus on the distal ureter. Thus the trial population seems reasonable. One possibility is that if MET only works in the distal ureter (as almost all the studies only look at this), this could this explain the negative findings. Sub-group analysis of this based on location or stone size seems to suggest not unless it was underpowered to show a difference for this cohort of patients.

Whilst the odds ratios (see table) seem clear, the Forest plot shows the breakdown of subgroup by sex, stone size and location. Whilst not statistically significant, this does suggest a trend towards favouring MET for lower ureteric stones.

Thirdly, is it possible this trial is wrong … a type II error ? Well of course anything is possible, and the trial may be criticised for the follow-up mentioned above. However it does seem to provide easily the best evidence to date. Thus why has the use of MET been allowed to become routine practice based on a number of small trials all introducing inherent bias which is then amplified when a meta-analysis is performed. I guess it was the best evidence around at the time although it makes you wonder how many other interventions there are that we currently use that are based on smallish trials, and would they actually stand up to the rigour of a well conducted big multicentre trial?

My last question is will this change practice again? Well it should, but with no alternative (except time, fluids and NSAID’s) to offer patients with ureteric stones and given that alpha blockers are usually well-tolerated, I wonder whether people will continue to prescribe MET for the foreseeable future. But if we believe in evidence based medicine, and we do, then surely we should no longer prescribe MET for ureteric stones which after all is an off-licence indication.

Finally congratulations must go to the NIHR and the research team for answering a very important clinical question. Was the whole ‘MET’ story a placebo effect all along … or to quote another less well known song title from The Verve, was it “All in the mind”? The conclusion from this excellent study has to be yes.

Conflict of interest: Acted as PI for Guy’s and St. Thomas’ Hospital for this trial recruiting patients although have no part of study design, data analysis or publication.

Matthew Bultitude

Consultant Urologist, Guy’s and St. Thomas’ Hospital

Associate Editor, BJUI

EAU 2015 Review Days 1 and 2

March 23, 2015/1 Comment/by Rebecca Tregunna

The 30^th anniversary EAU congress is currently taking place in the beautiful but rainy city of Madrid with over 12,000 delegates attending. The opening Friday proved a monumental day with the start of the congress as well as personally as I gave into the pressure of social media, and joined Twitter. This is being heavily promoted by the EAU this year and with multiple engaging sessions going on at the same time this seemed to be the best way to have my cake and eat it and enjoy highlights from different parts of the meeting.

The second ESO prostate cancer observatory was well attended and led to interesting debates about PSA screening and informed consent due to risks of over-detection and subsequent overtreatment of indolent disease. Indeed Andrew Vickers also highlighted that the results of the much anticipated ProtecT trial should be interpreted with caution given the high number of Gleason 6 patients that have been randomised.

In the evening the opening ceremony took place with an emotional final introduction to the congress by Per Anders Abrahamsson as he steps down and hands over to Chris Chapple as EAU Secretary General (photo courtesy @uroweb).

The EAU also gave out a number of awards including the Crystal Matula award for promising young urologist which was given to Morgan Roupret.

The scientific programme on Saturday started with the main plenary session on controversies in bladder and kidney cancer. It is difficult to draw conclusions regarding lymphadenectomy in upper tract tumours due to a lack of randomised data but certainly based on retrospective data a benefit is seen both in terms of staging and cancer specific survival. A hot topic lecture on molecular profiling in bladder cancer gave a thrilling insight into how agents will be able to target pathways based on specific mutations and Professor Studer, in his last ever plenary session, led to an interesting debate on robotic vs. open radical cystectomy. This has caused much controversy recently with the Bochner randomised controlled trial and this debate will surely run and run. Maybe most importantly, as Studer concluded “The surgeon makes the difference not the instrument”. This was highlighted on the front cover of the congress news with a more downbeat headline on robotic cystectomy.

Next came an intriguingly titled talk “What would Charles Darwin make of renal cell carcinoma?” with discussion about the heterogeneity of renal tumours making it difficult to identify specific targeted treatments based on renal biopsy alone.
Multiple section meetings then ensued. From the EAU section of urolithiasis (EULIS) meeting it seems that PCNLs are increasingly being miniaturised with development to mini, ultra-mini and micro procedures. The issues behind “diabesity” and stones were discussed with Professor Reis Santos predicting an epidemic of stones either due to uric acid stone formation from obesity or calcium oxalate formation from malabsorbative bariatric procedures. There was also a recurring theme with poster and podium sessions on “ESWL – is there still a role?” While the argument is made for ESWL there is no doubt that worldwide treatment rates for ESWL are falling.
As the EAU Section of Female and Functional Urology there was an excellent series of talks on mesh and mesh complications. There was a fantastic review of dealing with these complications through a variety of approaches and techniques and whether all these should all be dealt with in high volume centres. Unfortunately, no one knows what high volume means for this. Interestingly the terminology is changing, moving away from ‘erosion’ to ‘exposure’ and ‘perforation’. Removing the mesh only relieves associated pain in 50% of cases and these dedicated centres need to offer multimodality treatments to deal with pain and ongoing continence issues.
In the parallel EAU section meeting of Genito-urinary Reconstructive Surgeons, Professor Mundy gave a personal 30 year series of 169 patients treated with both clam cystoplasty and artificial sphincter. The majority of complications were related to the sphincter. The largest subgroup was patients with Spina Bifida but were the patients with the best outcomes.
David Ralph in the EAU Section of Andrology stated that shunts were ineffective after 48 hours after priapism and that a prosthesis instead should be inserted to prevent corporal fibrosis.
The EAU section of Oncological Urology also heard that 68Ga-S+PSMA-PET improves detection of metastatic lymph nodes in prostate cancer and can be used intra-operatively in radioguided surgery for targeted lymph node dissection.
Overall the organisers have done a fantastic job with a well organised meeting and a great venue despite the disappointing weather. There were sessions that people could not get in to as the rooms were full.

However, with live TV screens outside those rooms and transmission to an adjacent overflow room this didn’t seem to matter too much. Much to look forward to for the rest of the conference #EAU15.

Rebecca Tregunna, Speciality Trainee, Burton Hospitals NHS Foundation Trust, West Midlands Deanery. @RebeccaTregunna

Matthew Bultitude, Consultant Urologist, Guy’s and St. Thomas’ Foundation Trust; Web Editor BJU International. @MattBultitude

Digital Doctor Conference 2013

January 28, 2014/1 Comment/by Nishant Bedi

Digital consumerism is progressing relentlessly and whilst the advantages of new technology are evident in our personal lives, there is a palpable air of concern amongst the medical profession. “The Digital Doctor” team are positively embracing the benefits of moving healthcare into a new era and hope to direct the use of new technology in a constructive manner that will benefit both healthcare professionals and patients. To achieve these aims the “Digital Doctor Conference 2013”, was held for its second year last November, again kindly sponsored by the British Computer Society and held at their excellent headquarters in Covent Garden, London. The conference was attended by IT professionals, doctors, medical students and patients; thus group sessions contained some perspective on every aspect of healthcare technology. The organisers are also an eclectic mix of doctors and IT professionals, united by their interest in improving Health IT.

The conference included plenary talks, interactive group sessions and workshops. Eminent plenary speakers included Martin Murphy, Clinical Director at NHS Wales Information Service.

Martin challenged us to redefine our relationship with our patients in a new era where clinical information will be in control of patients and access to healthcare professionals can be as easy as a click away. Currently, services like those at rocketdoctor.ca are now properly stablished and operating everyday. Adapting to this change works the same way as medicine has always done. Implementing new technologies to improve medicine is and always has been a top priority, looking only to more effectively save or better lives.

Software mediated care – implications for our patients and ourselves from Digital Doctor on Vimeo.

Popular teaching sessions at the conference were daily life IT tools, including the “Inbox Zero” philosophy, how to collaborate online, keeping up to date with RSS readers and Stevan Wing gave an introduction to the open-source “R project” for statistics. Other sessions focused on how to develop IT systems. This insight is useful both to allow healthcare professionals to construct their own IT solutions but also to help translate ideas to IT professionals. One such example being Sarah Amani, who used her experience as a mental health nurse to develop a mental health app for young people, called “My Journey”. In her inspiring plenary, co-presented with Annabelle Davis who developed the Mind of my Own app, she makes the point that the vast majority of young people rely on email, social media and online services therefore this is the best place to reach them. A session giving the methods and practicalities of developing IT systems was given by Rob Dyke, Product Development Manager of Tactix4. To help delegates get their ideas to reality Ed Wallitt, one of the organisers and the founder of Podmedics, built on earlier sessions about how to code, how a website works and information design, explaining how to use wireframes and prototypes, to achieve professional design of websites and apps.

Existing NHS IT systems were explained using the example of an emergency patient admission. Tracking the patient journey from home to hospital, via A+E, then transfer to ward, rehab back home, with GP clinic the final destination. At each stage a different IT system is employed such as the emergency 999 network and the N3 private network. Concepts such as the NHS spine were introduced and explained. A complex web of systems were shown to be in use, with numerous safety mechanisms; providing some explanation as to the difficulties faced by employees in the NHS.

Delegates were able to implement this teaching in the “App factory”, to solve problems they face in daily life or work. Three app ideas were created and presented by separate teams. These were a teaching log for doctors to record teaching sessions and simultaneously get feedback from students, a productivity app to provide useful information for new doctors to know about any hospital, however the winning idea was a patient facing app for use in hospital, to track updates in ongoing care.

In another session Matthew Bultitude, an Associate Editor of BJUI, was invited by Nishant Bedi (another organiser) for his vision of the future of medical journals. Journals are key in shaping the way medical practice is conducted and the dissemination of information is as important as ever in the digital age. Paperless journals may be the future however traditional business models rely on paper journals for revenue and many journals have yet to feel confident in moving all of their content exclusively online. Yet there are signs of change with European Urology adopting a paperless format for members from Jan 2014, now surely others will follow?

Under new leadership, the BJUI has recently focused on revolutionising its online presence, starting with a complete website overhaul. Amongst many changes to its design, the website now hosts an article of week, user poll, blogs and picture quiz. Numerous metrics for the website now show significant improvement in website visitors, duration of visit (1 to 3 min) and “bounce” rate. The increasing importance of social media for health professionals is demonstrated by the fact that more than ¼ of website traffic now arrives from Twitter and Facebook, having previously been dominated by search engines. Matthew finished by discussing alternatives to impact factor, such as the journal’s “Klout” score or “individual article” metrics, which are likely to be increasingly important as medical journals develop more web and social media presence. Extremely accurate individual “article level metrics” are calculated by checking number of views, tweets and re-tweets, and mentions in review sites (such as F1000 Prime). It is clear to see how powerful this could be, for example when discussing viewing numbers and duration of reading, Matthew can inform us that currently BJUI Blog articles are each read for a total of 5 min, with even the 15th most popular article receiving almost 500 views.

This talk was paired with one from the futuristic journal “F1000 Prime”. This journal provides an extra layer of expert peer review, using scientific articles that are already published in other journals. Thus articles selected by F1000 Prime direct users to the most significant developments in their chosen field, the expert reviews of the articles include an article rating, relevance to practice and whether there are any new findings. Research has shown that selection of an article by F1000 Prime, is an accurate indicator of future impact factor. Users may also receive email alerts of recommended relevant papers and they are able to nominate articles, follow the recommendations of an expert reviewer. Also refreshingly, any submissions to the journal, receive a completely transparent peer review process, openly available to any user.

Conference attendees were given the patients’ perspective of Health IT, by a panel chaired by Anne-Marie Cunningham (another organiser). These real life stories, gave insight into the mindset of people suffering from demanding chronic disease, both at home and in the hospital. Importance is given to people taking ownership of their health; both rare and common diseases were mentioned including Addison’s disease, asthma and mental health issues, where 24 hour support is an unfulfilled requirement and there is a need for a more integrated approach. Positive examples were given with one patient gaining reassurance by regular home peak-flow monitoring that can be reviewed remotely by her respiratory consultant. This helps to determine optimal timing for clinic review, with other similar examples seen in home blood pressure or blood sugar monitoring. Importantly social media and support groups can provide 24 hour advice and connect patients with expert doctors or similar sufferers all over the world. It was clear that the lack of hospital WiFi disconnects some patients from their online support networks, when they are actually most vulnerable. Other complaints centred around the underuse of email appointments and text alerts, which could empower patients to chase their own appointments or scans.

Delegate feedback suggests this conference is unique and covers a rapidly expanding area of Medicine. We look forward to the next conference in 2014. The Digital Doctor 2013 conference program and highlights are available from the website or directly on our vimeo chanel. For updates and upcoming events follow us on Twitter @thedigidoc and the podcast is available from iTunes or our website.

Mr. Nishant Bedi
Core Surgical Trainee (Urology), West Midlands Deanery

Dr Stevan Wing
Academic Neurology Registrar, East of England and The University of Cambridge

Annabelle Davis

Out with the old; In with the new. Stats and metrics: The BJUI website 2013

January 27, 2014/2 Comments/by Matthew Bultitude

Is it already over twelve months since the new Editor took over and the new BJUI web journal was launched? The old one had served its purpose well but the editorial board had decided the change of leadership dictated a clean new website would be launched in January 2013. Decisions were hard. Out went non-journal content such as case reports and in its place we created four main content areas with the aim of maintaining fresh, regularly changing content. These (article of the week; BJUI blogs; picture quiz of the week; BJUI poll) you will by now be familiar with, but how has the new web journal performed? Let’s look at the metrics over the last year.

The BJUI website prior to 2013

Firstly, most of the figures referred to in this article are for the www.bjui.org site only. They do not include direct access to the journal articles in the Wiley Online Library where the issues are stored. Thus analysing overall visitor numbers is not that valid and doesn’t allow for meaningful comparison. However, it appears there has been an increase in web visits of at least 10%. When we drill deeper, this is where we really notice a change. Readers now spend on average over 3 minutes on the site per visit. This is a dramatic change from previously – in 2012 the mean visit duration was just 87 seconds!

More and more people today decide to get involved with an online business, due to the fact that having a business operated through the internet offers a lot of advantages over doing it the traditional way. Online business means that you can do business right at the comforts of your own home. Thus, there is no need for you to get dress and step out of your house to earn a living. However, there are many important things that you need to learn more about in getting your online business off the ground. One of which is the creation of your own website, and the need to obtain hosting, in order to get it launched onto the World Wide Web. With so many employees working from home it’s understandable that so many businesses are now using software to monitor online activity as this means that staff can be easily managed.

Knownhost web hosting can be obtained through a company who have its own servers, where websites are hosted. In other words, a hosting service is one of the necessities in getting your own website visible through the internet. For sure, there are many ways that you can have your own web page today, such as creating a free blog or a free website. However, in most cases, these types of services are limited and having one of those pages does not mean that you entirely own them, since another website is actually hosting it.

In a nutshell, website hosting is very important because you simply could not launch your own website without having it. The hosting service provider is the one that will provide you with the space where you can upload your files that are related to your site, and they are also the ones who will ensure that your website is visible to people when they type your site’s address on their favorite web browsers.

Since there are a lot of web hosting service providers available in the market today, selection is very important in order to get associated with a reliable one. When you are able to obtain a hosting account from a reliable provider, you will be able to avoid loss of sales caused by downtimes. There are actually hosting service providers, which do not have reliable servers. In other words, they encounter a lot of downtimes, and because of that, your business would lose a lot of sales opportunities. This is because server downtimes mean that your website would not be visible on the net during those times. Thus, people who are suppose to make certain purchases, may decide to buy the items from your competitors.

In relation to that, aside from the importance of hosting for your online business, you should also become more aware of the importance of selecting a reliable web host; and one of the best ways to do that is by learning about the features of the hosting account that they can offer to you.

Geographically, the top country by visit is the United States with 22% of all visits, closely followed with the UK (21.6%) with Australia third. In total there were visits from 189 countries with both India and Japan making the top 10 (numbers of visitors) emphasising the journal’s global reach. This is truly an international journal.

Global subscriptions to BJUI represented as a “heat map”

Another major difference we have noticed is in bounce rate. This refers to the percentage of people who leave immediately after visiting the page they landed on i.e. if everyone only looks at the first page they come to then the bounce rate would be 100%. In 2012 the bounce rate was 66% – and this has improved significantly to 50% in 2013. This rate is never going to be very low – people come directly to a blog, quiz or just go straight onto the author guidelines or an article on Wiley Online Library. But to see such a reduction is encouraging and vindicates the approach we have taken with the web.

When we look at traffic sources, again we see another big change. This is how the visitor came to the site i.e. do they type in the web address, use a search engine or get driven to the site by social media. As you might expect, the largest single source of traffic (45%) is from Google – these visitors also spend over 3 minutes on the site with a bounce rate of 40% – so the site is not being found by accident and readers move onto other pages. 24% of traffic is direct but what is new behaviour is that 12% is from Twitter and 6% from Facebook – so social media is now driving nearly 20% of all website traffic. Facebook visitors also spend over 4 minutes on the site – they come for a reason! Of course there are the quirks – a men’s health magazine drove 1% of visits to a specific article on penis extenders! Those readers aren’t urologists as they only spend 16 seconds on the site with a bounce rate of 99.4% – this, however, does give credibility to the use of these statistics.

Apart from the homepage, the majority of social media-driven traffic is to the blogs. This has been highly successful with regular topical blogs and comments. Blog traffic has been high with the most popular (Melbourne Consensus Statement) receiving over 6500 views and 58 comments. Whilst this is clearly the highest, the top 8 blogs all have over 1000 views. Time spent on these blogs is high with several being read for an average of over 6 minutes. In January 2014 we added widgets to our blogs that allow you to see the number of reads each blog has received, and also to allow tweeting and Facebook liking directly from the blog. Blogs posted prior to this time also have these features but the number of reads prior to January 2014 are not displayed. With this section being so popular are Letters to the Editor dead?

In a recent poll, we asked you what single feature you had liked best. Exactly equal with 34% were the blogs and the free Articles of the Week (which have also been popular in the web metrics with over 13,000 views). Picture quizzes have been successful with over 10,000 views. These demonstrate a shorter time on the page as one would expect (100 secs) but also a lower bounce rate (48%) – these readers often go elsewhere on the site. The video section has also been popular with over 2000 views although obtaining good quality videos is challenging and we encourage authors to submit video with their articles to further drive this section.

How does this translate to actual journal article downloads? Interestingly our approach has led to an increase of over 35% in full text downloads from Wiley Online Library compared with 2012. This is exciting and shows the web journal has been very successful not only in driving website activity as described above but also in promoting core journal content.

So for 2014 we have a new App to view the journal. Currently only on the Apple platform (80% of mobile devices used in 2013 to view the website were Apple), this is free to download although requires a log-in to view full content (available via your institutional subscription, from Wiley or from your society). It works really well on the iPhone as well as the iPad and allows access to not only the monthly journal but ‘Early View’ articles as well. This is already my preferred method for reading the journal and I highly recommend trying it.

With high-quality web and mobile interfaces, the question has to be are we ready to go paperless? As the Web Editor I should of course say yes. We discussed this at length at our first board meeting in November 2012. Due to our diverse international readership it was felt to be too early for such innovation. This will inevitably happen and another major urology journal has taken this step in 2014 (€60 supplement for the print version of European Urology). It is surely only a matter of time until digital is the standard platform. Hopefully you, the readers, will tell us when the time is right.

Matthew Bultitude
Associate Editor, Web

Clinicians and their cameras

October 3, 2013/9 Comments/by Matthew Bultitude

15 years ago, many people reading this blog won’t have even had a mobile phone! Fast forward to today and we wouldn’t leave home without it. Not content with just having a phone, we now crave the multimedia functionality of smartphones which dominate the market. With this ability to spread and share information so easily comes medico-legal dangers, not only for individuals but also hospitals concerned about patient confidentiality for which they are corporately responsible.

Not long ago, taking a picture of a medical condition for any purpose was a major effort. Contacting the medical photography department of the hospital would take an age and often the moment would be lost. Things began to change with affordable digital cameras although images were usually stored in one location on that camera, often locked away. This situation has altered completely with mobile phone now offering cameras capable of extremely high quality photography (I don’t own one but the Samsung Galaxy S4 possesses a 16MP lens offering far greater resolution than my digital SLR which is only a few years old and Nokia have just released a 41MP cameraphone!). Here you will get the brief idea about the wired vs wireless security system. Suddenly if we see an interesting condition, we can whip our phones out, take a picture and immediately send it round the world on social media platforms. Even if the photos are just stored on the phone, with these being such desirable objects for thieves, this poses a significant risk to loss of that data and potential breach of patient confidentiality. It used to be that CCTV cameras were all that was required to ensure that things ran well in terms of security within a business. Tough circumstances, on the other hand, necessitate even harder measures, which necessitate the installation of detection and alarm systems. The fact that these commercial access control systems are available in a number of models is the nicest part about them.

So where am I going with this ? Well, I read with interest a recent article on “Clinicians and their Cameras” in Australian Health Review 2013. In this survey of one hospital in Australia, one fifth of clinicians reported using their personal mobile phones for medical photography. The authors describe as “endemic” the non-compliance with policy requirements for written consent for these images. Only 6% disposed of the images according to hospital protocol. What is scary is that I suspect the use of personal mobile phones may be under-reported!

There are many benefits to being able to immediately take a medical image in an appropriately consented patient. It may allow a condition to be tracked e.g. serial photographs of cellulitis; or allow discussion with a senior doctor where the most salient image e.g. the infected wound or an x-ray could even be sent to the consultant at home to review. These moments require spontaneity or the chance is lost.

Many hospitals, certainly in the NHS in the UK, completely ban the use of mobile phones for photography. This is an understandable corporate response to the problem which includes consent, confidentiality, appropriate use, storage and disposal.

Medical staff clearly need to be aware of the ethical issues and regulations regarding the use of medical images. The European Commission has found that collection of medical data and maintenance of medical records fall within the sphere of Article 8 of the European Convention on Human Rights. Thus failure to comply with regulations not only contravenes policy from your employer and regulatory body but also breaches the patients human rights. In the UK the Data Protection Act states that all organisations have a legal obligation to protect personal data which would include an individual taking images on any device and thus non-compliance also breaks the law.

The General Medical Council (GMC) in the UK has guidance on visual and audio recordings of patients. This makes clear the following points:

Appropriate consent must be obtained. This seems obvious although the guidance does say that separate consent is not necessary for images of internal organs, images of pathology slides, endoscopic images, x-ray and ultrasound images. These maybe used for “secondary purposes” without seeking consent if appropriately anonymised and non-recognisable. However this only applies if they are taken as part of the patient’s care. Images for research, teaching or training require appropriate consent which should be stored with the image.
All images should be anonymised/coded for storage. What mechanisms exist for this in your hospitals?
Images should be stored securely and follow local procedures and protocols. Fine in principal but how does this work in practice?
Recordings or images form part of the medical record. So if we do take an image we are responsible for ensuring it is accessible as part of the medical record.

But what about the unexpected finding in the middle of a case? The GMC guidance is clear: In this situation “you must not make recordings for secondary purposes without consent”. So you need it in advance if you are going to do it.

This study suggests that the use of mobile phones for photography in hospitals is commonplace and local protocols are not met. This is likely to be a widespread problem in hospitals in many countries. In my hospital the policy is clear: NO PHOTOGRPAHY ON PHONES OR PERSONAL DEVICES IN THE HOSPITAL. Any breach of this is a disciplinary offence. This prompted the following response from one of my colleagues: “This is ridiculous on many fronts. Bad for patient care, bad for education”. From a managerial perspective I can understand this. From a clinician’s point-of-view, I find this very sad with multiple opportunities lost for improving patient care and medical education. In a highly regulated workplace these rules are likely here to stay and we must all ensure we are compliant with them to avoid potential disciplinary action. I would be interested in the experiences and opinions of readers from other hospitals and countries.

Matthew Bultitude
BJUI Associate Editor

EAU Annual Meeting 2013 – Final thoughts

March 20, 2013/1 Comment/by Declan Murphy

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 11-15^th 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

March 18, 2013/by Matthew Bultitude

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.

Podcasts Made Simple

March 4, 2013/by Prokar Dasgupta

The other day we were listening to a podcast of a surgical technique; sadly, it sounded like a report from the BBC’s war correspondent in Afghanistan. The static was considerable and the recording of poor quality, as if transmitted by radiophone from a remote part of the world.

In keeping with our pledge to improve the quality of the BJUI, we present here a simple method of recording and submitting podcasts of the highest quality from your home or office. The results are obvious on bjui.org, where you can listen to a 60-second podcast on successful podcasting, in the BJUI Tube section. We encourage authors who have had their papers accepted to try this simple trick. We look forward to receiving your podcasts, which may enhance your articles in the right circumstances.

If you use an iPhone you should select the preinstalled ‘Voice Memo’ app. Similar apps are available for Android and other systems.

Simply tap ‘record’ when you are ready and start talking. Remember to breathe normally and speak in an even tone.

Once you are happy with your recording, simply use the share button to submit the file to us using our editorial office email address: [email protected]

In this issue, the Article of the Month is by Cooperberg et al. who present an analysis of the lifetime cost-utility of treatments for localised prostate cancer. This is a timely and controversial paper with an accompanying editorial from Pickard and Vale, who have been involved in a number of Health Technology Assessment. Cost-effectiveness ratios are now as important as clinical effectiveness although it does not necessarily mean that cheaper is always better. You can also enjoy a YouTube video provided by the authors to accompany their article in the BJUI Tube section of our website. To promote immediacy, we request you to add your comments to Blogs@BJUI. These will eventually replace the current section entitled Letter to the Editor. The debate needs to be topical and timely and not a year on when hardly anyone can remember what the original fuss was all about.

Prokar Dasgupta
Editor-in-Chief

Matthew Bultitude
Associate Editor, Web

Disclaimer: The BJUI does not support any particular smart phone. That choice is entirely up to our readers. Who knows, you may even decide not to have one, hence here is the paper version of our simple trick.