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Technological Innovation in the BJUI

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Time waits for no man St. Marher, 1225

Urology is arguably the leading technology driven surgical specialty. This is no accident. As surgeons we have always looked towards minimal invasion to reduce the trauma of access to our patients. One would have thought that the advent of drugs for BPH and OAB would perhaps reduce our hunger for technology.You can visit One Click Power if you are always hungry for knowing trends in technology. On the contrary, many urologists have moved on to effective alternatives to TURP such as HoLEP and having learnt the lessons from previous unproven over enthusiasm, relied on the results of high quality randomised trials before accepting the results.

The BJUI has a long history of publishing innovative manuscripts in the fields of basic science, imaging and therapeutics. We aim to bring the readership entire new paradigms in surgical diagnostics and treatment. Indeed while we enjoy #ERUS13 in sunny Stockholm, the autumn sunshine reminds us of the role played by robotics in the steady rise of technological innovation. This “sub specialty” has become so prominent that the EAU are soon accepting ERUS and its committee as an integral part of the European Association of Urology. The randomised trials, meta analysis and health technology assessments are gradually appearing in contemporary literature such that it is no longer true to say that robotics is just a fad backed up by little or poor evidence. Robotics remains one of the most highly cited parts of the BJUI and therefore together with laparoscopy has its own dedicated section. We were pleased to publish the novel method of suprapubic catheterisation as an alternative to the urethral route after robotic prostatectomy [1] which led to much conversation on the BJUI twitter page. Our readers ultimately decide whether to adopt a particular technique or technology and are now able to vote via the BJUI Poll.

Last month, Mahesh Desai demonstrated microPCNL in London. The technology is truly breathtaking. It is hard to believe that light and image transmission as well as stone disintegration can be effectively achieved via a needle so thin! We almost stopped doing robotics and were thinking of re-training to become stone surgeons. Mahesh and his team went on to back up the technology with a randomised comparison against flexible ureterorenoscopy [2]. It should come as no surprise that such an article should come from the sub-continent where stone disease is endemic.

And the technological innovations in the BJUI continue. This month we present three rather different articles for your reading pleasure. The first is an international collaboration demonstrating the ideal dose and safety of photodynamic TOOKAD therapy (a light-activated vascular occluding agent) in localised prostate cancer. Nearly 80% of patients had negative biopsies at 6 months [3]. Next we evaluate the role of PET CT in bladder cancer patients undergoing cystectomy. With almost a 20% greater pickup than standard imaging, we may be able to save a number of patients a morbid operation in the presence of metastasis. Advanced imaging may also allow better stratification of patients for neo-adjuvant chemotherapy [4]. Finally, we have an exciting paper from Iran on the use of endometrial derived stem cells for creating bladder replacements and alternatives to meshes in prolapse surgery. The immuno and scanning electron micrographic images in this paper are just stunning [5].

The BJUI intends to continue leading technological innovation in urology. We will bring our readers early phase safety data on new technologies in addition to long-term results to truly judge their efficacy and durability. We hope you enjoy reading, citing and interacting with these articles online at bjui.org and ultimately translate them to your own clinical practice.

Prokar Dasgupta, Editor in Chief, BJUI
Ben Challacombe, Associate Editor, BJUI
King’s Health Partners

References

  1. Ghani KR, Trinh Q-D, Sammon JD et al. Percutaneous suprapubic tube bladder drainage after robot-assisted radical prostatectomy: a step-by-step guide. BJU Int 2013; 112: 703–705
  2. Sabnis RB, Ganesamoni R, Doshi A, Ganpule AP, Jagtap J, Desai MR. Micropercutaneous nephrolithotomy (microperc) vs retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial. BJU Int 2013; 112: 355–361
  3. Azzouzi A-R, Barret E, Moore CM. TOOKAD® Soluble vascular-targeted photodynamic (VTP) therapy: determination of optimal treatment conditions and assessment of effects in patients with localised prostate cancer. BJU Int 2013; 112: 766–774
  4. Mertens LS, Fioole-Bruining A, Vegt E, Vogel WV, van Rhijn BW, Horenblas S. Impact of 18F-fluorodeoxyglucose (FDG)-positron-emission tomography/computed tomography (PET/CT) on management of patients with carcinoma invading bladder muscle. BJU Int 2013; 112: 729–734
  5. Shoae-Hassani A, Sharif S, Seifalian AM, Mortazavi-Tabatabaei SA, Rezaie S, Verdi J. Endometrial stem cell differentiation into smooth muscle cell: a novel approach for bladder tissue engineering in women. BJU Int 2013; 112: 854–863
Original publication of this editorial can be found at: doi 10.1111/bju.12431. BJUI 2013; 112: 707.

 

Bringing science closer to urologists

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The BJUI has always promoted the best in basic science through its ‘Investigative Urology’ section. However, the new editorial team noticed a small problem – these articles were rarely cited, probably because they were rarely read. As we started speaking to our readers, the truth became rapidly obvious. Most urologists, being clinicians, could not understand the scientific content of these articles. Here was a major challenge. How were we going to attract our surgical readership to science?

Whilst maintaining our commitment to quality, we took three bold steps in discussion with our readership:

  1. Rename the section ‘Translational Science’, so as to highlight the potential clinical relevance of the best basic science papers.
  2. Assemble an editorial team of the best clinician-scientists, not just from molecular and cellular biology but other diverse fields, such as immunology, imaging, engineering and computational sciences.
  3. Precede original science papers with ‘Science made Simple’ articles. These were inspired by the highly successful For Dummies series from Wiley.

The idea behind For Dummies is making everything easier. With >250 million books in print and >1800 titles, For Dummies is the most widely recognised and highly regarded reference series in the world. Since 1991, For Dummies has helped millions make everything easier. Now, Dummies.com is bringing the ‘how-to’ brand online, where readers find proven experts presenting even the most complex subjects in plain English. Whether that means directions on how to hook up a home network, carve a turkey, knit your first scarf, or load your new iPod, you can trust Dummies.com to tell it like it is, without all the technical jargon. For Dummies is a simple, yet powerful concept. It relates to the anxiety and frustration that people feel about technology by poking fun at it with books that are insightful and educational and make difficult material interesting and easy.

Thus we originally thought of publishing articles entitled ‘Science for Dummies’.

Thankfully during a Visiting Professorship in Detroit, one of our science colleagues politely pointed out that urologists are anything but dummies. We have to thank her for suggesting a change of name to ‘Science made Simple’. The format is straightforward – simple language, to the point, along with a simple diagram.

This month we feature an original article on gene fusions in prostate cancer in particular TMPRSS2:ERG. This is made simple by a For Dummies style explanation from Deloar Hossain and David Bostwick. You only have to see the vividly simple diagram to understand how a genetic deletion or translocation can make the joining of two genes possible. Important discoveries of the future will occur if top scientists wherever they maybe, work more closely with their clinical counterparts. We are keen to attract the best science to the BJUI by providing an attractive publishing platform to our best scientists. We also hope that you, our readers will enjoy this new format, engage with quality science in the BJUI, cite these important papers and ultimately relate to their clinical relevance for the benefit of your patients.

Dirk De Ridder, Associate Editor BJUI
Jo Wixon, Publisher BJUI
Prokar Dasgupta, Editor-in-Chief BJUI and King’s Health Partners

 

Design and the new BJUI

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One of the most exciting challenges in magazine design is updating the look of a medical journal. In the past, academic publications did not discernibly change their look, even with editorial changes. A recognised font and layout was perhaps seen to imbue trust and respect, which are important to the integrity of the journal. However, just as editorial content and practice evolves there is great potential in pushing forward design and layout in academic text for both the reader and the editorial team.

WOUND Magazine, Issue 2, Spring 2008, courtesy Ben Slater.

Beyond the content, which aims to be of the highest quality, the experience of the reader as his/her eyes ‘walk’ through the journal is paramount. Take the cover – the ‘old style’ journals serve textual content on their front cover, much like the classical paintings depicting a familiar scene. In the same vein, modern abstract pieces evoke something more intangible, more individual. This is not to say we wanted a design based in abstraction, it is in fact the opposite; we wanted the new design to be relevant to the content, the reader and the field. But we needed to break away from the past, to reflect how we are an exciting specialty and to do this we distilled the essence of The Journal into design elements that acknowledged its past but looked to its future. What you see on the new covers are our amazing treasure trove of ‘Surgery Illustrated’ images from Stephan Spitzer and Joe Thüroff, a clean new font and a subtle wave pattern separating text and image, to herald the energy and change that we are proud to be a part of at the new BJUI. More changes lie within The Journal itself. There is greater emphasis on visual relevance: photography, useful illustrations, prioritising content. Different fonts and sizes have been developed to ensure excellent readability. The gamut of section colours in previous editions has been pared down to allow greater visual cohesion. Our readers have told us that it is simply a more pleasant read, graphically speaking.

The same return to clean lines is seen in the new website, www.bjui.org. Web journals usually have a much bigger audience than the paper versions, as they are easily accessible by non-medical groups. In fact, we discovered this when we did an initial analysis of who actually visited our website: answer, a lot more patients and concerned spouses than we assumed. So easy, clear navigation, with an uncluttered, intuitive design were imperative. The effect is plain to see – the website now feels vital: in addition to fully indexed articles of the week and editorials, it has dynamic image reels, blogs, videos, archives and a social media platform, basically all the things that a paper journal cannot provide. By constantly interacting with our readership, we are at the pulse of what is happening in the urology world and our new website aims to be the best forum to do so. So imagine all this resource packed into a single landing page that adapts to any mobile device or tablet. Good design encourages the reader to stay, explore and engage, rather than become overwhelmed and look elsewhere.

In keeping with the theme of bold design, this month we feature a beautiful article from Bennett et al. accompanied by an editorial from Vincent Zecchini and David Neal. The translational message is simple – bicalutamide enhances autophagy of LNCaP cells, which in turn has a pro-survival effect. The inhibition of autophagy enhances the killing of prostate cancer cells by docetaxel chemotherapy. The article contains not just quality science but stunning images of confocal and phase-contrast microscopy, which feature prominently @BJUI.org.

The design of the BJUI will continue to evolve as we grow and explore more ways to bring our message across the global urological, surgical and scientific communities. What you see is only the start of what we aim to achieve. We hope you enjoy the journey with us.

Tet Yap
Associate Editor (Design)

Prokar Dasgupta
Editor-in-Chief

Podcasts Made Simple

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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.

The Journal that never sleeps

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Thank you all for your overwhelming support of the new web and paper versions of the BJUI. For those who have missed it, please check out the web journal at: www.bjui.org.

We hope you had a relaxing holiday period – we certainly did and recharged our batteries. Despite this, the editorial team at the BJUI handled 76 articles between Christmas 2012 and New Year’s Day 2013; an average of 10 per day.

This is a reflection of the global popularity of the BJUI. We have papers coming in from all over the world from many different time zones. Furthermore, New Year celebrations in the West do not necessarily match others, such as the Chinese New Year or the Baisakhi in the Northern Indian subcontinent. The BJUI wants to continue receiving the best papers from our authors irrespective of where they are on this planet.

As a celebration of our truly global presence we are delighted to present content from around the world at www.bjui.org as articles, blogs and videos, and we invite you to post your comments on any or all of these.

The BJUI poll shows that our readers love the ‘article of the week’, which is available completely free to everyone, everywhere.

In this issue we highlight the role of tadalafil, not just in erectile dysfunction but also in ejaculatory and orgasmic dysfunction. This article provides Level 1 evidence and is accompanied by an editorial from Mike Wyllie, our expert in Sexual Medicine.

Please keep the conversations going on Twitter, Facebook and Blogs@BJUI. Your web journal needs you.

Prokar Dasgupta, Editor-in-Chief

Ashutosh Tewari, Editorial Board

Video of Ashutosh Tewari reading the Journal in New York

Editorial: Oncological outcomes: open vs robotic prostatectomy

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John W. Davis and Prokar Dasgupta*

Departments of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA and *Guy’s Hospital, Kings College London, London, UK
e-mail: [email protected]

For men at significant risk of dying from untreated prostate cancer within reasonably estimated remaining life spans, which technique offers the best disease-free survival: open radical prostatectomy (RP) or robot-assisted RP (RARP)? The practice patterns in many countries suggest RARP, but many concerns have been raised about the RARP technique for high-risk disease, including positive surgical margin rates, adequate lymph node dissections (LNDs), and the learning curve. In this issue of the BJUI, Silberstein et al provide a convincing study, short of a randomised trial, that suggests that in experienced hands both techniques can be effective, and that surgeon experience had a stronger effect than technique. In contrast to large population-based studies, this study sought to take the learning curve and low-volume surgeon variables out of the equation by restricting the inclusion criteria to four high-volume surgeons from a single centre. The follow-up is short (one year), and may underestimate the true biochemical relapse rates, and needs follow-up study, but for now offers no difference in relapse rates nor pathological staging outcomes.

Beyond the comparative effectiveness research (CER), Silberstein et al also provide a valuable vision for prostate cancer surgeons using any standard technique. Several recent landmark studies on PSA screening, the Prostate cancer Intervention Versus Observation Trial (PIVOT), and comparisons of metastatic progression between RP and radiation, all indicate the need to shift our practice pattern towards active surveillance for lower risk patients (with or without adjunctive focal therapy, but the former still experimental in our view), and curative therapy for intermediate- to high-risk disease. Such a practice pattern is evident when you compare this study (2007–2010) with a similar effort from this institution (2003–2005) comparing RP with laparoscopic RP (LRP). In the former study, >55% had low-risk disease compared with <35% from the current study. As expected, the present study shows higher N1 stage (9%) and positive surgical margin rates (15%) than the former (7% and 11%, respectively). While erectile function recovery was not presented, the authors noted the familiar reality that patients demand nerve sparing whenever feasible, only 2% in this study had bilateral non-nervesparing and 91% had a combination of bilateral or partial nerve sparing. The number of LNs retrieved has increased from 12–13/case to 15–16, and the authors state that even with nomogram-based exclusion of mandatory pelvic LNDs with <2% risk of N1 staging, this modern cohort had a pelvic LND in 94% of cases, including external iliac, obturator, and hypogastric templates.

We fully concur with this practice pattern, and have recently provided a video-based illustration of how to learn the technique, and early experience showing an increase in median LN counts from eight to 16, and an increase in positive LNs from 7% to 18%. By risk group, our positive-LN rate was 3% for low risk, 9% for intermediate risk, and 39% for high risk. We certainly hope that future multi-institutional studies will no longer reflect what these authors found, in that RARP surgeons are five times more likely to omit pelvic LNDs than open, even for high-risk cancers.

Finally, Silberstein et al and related CER publications leave us the question, does each publication on CER in RP have to be comprehensive (i.e. oncological, functional, and morbidity) or can it focus on one question. Members of this authorship line have published the ‘trifecta’ (disease control, potency, and continence) and others the ‘pentafecta’ (the trifecta plus negative surgical margins and no complications). Indeed, Eastham and Scardino stated in an editorial that ‘data on cancer control, continence, or potency in isolation are not sufficient for decision making and that patients agreeing to RP should be informed of functional results in the context of cancer control’. We feel that the answer should be no, focused manuscripts have their merit and publication space/word limits create this reality. But we should not discount the sometimes surprising results when one institution using the same surgeons and methodologies publishes on the broader topic: the Touijer et al. paper discussed above found the same oncological equivalence between RP and LRP as this comparison of RP and RARP, but also included functional data showing significantly lower recovery of continence with LRP. Nevertheless, the recent body of work in the BJUI now provides a well-rounded picture of modern CER including oncological outcomes, complications, recovery of erectile dysfunction, continence and costs. We feel it is reasonable to conclude that patients should be counselled that RARP has potential benefits in terms of blood loss, hospital stay, and complications (at increased costs), but oncological and functional results are probably based upon surgeon experience.

Abbreviations

CER, comparative effectiveness research; LN(D), lymph node dissection; (RA)(L)RP, (robot-assisted) (laparoscopic) radical prostatectomy

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BJUI and The Urology Foundation at 10 Downing Street

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Last night, I was delighted, along with other members of the BJUI Editorial Board, to attend a reception for The Urology Foundation at Number 10 Downing Street, hosted by the UK’s “First Lady” Samantha Cameron.

The reception was attended by many eminent urologists as well as a number of well-known personalities.

The primary aim of the reception was to raise awareness for the Foundation and its work and all of us at the BJUI are happy to help in that aim.

Prokar Dasgupta, Editor-in-chief

 

 

 

The Urology Foundation issued the following Press Release:

TUF Downing Street Reception hosted by Samantha Cameron

On Tuesday 22nd January 2013, Samantha Cameron kindly hosted a reception at No 10 Downing Street, for The Urology Foundation.

The Urology Foundation is the only UK charity that covers all urological diseases. It aims to improve the diagnosis, choice and care of patients with urological diseases by supporting pioneering research and providing specialist training to improve the skills and effectiveness of UK health professionals working in urology.

Around 120 dedicated supporters and friends gathered together in the Terracotta and Pillared Rooms, to celebrate The Foundation and the exceptional work it undertakes. Speeches were given by Samantha Cameron as well as the Hon Secretary of The Foundation, the esteemed Professor Roger Kirby, who announced an exciting new Bladder Cancer Awareness campaign for 2013.

Kindly showing their support were, amongst others, Ronnie Corbett CBE who is embarking upon a radio campaign for The Foundation, Private Eye editor Ian Hislop and actors, Jemma Redgrave, Vanessa Kirby and Douglas Booth.

 

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“The most read surgical journal on the web”

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It is an enormous privilege becoming the new Editor-in-Chief of the BJUI. As an academic it has been my ultimate dream. Thank you for this exciting opportunity to serve our readers and authors. I also wanted to express my gratitude to our editorial board and reviewers without whom this journal would not exist.

Early one morning during the BAUS annual meeting 2012, I had the great pleasure of having breakfast with John Fitzpatrick. He has done wonders with the BJUI and I wish to thank and congratulate him for his excellent leadership, international collaboration and innovative approach, which has established the journal as a global landmark in urology. I asked him to describe his most important contribution to the BJUI in one word. The answer without hesitation was ‘colour’.

John immediately asked me the same question. With equal conviction I uttered the words that would describe the BJUI in the next 5 years –’the web’.

The other day I made my usual trip to the Guy’s Hospital, King’s College London, library. I love reading the new journals as well as archived copies that are stored on the first floor. I have done so regularly for the last 10 years. On this occasion I requested our friendly librarian to guide me towards the new editions of Science and the N Engl J Med. Rather to my astonishment, she said that the first floor had been shut and there were no paper journals there anymore! Instead she directed me to a computer terminal where I could browse every scientific journal with my college user name and password. It was then that I realised that my own library had stopped subscribing to paper journals. I have since learned that many other libraries have done the same. Libraries and not urologists are the largest subscribers of the BJUI. If they do not want paper journals they are just not going to buy them.

Welcome to the green revolution.

Over the next few years it will be my mission to make the BJUI the most read surgical journal on the web. We have not made the mistake of assuming that this is what all our readers want. Therefore, while we make the transition to the web, the paper version continues, but with a few differences. We will be reducing the number of paper issues to once a month. Our readers have told us that as soon as the first edition comes out of its plastic cover, the next one arrives. This is often rather overwhelming for a busy urologist who may find it challenging to find the important messages. A direct result of reducing the number of volumes is that fewer papers will ultimately be published and the acceptance rate will fall to ~15%. A triage system has been introduced whereby papers that are not felt to be suitable for the new journal are returned immediately to the authors. This is not a reflection of the quality of the papers but reduces wastage of valuable time and allows the articles to be submitted elsewhere without delay.

The BJUI website www.bjui.org has been entirely redesigned and, in keeping with our main mission statement, I have gathered a dedicated new team of enthusiastic innovators. You will notice that unlike other journals we have Associate Editors for innovation, impact, web, social media and design. These are young urologists with unique skills allowing us to deliver the BJUI on an exciting web-based platform that will evolve continuously. I hope you can join us on this journey.

The busy modern surgeon has a short attention span. If we cannot attract them to our key messages within 30 seconds of reaching our landing page, it is unlikely that they will stay there for 3 minutes rather than go elsewhere. Extensive studies and searches on web-based metrics have made these facts obvious to me. These are the realities of modern academic publishing. The web-based journal will have a much wider readership, not just amongst urologists but also other doctors, nurses, students and most importantly patients and their families.

With this in mind we have introduced the ‘article of the week’, almost like the headline news of The Times. If most urologists read just this on their iPads or smart phones, rather than ever even look at the paper version, we have successfully made our point. This month one such article is the updated Partin tables. As a predictive tool, they are important to urologists and patients alike and will allow our readers to counsel patients about the potential outcomes after treatment of their prostate cancer.

Another new feature is the BJUI blog for immediacy, HuffPost style; the days of writing a letter to the editor that gets published a year later are no more. Instead, your opinions will be moderated and appear real time on the website. The debate will be timely, educational and enjoyable.

Social media, especially Twitter, will play an important role in highlighting the most important content and allowing rapid interaction during international meetings. We have engaged the services of a group specialising in social media and I urge you to follow the BJUI on Facebook and Twitter. Who knows ‘tweetations’ might become as important as the impact factor, one day soon.

Finally, I wanted to especially thank Francesco Montorsi for inspiring me during dinner one autumn evening in Milan, where I had been invited to review a European Union grant application. The lesson I learnt from him was humility. As the Editor-in-Chief I always remember an important tale published by Hans Christian Andersen in 1837. ‘The Emperor’s New Clothes’ describes what happens when a vain king is paraded by two rogue weavers in his invisible new clothes through the streets of his own capital. I hope I will always manage to avoid the ‘emperor syndrome’. My job is to serve our readers and focus above all on the one thing that is of utmost importance to the BJUI – quality.

Prokar Dasgupta

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