Rajiv Singal

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Urology in Zomba, Malawi. Reflecting on surgical care in a Resource-Limited country

June 28, 2016/13 Comments/by Rajiv Singal

At the recent AUA meeting in San Diego as at all of our major meetings, a tremendous amount of data was presented and technology displayed to advance our specialty. Walking through exhibit hall one sees an expensive bauble at every turn. The advancement of urology over the last 50 years has been remarkable. We have a lot to be proud of. I think we have the most interesting, exciting specially in all of medicine. Urologist are generally technophiles and have always loved to push surgical procedures to new heights. From robotics, lasers and endourology to advancing the molecular understanding of disease, urologists have always aimed to drive the bus.

As many of you know, I am on a short trip to Malawi Africa. I have written about this elsewhere. I am here on one hand as a board member for Dignitas International. On the surgical side it is not a mission under the guise of anyone but rather my own personal attempt to understand what urology and surgery in a resource poor country might look like. I have been here in Zomba, Malawi and working at Zomba Central Hospital, which is one of four central hospitals in the country.

A goal has been to try and assess what the basic urological needs might be in this part of the world and see how I could help bridge the gap, whether it would be with equipment, external manpower or ultimately by improving training and leaving something sustainable. I optimistically set out, confident in my abilities to eventually network and bring colleagues together and establish over time a reasonable urology program that at least resembles something familiar. I have the COSECSA guidelines on what it takes to establish a training program at my side. Perhaps nothing illustrates what a daunting task this will be like my days in surgery this week.

To start with, a typical OR at ZCH requires some refocusing compared to what I am used to. My DaVinci robot is nowhere to be seen

I made ward rounds with my clinical officer yesterday and lined up several TUR type cases to try and do, with men bleeding from bladder tumours (all invariably Bilharzial disease) as well as men in retention. Some have had catheters for months, even years.

First there is the set up. No discussion about lasers and lifts or any other such fun. We don’t even have the 3L irrigation bags. For my irrigation set up, with a little water and some chlorine pucks we are ready to go.

My first patient was a TURBT. A very large, incompletely resected lesion, actively bleeding. I clearly left disease behind but perhaps he won’t bleed for a while. The tissue will not be sent to pathology. Patients need to pay 16,000 MWK for it. The typical pay for many is 20,000-30000/month and 1$USD=700 MWK. Managing him from any even rudimentary oncological perspective is a non-starter.

The second patient also had a bladder tumour. It was palpable as a mass to just under the skin. Again, the goal was to stop some bleeding, at least for a few weeks. He almost certainly has metastatic disease but I have no way to image and know for sure. I did order a chest xray to look for obvious pulmonary nodules. He will eventually just quietly die.

Before I could start a third case I found myself in the gynecology OR 2 weeks after a hysterectomy post-delivery for bleeding. Following an injury, the left ureter was leaking. I attempted the repair as best as I could with no proper light, no electrocautery no retractors and no ability to stent my freshly re-implanted ureter. All of this on an HIV+ve new mother. I hope it heals open. I am not sure if it will. I have come to understand that ureteral injuries are a not uncommon consequence of obstetrical care in Malawi.

My third patient had a TURP which was fairly straightforward. He should hopefully void assuming reasonable residual bladder function. He has had a catheter in place for months.

At least we did do some work Thursday. On Tuesday my four patient list turned into one as my anesthetist did not attend. Before surgical care can be improved, the critical shortage of anesthesia care has to also be addressed. I also wrote about that earlier.

I did bring a surgery checklist to ZCH on Tuesday.

And Thursday in follow up, I gave a talk to the surgical team about checklists and so that is certainly good.

They keep asking me to see men in the clinic with catheters. With the inefficiencies of late start times, anesthesia shortages and only a week to go, most will get left behind. It is really a depressing thought.

My OR team though is there to help and keen to learn.

Daniel, Rex (T Rex) and Maryeuster

As I reflect on my experience in the operating room during week one I am struck by how discordant what I saw in San Diego was from the realities still faced in much of the world. Basic endoscopic equipment does not exist. Serendipitously, a retired colleague of mine did bring some basic equipment a few months ago and this one set, washed and then resterilized (in a pail of chlorinated water) is all that we have. I am still not clear what happens when the loops wear out.

I do question when we pull millions of dollars and much intellectual capital into improving technology and chasing robots as to what are we really doing to benefit the care of our urological patients on a global scale. Do we have some obligation as champions of mens’ health and urologic care more broadly, to play a part? I do wonder whether some of our intellectual energy and financial resources could be better spent simply bringing parts of this world even into the 1970s. If this was valued as worthy of academic support and promotion the way oncology, endourology and everything else is in our specialty is, then some of the bright young minds in our field might move this along further. Whether we do a robot prostatectomy retroperitoneally or intraperitoneally, debate about a Rocco stitch or tweak this or do that, these changes are often incremental at best. Supine versus prone PCNL? Who cares. Other parts of the world I think deserve some of our high-level expertise to meet their complex challenges. I would invite the urological community to try and collectively address this problem. Should we keep pouring all of our massive resources only to steady, incremental benefit? Clearly we always must advance the body of knowledge and the state of the art. However, is there a role for reserving some resource and energy to advocate for simpler things that could affect a change on the order of several magnitudes? Some of the easier things we might do is to at least act as advocates and lead some process change whether it be a surgical checklist, counting instruments and sutures pre and post operatively and ensure better preoperative screening and post-operative care. Updating equipment and building surgical expertise necessarily follows.

Laser TURP? Plasma button? Urolift? The men in Malawi and much of Africa would be happy just to get rid of their catheters.

We often joke about our ‘first world problems’. It’s time to get serious.

Let’s do better.

Dr Rajiv Singal is a Urologist at Michael Garron Hospital and an Assistant Professor in the Department of Surgery at the University of Toronto

Follow him on Twitter at @DrRKSingal

To read more about Dr Singal’s experience in Malawi follow this link https://www.rajivsingal.com/blogCategories/view/malawi-june-2016/

Movember and the Importance of Patient Advocacy

October 25, 2013/8 Comments/by Rajiv Singal

In October 2009 the resident on my service was Dr Dean Elterman. I have had many residents and fellows over the years and have always felt that as much as they hopefully learn something from me I probably learn more from my time with them. The concept of ‘drilling down’ to make lasting connections with leaders of the next generation is not something that is always intuitively grasped in the hierarchy of surgical life. As it was, in late October of that year Dean mentioned Movember to me and asked whether I would like to participate. At that point, not knowing what he was talking about I proceeded to tell him to consult his spell-check. Having once before sported facial hair in my early 20s to very little acclaim I had not entertained the thought since. My immediate reaction was dismissive. Nevertheless after some further discussion it became obvious to me that the whole concept of Movember is not simply to raise money for men’s health and prostate cancer research but to generally shine a brighter light on the nature of the disease, the work we do as urologists and to start a dialogue. This grassroots movement, started in 2003 in Australia by Adam Garrone has quickly grown into a worldwide phenomenon. That fall I anchored Dean’s team of residents and we broke into the top 20 of small teams worldwide.

Last year I set up a local team at Toronto East General Hospital with tremendous success. On an individual level I raised $46,000 in support of men’s health, the seventh highest individual total worldwide. While that certainly was nice, as the month wore on what became increasingly clear to me was the larger role that my involvement in Movember had created in engaging patients, other healthcare providers and society at large. The quirky nature of the campaign lends itself to a fun, easy discussion about an important topic. Having a dialogue around prostate cancer including how to screen as well as when and when not to treat is very important. The significant emotional and physical consequences of treatment deserve attention. A particularly great example by the terrific @docmikeevans illustrates the space that Movember now inhabits. The role that urologists in particular have as advocates of men’s’ health is very clear.

It is with this last thought in mind that I call upon my colleagues in Canada and around the world to take up the charge. In recent years, much of the progress that we have made in treating prostate cancer is at risk of being undermined. The confusing and rather opaque nature of screening guidelines have increasingly promoted prostate cancer as an indolent disease not worth having a discussion about. I certainly have previously written about this and recently a group of experts met in Melbourne and attempted to better make sense of screening and stratify risk. Prostate Cancer Canada, an important advocacy group in Canada has also done a great job this fall with their #knowyournumber campaign. I was proud to be a part of it. Their CEO Rocco Rossi has embarked upon a terrific campaign of support by walking the Camino to Santiago de Compostella this month. All leaders must actively embrace the role of advocacy for our patients. Movember to me is a great vehicle for this. Will you look silly and unprofessional in the clinic during Movember? Absolutely not. In reality, every patient in the clinic is immediately reassured that their urologist walks along beside them, although perhaps not as far as Rocco.

It is in this context that I would call on all of my urological colleagues to stop shaving in Movember, start a team, create a network and share this experience with our brave patients and their partners for a month. The amount raised is really secondary. Having that visible presence is crucial. With epidemiologists, policy makers and many others expressing expert opinions about a disease that we treat every day don’t you think we should also embrace that role? Movember is the forum where the most important group, our patients, will be having that conversation for a month. Join them. Simply caring for them after diagnosis or waiting for a research grant to materialize is not good enough. My female colleagues can join as ‘mo-sistas’. You can certainly follow my ‘progress’ and support my venture as well. I look forward to seeing my colleagues from around the world and the self-described #urotwitterati that contributes regularly on #urojc in particular to join in the fun. I expect to be pushed on the leaderboard.

Dr Rajiv Singal is a Urologist at Toronto East General Hospital and an Assistant Professor in the Department of Surgery at the University of Toronto

Follow him on Twitter at @DrRKSingal

Canadian Urological Association annual meeting at Niagara Falls

July 1, 2013/6 Comments/by Rajiv Singal

The Canadian Urological Association held its annual meeting in the city of Niagara Falls, Ontario from June 22-25, 2013. Traditionally this meeting signals the start of summer in Canada and after a prolonged cool and wet spring the hot weather arrived as everyone convened. The central location in our vast country assured that the meeting was well attended with attendance far exceeding expectations. Even though I probably have seen this place two dozen times since childhood the physical spectacle of this natural wonder of the world never fails to awe.

Even renewing acquaintances with the venerable old Maid of the Mist after many years provided a memorable experience.

The meeting started on Saturday and as with other international societies, many specialty sections held their meeting on this day. These included the Canadian Urological Oncology Group (CUOG) as well as the Canadian Endourological Group (CEG). A Multi-Disciplinary Collaborative meeting for Genitourinary Cancers also took place. Canadian urology has long enjoyed a fruitful and respectful relationship with our radiation and medical oncology colleagues. The featured speaker of CEG was Dr. Brian Matlaga from @brady_urology who spoke about the role of technology assessment and health economics and how they will intersect to alter care in the treatment of urolithiasis over the next decade. I suspect the same debate will occur in many other domains of our specialty. The first of many Educational Forums also began on Saturday with a review of the management of castrate-resistant prostate cancer.

Sunday served as the formal start to the meeting with the first plenary sessions and a number of abstracts presented. Dr. Patrick Walsh from Hopkins was the keynote speaker to start things off and gave an outstanding evidence-based review as well as personal account of where we are in prostate cancer care and how we can work to improve things.

Day 1 ended with the annual CUA fun night. The CUA annual meeting has always enjoyed a reputation for being a very social meeting. Our country is relatively small and the urological community is well connected. While everyone took advantage of walking behind the falls in tunnels within the Niagara Escarpment the highlight of the night was the debut of the band “The Void”. Six talented urologists from across the country held court and provided a very high-calibre performance to the delight of everyone. They have been hired back for #cua14 in St Johns Newfoundland and I suspect will offer a member’s discount.

Monday June 24 brought more great abstracts and vigorous discussion. A major highlight for me was an outstanding talk given by @Robert_Uzzo of @FCCCUroOncology on the management of renal cell carcinoma in the elderly. It was a tour-de-force that was in large part philosophical discussion on managing risk and probability in clinical decision-making supported with good evidence. It was a talk that could easily be applied to most of what we do as urologists.

Dr. Andrew Macneilly the long-time program director at the University of British Columbia gave the CUA Scholars Fund address that surveyed training of residents and implications in a future environment where job prospects may be tight and where concerns about whether we have adequate volumes to teach operative skills will continue to grow.

As with the AUA and EAU the Canadian Urological Association has a well-established set of guidelines. New guidelines approved at this meeting include:

1. Management of Castrate Resistant Prostate Cancer
2. Postoperative Surveillance of Upper Urinary Tract Urothelial Carcinoma
3. Management of the Small Renal Mass

The President’s dinner on Monday night was very well attended. Dr. Klotz teamed up with half of the other member of The Void as well as Dr. Andrew Hussy from Stratford, Ontario to form a proficient jazz quartet. Four CUA Scholars Awards were given that night. Congratulations to Dr. Robert Hamilton of University of Toronto, Dr. Geoff Gotto from the University of Calgary, Dr. Lysanne Campeau from McGill University and Dr. Andrew Fiefer aka @urologymd1, also of the University of Toronto. The major disappointment of the night for me personally was the late collapse in the Stanley Cup Finals of my beloved Boston Bruins.

The final day brought with it more great educational forums and abstract presentations. A highlight for me was an address given by Dr. James Orbinski, the co-founder of Dignitas International and former president of Medicins Sans Frontieres. It was a brilliant overview on humanitarianism, global health and our role as urologists and citizens of the developed world. I think we have a strong obligation to promote these themes in our specialty.

Finally #cua13 was the year that the use of Social Media arrived in full force at the CUA.

A twitter board was set up in the main meeting hall to provide a real-time update of the conversation.

A good WIFI connection, which has been an issue at other recent meetings, served everyone very well. With a growing number of Canadian urologists now on twitter (joining early adopters including @_theurologist_, @urooncmd, @qdtrinh and myself). As these analytics show, 78 people participated via twitter during the actual meeting.

Many international colleagues joined in and @mattbultitude even made the top 10 from across the pond.

This form of communication has greatly enhanced our ability to connect and exchange ideas with colleagues from around the world. All urologists would be well advised to explore this technology. A nice primer with a Canadian perspective by @cmaer on the use of social media and twitter for physicians can be found here. At the recent #USANZ13 meeting use of Social Media for Urology was part of the scientific agenda as this presentation by @declangmurphy illustrates. I would like to see the number of participants at #cua14 surpass 200!

Of course living in Toronto made leaving on Tuesday from Niagara Falls about as easy an escape as one can make from any meeting. As we approach summer (at least in the Northern Hemisphere) I wish everyone a safe and restful time and look forward to continuing to engage with colleagues over the next year.

Dr Rajiv K Singal is a Urologist at Toronto East General Hospital and Assistant Professor in the Department of Surgery at the University of Toronto.
Follow him on Twitter @DrRKSingal

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Early Prostate Cancer Detection. One Canadian Urologist’s Perspective

June 6, 2013/57 Comments/by Rajiv Singal

After seventeen years as a practicing urologist and a further six in training, it amazes me that we still regard prostate cancer as a mystical science and view the issue of screening through the opaque prism of controversy. For so long it seems that the advanced stage disease that I learned about in the mid 1980s in medical school was irreversibly altered by early detection and treatment. Of course we now know that much of this early detection was simply a lead-time bias and that many men who were treated required only observation and were left with many potential compromises to quality of life. “Doctor, my cancer is gone, why am I so miserable?”

At the recent annual meeting of the American Urological Association in San Diego, new guidelines on prostate cancer screening were unveiled. In the past, routine testing at age 50 was recommended with age 40 being the threshold for those at risk. Essentially they can be summarized as:

Avoid screening under 40
Do not routinely screen between 40 and 54 for average risk men. For those at risk screening should be individualized.
For those between age 55 and 69 there is possibly some benefit and shared decision-making with a patient should be the rule.
Finally no routine screening after 70.
PSA should be considered every two years

The motivation for this more cautious recommendation stems for the fact that many men have indolent disease. Many of these men don’t require treatment. Treatment brings with it the potential to harm and therefore casts into doubt the value of any treatment.

The problem of course is while that may represent a possible, cost-effective strategy across the wider population, there is little doubt in my mind that this will lead to many younger and even older men falling through the cracks. It will be justified as too high a number needed to treat to make sense to find these men. Policy makers and health economists may shrug. My own experience is that we have much to learn about risk factors and that many men present seemingly without warning with significant disease.

This email from a patient illustrates the concern. Identifiers of course are removed. Both men had disease beyond the capsule of the prostate. Neither man had risk factors. Our patients are very wise and quickly become experts in the disease.

In Canada, the Canadian Urological Association has taken the view for some time that we should look at multiple factors as we “build a case” for prostate biopsy. Its own guidelines reflect this. This paper that we published speaks to the use of nomograms to make better biopsy decisions. Many calculators are available on the web.

So what is shared, informed decision-making? The assumption after the AUA meeting is that somehow patients and their primary care doctors will somehow know. What sort of conversation is happening if urologists themselves don’t seem to provide clear guidance? I suspect it will go something like “PSA doesn’t work, prostate cancer is not lethal and you will likely die from something else” Many family doctors have much of their time rightfully diverted to treating important disease entities such as hypertension, depression and diabetes. A not insignificant number of primary care doctors don’t necessarily even do a DRE anymore. If the urological community conveys the message that prostate cancer is not worth the effort it will further fall down the priority list.

In my view I am a little dismayed by the rhetoric that has started since these guidelines were presented. Much of this is well intentioned and a reaction to years of potential over-treatment. This earlier 2012 piece from the highly respected @OtisBrawley of the American Cancer Society illustrates the false promise of screening message that is being told. It will only be amplified after San Diego. In my view PSA itself is a blood test. It is harmless. It is the treatment machinery that it often initiates that potentially gives it a bite and needs careful reflection.

To many, prostate cancer is simply a benign disease in aging males along the lines of male pattern baldness. This would be a disaster in my view. We have definitely shifted the curve to the left but in addition to lowering overall mortality have greatly lessened the burden of disease complications. Men presenting with hematuria, urinary retention and renal failure has significantly diminished. It is rare that we get asked to insert nephrostomy tubes for advanced disease. This was a common clinical scenario when I was a resident in the early 1990s. I think we will see much more of that if we massively abandon screening.

I think as urologists we have a big responsibility to lead within our local communities. This comment from Dr. A Partin speaks to this very well. In the absence of the perfect pre-test conditions that predict meaningful disease my view is that we have to cast a wide net. In doing so we will uncover disease that does not need to be treated. We must then be prepared to separate diagnosis from treatment and carefully counsel our patients in a way that takes much detail and effort. It is not a five-minute discussion you can have in the middle of a busy clinic. Active Surveillance does work for low-risk disease. Our patients are sophisticated and will not blindly ask for treatment out of overwhelming anxiety. In parallel, we must continue to improve. The risk of biopsy, which has greatly increased over fifteen years, must be modified. Biopsy accuracy to find “real” disease can perhaps be improved with technology such as MRI. Techniques that lessen quality of life issues need to be modified. Robotic surgery can’t be a marketing free-for-all. In other words the onus is on us experts to get it right and do better.

Prostate cancer is a very significant disease and the source of pain and suffering for men and their families. We must continue to be vigilant of its implications, respectful of patient desires and hopeful ultimately of a cure. A benign disease it most certainly is not.

Dr. Rajiv K Singal is a Urologist at Toronto East General Hospital and Assistant Professor in the Department of Surgery at the University of Toronto.

Follow him on Twitter at @DrRKSingal

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AUA Blog – Highlight of Day 1 and 2

May 6, 2013/8 Comments/by Rajiv Singal

Greetings from San Diego, California! The annual meeting of the American Urological Association (AUA) is underway with over 15,000 attendees converging on this beautiful city from around the world. As I arrived at Pearson International Airport in Toronto on Friday and made my way through security I ran into roughly twenty of my colleagues from in and around Toronto getting ready to board the same plane. Canadians have attended this meeting in droves for as long as I can remember. Arriving in San Diego was easy with nice access to the city from the airport. After checking into hotel the first order of business was to register, which was also easy at least on Friday.

As I arrived on Friday it was clear that the meeting was already in full swing. A variety of research programs were underway including a Basic Science Symposium that explored the underlying role of inflammation and fibrosis in urological disorders.

Most noteworthy and newsworthy on Friday was the AUA news release of its new Guidelines on the Early Detection of Prostate Cancer. These will be sure to generate a lot of discussion. In summary:

Screening under age 40 is not recommended
Routine screening of men between age 40 and 54 at average risk is not recommended
For those aged 55-69, a shared decision to screen is advocated with a PSA drawn perhaps every two years.
Routine screening is not recommended after the age of 70.

These guidelines will be formally presented during Monday’s plenary session. The full document can be found here. It is clear to me that our challenge as urologists to properly council our patients in light of these new guidelines will only increase when you consider some of the headlines in the media. What do you think of these new Guidelines? Comments below please?

The first full day of scheduled activity was Saturday. A variety of sections and societies held meetings on this day. A number of courses were offered that continue to be well attended. This year a course pass was adopted that allowed individuals to get into most things available – a popular addition for AUA delegates. Highlights from the first day included:

The Engineering in Urology Section of the Endourology Society, highlighting advances in imaging as well as new robotic prototypes being developed from around the world. It will be interesting to see if any of these strange devices make it into the OR.
The Society of Urological Oncology was extremely well attended as usual. Dr Urs Studer delivered the Dr. W Whitmore Memorial Lecture and suggested that after more than 25 years in the PSA era a major re-think of how we treat prostate cancer is required.

Another very popular event was the live surgery session, which ran all day on Saturday. Highlights including a virtuoso robotic radical cystectomy with orthotopic ileal neobladder formation performed by Dr Indy Gill.

The role of robotic surgery to treat a variety of urological conditions is clearly expanding. For those of us in Canada the time is now to figure out how we will obtain, deploy, credential and manage this technology in our own publically funded healthcare system

The first plenary sessions began on Sunday. With the weather turning a little (I thought it never rains in Southern California?!) it made it easier to go indoors and listen to the talks and lectures inside. Highlight from plenary session one included a State-of-the Art Lecture of Technology’s role in the Future Management of Erectile Dysfunction by Dr Run Wang. Mention was made of nanotechnology and tissue engineering but perhaps the most intriguing near-term advance may be the advent of a smart phone app for operation of penile prostheses (yes it’s true!). Drs. Allen Seftel and Serge Carrier debated the role of the urologist in screening men with erectile dysfunction for cardiac disease. There was agreement on the link to cardiac disease but debate remains as to how many urologists will requisition stress tests. The second plenary session included an AUA Health policy update by Dr. David Penson and review by Dr. Peggy Pearle of the recertification process for urologists for the American Board of Urology.

As always, tremendous scientific efforts were on display at multiple poster and podium sessions. Predictably there was far too much for any one individual to entirely see. The discussion on Twitter via #AUA13 did allow for some ‘reporting’ at sites that I could not attend. A tremendous amount of work focusing on screening and active surveillance was clearly evident as well as the increasing use of new imaging techniques for managing these patients were evident. An afternoon session on HIFU and focal therapy left many people scratching their heads as to the utility of these modalities. The 47 % positive biopsy rate for HIFU was particularly disappointing. The best (or at least most entertaining) editorial of this session can be found in the twitter feed of @daviesbj.

In the science and technology exhibition area a tremendous presence from industry was again noted. Again, as a Canadian I am a little unsure as to how we will manage to incorporate all of this new technology when our hospital system is already strained. The Second Annual Residents Bowl narrowed down the field to two finalists, from the Western and South-eastern Sections. They will faceoff Monday at 1230 for the final. Finally the first Chief Residents’ debate highlighted that the future of our great speciality is very bright under the stewardship of these incredible young people.

For me a significant change to this meeting from past meetings is the use of social media to network, distribute ideas and scale down what often is a very large meeting into something that seems more accessible and local. The use of these multiple platforms has transformed the way we attend meetings. The recent meetings of the European Association of Urology (#eau13) and Urological Society of Australia and New Zealand (#USANZ13) highlight what can be achieved when this technology is used. Those not attending can participate actively. This has created an international participation in meetings in a way I have never seen before. The live twitter boards that you see around the convention centre here in San Diego, which are helping to spread the word, got their inspiration from these recent meetings.

A few individuals such as @daviesb and @DrHWoo and @tdave deserve credit for insisting that these boards become of feature of the 2013 meeting. Well done to AUA for taking a proactive approach to social media this year and for listening to your members. The hashtag to follow is #AUA13. I would encourage all to participate in this community. You will be amazed at how easily you can find out about what’s really going on at this meeting and also check in at venues that you cannot otherwise physically attend. You can see who are the leading influencers on twitter at #aua13 by checking out updated metrics via Symplur. You can see from this link that the chatter is building daily. I look forward to seeing a similar picture at #CUA13 when the Canadian Urological Association meets in June.

The use of Social Media will rapidly increase in scope and become a necessary part of communication within our Urological meetings. The AUA (@Americanurol) has recently established a committee to establish guidelines help grow its use for AUA members. Sign up for an account and dive in. It is highly engaging, somewhat addictive, very informative and always fun!

The BJUI hosted a great event, The BJUI Social Media Awards, for all of the early adopters of social media on Saturday evening. In particular this group has networked and communicated regularly over the last six months and ‘meet’ once a month to run a journal club on twitter using the hashtag #urojc. They self-identify as urotwitterati. The BJUI
arranged for many of us to meet for the first time by hosting the #BJUISoMeAwards. It was a great event and will be fully featured in a separate blog this week along with details of the well-attended BAUS/BJUI Session that took place on Sunday afternoon and included the awarding of the Coffey-Krane Prize.

Lastly on Sunday, by the security guards in Sacramento CA, we were treated to a spectacular Reception on board the USS Midway, a first opportunity for most of us to go on board a gigantic aircraft carrier and see some wonderful aircraft. The flight simulators were only for those who had not had a few beers already and who could tolerate the high G forces! Well done again to AUA for this excellent event.

Monday’s plenary session will include some very interesting debate around nephrolithiasis and I look forward to a Town Hall led by Dr. Ralph Clayman debating Robots as a possible harbinger of Surgeon Obsolescence. New guidelines on castration resistant prostate cancer will also be presented. Stay tuned for further updates from @Matthayn on Wednesday

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Read Day 3 & 4 Highlights here