Roger Kirby, Uday Patel, Ben Challacombe and Prokar Dasgupta
The Prostate Centre, London, UK
Published as a comment article in BJU International 2013; 112: 283–285. doi: 10.1111/j.1464-410X.2012.11779.x.
Video Commentary by Roger Kirby, BJUI Associate Editor.
“You never have a second chance to make a first impression.”
How you initially come across to your colleagues, the nurses and your patients as a newly appointed consultant can set the tone for your consultancy for the rest of your career. Once an opinion (winner or loser) has been formed about you, it is virtually set in stone. It is much too important to leave these things to chance. In your first year you will either sink, float or swim!
‘Thriving and Surviving as a new consultant’ [1] is a course by The Urology Foundation (TUF) specifically designed to help consultants at the start of their careers take control of situations and to become good leaders, colleagues and, most importantly, good medics. Good communication and presentation skills are vital to how others perceive and respond to you; fortunately these can be learned and developed. More importantly, leaders are not born, they can be made and it is possible to improve and hone your skills and attributes so that you can become a more confident and natural leader.
A good or natural leader always features a strong resume. a robust resume not only emphasis an excellent impression on the interviewer but also step up your confidence. the primary and most vital factor that contributes to obtaining an honest job is that the resume. Building knowledgeable resume that stands call at the gang can sometimes end up to be an intimidating, confusing and stressful task. But, with the advancement in technology building knowledgeable resume has become quite easy.
The resume builder online is one such innovation that has made professional resume building easy, efficient and fewer stressful. The professional resume builder saves tons of quality time which may be utilized for other purposes like gaining education or developing skills. you only got to fill within the details within the appropriate fields mentioned within the resume template online and knowledgeable resume is produced in minutes.
Last weekend, a number of newly, or about to be appointed, consultants attended an interactive two-day course in Leeds where subjects such as team building and development were discussed. “The team” was considered to be the colleagues, managers, nurses and other healthcare professionals involved in the urological care of patients. We discussed and debated how we could create the “Manchester United” department of urology, delivering the best possible in patient treatment and care.
A new consultant shouldn’t try to change too much at first, but instead carefully assess and evaluate the lie of the land. Learning about the department, associated departments and the hospital itself takes time and trouble. It is good though to have at least five SMART (Specific, Measurable, Achievable, Realistic and Time-constrained) goals to be achieved within the first year of his or her appointment. But what should these be? Do let us know.
The medical defence organisations recognise that the first year of a consultant’s career is one of exceptionally high risk for complaints and litigation. We focused therefore on avoiding pitfalls, dealing with complications, and responding to complaints and serious untoward incidents (SUOs).
Navigating your way though the dangerous waters of your first year as a consultant can be a very tricky business. We would love to hear about your experiences in that situation, or, if you attended the course, what you thought of it and how we could do it better.
Roger Kirby, The Prostate Centre, London
Louise de Winter, Chief Executive, The Urology Foundation
[1] The course was made possible by an Educational Grant from Takeda UK Ltd. Takeda had no involvement in the content of organisation of the meeting.
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There was a time when doctors were reluctant to tell patients the truth about a diagnosis of cancer, and even more unwilling to discuss any illness from which they themselves suffered. John Anderson broke the mould last year when he made a public announcement about his newly diagnosed liver metastases, which subsequently turned out to be the result of secondary spread of adenocarcinoma of the prostate.
John was President Elect of the British Association of Urological Surgeons (BAUS) at the time, so sadly had to resign his presidency (the best president we never had!) and subsequently his trusteeship of the Prostate Cancer UK charity. John’s energy and drive are legendary, he is a true surgeon’s surgeon. The stoicism and determination that he has displayed throughout a year in which he has received hormonal treatment, followed by chemotherapy, is awe-inspiring.
My admiration for John, in addition to my own recent diagnosis of localised prostate cancer, requiring robot-assisted radical prostatectomy (https://moreintelligentlife.co.uk/content/ideas/simon-garfield/prof-roger-kirby) led me to approach Sean Vesey and Damian Hanbury, whom I knew were similarly afflicted by a disease that carries a 1 in 9 lifetime risk. It occurred to me that there was a great deal to be gained from frank disclosure and discussion, as opposed to treating this problem as some dark, furtive secret. Women suffering from breast cancer are generally much more open about their problem and consequently receive much more support from friends, relatives and others who have been touched by the disease. This empowers them to make the difficult but smarter choices about their health by opting in to breast cancer treatment. Men need this kind of social encouragement and support so that we can be within reach to them as well.
The result was a publication entitled “a Tale of Four Prostates” in the upcoming issue of Trends in Urology and Men’s Health (www.trendsinurology.com) and a short accompanying video.
In this John, Damian and myself discuss the impact of our respective diagnoses and treatment. We sincerely hope that, by being frank, honest and transparent about our own situation, we can help other patients to help themselves by seeking advice and treatment earlier, and by sharing information about their diagnosis with others in order to mobilize support from their family and friends.
Sadly, John Anderson has since died. You can read an obituary by Roger Kirby here.
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I have the fondest memories of Bill Hendry, who sadly died, aged 73, last autumn. I first met him, and his wife Chirsty, on a urology section of the Royal Society of Medicine (RSM) ski trip, when I immediately fell for his infectious enthusiasm and energy. I remember hearing him delivering a brilliant lecture on the outcomes of radical cystectomy, an operation of which he was consummate performer.
I joined Bill and Hugh Whitfield as a consultant at St Bartholomew’s Hospital in 1986, where I saw first hand his skill as a surgeon and his unerring caring compassion towards his patients. I used to do Friday afternoon clinics with him at Bart’s: he focussed on infertility, while I ran an erectile dysfunction clinic. Bill used to joke that we should have a signpost: Penises this way, testicles the other!
I was honorary secretary when Bill was President of the RSM urology section. With typical energy he decided to depart from the ski meeting formula and instead led the group to Zimbabwe, an excellent meeting that finished memorably with a dinner in the Victoria Falls Hotel. A fabulous evening was had, significantly enhanced by the generous provision of specially imported South African Meerlust (sea breeze) wine.
I also had the privilege of being honorary secretary when Bill was president of the British Association of Urological Surgeons (BAUS). We had so much fun together, planning and running the annual meetings, and we can claim the honour of founding the very successful BAUS Section of Oncology. I remember discussing the idea with Bill on a ski lift in Grindelwalt. He had the vision and drive to get it established.
Bill took rather early retirement and went to live on the Isle of Lewes, where took up breeding highland cattle and won a number of prizes. Unfortunately Chirsty died and only a few months later Bill suffered a heart attack and passed away. He will be remembered as a brilliant surgeon, teacher and communicator. I do hope some of those who trained under him will add their own special memories to this blog.
Roger Kirby
BJUI Associate Editor
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It was weird, having spent a career looking after men with prostate problems, to discover that my own PSA was raised to 4.3ng/mL. A 3 Tesla MRI with gadolinium enhancement revealed a lesion in the right peripheral zone, which a biopsy confirmed as a Gleason 3+4=7 adenocarcinoma. The decision wasn’t difficult for me: I opted for a robot-assisted radical prostatectomy (RARP), to be performed by the Editor-in-Chief of this journal, Professor Prokar Dasgupta, ably assisted by Ben Challacombe and Krishna Patil. Details of my whole journey are available here for those who are interested.
The key point for discussion in this blog is the availability of the latest technology for the care of patients with prostate cancer who are less in the know than me. Shouldn’t we be lobbying for greater access for all to the latest pieces of high tech gear?
3 Tesla MRI imaging, together with the expertise to interpret the findings of diffusion-weighted images, for example, offers the possibility of a “prostate mammogram” which facilitates the targeting of the biopsy and holds the promise of avoiding biopsies in those in whom the MRI images appear blameless.
Da Vinci robotic technology undoubtedly facilitates the surgical procedure, especially the preservation of the neurovascular bundles and the very precise vesico-urethral anastomosis. It certainly was an interesting experience to sit and watch the DVD of my own operation at home, with a catheter still draining my bladder, wondering about my future continence and sexual function, as well as the histopathology report! After an operation like this anybody is going to need assistance to move around the house just to do basic activities like go to the bathroom or even change clothes. That’s why it is very important to check into a nursing home where they offer their professional service. In some cases these nurses don’t work professionally and often neglect their patients needs, so that is why it’s recommended to contact a nursing home neglect attorney for situations like this for legal help.
Am I discombobulated by this experience? Not especially, I genuinely found being on the receiving end of prostate surgery a truly educational experience and I now feel energised to help others get through their journey. In the upcoming issue of Trends in Urology three other of our urological colleagues share their own experiences of prostate cancer, as well as the lessons that can be learned from them. Check out the Trends in Urology website from mid-March onwards.
In the meantime we would be interested in your own thoughts on these issues. Do add a comment or question to this blog.
Roger Kirby
The Prostate Centre, London W1G 8GT
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You wouldn’t expect the pilot of the aeroplane in which you fly to the EAU or AUA meeting to be a novice who was training on the aeroplane that you were being transported in! Similarly, patients undergoing robot-assisted surgery do not expect to be the “guinea pigs” upon which trainee surgeons move up the learning curve of surgical experience. Sometimes, however, they are.
Surgical simulators offer the means for surgeons to gain experience before moving to operating on actual patients. However, the publication from Guy’s and St Thomas’s illustrates how little research has been done yet to confirm that outcomes are improved by such a move.
Patient safety is a “buzz word” at present, especially after the report of Robert Francis QC on the Mid-Staffordshire NHS Trust disaster. It seems probable that virtual reality (VR) simulators can improve safety, not only by improving technical skills, but also by enhancing non-technical “human factor” responses.
Much work needs to be done to provide the VR training facilities and ensure access to them for all urology trainees. Once they are in place studies will be needed to confirm their value. In a world where doctors and Trusts are facing a tidal wave of litigation there seems little doubt that this is the way ahead.
Roger Kirby
The Prostate Centre, London W1G 8GT
The Patagonia trans-Andes Challenge was the fourth in the series of cycle rides that have taken us to Sicily, Malawi and Madagascar to raise funds for The Urology Foundation (TUF) a charity that supports research and training into all urological diseases. It brings 14 urologists, including the indefatigable Roland Morley, Neil Barber and Richard Hindley, not forgetting the incredibly plucky Jo Cresswell, together with patients and other enthusiastic supporters.
The TUF team gathered in Bariloche, a town in the foothills of the Andes and on the shore of the incredibly beautiful Lake Nahuelhuapi. We were so lucky with the weather: although we were greeted by a torrential downpour when we arrived, we awoke to a perfect day and collected our almost new Wisper bikes which were sturdy enough to get us over and across the Andes to Chile, on and off road!
We set off in convoy, 47 cyclists, plus our handsome Argentinian guide, Roderigo as well as our leader Miriam, who has guided all our cycling adventures for TUF in Sicily, Malawi and Madagascar. On day one, Lesley Hawker, a bladder cancer survivor, is unceremoniously jettisoned from her saddle by an Argentinian driver who fails to give her a wide enough berth and clips her from behind with a wing mirror. Luckily Lesley suffers nothing worse than a few scratches and bruises, but it was a near miss! Later, Abhay Rane manages to outdo her with a more spectacular fall, flying gracefully over his handlebars, but like her, emerges bloodied, but unbowed.
The scenery in Patagonia is unbelievably spectacular: dramatic desert-like landscapes, then forests and mountains on the approach to the Villa La Angostura, a colonial type hotel, beside a stunning lake where we spend the night. The pre-trip information stressed the need for fitness preparation, but didn’t mention the need to induce liver enzymes to cope with vast quantities of Argentinian and Chilean wine consumed in the evenings!
The next morning we were back on our mountain bikes, notwithstanding sore heads and even more uncomfortable perineal parts, the legacy of the previous day’s cycling. A 90 Km ride with three seemingly endless climbs takes us to Aguas Calientes, where our weary legs benefit from alternate immersion in hot springs and submersion in freezing river water formed by glacial melt-water.
An Andean vulture circles ominously overhead as the last weary cyclists toil to the top of the Puyehue Pass in Argentina. A gruelling 27 Km uphill ride has brought 47 sweating participants to the border with Chile. Here, at the highest point that we reach on this Challenge, we hold a minute’s silence to remember friends, relations and patients who are sadly no longer with us.
After toiling up the Argentinian side of the Andes, we hurtled down the Chilean slopes where we encountered snow-capped volcanoes, turquoise lakes and spectacular waterfalls rushing between the rock formations of the beautiful Osorno volcano. The laughter and team camaraderie continued to build as the four sporty Belgians who cycle all in black are integrated seamlessly into the group. We dubbed them “L’Equipe Noir”
Luckily for us the good weather held for the week and although there were a few more plummets from the bikes, there were no serious injuries. We cycled 462 Km and climbed in all 16,454 feet. We held a celebratory dinner in Puerto Varas, by Lake LLanquihue, in Chile, with an Awards Ceremony, which includes the sought-after prize for the “best female bum”, proudly won by Georgina Stewart. The really great news is that we have raised more than £287,000 for TUF. The money will be targeted on research into urological cancers, as well as training urologists in new surgical technologies, utilizing robotics and laparoscopy. We will also deploy funds to develop our personal development programmes for trainees and younger consultants, including “SpRUCE ” interview training and “Thriving and Surviving as a First Year Consultant.” To do these important things we need your support. Why not join us on our next cycle Challenge for TUF in South Africa in November 2013? For more information check out www.theurologyfoundation.org or www.actionforcharity.co.uk . Come on guys and gals, get on yer bikes!
When a bicycle crash involving a motor vehicle results in injuries, there is a common misconception that it is the cyclist who is probably to blame. However, statistics show motorists are more often at-fault.
The City of Boston reported that in 55 percent of bicycle vs. vehicle accidents locally, it’s the motor vehicle operator who is cited.
If you get involved on any kind of traffic accident with injuries result from carelessness or recklessness of a driver, appeal law and order to pursue a claim for compensation.
Bicycle accident fatalities account for 2 percent of all traffic-related deaths, according to the National Highway Traffic Safety Administration (NHTSA). However, hospital data shows only a fraction of bicycle accidents that result in injury are recorded by police. Even among recorded cycling accidents, the National Safety Council reports a 9 percent increase between 2001 and 2011. There was also a 9 percent increase in bicyclist deaths between 2011 and 2013.
For insurance purposes, collisions between bicyclists and vehicle drivers are considered “auto accidents,” and injured cyclists are entitled to collect damages to cover hospital bills, lost wages and other costs. In hit-and-run accidents or those in which the driver lacks or has limited insurance, the cyclist can also use his or her own uninsured/ underinsured auto coverage.
The idea of a joint fund-raising trek in support of Prostate Cancer UK (formerly Prostate Action) and Well-Being of Women (WoW) dates back to 2005, when almost 100 trekkers joined us to walk across the desert to Petra in Jordan to raise more than £600,000 for these two noble causes. Neither Marcus Setchell nor I thought then that subsequently we would go on to trek in Kenya, Sinai, Kerala, and most recently Morocco, to raise an eventual cumulative sum of £1.3 million.
The fifth and final Hike for Hope started inauspiciously with dark clouds and pouring rain, even though we were in Morocco in September, just a couple of hundred miles North of the Sahara desert. They told us it hadn’t rained for the whole year before we got there! Undaunted, but with little in the way of rain-gear, rather, an excess of redundant sunscreen products, we set off across the Ante-Atlas mountains in the direction of Marrakesh.
This time, there were 27 intrepid trekkers, including the redoubtable Andrew Etherington, Felicity Hoare and Rex Willoughby, veterans who had each accompanied us on all the previous four Hikes for Hope, as well as Rosemary Macaire. Unfortunately on day one the rain became steadily heavier, with the result that the beds of the mountain streams, usually dry, became minor torrents, which were more and more difficult to cross. We made the decision to abandon the last hour’s walking to the camp and instead managed to persuade some of the local people to let us shelter in two of their mountain huts for that night.
Days two and three were tough trekking, but in fine dry weather. We got to the very highest point of the mountain before holding a minute’s silence for those relatives and friends who had succumbed to prostate or pelvic cancer, the cures for which we were raising money. Perhaps as the result of our efforts, we are a little closer to that goal.
On day four the rain returned, this time with even greater intensity, and accompanied by a bitterly cold wind. With little in the way of protective clothing, hypothermia became an issue. Again the amazing hospitality of the local Berber goat herders came to our rescue. Cold, wet and shivering, packed in again like sardines, we managed to get some sleep, occasionally interrupted by a goat or two, who seemed justifiably irritated to be displaced from their usual place of nocturnal shelter! To the credit of the guides, the trek doctor and the trekkers themselves, morale and good humour were maintained.
On the final day the weather improved sufficiently for us to trek down the mountain to join the first road we had encountered for five days. A drive through the Atlas Mountains took us to the wonderful city of Marrakesh, where a well-deserved celebratory dinner and award ceremony took place. The trials and tribulations of our mountain trek had brought us all much closer together, so it was with a tinge of sadness that the Hikers for Hope disbanded and headed for home. The final sum of money raised and the camaraderie and bonding that occurred during the trek made the whole experience so very worthwhile.
A recent editorial in the BMJ by Christopher Parker (Treating prostate cancer. BMJ 2012; 345: e5122) uses the “best available evidence” from the PIVOT study (Wilt TJ, et al) to argue the case for watchful waiting for low risk prostate cancer and question the need to diagnose the condition at all. Unfortunately the PIVOT trial was marred by a number of serious flaws that should make us doubt its conclusions.
The original design of the PIVOT trial included a randomisation of 2000 patients to surgery or observation (Prostate cancer, uncertainty and a way forward. NEJM 2012; 367: 270-1). Unfortunately, this goal was not achieved; the design was modified to justify a randomization goal of only 740 patients. Median survival was assumed to be 15 years in the original study design and 10 years in the updated version. If the median survival of 12 years in the study’s observation group is taken and 7 years for enrollment and 8 years of follow-up assumed, the sample requires 1200 patients in order to detect a 25% relative reduction in mortality with 90% power and a two-sided alpha level of 0.05. With an actual enrollment of only 731 patients, the study was consequently underpowered to detect this relatively large clinical effect. The wide 95% confidence interval around the hazard ratio for death in the treatment group illustrates this point. A relative increase of 8% to a relative reduction of 29% in the risk of death in the prostatectomy group, as compared with the observation group, cannot be excluded with 95% confidence. Only 15% of the deaths were attributed to prostate cancer or its treatment.
Although a “life expectancy of at least 10 years” was an entry criterion, by 10 years almost half the participants had died, leaving only 176 men in the surgery group and 187 in the observation cohort, and by 15 years only 30% were alive. The investigators therefore did not recruit healthy men who would be the normal candidates for surgery and randomize them to observation; instead they recruited elderly and co-morbid men with very limited life expectancy and randomised them to surgery (with one fatality!). Furthermore, the finding that one fifth of patients did not adhere to the assigned treatment further reduces the ability of the trial to discern a treatment effect.
Prostate cancer is a slowly progressive condition which eventually, and after many years, results in a painful death from metastases in a significant number of patients, unless mortality from other causes supervenes. Radical prostatectomy, now usually performed minimally invasively with robotic assistance (Goldstraw MA, et al), prevents disease progression in >80% of well-selected cases. We appear to manage localised prostate cancer in a much more holistic way than our American colleagues and MDT decision-making and robust active surveillance programmes have enhanced this. Others were also outraged by the Parker editorial and the intrinsically flawed results of the PIVOT study should definitely not encourage us to turn our backs on a disease that kills more than 10,000 men per annum in the UK and hundreds of thousands more worldwide.
Roger Kirby, Ben Challacombe and Prokar Dasgupta
The Prostate Centre, London W1G 8GT and Guy’s Hospital, King’s College London, King’s Health Partners
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Deep vein thromboses (DVT) and pulmonary embolism (PE) are rare, but potentially devastating, complications of major pelvic surgery. We have performed more than 1000 robot assisted radical prostatectomy (RARP) procedures in Central London (Lessons learned from 1000 RARP operations BJUI 2013;111(1):9-10.) and to date encountered just a couple of DVTs, as well as a single, non-fatal instance of PE. However, in the case of one of us (RK), a close relative passed away as a result of a PE 10 days after a routine hip replacement performed in Oxford, a very sad event which highlighted the very negative impact on the family of this preventable surgical complication.
Guidance from NICE recommends that evidence-based steps be taken to reduce the risk of venous thromboembolism (VTE). Failure to do so therefore renders us open to criticism if a DVT, or worse a PE, does develop. On the other hand, pelvic haematoma and haematuria are troublesome complications of RARP, the risks of which may be exacerbated by anticoagulation.
What therefore should we be doing to reduce the risk of before and after laparoscopic pelvic surgery? Few would disagree that TED stockings should be worn before and after surgery, but how long should they be retained, as many patients do find them rather uncomfortable? Calf compression boots during surgery and for 12 hours or so post-operatively should also be standard practice.
More contentious is the duration of use of low molecular weight heparin (LMWH). Some surgeons use a single dose immediately prior to the operation; we have used 5000 Units of Clexane post-operatively for 2-3 days. Orthopaedic surgeons are increasingly continuing LMWH for 28 days at home after joint replacement surgery, which carries a significant risk of VTE. Should we follow their lead? A simpler alternative from the patients’ viewpoint is daily use of one of the new oral anti-coagulants such as dabigatran.
Perhaps the most sensible approach clinically is to perform a risk assessment of all RALP candidates pre-operatively. A calf compression device and TED stockings should be used for all patients, together with LMWH, while in hospital. Those considered especially at risk with, for example, a BMI >30 (Becattini CA) (See Box 1), should usually go home for a month with either LMWH injections or daily oral dabigatran, or equivalent oral anticoagulant agent.
We would be most interested in the views, experiences and current practice of the readers of this piece. Please do post your own response.
Roger Kirby, Ben Challacombe and Prokar Dasgupta
The Prostate Centre, London W1G 8GT and Guy’s Hospital, King’s College London, King’s Health Partners
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