Tag: Robotic Surgery

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RSM Urology Winter Meeting 2017, Northstar, California

February 17, 2017/6 Comments/by Niyati Lobo

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

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

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

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

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

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

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

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

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

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

@niyatilobo

Laparoscopy and robotics – an overhyped rivalry?

January 24, 2017/14 Comments/by Gagan Gautam

Highlights from the Laparoscopy & Robotics subspecialty meeting at the 50^th annual conference of the Urological Society of India (Mumbai, India)

It was like Australia and England playing a friendly cricket match in the middle of the Ashes tour…or perhaps Liverpool and Manchester United fans celebrating together in the spirit of bonhomie…

In an ably conducted sub specialty meeting during the golden jubilee annual conference of the Urological Society of India, Dr. Mallikarjuna Chiruvella from Hyderabad, the hub of the Indian software revolution, brought together traditional rivals, Laparoscopy and Robotics – not for comparisons and conflicts – but to find common ground in terms of improving outcomes and handling complications.

Undoubtedly, there is a lot in common when it comes to these two modalities. Indeed one is the progeny of the other. The anatomy, approach, indications, complications, and indeed, the ways of dealing with them have more similarities than differences. Experts from both sides of the fence highlighted these similarities and delved into the finer technical points of these modalities across the wide spectrum of urological ailments – urolithiasis, reconstructive urology and urologic oncology. An important component was the special emphasis on laparoscopic training and suturing techniques.

Our very own Editor In Chief, Prof. Prokar Dasgupta, was the show stopper with an exciting talk on the future of robotic surgery in which he explored advancements related to imaging integration, in vivo microscopy, automation, virtual reality and haptic feedback in the next gen robotic systems of the future.

Video clip of Prof Dasgupta’s slides (no audio).

Sub specialty convener, Dr Mallikarjuna and co conveners, Dr Arvind Ganpule from Nadiad, Gujarat and Dr. Gagan Gautam from New Delhi managed to raise some goosebumps in the 500+ attendees by presenting 3 ‘nightmares’ video sessions which took a keen look at intraoperative disasters and ways and means of preventing and managing them.

While the debates on laparoscopy versus robotics continue, the content and conduct of the meeting ensured that everyone could take away something practical and implementable from this session. Here’s to the new found common ground!

Gagan Gautam Head – Urologic Oncology & Robotic Surgery, Max Institute of Cancer Care, New Delhi, India. Twitter: @DrGaganGautam

Dr. Mallikarjuna Chiruvella Managing director, Asian Institute of Nephrology and Urology, Erramanzil colony, Hyderabad, India

In search of the ROSETTA stone (again)?

October 31, 2016/2 Comments/by Prokar Dasgupta

We are having an amazing year of scientific discovery in our specialty. 2016 has already seen the results of the only randomised trial comparing open versus robotic radical prostatectomy from Australia and the ProtecT trial from UK discussed intensively on Blogs@BJUI. The PROMIS of MRI is expected to change the practice of prostate biopsies in response to a raised PSA. The teams completing these trials deserve our heartiest congratulations as it is well known how difficult randomised trials in surgery are to initiate and complete.

As if this was not enough, this month the randomised controlled trial comparing Botox (Onabotulinum toxin A) to Interstim (sacral neuromodulation) in patients with refractory overactive bladder has been reported in JAMA. It is otherwise known as the ROSETTA study (Refractory Overactive Bladder: Sacral NEuromodulation v. BoTulinum Toxin Assessment).

This is an example of what collaboration between individuals and teams within a pelvic floor group can achieve. Cindy Amundsen, the lead author, presented the trial results at the #AUA16 late breaking abstract session in San Diego.

The CONSORT diagram is shown here

The primary outcome measure showing Botox winning over Interstim (narrowly) in reducing urgency urinary incontinence is demonstrated in this diagram.

The summary results are shown here

So what would you do for your patient with refractory overactive bladder who has failed Anticholinergics and Mirabegron?

I have spent the last week thinking about the trial results carefully and was asked exactly this question at the International Endourology Forum in China. There are a number of important aspects to consider. The dose of Botox used in the trial was 200 units while the licensed dose is 100 units for overactive bladder of non-neurogenic origin. We know that one size does not fit all and indeed some patients failing 100 units need higher doses of Botox. It remains unknown as to what would have happened if 100 units of Botox was compared to Interstim as the authors are quite guarded about their own conclusions about the benefits.

The side effects also need to be carefully discussed with the patient. The UTI rate in the Botox group is about three times that of the Interstim group. Most patients may accept a period of oral antibiotics to counter this. The risk of CISC dropped from 8% at 1 month to 2% at 6 months in the Botox group. This is lower than previously reported in Phase lll studies. The need for revision or removal in the Interstim patients was around 3% – small but not to be ignored.

Punchline
If I was the patient in question, I would have Botox initially, preserving Interstim for later. It is less invasive and can be repeated roughly once a year if needed. Call me “lilly livered” but I do not like the idea of having a little box, however tiny, inside my bum and occasionally having to sit on it! I look forward to the smarter new generation of minimally invasive or even non-invasive nerve stimulators. But then it would need another randomised trial, many years of unanswered questions, perhaps even wastage of a lot of grant money…………..yawn!!

In the meantime, I will take my chances with Botox and counsel my patients accordingly. Unlike the famous ROSETTA stone, the key to understanding the mystery behind hieroglyphs and the controversy as to whether it should at all be in the British museum, I fail to see any such controversy with this nice trial in JAMA.

My thoughts and message are clear. Are yours?

Article of the Week: Performance of robotic simulated skills tasks is positively associated with clinical robotic surgical performance

September 21, 2016/by admin Z.9

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Alvin Goh, discussing his paper.

If you only have time to read one article this week, it should be this one.

Performance of robotic simulated skills tasks is positively associated with clinical robotic surgical performance

Monty A. Aghazadeh*,†, Miguel A. Mercado*,†, Michael M. Pan†, Brian J. Miles

‡ and Alvin C. Goh*,‡

*Methodist Institute for Technology, Innovation, and Education (MITIE), Houston Methodist Hospital, †Scott Department of Urology, Baylor College of Medicine, and ‡Department of Urology, Houston Methodist Hospital, Houston, TX, USA

Read the full article

Objective

To compare user performance of four fundamental inanimate robotic skills tasks (FIRST) as well as eight da Vinci Skills Simulator (dVSS) virtual reality tasks with intra-operative performance (concurrent validity) during robot-assisted radical prostatectomy (RARP) and to show that a positive correlation exists between simulation and intra-operative performance.

Materials and Methods

A total of 21 urological surgeons with varying robotic experience were enrolled. Demographics were captured using a standardized questionnaire. User performance was assessed concurrently in simulated (FIRST exercises and dVSS tasks) and clinical environments (endopelvic dissection during RARP). Intra-operative robotic clinical performance was scored using the previously validated six-metric Global Evaluative Assessment of Robotic Skills (GEARS) tool. The relationship between simulator and clinical performance was evaluated using Spearman’s rank correlation.

Results

Performance was assessed in 17 trainees and four expert robotic surgeons with a median (range) number of previous robotic cases (as primary surgeon) of 0 (0–55) and 117 (58–600), respectively (P = 0.001). Collectively, the overall FIRST (ρ = 0.833, P < 0.001) and dVSS (ρ = 0.805, P < 0.001) simulation scores correlated highly with GEARS performance score. Each individual FIRST and dVSS task score also demonstrated a significant correlation with intra-operative performance, with the exception of Energy Switcher 1 exercise (P = 0.063).

Conclusions

This is the first study to show a significant relationship between simulated robotic performance and robotic clinical performance. Findings support implementation of these robotic training tools in a standardized robotic training curriculum.

Editorial: Robotic simulation: are we ready to go?

September 21, 2016/by admin Z.9

In a study in this issue of BJUI, Aghazadeh et al. [1] were able to show that there was a significant relationship between simulated robotic performance and robotic clinical performance. The authors conclude that this supports the implementation of such robotic training tools in a standardized robotic training curriculum. Evidently, particularly in minimally invasive surgery, we must assess and learn from our surgical errors in order to prevent them in future [2]. For this, the dream scenario would be the ability to simulate a surgical procedure before being allowed to perform the real operation on the patient, similarly to pilots being trained on a flight simulator [3]. A robotic (virtual) simulator would be the ideal way to provide training on the respective robot-assisted procedure [1].

The authors are to be congratulated in their effort to prove the transfer validity of their training model using 12 previously validated robotic skill tasks consisting of four inanimate models and eight selected virtual reality tasks on the da Vinci Skills Simulator [1]. Endopelvic fascial dissection during robot-assisted radical prostatectomy was chosen to assess clinical robotic performance. Trainees were evaluated using the Global Evaluative Assessment of Robotic Skills (GEARS) scoring system, which distinguishes among depth perception, bimanual dexterity, efficiency, force sensitivity, autonomy, robotic control in relationship to the case difficulty using scores ranging from 1 to 5.

Nevertheless, there is still a long way to go! The authors have already conceded that there are some limitations to their study. It involved a small cohort of urological surgeons of different levels of expertise. It was not a randomized study comparing the impact of virtual simulator training on the surgical outcome, therefore, the authors could only show that they might be able to predict a surgeon’s performance during a real case based on his/her performance at the simulator. Based on this, the simulator training could theoretically pre-assess surgeon’s quality in robot-assisted surgery.

The authors probably chose endopelvic dissection because it represents a relatively easy part of robot-assisted radical prostatectomy. Accordingly, it remains unclear whether such basic tasks are really the best models to prepare a surgeon for this operation. Using low-fidelity training models, including vesico-urethral anastomosis, we were able to demonstrate the transfer validity of a six-step training programme [4]. It would be interesting to see the impact of the simulator training on clinical performance of robot-assisted vesico-urethral anastomosis because a valuable exercise for this already exists on the da Vinci Skills Simulator.

Despite this progress, we must recognize that we are far away from equalling the simulator training of pilots [3]. It is much easier to simulate turbulence during a flight than significant bleeding during robot-assisted surgery. Trials in simulating a complete laparoscopic procedure are still in their infancy [5]. This may differ with regard to other minimally invasive procedures such as ureteroscopy, where sophisticated trainer exercises exist; however, even in this field there is actually no proven evidence of the significant impact of simulators on shortening the learning curve. For all ‘hands-on’ simulation there will be always the problem of soft-tissue engineering and navigation [6]. Robotic simulators have the advantage compared with laparoscopy of three-dimensional video technology and the fact that there is no tactile feedback for the surgeon.

Evidently, information technology is continuously advancing and we may one day have a robotic simulator that can compare with the flight simulators used in aviation; however, to date, only training on basic skills can be provided and evaluated using the existing simulation systems in urology.

Read the full article

Jens Rassweiler

Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heidelberg , Germany

1 Aghazadeh MA, Mercado MA, Pan MM, Miles BJ, Goh AC.

Performance of robotic simulated skills tasks is positively associated with clinical robotic surgical performance. BJU Int 2016; 118: 475–81

2 Rassweiler MC, Mamoulakis C, Kenngott HG et al. Classiﬁcation and

detection of errors in minimally invasive surgery. J Endourol 2011; 25:

1713–21

3 Sommer KJ. Pilot training: what can surgeons learn from it? Arab J Urol 2014; 12: 32–5

4 Klein J, Teber D, Frede T et al. Development, validation and operating room of a six-step laparoscopic training program for the vesicourethral anastomosis. J Endourol 2013; 27: 349–54

5 Shamim Khan M, Ahmed K, Gavazzi A et al. Development and

implementation of centralized simulation training: evaluation of

feasibility, acceptability and construct validity. BJU Int 2013; 111:

518–23

6 Baumhauer M, Feuerstein M, Meinzer HP, Rassweiler J. Navigation in

soft tissue surgery: perspectives and limitation. J Endourol 2008; 22: 751–66

Video: Performance of robotic simulated skills tasks is positively associated with clinical robotic surgical performance

September 21, 2016/by admin Z.9

Performance of robotic simulated skills tasks is positively associated with clinical robotic surgical performance

Monty A. Aghazadeh*,†, Miguel A. Mercado*,†, Michael M. Pan†, Brian J. Miles

‡ and Alvin C. Goh*,‡

Read the full article

Objective

Materials and Methods

Results

Conclusions

Read the full article

Randomised Controlled Trials in Robotic Surgery

August 17, 2016/by admin Z.9

It has been nearly 15 years since one of the first ever randomised controlled trials (RCT) in robotic surgery was conducted in 2002. The STAR-TRAK compared telerobotic percutaneous nephrolithotomy (PCNL) to standard PCNL and showed that the robot was slower but more accurate than the human hand [1].

In the 24 h since the much anticipated RCT of open vs robot-assisted radical prostatectomy was published in The Lancet [2], our BJUI blog from @declangmurphy was viewed >2500 times, receiving >40 comments, making it one of our most read and interactive blogs ever. It is a negative trial showing no differences in early functional outcomes between the two approaches.

And it is not the only negative trial of its kind as a number of others have matured and reported recently. The RCT of open vs robot-assisted radical cystectomy and extracorporeal urinary diversion showed no differences in the two arms [3], and likewise a comparison of the two approaches to cystectomy as a prelude to the RAZOR (randomised open vs robotic cystectomy) trial showed no differences in quality of life at 3-monthly time points up to a year [4]. The only RCT comparing open, laparoscopic and robotic cystectomy, the CORAL, took a long time to recruit and yet again showed no differences in 90-day complication rates between the three techniques [5].

In all likelihood, despite the level 1 evidence provided in The Lancet paper showing no superiority of the robotic over the open approach, the Brisbane study may not change the current dominance of robotic prostatectomy in those countries who can afford this technology. Why is this? Apart from the inherent limitations that the BJUI blog identifies, there are other factors to consider. In particular, as observed previously in a memorable article ‘Why don’t Mercedes Benz publish randomised trials?’ [6], there may be reasons why surgical technique is not always suited to the RCT format.

A few additional reflections are perhaps appropriate at this time:

Despite the best statistical input many of these and future studies are perhaps underpowered.
Many have argued that the RCTs have shown robotics to be as good, although not better than open surgery, even in the hands of less experienced surgeons.
Patient reported quality of life should perhaps become the primary outcome measure because that in the end that is what truly matters.
Cost-effectiveness ratios should feature prominently, as otherwise there is much speculation by the lay press without any hard data.
Industry has a role to play here in keeping costs manageable, so that these ratios can become more palatable to payers.
Surgery is more of an art than a science. The best surgeons armed with the best technology that they are comfortable with will achieve the best outcomes for their patients.

While this debate will continue and influence national healthcare providers and decision makers, the message looks much clearer when it comes to training the next generation of robotic surgeons. A cognitive- and performance-based RCT using a device to simulate vesico-urethral anastomosis after robot-assisted radical prostatectomy (RARP) showed a clear advantage in favour of such structured training [7]. In this months’ issue of the BJUI, we present the first predictive validity of robotic simulation showing better clinical performance of RARP in patients [8]. This is a major step forward in patient safety and would reassure policy makers that investment in simulation of robotic technology rather than the traditional unstructured training is the way forward.

Most of our patients are knowledgeable, extensively research their options on ‘Dr Google’ and decide what is good for them. It is for this reason that many did not agree to randomisation in other robotic vs open surgery RCTs, like LopeRA (RCT of laparoscopic, open and robot assisted prostatectomy as treatment for organ-confined prostate cancer) and BOLERO (Bladder cancer: Open vs Lapararoscopic or RObotic cystectomy). Many of them continue to choose robotic surgery without necessarily paying heed to the best scientific evidence. Perhaps what patients will now do is select an experienced surgeon whom they can trust to use their best technology to deliver the best clinical outcomes.

Prokar Dasgupta @prokarurol

Editor-in-Chief, BJUI

@declangmurphy
Associate Editor BJUI

References

1 Challacombe B, Patriciu A, Glass J et al. A randomized controlled trial of human versus robotic and telerobotic access to the kidney as the ﬁrst step in percutaneous nephrolithotomy. Comput Aided Surg 2005; 10: 165–71

2 Yaxley JW, Coughlin GD, Chambe rs SK et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 2016 [Epub ahead of print]. doi: 10.1016/S0140-6736(16)30592-X

3 Bochner BH, Sjoberg DD, Laudone VP, Memorial Sloan Kettering Cancer Center Bladder Cancer Surgical Trials Group. A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med 2014; 371:389–90

Messer JC, Punnen S , Fitzgerald J et al. Health-related quality of life from a

prospective randomised clinical trial of robot-assisted laparoscopic vs open radical cystectomy. BJU Int 2014; 114: 896–902

Khan MS, Gan C, Ahmed K et al. A single-centre early phase randomised controlled three-arm trial of open, robotic, and laparoscopic radical cystectomy (CORAL). Eur Urol 2016; 69: 613–21

6 O’Brien T, Viney R , Doherty A, Thomas K. Why don’t Mercedes Benz publish

randomised trials? BJU Int 2010; 105 : 293–5

7 Chowriappa A, Raza SJ, Fazili A et al. Augmented-reality-based skills training for robot-assisted urethrovesical anastomosis: a multi- institutional randomised controlled trial. BJU Int 2015; 115: 336–45

8 Aghazadeh MA, Mercado MA, Pan MM , Miles BJ, Goh AC. Performance of

robotic simulated skills tasks is positively associated with clinical robotic surgical performance. BJU Int 2016; 118: 4 75 –81

Step-By-Step: RAPN with intracorporeal renal hypothermia using ice slush

March 9, 2016/by admin Z.9

Robot-assisted partial nephrectomy with intracorporeal renal hypothermia using ice slush: step-by-step technique and matched comparison with warm ischaemia

Daniel Ramirez, Peter A. Caputo, Jayram Krishnan, Homayoun Zargar* and Jihad H. Kaouk

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA, and *Royal Melbourne Hospital, Melbourne, Vic, Australia

Read the full article

Objectives

To outline our step-by-step technique for intracorporeal renal cooling during robot-assisted partial nephrectomy (RAPN).

Patients and Methods

Patient selection was performed during a preoperative clinic visit. Cases where we estimated during preoperative assessment that warm ischaemia time would be >30 min, as determined by whether the patient had a complex renal mass, were selected. The special equipment required for this procedure includes an Ecolab Hush Slush machine (Microtek Medical Inc., Columbus, MS, USA) a Mon-a-therm needle thermocouple device (Covidien, Mansfield, MA, USA) and six modified 20-mL syringes. Patients are arranged in a 60° modified flank position with the operating table flexed slightly at the level of the anterior superior iliac spine. For the introduction of a temperature probe and ice slush, an additional 12-mm trocar is placed along the mid-axillary line beneath the costal margin. Modified 10/20 mL syringes are prefilled with ice slush for instillation via an accessory trocar. Peri-operative and 6-month functional outcomes in the cold ischaemia group were compared with those of a cohort of patients who underwent RAPN with warm ischaemia in a 2:1 matched fashion. Matching was performed based on preoperative estimated glomerular filtration rate (GFR), ischaemia time and RENAL nephrometry score.

Results

Strategies for successful intracorporeal renal cooling include: (i) placement of accessory port directly over the kidney; (ii) uniform ice consistency and modified syringes; (iii) sequential clamping of renal artery and vein; (iv) protection of the neighbouring intestine with a laparoscopic sponge; and (v) complete mobilization of the kidney. Kidney temperature is monitored via a needle thermocoupler device, while core body temperature is concurrently monitored via an oesophageal probe in real time. Renal function was assessed by serum creatinine level, estimated GFR (eGFR) and mercaptoacetyltriglycine (MAG-3) renal scan, peri-operatively and at 6-month follow-up. In the separate matched analysis, cold ischaemia during RAPN was found to be associated with a 12.9% improvement in preservation of postoperative eGFR. No difference was seen in either group at 6-month follow-up.

Conclusions

We conclude that RAPN with intracorporeal renal hypothermia using ice slush is technically feasible and may improve postoperative renal function in the short term. Our technique for intracorporeal hypotheramia is cost-effective, simple and highly reproducible.

Video: Step-By-Step: Extended PLND – Creating the Spaces

January 13, 2016/by John Davis

Sequencing robot-assisted extended pelvic lymph node dissection prior to radical prostatectomy: a step-by-step guide to exposure and efficiency

Stephen B. Williams, Yasar Bozkurt , Mary Achim, Grace Achim and John W. Davis

Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

Read the full article

OBJECTIVE

To describe a novel, step-by-step approach to robot-assisted extended pelvic lymph node dissection (ePLND) at the time of robot-assisted radical prostatectomy (RARP) for intermediate–high risk prostate cancer.

PATIENTS AND METHODS

The sequence of ePLND is at the beginning of the operation to take advantage of greater visibility of the deeper hypogastric planes. The urachus is left intact for an exposure/retraction point. The anatomy is described in terms of lymph nodes (LNs) that are easily retrieved vs those that require additional manipulation of the anatomy, and a determined surgeon. A representative cohort of 167 RARPs was queried for representative metrics that distinguish the ePLND: 146 primary cases and 21 with neoadjuvant systemic therapy.

RESULTS

The median (interquartile range, IQR) LN yield was 22 (16–28) for primary surgeries and 21 (16–23) for neoadjuvant cases. The percentage of cases with positive LNs (pN1) was 16.4% for primary and 29% for neoadjuvant. The hypogastric LNs were involved in 75% of pN1 primary cases and uniquely positive in 33%. Each side of ePLND took the attending surgeon a median (IQR) of 16 (13–20) min and trainees 25 (24–38) min.

CONCLUSIONS

Robot-assisted ePLND before RARP provides an anatomical approach to surgical extirpation mimicking the open approach. We think this sequence offers efficiency and efficacy advantages in high-risk and select intermediate-risk patients with prostate cancer undergoing RARP.

Highlights from #BAUS15

June 24, 2015/by Rebecca Tregunna

#BAUS15 started to gain momentum from as early as the 26^th June 2014 and by the time we entered the Manchester Central Convention Complex well over 100 tweets had been made. Of course it wasn’t just Twitter that started early with a group of keen urologists cycling 210 miles to conference in order to raise money for The Urology Foundation.

Monday 15^th June 2015

By the time the cyclists arrived conference was well under way with the andrology, FNUU and academic section meetings taking place on Monday morning:

The BJU International Prize for the Best Academic Paper was awarded to Richard Bryant from the University of Oxford for his work on epithelial-to-mesenchymal transition changes found within the extraprostatic extension component of locally invasive prostate cancers.
Donna Daly from the University of Sheffield received the BJUI John Blandy prize for her work on Botox, demonstrating reductions in afferent bladder signaling and urothelial ATP release.

Professor Reisman’s talk on ‘Porn, Paint and Piercing’ as expected drew in the crowds and due to a staggering 44% complication rate with genital piercings it is important for us to try to manage these without necessarily removing the offending article as this will only serve to prevent those in need from seeking medical attention.
With the worsening worldwide catastrophe of antibiotic resistance, the cycling of antibiotics for prevention of recurrent UTIs is no longer recommended. Instead, Tharani Nitkunan provided convincing evidence for the use of probiotics and D-Mannose.

The afternoon was dominated by the joint oncology and academic session with Professor Noel Clarke presenting the current data from the STAMPEDE trial. Zolendronic acid conferred no survival benefit over hormones alone and consequently has been removed from the trial (stampede 1). However, Docetaxal plus hormones has shown benefit, demonstrated significantly in M1 patients with disease-free survival of 65 months vs. 43 months on hormones alone (Hazard ratio 0.73) (stampede 2). This means that the control arm of M1 patients who are fit for chemotherapy will now need to be started on this treatment as the trial continues to recruit in enzalutamide, abiraterone and metformin arms.

The evening was rounded off with the annual BAUS football tournament won this year by team Manchester (obviously a rigged competition!), whilst some donned the

lycra and set out for a competition at the National Cycle Centre. For those of us not quite so energetic, it was fantastic to catch up with old friends at the welcome drinks reception.

Tuesday 16^th June 2015

Tuesday kicked off bright and early with Professor John Kelly presenting results from the BOXIT clinical trial, which has shown some benefit over standard treatment of non-muscle invasive bladder cancer, but with significant cardiovascular toxicity.

The new NICE bladder cancer guidelines were presented with concerns voiced by Professor Marek Babjuk over discharging low-risk bladder cancer at 12 months given a quoted 30-50% five-year recurrence risk. Accurate risk stratification, it would seem, is going to be key.

The President’s address followed along with the presentation of the St. Peter’s medal for notable contribution to the advancement of urology, which was presented to Pat Malone from Southampton General Hospital. Other medal winners included Adrian Joyce who received the BAUS Gold Medal, and the St. Paul’s medal went to Mark Soloway.

A plethora of other sessions ensued but with the help of the new ‘native’ BAUS app my programme was already conveniently arranged in advance:

‘Heartsink Conditions’ included pelvic and testicular pain and a fascinating talk by Dr Gareth Greenslade highlighted the importance of early and motivational referral to pain management services once no cause has been established and our treatments have been exhausted. The patient’s recovery will only start once we have said no to further tests: ‘Fix the thinking’

Poster sessions are now presented as ‘e-posters’, abolishing the need to fiddle with those little pieces of Velcro and allowing for an interactive review of the posters.

Pravisha Ravindra from Nottingham demonstrated that compliance with periodic imaging of patients with asymptomatic small renal calculi (n=147) in primary care is poor, and indeed, these patients may be better managed with symptomatic imaging and re-referral as no patients required intervention based on radiograph changes alone.

Archana Fernando from Guy’s presented a prospective study demonstrating the value of CTPET in the diagnosis of malignancy in patients with retroperitoneal fibrosis (n=35), as well as demonstrating that those with positive PET are twice as likely to respond to steroids.

Wednesday 17^th June 2015

Another new addition to the programme this year was the Section of Endourology ‘as live surgery’ sessions. This was extremely well received and allowed delegates to benefit from observing operating sessions from experts in the field whilst removing the stressful environment and potential for risk to patient associated with live surgery. This also meant that the surgeon was present in the room to answer questions and talk through various steps of the operation allowing for a truly interactive session.
Wednesday saw multiple international speakers dominating the Exchange Auditorium:

The BJU International guest lecture was given by Professor Hendrik Van Poppel: a heartfelt presentation describing what he believes to be the superiority of surgery over radiotherapy for high-risk localised prostate cancer.
The Urology Foundation presented the Research Scholar Medal to Ashwin Sachdeva from Freeman Hospital, Newcastle for his work on the ‘Role of mitochondrial DNA mutations in prostate carcinogenesis’. This was followed by an inspiring guest lecture by Inderbir Gill on ‘Robotic Urologic Oncology: the best is yet to come’ with the tag line ‘the only thing that should be open in 2015 is our minds’
Robotic Surgery in UK Urology: Clinical & Commissioning Priorities was a real highlight in the programme with talks from Jim Adshead and Professor Jens-Uwe Stolzenburg focussing on the fact that only 40% of T1a tumours in the UK were treated with partial (as opposed to radical) nephrectomy, and that the robot really is the ‘game-changer’ for this procedure. Inderbir Gill again took to the stage to stress that all current randomised trials into open vs. robotic cystectomy have used extracorporeal reconstruction and so do not reflect the true benefits of the robotic procedure as the dominant driver of complications is in the open reconstruction.

These lectures were heard by James Palmer, Clinical Director of Specialised Commissioning for NHS England who then discussed difficulties in making decisions to provide new technologies, controlling roll out and removing them if they show no benefit. Clinical commissioning policies are currently being drafted for robotic surgery in kidney and bladder cancer. This led to a lively debate with Professor Alan McNeill having the last word as he pointed out that what urologists spend on the robot to potentially cure cancer is a drop in the ocean compared with what the oncologists spend to palliate!

Thursday 18^th June 2015

The BJU International session on evidence-based urology highlighted the need for high-quality evidence, especially in convincing commissioners to spend in a cash-strapped NHS. Professor Philipp Dahm presented a recent review in the Journal of Urology indicated that the quality of systematic reviews in four major urological journals was sub-standard. Assistant Professor Alessandro Volpe then reviewed the current evidence behind partial nephrectomy and different approaches to this procedure.

Another fantastic technology, which BAUS adopted this year, was the BOD-POD which allowed delegates to catch-up on sessions in the two main auditoria that they may have missed due to perhaps being in one of the 21 well designed teaching courses that were available this year. Many of these will soon be live on the BAUS website for members to view.

The IBUS and BAUS joint session included a lecture from Manoj Monga from The Cleveland Clinic, which led to the question being posed on Twitter: ‘Are you a duster or a basketer?’The audience was also advised to always stent a patient after using an access sheath unless the patient was pre-stented.

The updates session is always valuable especially for those studying for the FRCS (Urol) exam with far too many headlines to completely cover:

Endourology: The SUSPEND trial published earlier this year was a large multi-centre RCT that showed no difference in terms of rates of spontaneous passage of ureteric stone, time to stone passage or analgesic use between placebo, tamsulosin and nifedipine. There was a hot debate on this: should we be waiting for the meta-analysis or should a trial of this size and design be enough to change practice?
Oncology-Prostate: The Klotz et al., paper showed active surveillance can avoid over treatment, with 98% prostate cancer survival at 10 years.
Oncology-Kidney: Ellimah Mensah’s team from Imperial College London (presented at BAUS earlier in the week) demonstrated that over a 14-year period there were a higher number of cardiovascular-related admissions to hospital in patients who have had T1 renal tumours resected than the general population, but no difference between those who have had partial or radical nephrectomy.
Oncology-Bladder: Arends’s team presented at EAU in March on the favourable results of hyperthermic mitomycin C vs. BCG in the treatment of intermediate- and high-risk bladder cancer.
Female and BPH: The BESIDE study has demonstrated increased efficacy with combination solifenacin and mirabegron.
Andrology: Currently recruiting in the UK is the MASTER RCT to evaluate synthetic sling vs. artificial sphincter in men with post-prostatectomy urinary incontinence.

Overall BAUS yet again put on a varied and enjoyable meeting. The atmosphere was fantastic and the organisers should be proud of the new additions in terms of allowing delegates to engage with new technologies, making for a memorable week. See you all in Liverpool!

Rebecca Tregunna, Urological Trainee, West Midlands Deanery @rebeccatregunna

Dominic Hodgson, Consultant Urologist, Portsmouth @hodgson_dominic