Nathan Lawrentschuk

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USANZ 2018: Melbourne

March 7, 2018/by Sophie Rintoul-Hoad

G’day! The 71^st annual USANZ Congress, was held in Melbourne and had the biggest attendance on record for the past 6 years. The Urological Nurse’s congress: ANZUNS ran concurrently, encouraging multi disciplinary learning. An excellent and varied educational programme was masterminded by Declan Murphy, Nathan Lawrentschuk and their organising committee. Melbourne provided a great backdrop and soon felt like home with a rich and busy central business district, cultural and sporting venues, the Yarra river flowing past the conference centre, edgy graffiti and hipster coffee shops, plus too many shops, bars and restaurants to visit.

The programme included a day of masterclasses on a range of subjects, including: urological imaging, advanced robotic surgery with a live case from USC, metastatic prostate cancer and penile prosthetics. These were well attended by trainees and consultants alike. The PCNL session (pictured) with Professor Webb was popular and he generously gave his expertise. The session was supported by industry and provided an opportunity to use the latest nephroscopes on porcine models and innovative aids to realistically practice different puncture techniques.

Two plenary sessions were held each morning covering the breadth and depth of urology and were well attended. Dr Sotelo is always a highlight; he presented, to an auditorium of collective gasps, a unique selection of ‘nightmare’ cases His cases gave insight in how intraoperative complications occur and how they can be avoided. Tips, such as zooming out to reassess in times of anatomical uncertainty during laparoscopy or robotic surgery have great impact when you witness the possible consequences. Tim O’Brien shared his priceless insights on performing IVC thrombectomy highlighting the need for preoperative planning, early control of the renal artery and consideration of pre-embolisation. His second plenary on retroperitoneal fibrosis provided clarity on the management of this rare condition highlighting the role of PET imaging and, as with complex upper tract surgery, the importance of a dedicated team.

Tony Costello’s captivating presentation covered several myths in robotic prostate surgery, plus the importance of knowing your own outcome figures and a future where robotics will be cost equivalent to laparoscopy. Future technology, progress in cancer genomics and biomarkers were also discussed in various sessions. One example of new technology was Aquablation of the prostate; Peter Gilling presented the WATER trial results suggesting non-inferiority to TURP. A welcome addition to the programme was Victoria Cullen (pictured), a psychologist and Intimacy Specialist who provides education, support and strategies for sexual rehabilitation. She described her typical consultation with men with sexual dysfunction and how to change worries about being ‘normal’ to focusing on what is important to the individual.

Joint plenary sessions with the AUA and EAU were a particular highlight. Prof Chris Chapple confirmed the need for robust, evidence guidelines which support clinical decision making; and in many cases can be used internationally. He suggested collaboration is crucial between us as colleagues and scientists working in the field of urology. Stone prevention and analysis of available evidence was described by Michael Lipkin; unfortunately stone formers are usually under-estimaters of their fluid intake so encouragement is always needed! Amy Krambeck presented evidence for concurrent use of anticoagulants and antiplatelets during BOO surgery and suggested there can be a false sense of security when stopping these medications as it isn’t always safe. She championed HoLEP as her method of BOO surgery and continues medications, although the evidence does show blood transfusion rate may be higher. She also uses a fluid warming device which has less bleeding and therefore improved surgical vision; importantly it is preferred by her theatres nurses! MRI of the prostate was covered by many different speakers, however Jochen Walz expertly discussed the limitations of MRI in particular relating negative predictive value (pictured). He eloquently explained the properties of cribiform Gleason 4 prostate cancer and how this variant contributed to the incidence of false negatives.

Moderated poster and presentation sessions showcased research and audit projects from the UK, Australia, New Zealand and beyond, mainly led by junior urologists. The best abstracts submitted by USANZ trainees were invited to present for consideration of Villis Marshall and Keith Kirkland prizes. These prestigious prizes were valiantly fought for and reflected high quality research completed by the trainees. Projects included urethral length and continence, no need for lead glasses, obesity and prostate cancer, multi-centre management of ureteric calculi, mental health of surgical trainees and seminal fluid biomarkers in prostate cancer. This enthusiasm for academia will undoubtedly stand urology in good stead for the future; this line up (pictured) is one to watch!

The Trade hall provided a great networking space to be able to meet with friends and colleagues and engage with industry. It also hosted poster presentation sessions, with a one minute allocation for each presenter – which really ensures a succinct summary of the important findings (pictured)! It was nice to meet with Australian trainees and we discussed the highs and lows of training and ideas for fellowships. Issues such as clinical burden and operative time, selection into the specialty, cost of training, burn out and exam fears were discussed and shared universally; however there is such enthusiasm, a passion for urology and inspirational trainers which help balance burdens that trainees face. Furthermore, USANZ ‘SET’ Trainees were invited to meet with the international faculty in a ‘hot seat’ style session which was an enviable opportunity to discuss careers and aspirations.

In addition to the Congress I was fortunate to be invited for a tour and roof-top ‘barbie’ at the Peter Mac Cancer centre; plus a visit to Adelaide with Rick (Catterwell, co-author) seeing his new hospital and tucking into an inaugural Aussie Brunch. Peter Mac and Royal Adelaide Hospital facilities indicated an extraordinary level of investment made by Federal and State providers; the Peter Mac in particular had impressive patient areas, radiotherapy suites and ethos of linking clinical and research. However beyond glossy exteriors Australian public sector clinicians voiced concerns regarding some issues similar to those we face in the NHS.

Despite the distance of travelling to Melbourne and the inevitable jet lag the world does feels an increasingly smaller place and the Urological world even more so. There is a neighbourly relationship between the UK, Australia and New Zealand as evidenced by many familiar faces at USANZ who have worked between these countries; better for the new experiences and teaching afforded to them by completing fellowships overseas. The Gala Dinner was a great chance to unwind, catch up with friends and celebrate successes in the impressive surrounding of Melbourne Town Hall (pictured); the infamous organ played particularly rousing rendition of Phantom of the Opera on arrival.

The enthusiasm to strive for improvement is similar both home and away and therefore collaboration both nationally and internationally is integral for the progress of urology. The opening address by USANZ President included the phrase ‘together we can do so much more’ and this theme of collaboration was apparent throughout the conference. The future is bright with initiatives led by enthusiastic trainee groups BURST and YURO to collect large volume, high quality data from multiple centres, such as MIMIC which was presented by Dr Todd Manning. Social media, telecommunications and innovative technology should be used to further the specialty, especially with research and in cases of rare diseases – such as RPF. Twitter is a tool that can be harnessed and was certainly used freely with the hashtag #USANZ18. Furthermore, utilisation of educational learning platforms such as BJUI knowledge and evidence based guidelines help to facilitate high quality Urological practice regardless of state or country.

So we’d like to extend a huge thank you to Declan, Nathan and the whole team, and congratulate them for a successful, educational and friendly conference; all connections made will I’m sure last a lifetime and enable us to do more together.

Sophie Rintoul-Hoad and Rick Catterwell

Publons – Now Part Of Your Verifiable Online Digital Curriculum Vitae

November 9, 2017/by Nathan Lawrentschuk

Last year I introduced Publons via a BJUI Blog . It is pleasing that Wiley, the publishers of the BJUI, have now partnered with Publons to make digital archiving and verification of reviewer (and editorial) work easily accessible with a mouse click once a review is completed.

So, what is Publons again? Perhaps a brief reminder: Just as PubMed collates publications, Publons collates peer reviews you have performed and verifies you did them. With one hyperlink you may go to all of your reviews listed by date and under sections of journals. In addition, Publons also allows you to showcase to what editorial boards you belong. It also now allows editorial board work to be collated and rewarded.

I can do this all myself, can’t I? Well yes you can but this service is free and offers third party verification of peer reviews. This is important in the era of fake news. You also find out when an article you reviewed is published.

Publons is important because until now it has been difficult to track and quantify the hard work done by reviewers that is all pro bono. Getting credit for reviews is important and this website finally acknowledges that fact. Finally you can compete with other colleagues (all friendly of course). For those with editorial roles for journals the handling of manuscripts can also be collated to again get credit. A final side point is that making your reviews public is possible should you choose to do so (and gets your more points) but that is an individual (and sometimes journal) decision.

Reminder how to access and use Publons:

1) The journal may be aligned with Publons (as BJUI now is) so just click the box at time of review (see example here):

2) Simply forward your official thank-you receipt email as below to [email protected] and they will do the rest (example here):

3) I can’t find the emails- is there any way of back tracking to reviews done over the years? Yes- take screen shots of your “Official Journal Dashboard “like this de-identified one below and send to reviews@publons (I have done this and it works quite well but you may need to take more than one screen shot per page to make it more easily digestible)

4) You can ask a journal to email you a summary and provided they send enough detail Publons will look at it and probably accept it (I have not done this but heard it may work)

So there you have it. The variety of methods is straightforward. A new Publons dashboard will be created and is easy and documents well which journals you have reviewed for and when.

What are the Publons awards? We can see here in the example of Prof Henry Woo (urologist, Australia) whom has reviewed many papers (see his total score and review numbers). Publons also ranks overall reviewer status and within different reviewers topic sections. It also gives “awards” each quarter to the best reviewer overall, best from your university etc. The value of such awards is likely to rise each year as more people use the Publons platform.

Are there other benefits? Well for Editors and Publishers to be able to tap into key reviewers will be extraordinary moving forward.

So its easy and free to join and benefit from Publons and the earlier you start the easier it is to track your digital online CV. Get credit and build your online presence (it allows a photo and short biography and links to your ORCID identification) and gain a sense of accomplishment by being a peer reviewer- without whom journals would not exist. It is also quite fun to see how your colleagues are ranked (or others from your country, specialty and university) and also the ridiculous number of reviews people from different fields has done.

Nathan Lawrentschuk PhD MBBS FRACS

Associate Editor BJU International/Editor USANZ BJU International Supplement

University of Melbourne AUSTRALIA

Capitalising On Our Strengths: The 70th USANZ ASM

March 14, 2017/by admin Z.9

Canberra, our nation’s capital and the host city for the 2017 USANZ ASM, is a gem in its own right, but one which was created to satiate two feuding states locked in a bitter rivalry. In 1908, Canberra embodied the very meaning of compromise and collaboration, a technique which has garnered much success for our Country over the ensuing 100 odd years. Arguably the first official Australian collaborative effort, this way of thinking has become an almost uniquely Australian attribute and a strength imbued in our national pride.

Canberra from up high, a breathtaking backdrop for a fantastic USANZ ASM.

Given this year’s mantra of: “Capitalising on our strengths” It is perhaps fitting then, that the 70^th anniversary of the Urological Society of Australia and New Zealand (USANZ) Annual Scientific Meeting (ASM) including the Australia and New Zealand Urological Nurses Society (ANZUNS) 22^nd ASM, should be held in such a location. In addition to providing some wonderful tourist opportunities for guests including the War Memorial, the National Gallery and Parliament House.

Convenors A/Prof Nathan Lawrentschuk and Kath Schubach went to great efforts to successfully welcome both national and international guests and Scientific Program Directors A/Prof Shomik Sengupta and Carla D’Amico ensured a star-studded academic program addressing contemporary updates in Urological evidence based practice, which were aptly discussed both inside and outside the confines of the National Convention Centre.

Senior YURO members standing outside Parliament House (from left to right): Dr. Daniel Christidis, Dr. Tatenda Nzenza, Dr. Todd Manning, Dr. Shannon McGrath

The representation by International faculty was exceptional, with countless urological household names from world leading centres across the globe both involved in the academic program and socially. Urological goliaths including Prof. Christopher Chapple, Prof. Prokar Dasgupta and Prof. Laurence Klotz weighed in on various topical issues providing an intercontinental perspective that complimented the equally impressive national line-up of speakers.

As with previous years, use of social media was rife, with those not able to attend kept in the loop via #Usanz17 and a steady stream from the ever focused twitterati. The ASM provided more than 5 million impressions and over 2800 individual tweets from more than 400 participants. The usual suspects were eminent as always, along with a few newcomers who provided impact in their own right. The official USANZ 2017 App also kept participants up to date via timely notifications and was user friendly.

Guests were spoilt for choice in the convention centre during well timed breaks, which was perpetually abuzz with attendees networking. In the background the ‘Talking Urology’ team headed by Mr Joseph Ischia and A/Prof Nathan Lawrentschuk provided a steady stream of captivating interviews with guests, regarding a myriad of urological topics. Simultaneously, numerous academics gave brief summaries of research posters during allocated presentation sessions. Exhibitors provided a captivating backdrop for these activities including many hands-on simulators and challenges for those keen to test their dextrous mettle. All the while guests relished a variety of delectable culinary options.

Guests networking at the Gala Dinner, whilst being entertained by opera classics in the Great Hall foyer of Parliament House

The meeting’s common themes were strong and pertinent to contemporary urology. They centred around collaborative research efforts such as the ANZUP trials group and the Young Urology Researchers Organisation (YURO), technology especially PSMA PET and social media and social justice including women in urology and operating with respect. Discussions were directed by chairpersons during purposefully allocated Q&A times at the conclusion of each session, a new and well received addition to this years meeting. This was generously embraced by both senior and junior academics and led to intriguing symposiums and at times heated debate.

USANZ 2017 Friday Highlights

The first official day of proceedings provided a smorgasbord of morning and afternoon workshops ranging from technical skills courses to the medico-legal implications of E-Health and technology. This was followed by an allocated networking session for Urology trainees with International faculty.

Officially opening the conference in the Royal Theatre of the convention centre, A/Prof Lawrentschuk introduced this year’s Harry Harris orator; Elizabeth Cosson, AM CSC. Her speech entitled “leading with grit and grace” eloquently detailed her journey in the armed forces and highlighted the difficulties of the unmistakably imbalanced workplace for women in the military. Her talk clearly underlined her role in not only forging a highly successful career for herself but also for those women following in her footsteps. Her inspiring dialogue was synchronous with contemporary issues surrounding Urological practice, especially concerning equality for women but more resolutely, appropriate equity both in training and established practice.

With the tone well established for an exceptional meeting, guests enjoyed a variety of canapés and drinks in the exhibition hall, unwinding with social discussion.

YURO President, Dr Todd Manning talks to young researchers with help from Prof. Henry Woo and A/Prof. Lawrentschuk during the YURO annual meeting

Saturday Highlights

Plenary sessions aplenty began the second day of proceedings with International academic giants including Prof. Klotz, Prof. Chapple, Prof. Traxer and Prof Nitti mixed in with National heavy hitters such as Prof Frank Gardiner, Mr Daniel Moon and outgoing USANZ president Prof. Mark Frydenberg.

Afternoon sessions included subspecialty discussions and some stellar Podium Poster presentations, with an especially impressive mix of senior and junior researchers regarding countless and diverse urological topics.

Sunday Highlights

Heralding the beginning of another exceptional day, the ‘Women in Urology’ breakfast symposium chaired by Dr Anita Clark along side distinguished panellists including Dr Caroline Dowling and Dr Eva Fong was a conference stand out for many.

Following this, more plenary sessions filled the remainder of the pre-lunch program, leading into the highly anticipated Keith Kirkland and Villis Marshall presentations by Urology SET trainees. The presentations did not disappoint. As in previous years, research of unyielding professional and academic quality was offered by the group of future urologists, who as is tradition weathered the gauntlet of probing and tough questions from the floor. All presentations were captivating in their own right. 2017 Villis Marshall winner Dr Marlon Perera presented ground-breaking research regarding the reno-protective role of zinc in contrast nephropathy. Dr Amila Siriwardana was deservedly awarded the Keith Kirkland award for his multicentre retrospective review on Robot assisted salvage node dissection to treat recurrences detected by PSMA PET.

Following these presentations, the YURO annual meeting once again heralded a complement of enthusiastic, innovative and clever minds from all Australian states, eager to pursue research opportunities through collaborative means. Joined this year by Prof. Henry Woo, the group was fortunate to receive his valuable insight and feedback regarding past success and future direction. The group solidified upcoming positions of leadership and highlighted new directions in educational, research and mentorship avenues for younger members.

The Gala Dinner is a stand out affair during each ASM and this year was no exception. Guests were provided with the unique opportunity to see Australia’s Parliament House from the inside. The night began with surprise operatic renditions of many well known classics in the spacious foyer of the Great Hall and culminated with a climactic performance of Nesson Dorma. Guests then enjoyed a delectable 3 course meal in identical fashion to a rare collection of political royalty including; Barack Obama, Prince William and the Duke and Duchess of Cambridge.

Twitter metrics tabulated from the conference via the #Usanz17 (courtesy of Symplur LLC)

Monday Highlights

The final day of proceedings saw once again provided an array of interesting and thought provoking topics. The clear highlight of the morning was the metaphorical prize fight between Mr Joseph Ischia and Dr Shankar Siva debating the roles of surgery and radiotherapy in Oligometastatic disease. Although these two went toe to toe over many rounds, the inevitable conclusion was understandably a draw. Although on PowerPoint slide pictures alone, Dr Siva’s extensive use of Star Wars based analogies won my vote.

Insight and introduction to the 71^st USANZ ASM was then delivered and as a Melbournian my bias was admittedly hard to hide. Attendees received a taste of the excitement to come, with what is assured to be another blockbuster cast of national and international urologists led boldly by Convenor Mr Daniel Moon and Scientific Program Director Prof. Declan Murphy. I for one, eagerly anticipate the return of the ASM to out Nation’s culinary and cultural capitol and I’m sure guests in 2018 will be captivated by the world most liveable city!

It can be said with certainty that this years USANZ 70^th ASM presented a scientific program as strong as ever within a fascinating and historical backdrop and complimented by a lively social atmosphere. This consensus of a highly successful meeting, I’m sure was shared by all.

I look forward to seeing you all next year and hope you are eagerly anticipating the ‘flat whites’.

Dr. Todd G Manning, Department of Surgery, Austin Health, Melbourne, and Young Urology Researchers Organisation (YURO), Australia. Twitter: @DocToddManning

Publons: Giving Credit For Peer Review

April 4, 2016/4 Comments/by Nathan Lawrentschuk

Peer reviewing of journal articles may be one of the most unheralded and feel at times as the least rewarded of continuing medical activities we do. People give time, expertise and judgement to make articles of a higher scientific standard and are crucial to the nature of medical publishing. As an Associate Editor of the BJUI, I am aware of the significant contribution reviewers make. I also review myself for many journals. For me it is one of the best forms of learning we have available to us. This was made even more apparent at the recent peer-reviewing workshop just prior to the EAU in Munich, where reviewers were delighted to learn of the possibility of a verifiable metric of reviewing.

Most journals provide recognition of peer-review work by publishing lists of reviewers, often collating CME credits and points or even the ability to provide a letter of reference when asked.

Third-party collation and recognition of peer-review work has until recently been lacking. This means to ‘prove’ one has indeed reviewed for a journal we would have few options apart from possibly saved emails thanking us for our good work. Publons has many aims but chief is to do just that – provide a platform where there is authenticity and recognition for peer review.

How to do it?

Go to www.publons.com
Register (free)
Upload a photo, short biography and your academic affiliations (Figure 1 and 2)
Enter in your editorial board positions (the Journals you have reviewed for will be added by Publons once verified – Figure 3)
Add reviews

The final point of adding reviews has been made relatively easy – it is automated and quick.

The official emails you have received over the years (which of course you carefully filed away…) stating “thank you for your review of the journal article entitled … Manuscript number …‘ just need to be forward to [email protected]

This will then, within a few days, be placed into the system. You will get an email notification. The partner publishing organizations (e.g. Nature publishing group) have their logo which makes it look all the more official (Figure 3)

Now for those of us who have not kept all of the ‘thank you’ emails, a second way is to go to each journal you have reviewed for, log in to the reviewers dashboard. Take screenshots and send as a JPEG (be careful to include your name as part of screenshot for verification). This may take a small fiddle to cut and paste to a word document if you have multiple shots. You can then send as PDF or photo etc. Again email the attachment to [email protected]. The website has provided rules on the types of proof or verification they will accept but they are pretty open to suggestions if there is an issue.

The review records are collated (Figure 4) and then a chance to upload your review. This type of open access is only in its infancy and not mandatory.

To make it more interesting there are award merits, which are a nice touch. Each review gets you three merits. Prizes are awarded quarterly and displayed on your profile page (Figure 1). They are categorical or may be within your country or university. Remember in this environment everyone doing peer review is represented so you are up against engineers, theologians and the like in some categories. The opening of reviews with ‘extra merit points’ available, although noble, is unlikely at this stage to have uptake. The peer-review process is fragile enough and this may need to be reworked. Perhaps “open review” bonus merit points could be separated out as it seems unfair to penalise reviewers as most are single or double blinded in any case and will not wish to open. Publons goals of promoting discussion and interaction are fine but after having spent time doing the reviews and not getting remuneration, it is somewhat counterintuitive to want to take more of your valuable time on a review – but it may suit some (read more on history of Publons here)

In time it is likely that Publons will become the Pubmed for peer reviewers. Relationships will form with publishers and hopefully it may become a network for peer reviewers and a tool for handling editors. Overall a wonderful initiative and a great step to recognize and hopefully enhance peer review, which is a sacrifice many of us make – but for the good of medicine!

Nathan Lawrentschuk, University of Melbourne, Australia

@Lawrentschuk

That’s what’s wrong with you and your ‘Star Wars’ generation

August 10, 2015/2 Comments/by Nathan Lawrentschuk

Just a few years ago whilst operating, I was curious to find out about one of our unit’s patients on the ward. We still had a bit of time to go in the current case, a retroperitoneal lymph node dissection. There was a chance the patient on the ward would require surgery and being at that time of the day an earlier ‘heads up’ is always best. One of the theatre staff kindly paged our resident. It was 5.05pm. No response. The other resident who was scrubbed directed them to get the resident’s mobile phone and call direct. This did not seem unreasonable – perhaps they were tied up. Maybe the phone could rouse him? Ring ring… Finally an answer. It’s the urology team wanting an update from the ward. “Sorry I’m in the car”. Have you rounded yet? Sort of. Is there a handover? Silence. We’ll call you back later!’

I was astounded at two things – the resident having clearly left without giving a handover in person (or verbally) and the fact that they appeared to have left without the customary afternoon ward round being conducted. I grumbled and sent the other resident up to check on the patient. Was I becoming one of those ‘grumpy old surgeons ‘ whining at the ‘youth of today’? I didn’t think so as what was expected was probably the minimum expected.

Fast forward two weeks. Same time being 5.05pm and the same resident actually appears in person to give handover (were they learning?) I couldn’t miss the chance to poke at him “What a surprise – you’re still here and it’s after 5pm!” The scrub nurse and registrar and Anaesthetist all laughed having been there when he was in the car on the prior occasion. Clearly smarting he quipped “That’s what’s wrong with you and your ‘Star Wars’ generation”… “What do you mean? what’s wrong?” I quizzed. He thought… then responded: “You all think you are the only ones who have worked hard and that all Gen Y doctors are lazy… You guys shoe-box all of us… .”. I pointed out I was miffed that he had left without handover. He claimed all was fine with the ward and had no real excuse for not giving handover but no ill effects happened and the patient in question avoided theatre. “Only just” I added.

All the while the ‘Star Wars’ jibe had gotten under my skin. His blatant and underhand use of the name of a movie that was perhaps the “God amongst Gods” being a classic tale of good and evil that had delivered many new words and ideas and music to at least one generation…

I took my time. So wanting to get it out of my system I chose my words carefully: “So you say ‘I’m part of the ‘Star Wars’ generation’ so that must make you… part of the ‘Avatar’ generation?” He paused… “That’s right – you are exactly right”. This was potentially going to be fun.

OK. “So remind me, who were the lead characters on Avatar? The female lead Avatar?” Deafening silence…. “What about the actors’ names?” … Silence…… I then pointed out it was embarrassing given one was Australian and I couldn’t help but point out the other I quickly recalled being Sigourney Weaver!

Maybe I was being a bit hard – “OK, what was the mineral they were mining on their planet?” Silence …….”unobtainium!” I yelped… “Who could forget that? Alright give me a line from the movie, any line?” Silence …. “Alright hum me the ‘Theme to Avatar'”… Again, silence.

I paused, then in a friendly way with a wry smile, I stated: “May the force be with you!” and gleefully hummed the well known Star Wars theme… as he ducked off….

So was this reinforcing the stereotypes that Gen Y is all flash and glamour with No Substance?

Probably not, but it teaches us that one generation is not that far from the next (the other resident a Gen Y knew more about Star Wars than I did!!). And subsequently I have had some of the best residents ever. So it is all about attitude and understanding what is required. The resident really lifted their game after this, which was excellent and they ended up with a great report – having taken on board the veiled but constructive “criticism”.

Honesty and communication is the best policy, sometimes laced with humour and by doing this “Help them, you will”.

Nathan Lawrentschuk @lawrentschuk

University of Melbourne, Department of Surgery and Ludwig Institute for Cancer Research, Austin Hospital and Peter MacCallum Cancer Centre, Department of Surgical Oncology, Melbourne, VIC, Australia

Radiation within urology: challenges and triumphs

March 6, 2014/by Nathan Lawrentschuk

As gatekeepers urologists remain at the frontline of urological oncology in a position of trust that they have held since Charles Huggins, Nobel Laureate in Urology, pioneered the use of hormone manipulation to treat prostate cancer. However, radiation within urology is an important adjunctive, palliative and even primary treatment method for many urological malignancies. However, within many spheres, particularly internationally regarding prostate cancer, tensions appear to have been simmering between urologists and radiation oncologists. Fortunately, this does not appear to be the case in Australia and New Zealand but it is an important time to reflect on such issues as we move ever forward in the multimodality era.

In the USA the use of self-referral by urologists of men for adjuvant radiotherapy (RT) has come under scrutiny. Some urology groups have integrated intensity modulated RT (IMRT), a RT treatment carrying a high reimbursement rate, into their practice. This was highlighted in a recent New England Journal of Medicine article where the rate of IMRT use by urologists working at National Comprehensive Cancer Network centres remained stable at 8% but increased by 33% among matched self-referring urology groups [1]. This study has been criticised for bias but nonetheless captured political and academic attention. Certainly this situation has not arisen in our hemisphere but it remains important we think critically of what treatments we offer our patients and ensure patient’s best interests are maintained.

Clearly more research is required as to who should be receiving adjuvant RT and at what stage. In the latest issue of the BJUI USANZ supplement we highlight the Radiotherapy – Adjuvant vs Early Salvage (RAVES) trial for prostate cancer biochemical failure and high-risk disease [2]. There is no doubt this is an important trial because to date we have been unable to establish exactly which patients should receive adjuvant RT and when. Recruitment has been challenging as patients doing well after surgery often do not want additional treatment and a very small subset who are still recovering want to be enrolled but due to timing missing eligibility. Enthusiastic patients also may demand treatment rather than be randomised. Critics would also argue that the trial can never really answer the question because many men not requiring adjuvant RT will receive it [3]. Ongoing support of all parties should achieve accrual and in time, robust data. Excitingly imaging with MRI and other modalities will ensure further trials to assist in identifying disease in the salvage setting making choices easier based on more objective data [4].

Read the USANZ Supplement

Consumerism has driven robotic surgery [5] and is doing the same for RT but descriptions of treatment would be better placed to remain generic. The use of the term ‘radiosurgery’ has highlighted the shift away from the term ‘radical radiotherapy’. Of course the term ‘robot’ has become synonymous with radical prostatectomy but the ‘radical’ contribution remains and interestingly the term ‘robot’ has been trialled by radiotherapists: ‘image-guided robotic radiosurgery’ or its other more commonly used term Cyberknife^® (Accuracy Incorporated, Sunnyvale, CA, USA). Certainly this would be more accurately known as stereotactic body RT (SBRT). It is these terminology changes and continual shifts in treatment regimens that rankles many, with the old argument that RT treatment was done with inferior technology so results should be ignored receives disproportionate use at conferences. All groups need to acknowledge treatments have improved rather than disowning data from older treatment regimes. On the counter side one example from brachytherapy [6] concluded that despite the hype of improving dosimetry and reducing complications, the preoperative condition regarding erectile function and LUTS are the most important factors regarding postoperative outcome. This is almost certainly true for surgery as well. Comparison of side-effects appears unfair with grading of radiation toxicities more lenient than Clavien listed complications – an even playing field for comparison of complications is warranted.

Multimodality treatment for high-risk disease is becoming the standard of care. Urologists are beginning to embrace this regime of planned surgery with likely RT and ultimately systemic therapies. However, radiation oncologists often prefer to use radiation and hormonal manipulation and consider this ‘modified monotherapy’. Some men receive different modes of RT with concerns this leads to significantly more complications and in combination with androgen deprivation comes with all of the secondary effects of such therapy. An ideal study for such high-risk patients would randomise men to RT and androgen deprivation vs a graded multimodality treatment starting with surgery and then progressing to RT and systemic therapies when required (as some men will have T2 or T3a disease with clear margins that can be observed for a PSA rise necessitating treatment).

Complications do develop after any therapy and urologists are expertly placed to deal with them. Yet, there is a belief that RT and its long-term effects are real and these are often underplayed. This is contributed by a paucity of follow-up data beyond 5 years with primary RT. Major problems from surgery are generally able to be repatriated. However, the same may not be stated for RT complications: cystitis, stricture disease, permanent catheter drainage and chronic pain syndromes although uncommon, are not rare events and not easily remedied due to the altered tissues. Urologists are able to assist with these conditions but some feel that their efforts are unrecognised and that they share too much of the burden from somewhat surprised patients when situations are not able to be satisfactorily resolved. This reinforces the involvement by enthusiastic urologists with the patient selection and follow-up of brachytherapy and even other RT treatments being the cornerstone for ideal patient management and success.

Other areas worthy of engagement are with patients who develop a recurrence after RT treatment where the available data are sparse, making a decision even more difficult [3]. The perceived reluctance to refer RT failures to urologists in a timely fashion meaning many men are not offered salvage surgery or other options [7]. Occasionally urologists do the same with surgical failures but with multi-disciplinary teams, this is a rare event.

Communication remains a key to a multidisciplinary approach. Against the successes and strains, there are newer developments that will conspire to bring teams closer together, such as newer systemic therapies and the consideration of RT in men with oligometastatic disease. Also, based on Surveillance, Epidemiology and End Results (SEER) data, it appears that patients with limited metastatic disease may benefit from having treatment of the primary disease with a significant decrease in mortality (slightly more pronounced with surgery than radiation) [8]. This will ensure further debate on how far we stretch our primary treatment boundaries for the betterment of patients. Finally, use of fiducial markers and spacers will hopefully minimise morbidity and these are discussed in this supplement [9].

Just like any long-term relationship, the balance will shift at times and there has to be give and take on both sides. Many of the points in this editorial could be switched the other way with urologists at fault, so we must always be careful to be global, and not focal in our approaches. With everyone working together we have improved outcomes and survival of many with many urological malignancies. Overall, there is still harmony but room for even greater communication and collaboration as we strive towards better outcomes in future decades.

Nathan Lawrentschuk
University of Melbourne, Department of Surgery and Ludwig Institute for Cancer Research, Austin Hospital and Peter MacCallum Cancer Centre, Department of Surgical Oncology, Melbourne, VIC, Australia