Tag: surgery

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Worldwide Live Robotic Surgery 24-Hour Event 2015

October 15, 2015/4 Comments/by admin Z.9

For the first WRSE24 we had over 2500 unique viewers registered from 61 countries (58 on the day).

This time we want you the global audience to get involved and participate online

In the Worldwide Robotic Surgery Event

Register now for free

In February 2015, with EAU approval, ten robotic centers from 4 continents planned to stream live surgery continuously for 24hrs.

Viewing of live surgery was limited to medical professionals using password protection, following registration. LiveArena ™ provided the infrastructure and technological support. All surgeries were completed without incident and we have submitted our outcome data to the EAU live surgery committee, who are supporting our next planned event. Further details can be found at www.wrse24.org

Following previously published EAU Policy on Live Surgery Events (LSE’s), whilst ongoing live surgery at conferences is assured, there remains debate as to how best we can optimise this form of training. The EAU panel reached >80% consensus view that performing live surgery from home institutions may be safer, identifying several issues with a ‘‘travelling surgeon’’. A BJUI poll related to the first WRSE24 found that 76% of respondents would ‘attend’ a streamed virtual surgical conference rather than travel if accreditation were the same, further indicating the potential for uptake into training and education events.

The outcome from the first event surpassed many of our expectations. Registrants came from 61 countries. 1390 unique viewers visited the www.WRSE24.org website during the live 24 hours and this number increased to 2277 over the next 6 days.

The event was well received by industry and the project was a finalist in the category of “Innovative Technology for Good Citizenship” at the prestigious Microsoft Partnership awards held in July 2015, which received over 2,300 nominations from 108 different countries.

We are also delighted to announce that the forthcoming WRSE24 will involve surgeons from 2 more continents making it the first live urological conference to have contributors from 6 continents.

As well as all the surgeons previously involved we will be joined by 5 new surgeons including 2 additional robotic centres: Clinique St Augustin (Dr Richard Gaston and Professor Thierry Piechaud) and Sao Paulo University Hospital (Dr Rafael Coelho). Benjamin Challacombe will be operating from Guys Hospital, London and Ketan Badani will be operating from Mount Sinai, New York. Our aim is to stream live surgery from 12 leading robotic centres, a list of whom can be seen below. Finally we will have a live teleconference link via Skype between Professor Hassan Abol-Enien from the world famous Mansoura University Hospital and Professor Peter Wiklund at Karolinska.

The second event will also see the 24hour studio sessions split into six 4hour sessions. The contributing centres are Karolinska Stockholm, OLV Aalst, Guys London, Mt Sinai New York and Keck USC, Los Angeles.

The first event was primarily focused on providing access to live streamed HD video of world leading surgeons operating in their normal working day, with their expert teams. The second event plans to build on this format with more audience participation utilizing social media. We are working with LiveArena™ and Microsoft™ to optomise this aspect. There will be improved opportunities to ask questions to the surgeons utilizing a Microsoft Yammer ™ app that will be integrated into the WRSE24 site or via twitter using #wrse24. Although the concept of a Twitter backchannel at educational events has become familiar, future approaches may be able to improve on ways of communicating within a global audience. Our aim for the 2^nd WRSE24 is to enliven virtual participation, widening access to a fuller, interactive, experience for the online audience, with an emphasis on conversation, connection and crowd sourcing of opinions. To highlight the benefits of crowd sourcing of opinions we are planning an ambitious project to have an interactive live debate between Mansoura University Hospital and Karolinska University Hospital. This will include polling technologies available via Yammer™, so that the second part of this planned live discussion will potentially be guided by the opinions of the global audience. A research-group at Stockholm University, with a specialist interest in Social Media are also working closely with WRSE24 to help interpret this data, so that we can learn from this event.

For more details on this worldwide event and the complimentary activities that are planned please visit www.wrse24.org

The Urological Ten Commandments

September 7, 2015/3 Comments/by Jonathan Glass

“It is my ambition to say in ten sentences what others say in a whole book.” – Friedrich Nietzsche

The EAU guidelines on lower urinary tract symptoms have been published recently. These contain 36,000 words. It was pointed out to me that the American declaration of independence contained 1300 words and The Ten Commandments just 179 words.

The challenge was therefore to write ten commandments for urology in 179 words. The rules I set were that I should write them whilst keeping the spirit of the structure of the decalogue as closely as possible. (It may be worth rereading the original before reading on). So here goes.

1) I am a logical specialty. Thou shall investigate thoroughly prior to undertaking intervention for I am a specialty that avoids surprises.
2) Though interested in the whole of medicine thou will perform no other procedures other than urological.
3) Thou shalt not base intervention on old imaging for the clinical situation could have changed.
4) Remember that 80% of diagnoses can be made with history alone. Thou shalt listen carefully to your patient to this end.
5) Honour sound surgical principles. Urological tissue is forgiving but anastamoses under tension will not heal.
6) Thou shall not ignore haematuria.
7) Thou shall not leave a stent and forget it has been placed.
8) Thou shall not adopt new technology without proper clinical evaluation unless it is part of a trial.
9) Thou shall not fail to see the images yourself in assessing the patient before you.
10) Thou shall not fail to assess the potential for harm before embarking on a surgical procedure. If you would not do it to your family, your neighbour or friends, you will not do it to the patient who is in your clinic.

I put these out for discussion. Other offerings please.

Jonathan M. Glass @jonathanmglass1

The Urology Centre, Guy’s Hospital, London, UK.

[email protected]

Here comes the sun

July 29, 2015/by Ben Challacombe

Sun, sea, sand and stones: BJUI on the beach.

Welcome to this month’s BJUI and whether you are relaxing on a sun-drenched beach or villa somewhere having a hard-earned break, or back at your hospital covering for everyone else having their time off, we hope you will enjoy another fantastic issue. After an action packed BAUS meeting with important trial results, innovation, social media and the BJUI fully to the fore, this is a great moment to update yourself on what is hot in urology. This is probably the time of year when most urologists have a little extra time to take the BJUI out of its cover or open up the iPad and dig a little deeper into the articles, and we do not think you will be disappointed with this issue, which certainly has something for everyone.

In the ‘Article of the Month’, we feature an important paper from Egypt [1] examining factors associated with effective delayed primary repair of pelvic fractures that are associated with a urethral injury. Do be careful whilst you are travelling around the world, as most of the injuries in this paper were due to road traffic accidents. They reported 76/86 successful outcomes over a 7-year period. When a range of preoperative variables was assessed, four had particular significance for successful treatment outcomes. The paper really highlights that in the current urological world of robotics, laparoscopy and endourology, in some conditions traditional open surgery with delicate and precise tissue handling and real attention to surgical detail are the key components of a successful outcome.

Whilst you are eating and drinking more than usual over the summer, we have some food for thought on surgery and metabolic syndrome with one of our ‘Articles of the Week’. This paper contains an important message for all those performing bladder outflow surgery. This paper by Gacci et al. [2] from an international group of consecutive patients clearly shows that men with a waist circumference of >102 cm had a far higher risk of persistent symptoms after TURP or open prostatectomy. This was particularly true for storage symptoms in this group of men and should influence the consenting practice of all urologists carrying out this common surgery.

Make sure you drink plenty of Drink HRW to stay well hydrated on your beach this August, as the summer months often lead to increased numbers of patients presenting to emergency departments with acute ureteric colic, so it seems timely to focus on this area.To this end I would like to highlight one of our important ‘Guideline of Guidelines’ series featuring kidney stones [3] to add to the earlier ones on prostate cancer screening [4]and prostate cancer imaging [5]. This series serve to assimilate all of the major national and international guidelines into one easily digestible format with specific reference to the strength of evidence for each recommendation. Specifically, we look at the initial evaluation, diagnostic imaging selection, symptomatic management, surgical treatment, medical therapy, and prevention of recurrence for both ureteric and renal stones. Quite how the recent surprising results of the SUSPEND (Spontaneous Urinary Stone Passage ENabled by Drugs) trial will impact on the use of medical expulsive therapy remains to be seen [6].

So whether you are sitting watching the sunset with a drink in your hand or quietly working in your home at night, please dig a little deeper into this month’s BJUI on paper, online or on tablet. It will not disappoint and might just change your future practice.

References

1 Koraitim MM, Kamel MI. Perineal repair of pelvic fracture urethral injury: in pursuit of a successful outcome. BJU Int 2015; 116: 265–70

2 Gacci M, Sebastianelli A, Salvi M et al. Central obesity is predictive of persistent storage lower urinary tract symptoms (LUTS) after surgery for benign prostatic enlargement: results of a multicentre prospective study. BJU Int 2015;116:271–7

3 Ziemba JB, Matlaga BR. Guideline of guidelines: kidney stones. BJU Int 2015; 116: 184–9

4 Loeb S. Guideline of guidelines: prostate cancer screening. BJU Int 2014; 114: 323–5

5 Wollin DA, Makarov DV. Guideline of guidelines: prostate cancer imaging. BJU Int 2015; [Epub ahead of print]. DOI: 10.1111/bju.13104

6 McClinton S, Starr K, Thomas R et al. Use of drug therapy in the management of symptomatic ureteric stones in hospitalized adults (SUSPEND), a multicentre, placebo controlled, randomized trial of a calcium-channel blocker (nifedipine) and an a-blocker (tamsulosin): study protocol for a randomized controlled trial. Trials 2014; 15: 238

Ben Challacombe
Associate Editor, BJUI

While you slept: bad behaviour and recording in the operating room

June 25, 2015/2 Comments/by Mike Leveridge

A head-shaking story of operating room unprofessionalism has been making the rounds on news services and social media, as an unsuspecting patient inadvertently recorded audio during his colonoscopy, only to hear his person and personality belittled by the operating room staff while he was anaesthetized. The heat has fallen mostly on one anesthesiologist, but none has escaped rightful scrutiny.

The anesthesiologist of the day quipped to the newly asleep patient “after five minutes of talking to you in pre-op, I wanted to punch you in the face and man you up a little bit.” The OR team mocked a rash the patient had noted, alternately joking that it was syphilis or “tuberculosis of the penis”. “As long as it’s not Ebola”, remarked the surgeon. The case went to court and the patient was ultimately awarded $500,000US.

On reading the story and the clearly ghastly banter among the team, no doubt the first response would be along the lines of “they actually said those things?!”. I suspect, however, that more than a few surgeons’ gut reaction might have been “he heard what they were saying about him?!”, followed by squirming in one’s seat and the sudden recollection of a dozen blithe comments in one’s own ORs. This incident opens several proverbial cans of worms that merit some thought.

Clearly, this particular debacle is a no-debate-needed case of unacceptable behaviour, and the solution is simple: don’t do that! We have spent much energy in the past years establishing ground rules for online professionalism, but of course the rules of decorum have always applied in the material world as well. Recording or no recording, there is simply no place for mocking of patients, awake, asleep or in absentia.

As surgeons, and urologists perhaps in particular (with our warrant to investigate and operate on urogenital complaints), this provides a stark reminder about our own behaviour, when the audio isn’t being recorded. Ask yourself if you have openly lamented the challenges of operating within a morbidly obese patient’s pelvis or retroperitoneum, snickered or gasped at the enormity of a hydrocele or penile tumor, or glibly eulogized a torted or cancerous testicle.

A question then becomes, what is acceptable and unacceptable in the operating room? Are all off-topic conversations unacceptable? Given the intensity of surgery and the OR, is there room for joking and banter to decant some stress? My personal thought is that black-and-white dictates and zero-tolerance policies usually (read: usually) only serve to absolve us of having to actually think about issues, and that grey areas exist in most settings. Levity in the OR is no different, but caution and forethought are critical.

The other issue that clearly arises is that of recording within the OR during surgery. There are doubtless advocates of each extreme, from the sanctity of the theatre to full access to video and audio. We have all had patients bring recorders into the clinic room – does the Hawthorne effect improve our behaviour or our care, or does the added scrutiny lead to hedging, indecision or ambiguity on the part of the physician? You can see both sides play out in this post and its comments. Recording in the operating room is on a completely different level than clinic discussions, however. Aside from the content of conversation within the operating room, the complexities and individuality of each procedure and the thought of a second-by-second parsing of technical detail by non-expert patients seems to make this a totally unwieldy proposition. On the other hand, are the assumption of basic ethical standards and a post-op chat enough “data” for a patient to really understand all of the relevant details of their care? What about recording for skill development or assessment? Much has been written here as well.

The patient/plaintiff in this case was clearly subject to a debasement none of us deserves or would wish on ourselves. Reading and hearing this OR team’s contempt for their patient is a graphic reminder of what this behaviour can descend to unchecked, and hopefully a course-correction for surgeons, nurses and anaesthesiologists who hover on or over “the line”. As for its window into the merits of recording, the issue gets no clearer.

Mike Leveridge is an Assistant Professor in the Departments of Urology and Oncology at Queen’s University, Kingston, ON, Canada. @_TheUrologist_

Article of the Week: 3D percutaneous navigation, integrating position-tracking with a tablet display

April 22, 2015/by admin Z.9

Every week the Editor-in-Chief selects the 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 Dr. Osamu Ukimura, discussing his paper.

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

Three-dimensional navigation system integrating position-tracking technology with a movable tablet display for percutaneous targeting

Arnaud Marien, Andre Castro de Luis Abreu, Mihir Desai, Raed A. Azhar, Sameer Chopra, Sunao Shoji, Toru Matsugasumi, Masahiko Nakamoto, Inderbir S. Gill and Osamu Ukimura

USC Institute of Urology, Center for Focal Therapy of Prostate and Kidney Cancer, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Read the full article

OBJECTIVES

To assess the feasibility of a novel percutaneous navigation system (Translucent Medical, Inc., Santa Cruz, CA, USA) that integrates position-tracking technology with a movable tablet display.

MATERIALS AND METHODS

A total of 18 fiducial markers, which served as the target centres for the virtual tumours (target fiducials), were implanted in the prostate and kidney of a fresh cadaver, and preoperative computed tomography (CT) was performed to allow three-dimensional model reconstruction of the surgical regions, which were registered on the body intra-operatively. The position of the movable tablet’s display could be selected to obtain the best recognition of the interior anatomy. The system was used to navigate the puncture needle (with position-tracking sensor attached) using a colour-coded, predictive puncture-line. When the operator punctured the target fiducial, another fiducial, serving as the centre of the ablative treatment (treatment fiducial), was placed. Postoperative CT was performed to assess the digitized distance (representing the real distance) between the target and treatment fiducials to evaluate the accuracy of the procedure.

RESULTS

The movable tablet display, with position-tracking sensor attached, enabled the surgeon to visualize the three-dimensional anatomy of the internal organs with the help of an overlaid puncture line for the puncture needle, which also had a position-tracking sensor attached. The mean (virtual) distance from the needle tip to the target (calculated using the computer workstation), was 2.5 mm. In an analysis of each digitalized axial component, the errors were significantly greater along the z-axis (P < 0.01), suggesting that the errors were caused by organ shift or deformation.

CONCLUSION

This virtual navigation system, integrating a position-tracking sensor with a movable tablet display, is a promising advancement for facilitating percutaneous interventions. The movable display over the patient shows a preoperative three-dimensional image that is aligned to the patient. Moving the display moves the image, creating the feeling of looking through a window into the patient, resulting in instant perception and a direct, intuitive connection between the physician and the anatomy.

Editorial: A 3D window into the body?

April 22, 2015/by Matthew Bultitude

If real-time tracking is accurate enough to tell you that Roger Federer’s serve was on the line or that David Beckham’s free kick was indeed over the goal line, then surely tracking systems could help us guide needles and wires into different parts of the body? In this month’s BJUI, Marien et al. give us an insight into the future of access for percutaneous procedures [1]. Currently, percutaneous access to the body for biopsy, renal access or treatment of malignancy is usually based on two-dimensional imaging, with the expertise of the operator compensating for the lack of real-time three-dimensional (3D) visualization of the surgical field. In this paper, the authors hypothesized that integrating virtual reality visualization with real-time position tracking of the needle/instrument would improve navigation. This improvement remains unproven and the study is a first step on that road.

The authors assess the feasibility of a novel method of percutaneous access (Translucent^TM Medical Inc.) using a freely movable tablet display to help guide the percutaneous puncture to its target (see Fig. 1). The success of such a system would rely on a high degree of accuracy and the authors set out to test this in a cadaveric model. Fiducial markers were placed in the kidneys and prostates of cadavers to mimic tumours. A CT scan was then performed to allow 3D model reconstruction. An electromagnetic field was generated around the body and magnetic sensors (fixed to the skin and in the urethral catheter) were used for localization. The software then allows real-time demonstration of the needle trajectory with a predicted line beyond the needle tip overlaid on the 3D model. The authors were able to quickly reach the target (mean time 43 s) with apparent good accuracy, which was calculated to be within 2.5 mm; however, further fiducial markers were deployed at the centre of the target to allow the accurate measurement of accuracy. The distance between the ‘target’ fiducial and the ‘treatment’ fiducial was 16.6 mm in the prostate and 12.0 mm in the kidney. This difference was probably attributable to either movement of the organ or deformation of it from the needle puncture itself. These errors were predominantly in the z-axis (i.e. depth), suggesting that they were caused by movement and deformation by the needle itself, which therefore poses the challenge of how the errors might be reduced, especially when a living human model may have more compliant tissues and of course be moving with respiration.

Figure 1. Tablet screen displaying real-time ‘three-dimensional window into the body’ with real and projected trajectory of needle

The present paper by Marien et al. is not the first report of using tracking for percutaneous access in urology. Using different technology, Rassweiler et al. [2] reported on the percutaneous puncture of the kidney for nephrolithotomy using an iPad with surface skin markers, which were visualized by the rear-facing camera of the iPad, and this information was processed to calculate the location of the tissues beneath based on a preoperative CT. This system, and I suspect all others, will rely on a CT being performed in the exact position of the surgery, which is another limiting step until this can be performed at the same time as the surgery.

There are of course concerns regarding use of this technology. The accuracy was limited when analysing the actual position of the ‘treatment’ fiducial because of movement of the tissues. This is likely to be worse in living tissue. There was no respiratory movement which would probably make accurate tracking difficult, although placement of markers to allow movement tracking may help overcome this. Rodrigues et al. [3] reported high accuracy of percutaneous nephrolithotomy puncture after deployment of an electromagnetic sensor in the target calyx with ureterorenoscopy in a porcine model but without a 3D model.

My major concern is that of false reassurance. A nice image is portrayed on the screen which is believed by the surgeon, while in fact there is a significant mismatch caused by patient/tissue movement, either since the preoperative planning CT scan or intra-operatively. The falsely reassured surgeon then inadvertently damages surrounding organs.

It is clear that this technology is work in progress, but it does offer promise that real-time tracking of a percutaneous needle is possible, with accurate representation on a 3D model reconstruction helping to guide the surgeon to the target.

Read the full article

Matthew Bultitude

Department of Urology, Guy’s and St. Thomas’ Hospital, London, UK

References

1 Marien A, De Castro Abreu AL, Desai M et al. Three-dimensional navigation system integrating position-tracking technology with movable tablet display for percutaneous targeting. BJU Int 2015; 115: 659–65

2 Rassweiler JJ, Muller M, Fangerau M et al. iPad-assisted percutaneous access to the kidney using marker-based navigation: initial clinical experience. Eur Urol 2012; 61: 628–31

3 Rodrigues PL, Vilaca JL, Oliveira C et al. Collecting system percutaneous access using real-time tracking sensors: ﬁrst pig model in vivo experience. J Urol 2013; 190: 1932–7

Video: Percutaneous targeting using 3D navigation that integrates position-tracking technology with a tablet display

April 22, 2015/by admin Z.9

Three-dimensional navigation system integrating position-tracking technology with a movable tablet display for percutaneous targeting

Arnaud Marien, Andre Castro de Luis Abreu, Mihir Desai, Raed A. Azhar, Sameer Chopra, Sunao Shoji, Toru Matsugasumi, Masahiko Nakamoto, Inderbir S. Gill and Osamu Ukimura

USC Institute of Urology, Center for Focal Therapy of Prostate and Kidney Cancer, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Read the full article

OBJECTIVES

To assess the feasibility of a novel percutaneous navigation system (Translucent Medical, Inc., Santa Cruz, CA, USA) that integrates position-tracking technology with a movable tablet display.

MATERIALS AND METHODS

RESULTS

CONCLUSION

Kenny Rogers’ Law of Surgical Practice

February 3, 2015/1 Comment/by Jim Duthie

Although not a Country Music fanatic, I would like to acknowledge the contribution that Kenny Rogers, elder statesman of the genre, has made to the practice of modern surgery. I refer to his insightful song, and subsequent film, The Gambler. For the uninitiated, the song describes a chance meeting between a world-weary professional card player and an aspiring young gambler. If you are gambling lover then you may know Bitbola is a sbobet88 Mobile Indonesia site that provides a variety of online gambling games such as Sportsbook, Online Casino, Agile Ball, Online Poker, Online Togel, Cockfightingand many more, with a minimum deposit of only 25 thousand. There are so many benefits to be gained when you join Bitbola. For now, Bitbola is the Official SBOBET Mobile site in Indonesia which is well-known among all online gambling lovers. People are loving to play w88 games. The older man gifts the younger with pearls of wisdom on winning at cards, culminating in a chorus stating that a player needs to “know when to hold ‘em, know when to fold ‘em, know when to walk away, know when to run”. I am not for a minute condoning the practice of surgeons literally running away from their patients, however strong the urge, but I do think some of the other sentiments are instructional in our practice.

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The revelation came to me as a student, staying in the hospital late with the senior surgical trainee on call, hoping for something exciting to come through the door. Late that night, a very elderly, frail woman arrived shocked, in agony, confused, combative, and in multi-organ failure. The CT showed a significant portion of her small bowel was ischaemic. The trainee drilled me on management options; thrombolysis or endovascular techniques were impractical here, leaving only extensive resection; anastomosis with proximal diversion. Of course this would be a high-output stoma with associated high loss of fluid and electrolytes, difficult to manage, she would be a poor candidate for elective reversal… It did occur to me that this was going to be tough on the poor lady, and probably even futile, but a student can’t say “let’s just keep her comfortable” on a surgical rotation. The trainee had the experience and humility to suggest it himself. He confirmed my predictions of failed extubation, a prolonged ICU admission with worsening multi-organ failure, debates about whether to dialyse, increasing vasopressor and inotrope support, undying hope from the family that she would “turn the corner”, until finally a wrecked shell of a human being would succumb to an unavoidable complication of her treatment. “Sometimes, you’ve got to know when to call it quits”. This inspired me. “You’ve got to know when to hold ‘em, know when to fold ‘em?”. “Exactly”, he replied, and Kenny Rogers’ Law was born.

A mentor of mine once said, “there is no medical condition that can not be made worse with a poorly conceived operation”. This is the doctrine I cling to when feeling pressured to “push the envelope”, or attempt “heroic surgery” in the face of good sense. The most important factor influencing surgical outcomes is patient selection. Poor substrate results in poor results. The problem is that complex surgical problems often come wrapped in the most sympathetic, heart-breaking packaging. The delightful lady with a neurological disorder who is really fed up with the urinary diversion she had twenty years ago. The poor old fellow who can’t bear his nephrostomy. The tearful wife who asks if there is anything, ANYTHING you can do for him? At a departmental meeting it might be easy to assess these cases in a cold academic light, and rightly recommend against intervention. But then you don’t have to face the desperate human face of suffering at the meeting.

A surgeon I know who has a million useful platitudes once told me that if I was planning to do a surgery, but was not sure of the wisdom of it, to say out loud what I was going to do in the past tense with the preface, “well, Your Honour…” If you have never done this, I recommend it. “Well, Your Honour, I know she was morbidly obese and had had multiple laparotomies in the past with significant adhesion disease, and was admitted to the ICU with profound sepsis each time, but even though her dexterity is too poor for her to effectively self-catheterise, I thought it would be worth trying to reverse her ileal conduit and perform a clam cystoplasty. She was really sick of her conduit.”

As doctors, rather than just surgeons, sometimes our role is to convince a patient that however bad they think things are, we could certainly make things worse for them. Undoing an operation and its complications is usually not easy, and often impossible. Better to know when to fold ‘em.

Brown Sauce and honest reporting

May 2, 2014/6 Comments/by James Duthie

The British are fond of a condiment called Brown Sauce. The product itself leaves me unmoved, but the thing I find interesting about Brown Sauce is that it purports nothing about itself whatsoever, other than a description of its colour. It claims no link to any known product of nature, just a factual statement about its appearance. Consider, for instance, tomato ketchup. If an independent lab discovers that a ketchup is, in fact, only 5% tomato and 95% starch, sugar, salt, and flavor enhancer 621, people will be justifiably irate about the “tomato” claim. If, on the other hand, Brown Sauce is eventually proven to be made from asbestos and drowned kittens, the manufacturers can quite rightly state that they only said it was brown.

The same kind of plain speech is often missing in surgery. The truth has often been a casualty in the patient consent process due to a combination of ignorance, fear, avarice, or ego on the part of the surgeon. Whatever the motivation, when we explain rates of risks and benefits to the patient before us, many of us are not giving an honest report of our own outcomes. In the case of the battle between robotic and open radical prostatectomy, for example, real-world complication rates are often ignored in favour of Walsh’s rates on one side, and Patel’s on the other. Surgeons are certainly not all the same. If you have ever considered who you would allow to perform surgery on yourself the chances are you have written a very short short-list. When we tell a patient that the rate of complication x from procedure y is only 5% and we have not audited our own outcomes, we are likely giving the rates produced by the high-volume specialist centres that had the expertise, numbers, and clout to get their rates published in a reputable journal. Most surgeons do not work in those centres.

There is an on-going debate on whether hospitals should be compelled to publish their procedure-specific outcome data, so that the public can make informed decisions about their surgical care. I think this misses the point. Yes, there are potential hazards to compulsory publishing; centres of excellence may have worse outcomes than others due to operating on the sickest patients with the slimmest hopes of success, one major complication in a lower volume centre can skew the data, and there is the potential to develop a culture of suspicion and dishonesty, but the real point is more personal. We should honestly report to the patient in front of us from our own results as a matter of honesty and ethics, regardless of hospital policies. We can then (hopefully) reassure them that our outcomes are comparable to those published, and they can expect good quality care from us. If we cannot reassure them of this, our audit process will inform us of our shortcomings and we can seek to address them. We might even consider leaving certain procedures to a colleague who is better at it than us. A bitter pill, maybe, but arrogance is the enemy of improvement.

It can be a nuisance to collect and collate operative data. It can be painful to discover that we are not as good at something as we had assumed. Thankfully surgeons are mature adults who can take these challenges on the chin, and use the results to make our patient care better. Can’t we?

Otherwise, the information we give our patients is “pork-pies”, which is Cockney rhyming slang for lies, and no amount of Brown Sauce can make those pies palatable.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

Surgery or Radiation in Prostate Cancer?

February 28, 2014/5 Comments/by Prasanna Sooriakumaran

I am sure many of you are familiar with the clinical situation I see every week of a man with newly-diagnosed prostate cancer asking me about his options. While we steer many men with low risk prostate cancer towards surveillance nowadays, for those with intermediate or high risk disease intervention is usually their best option, especially if they have a long life expectancy. This gives us the dilemma of whether to recommend surgery or radiotherapy.

In Oxford, we have a long and pioneering history of evidence-based medicine, and I lament the lack of RCTs in this field. The only one, ProtecT, which is being led also by Oxford, will not report before 2016, and will at least in part be subject to volunteer bias. Now, the question of surgery or radiotherapy for prostate cancer is not a new question. Millions of men have undergone these treatments across the globe and over the decades, and many other investigators have evaluated this question.

Most of these previous studies suggest that surgery in indeed superior but the main problem with them is inadequate control for selection bias (what we term in the trade as confounding by indication) – i.e. that men undergoing surgery are fitter and have better prognosis from their cancer point of view than men undergoing radiotherapy, and thus it’s not a fair comparison. Another problem with these previous studies is that the datasets used are not very comprehensive – not all men are included, and we don’t know all their important risk factors. All this makes it difficult to be confident in their results.

What is different about the BMJ study (https://www.bmj.com/content/348/bmj.g1502) is that the dataset and the statistics were top-notch. More than 98% of men diagnosed with prostate cancer in Sweden from 1998 onwards were included, and virtually all important data points were recorded with <2% incomplete data. Men were followed for up to 15 years and 4 different sets of statistical models were done to balance the surgery and radiotherapy groups with each other.

Remarkably, all sets of models came up with the same answer: that surgery led to better survival results than radiotherapy, especially for the men with intermediate and high risk prostate cancer and even more so if they had a long life expectancy. If I were a barrister, I would say this study provides strong evidence to build the case that surgery is a better option in survival terms for the majority of men who need treatment for localized prostate cancer. Medicine, like law, is never about absolutes, it’s about risk and probability. Can I prove that surgery is better than radiotherapy from this study – no; but there certainly seems a strong case to argue.

The current BJUI Article of the Week is another excellent article on the same subject (https://www.bjuinternational.com/article-of-the-week/prostate-cancer-sun-shines-light-on-surgical-survival/)

You can download Drs Sooriakumaran & Wiklund’s slideshow on their article by clicking here (1.5mb)

Prasanna Sooriakumaran is a robotic prostate & bladder cancer surgeon and academic at Oxford and Karolinska. @PSooriakumaranu