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Stunned

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If you needed inspiration to pursue cognitive ergonomics as a career or hobby, you could do worse than starting with the book “Set Phasers On Stun” by Steven Casey. Presented as a series of bite-sized real-life vignettes, the book illustrates the inherent fallibility in humans who design and use systems in a very engaging manner.

The most relevant story for doctors is the titular tale about a man receiving radiation therapy for a tumour on his shoulder. Ray lay on the treatment table. The tech in the next room attempted to set the machine to an appropriate radiation dose, but accidentally turned it on to full power. She noticed her error, and reset the machine before firing. Unfortunately the software was not sufficiently powerful to acknowledge her rapid typing, and the setting stayed on full. Furthermore, after firing, the screen told the tech there was an error and that no dose had been delivered. She tried twice more, inadvertently dosing Ray each time, unable to hear Ray’s screams from the lead lined treatment room. He only avoided further doses by running away. As Ray died from the treatment over the ensuing weeks, he jokingly told people that “Captain Kirk forgot to put the machine on stun”.

As clinical doctors, we should acknowledge the fact that individually, we do not make that many people better. Disappointing though this is, as it is the Raison d’être for many of us, I think we understand on some level that it is the “Big Picture” people, the Epidemiologists and Public Health physicians that really make the difference. However many cancers I cut out in my career, I’m still likely to make less of a difference than one well in Sub-Saharan Africa. Many of us are prevented from entering the “Big Picture” career paths due to the fact that they are interminably boring. It is much more interesting to counsel and educate patients, and certainly more exciting to perform complex (and at times terrifying) operations than to sit in a small office in the medical school’s worst-funded department crunching numbers. And who is more likely to be invited to appear on Dr. Oz? The Robotic Surgeon? Or the Epidemiologist with meticulously gathered records of malaria rates in South East Asia? The sad truth of the world is that glamour and excitement are usually more revered than self-sacrifice for enduring positive change.

It took a tragedy, and software engineers to solve the problem that killed Ray on the radiation table, but fortunately, there are simpler avenues for clinicians to make a difference beyond the patients they personally treat. This does not necessarily mean being involved in research on expensive new drugs that often have an incremental (or even arguable) benefit over the existing standard. And you don’t have to be Atul Gawande, creating the WHO surgical checklist, but it helps to use his approach. Devoting some time and mental resources to identify problems that affect a large number of people, even if only in a small way adds up to a significant total benefit. This week I was sent a review article on inadvertent diathermy injuries. These are uncommon, but can be debilitating, as in the index case where a patient essentially lost the use of his right hand due to thermal injury-induced tendon contractures. A consistent problem was a loss of contact between skin and earthing plate. Sweat and traction can loosen the plate and result in occult burns, particularly during prolonged cases, or emergency cases where the plate was applied in a rush. Maybe another surgical check should be done at four, or six hours into an operation to assess the need for a second antibiotic dose, and check diathermy plate. If the case is taking significantly longer than expected, should we take the opportunity to ask; “Why is this taking so long? Do I need help, or a second opinion here?”

The electronic age has given us unprecedented opportunity to reach patients with quality information on the nature of their disease, what to expect from their surgery, and advice on when to seek urgent help. In many cases it just takes a person to assume responsibility for writing content for a web page. The more quality health content we write, the more we drown out the snake-oil merchants and charlatans that prey on credulous patients.

My challenge to you in the coming week is to devote some time to thinking of a “Big Picture” issue that could benefit more patients than those you see yourself, or alternatively dig a well in Africa.

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

 

USI Blog: The inevitable call!

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We all would agree that once in a while, during the course of an operation, we feel uneasy because of that little monster of a device…your cell phone starts ringing. The urge to pick up and answer the call often becomes insurmountable. We have all committed this “cardinal sin” of answering a call during surgery. A recent survey conducted in India showed that a “whopping 90% nurses and 50% technicians interviewed for the survey admitted to answering calls during surgery”. 10% of the doctors admitted to checking text messages during surgery. 

I am sure that this number is an underestimate. I have seen almost everyone in my peer group taking calls during surgery.  And this is not just what’s happening in my part of the world, mind you. New York Times also ran an article highlighting this issue.

I would also like you to have a look at this interesting discussion at AAOS Now.

 

It’s been my observation that the introduction of robotics has also made us “much more available” to take calls during surgery.  What’s the take of the community on this issue? Is this an unnecessary fuss (considering that we tend to consider ourselves excellent at multitasking…) or is it an issue that needs to be addressed urgently?

Dr Tarun Jindal, MBBS, MS, MCh Urology
Consultant, AGHL, Kolkata, India

 

The Surgical Spectacle: Blurred Lines

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October’s #urojc discussion marks a number of important milestones– not only the 1st anniversary of the online, international Twitter-based Journal Club, but this month we reached 1000 followers on Twitter – an achievement indeed! We also saw a record number of participants in demonstration of the #urojc concept going from strength to strength.

Fittingly, this month’s paper “The Surgical Spectacle: A Survey of Urologists Viewing Live Case Demonstrations” by Elsamra et al, with free online access provided by BJUI for the duration of the discussion, looks not so much at advances in our theoretical knowledge but rather at the way technological advances are changing our ability to obtain surgical ‘know-how’.

 

Elsamra et al undertook a survey of all those who attended the live surgery sessions at the Atlanta AUA Meeting in 2012 and the 2013 Paris 3rd International Challenges in Endourology Meeting, to gauge the perceived educational benefits of live case demonstrations (LCD) particularly when compared with taped case demonstrations (TCD). There were a number of problems highlighted in the paper itself:

David Chen won the best Tweet Prize, free registration at EAU 2014, kindly donated by @EUPlatinum, with the following:

Interestingly, while 78% of survey respondents felt that LCDs were ethical and only 26% that interactive discussion may lead to distraction of the surgeon and potential morbidity, only 58% would allow themselves or a family member to undertake their own surgical management as an LCD.

Live case demonstrations are by no means a new concept – they have been undertaken since the advent of surgery for the purpose of education and learning.

Recent innovations have seen a blowout in the size of the viewing audience, with live streaming to conference audiences and potentially worldwide viewers, live tweeting and more recently, as pointed out by Dr Brian Stork, the use of Google Glass for both live surgery and the purpose of remote assistance. LCDs have become the drawcard of many surgical conferences, are often the most packed sessions, arguably for the educational benefit and more importantly for the buzz and thrill of seeing ‘the masters’ deal with difficult situations in real time… while answering questions from the audience simultaneously… “so that bleeding sir, where is it coming from exactly?!?!”

It seems that there is no argument that case demonstrations are of great educational benefit and there are some perceived advantages of live vs taped sessions, as summarized by Amrith Rao in a recent BJUI blog.

The vast majority of those involved in this #urojc discussion, however, seemed to suggest that it was hard to argue that the benefits of LCD outweighed those of TCD. Are we simply promoting a surgical circus? Does the perceived stress of operating to a live large audience have a potential negative impact on patient outcomes? Declan Murphy has already blogged about his own personal experience with LCD.

As for the ethical conundrum regarding the patient?

As suggested by Henry Woo:

In 2012 the EAU released guidelines with respect to the use of live case demonstrations within its own jurisdiction. Importantly, this has highlighted the need for regulation by means of submitting outcomes to a data registry, so as to provide a means of analyzing complications and patient safety outcomes.

Position statements or guidelines have also been released by the Royal College Surgeons (UK), American Urological Association and the Royal Australasian College of Surgeons, to name a few.

Where to from here? Will we continue the trend for ‘reality TV’?

There is certainly evidence out there to suggest that recording of basic operations and comparing with peers is potentially a useful means of assessing surgeon proficiency.

I think it very much remains a case of watch this space!

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

A benedictory ode to urological live surgery

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This blog was originally published as a comment article in BJU International, 112: 11–12. doi: 10.1111/j.1464-410X.2012.11780.x

 

With the explosion and expansion of information technology, instantaneous dissemination of medical knowledge across the globe is a reality and here to stay. Performing live surgery to an audience, whether to the medical community or to the general public, has raised much controversy and continues to be hotly debated even today. While a recent article by a very senior urologist concentrated on the drawbacks of live surgery, little was written about the benefits [1]. We begin our debate with this ‘Benedictory Ode’ to live surgery:

Came the news about cancer of the prostate
Surgery, radiation or I had to be castrate
I was won over by the argument of the daVinci Robot
Surgical smile assured me protection of the lover’s knot
I was asked to be a patient for live surgery
I thought to myself, is it a circus or butchery?
Should I be scared, Should I be excited?
But was convinced many will be benefitted
My choice was voluntary and informed
Consent on the dotted line was performed
The day came and the day went
Surgery was smooth without a dent
Some might argue that I was a damn fool
But I am proud to have been an educational tool

Anonymous Patient

When did ‘live surgery’ really begin? Probably the answer would be as early as the birth of medicine itself. Medicine and surgery as we know them today have been based upon the ‘teacher–apprentice’ model for centuries. Whenever the ‘teacher’ became famous, apprentices from surrounding towns, and subsequently from surrounding countries, would flock to watch the way a diagnosis was made or indeed how the surgery was performed. In historical documents from the Middle Ages through to the Renaissance, we are reminded of the amphitheatre that was built especially to demonstrate anatomical dissections and surgeries. Indeed the very origin of the term ‘operating theatre’ probably stems from the fact that operations were carried out to an audience in a theatrical manner, as beautifully portrayed in many medical paintings across the world.

The birth of the first transmission of surgical procedures can be traced back to the famous British Broadcasting Corporation (BBC) series ‘Your Life in Their Hands’. This was first aired in 1958 and eight episodes were then broadcast over the next two months. This innovative series was conceived with three goals: to investigate new medical techniques; to applaud the medical profession; and to provide ‘reassurance’ for citizens at home. At the end of that period, the BBC had received 909 letters from viewers praising the programme and only 37 letters from viewers who were against it [2].

Professor Arthur Smith rightly points out the death of a patient that occurred in 2006 during live surgery organised by The Japanese Society of Thoracic Surgeons [1]; however, we should highlight that the very next year, the Japanese Society for Cardiovascular Surgery, the Japanese Association for Thoracic Surgery and the Japanese Society for Vascular Surgery collaborated in the development of guidelines for performing live surgeries [3]. In their guidelines, they rightly emphasize the need for feedback on the outcome of a patient who has undergone live surgery:

‘When a fixed interval has elapsed after live surgery, the surgeon must report on the postoperative course followed by the patient at an organized Society or research meeting. By this means, the body organizing such a meeting can investigate each of the cases in which live surgery has been conducted, and assesses the appropriateness of the use of live surgery in each.’

Recognizing the need for guidance for physicians and institutions with regard to live surgery, organisations such as the General Medical Council, AUA and the Royal College of Surgeons have published relevant guidelines. In their paper, Challacombe et al. [4] elegantly discuss the various aspects of the ethics of live surgery and highlight the important issues of patient consent and disclosures. We have followed the above guidelines for live robotic surgery to an audience and also to conduct the first live webcast in the UK of a robotic prostatectomy. Contrary to the norm, extra care is taken during live surgeries. Indeed, this may be an advantage for the patient as shown in Table 1. The operating surgeon is always an expert and, in our case, the surgeon was well trained to listen, respond to questions and operate without any hesitation. It is safe to assume that not all surgeons will achieve this high standard in their career. It is also vital to have a moderator who can manage the questions appropriately and convey them to the operating surgeon at the appropriate time.

In the era of evidence-based medicine, no debate can be complete without presenting supporting data from the literature. Several studies across different specialties have looked at the outcomes of patients who have undergone live surgeries. None of the studies showed any adverse outcome in the cohort of patients who subjected themselves to live surgery. Recently, a study analysed the outcomes of patients undergoing robotic partial nephrectomy as a live broadcast as compared with a cohort treated without observers [5]. The authors concluded that live robotic surgery is associated with excellent patient outcomes that compare favourably with cases performed under normal operating procedures. There is further evidence that live surgery as part of a course has a powerful impact on the practice patterns of a urologist [6]. Surprisingly, there is no published evidence in the literature that these patients come to any harm. There are several surveys of surgeons across specialties in the literature with contradictory views on live surgery, but there is no denying that transmission of live surgeries is becoming more and more popular, as evidenced by the packed rooms at all major urological meetings.

Conclusion

Performing live surgery on a patient is here to stay and will be an integral part of the dissemination of medical knowledge. The obligation that the medical society has towards the field of live surgery is to ensure that the operation is performed by the ‘right surgeon on the right patient in a right environment and with the right intentions’.

 

Amrith R. Rao and Omer Karim
Department of Urology, Wexham Park Hospital, Wexham, Berkshire, UK

References

1    Smith A. Urological live surgery – an anathema. BJU Int 2012; 110: 299–300 Full Article (HTML)

2    van Lingen A. Your life in their hands. Published online 27 November 2006. Accessed at https://www.birth-of-tv.org/birth/assetView.do?asset=1413260435_1164637516. Accessed 28 August 2012

3    Misaki T, Takamoto S, Matsuda H, Shigematsu H. Joint Committee for the Establishment of Guidelines for the Live Session of Thoracic and Cardiovascular Surgery. Published August 2007. Available at https://jscvs.umin.ac.jp/eng/live.html. Accessed 28 August 2012

4    Challacombe B, Weston R, Coughlin G, Murphy D, Dasgupta P. Live surgical demonstrations in urology: valuable educational tool or putting patients at risk? BJU Int 2010; 106: 1571–1574 Full Article (HTML)

5    Mullins JK, Borofsky MS, Allaf ME et al. Live Robotic Surgery: are outcomes compromised? Urology 2012; 80: 602–607 Web of Science®

6    Altunrende F, Autorino R, Haber GP et al. Immediate impact of a robotic kidney surgery course on attendees practice patterns. Int J Med Robot. 2011; 7: 165–169. doi: 10.1002/rcs.384 Full Article (HTML)

 

 

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The Best of British

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We live in a world that is getting smaller mainly because of global friendship, the Internet and the ease of travel. The British contribution to this should be a matter of pride for every UK urologist. Many friends and colleagues say that the BJUI has gone global, a decision that was made during the editorship of Hugh Whitfield and promoted under John Fitzpatrick. It was the correct move and has allowed British urology to maintain its prominent position in the rapidly changing world of academic publishing.

During BAUS 2013 we wanted our readers to know that the B in BJUI remains vital to the journal. We continue to publish and promote the best papers from UK for the benefit our local and international audience.

So here is the “Best of British” virtual issue, a selection of the most cited papers from UK in the BJUI in 2012-13. There are articles from every part of the British Isles proving that geography is not a barrier to quality.

It came as a surprise to me that Functional urology is the most cited section of the BJUI. We have highlighted a controversial but real life follow-up of patients having Botulinum toxin A injections for overactive bladder (OAB), a multicentre trial of a mini-sling and the natural history of urinary symptoms amongst ketamine users.

This is complemented by a Translational Science paper on the inhibition of stretching-evoked ATP release from bladder mucosa by anticholinergic agents. High-quality basic research with rapid translation is becoming real, thanks to the growth of Biomedical Research Centres in UK and overseas. We want to publish the best science papers and make them relevant to surgeons through Science Made Simple, a section that explains why our readers should care about science in a “dummies” fashion. The term “autophagy” is set to become as important as apoptosis.

Urological oncology is the largest section of the BJUI. There is considerable interest in prostate biopsies through the transrectal and transperineal routes and attempts at better imaging through MRI and perhaps Histoscanning. The role of surgery in high-risk prostate cancer is of particular relevance to British urologists within multidisciplinary teams as a number of our patients have aggressive, palpable and locally advanced disease. It is becoming clear that robotics can achieve oncological outcomes as robust as open surgery even in these patients. The Robotics and laparoscopy section of the BJUI has some of our most cited papers. We have given it prominence by featuring beautiful illustrations of  these common and evolving procedures in a Step by Step fashion on the front cover of our paper journal. Finally, a randomised controlled study evaluating the effects of metformin and lifestyle intervention on patients with prostate cancer receiving androgen deprivation therapy, has an important message.

While a number of new modalities of resection such as blue light and narrow band imaging are emerging, good quality white light resection by experienced endoscopists must not be ignored. It is not just about resection, however; adjuvant intravesical gemciabine found its way into a systematic review in patients with non-muscle invasive disease.

The Upper urinary tract often suffers at the hands of the bladder and prostate but is equally important. We have highlighted systematic reviews of ureteroscopic and percutaneous management of upper tract urothelial carcinoma, its surgical management by other modalities and the changing trends in stone disease that will be of interest to our endourological colleagues.

We have introduced a new Surgical Education section and bring to your attention the first results from the BAUS SIMULATE project, which combines technical and non-technical skills. This will be of great importance to every British trainee and indeed we are the international standard bearers in this field, thanks to your active participation.

We thoroughly enjoyed selecting this issue for your reading pleasure. A number of these articles have already been free downloads on www.bjui.org as articles of the week, and are now free to everyone as part of this virtual issue. They are further promoted internationally through our social media network and we are hoping to see a number of you at the BJUI SoMe course during BAUS.

Enjoy the highest quality, most cited articles from Britain. And be very proud, you deserve it!

The Best of British

Prof. Prokar Dasgupta, Editor in Chief, BJUI, Guy’s Hospital, King’s College London. @prokarurol

Scott Millar, Managing Editor, BJUI. @BJUIjournal

Social media as a conduit for resolving surgical challenges

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Wikipedia defines social media as a means of interactions among people in which they create, share, and exchange information and ideas in virtual communities and networks.

In 1965 Moore’s law stated that the volume required for a memory chip or processor would decrease by 50% every 18 months. This predicted exponential development rate has continued for the last 50 years and can be most visibly seen in everyday items such as smart phones or digital cameras. Whilst there is no clear explanation for this phenomenon it is most often attributed to the way in which ideas and technological breakthroughs are replicated throughout the industry and also transferable to different applications. It is the access to others’ knowledge that results in the rapid improvements.

We have recently had a paper accepted looking at Karolinska’s first 113 totally intracorporeal robotic cystectomies. Part of the published data is their complications and this includes a table of common complications with suggested solutions to avoid them. For example, when the results were analysed we found that 1 in 5 intracorporeal ileal conduits showed evidence of urinary leakage from the anastomoses. On reflection it was felt that this was probably due to the stoma spout being created after the undocking of the robot and that the anastomoses was put under too much tension. This part of the procedure had effectively been done blind. Their solution was to put the camera through one of the lateral ports when they pulled out the conduit through the stoma site, so that they could avoid rotation of the mesentery and tension on the anastomoses.

This was their experience and their insight and will not be the same as other series. But what if we created a table that surgeons shared and exchanged different insights into their more common or more severe complications, could we avoid making the same mistakes in our learning curves and improve our outcomes?

Consider the last time you were faced with a likely technical challenge during an upcoming case. Would it not be good to counsel the advice of a wider audience as you planned a robotic radical prostatectomy for a 200cc prostate and you worried about how to get the bladder down for a tension-free, watertight anastomosis? Sometimes small nuances of surgical technique do not get print space in the established surgical atlases or peer-review publications of surgical technique. Anecdote-based advice is sometimes essential to get through difficult cases, which is why it’s good to have a senior mentor available for advice as your own surgical experience develops.

But perhaps this is where the rapidity of communication and online archive in social media may have a role to play. Have we as a profession missed a trick in the directive to publish our results and our complications rates when we should be publishing and sharing our solutions to the complications? Could a blog of surgical tips and tricks for certain procedures provide a repository of surgical knowledge that others could both use and add to in a Wikipedia-style?

I hope we can utilise this blog to document our experiences of difficulties in robotic surgery with accompanying tips and tricks on how to avoid them. If we get enough then we could do something rather old fashioned, such as publishing them together in a table in a journal! Do leave a comment and let the world know what you think.

Justin Collins is a Consultant Urologist at Ashford and St Peters NHS Foundation Trust, UK and is a regular trainer on the faculty at IRCAD, Strasbourg, France. @4urology

 

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Think Twice About Operating on Fridays and Weekends and Stick to Golf Instead

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I recall participating many elective major procedures on Friday nights and Saturday mornings during my residency training, thinking to myself that not only should I be home, but this just can’t be good for the patient…can it? Well, apparently not.

A new population-based study by Aylin et al. published in the British Medical Journal suggests that patients undergoing surgery on Fridays and weekends have significantly higher of both 2-day perioperative mortality as well as 30-day mortality. Utilizing the robust information provided by the English National Health Service (NHS), the authors analyzed over 4 million elective cases performed in England from 2008-2011 and found a crude mortality rate of 6.7 per 1000 cases. While overall mortality seems low, after adjusting for confounding variables the authors found a stunning 44% and 82% statistically significant increase in 30-day mortality if an elective procedure was performed on a Friday or weekend compared to Monday, respectively. When analyzing 2-day mortality, the authors found a whopping 167% increase in mortality on a weekend compared with Monday.

A “weekend effect” has been proposed in prior studies, however these studies for the most part analyzed emergency admissions and included emergency surgeries on patients that were likely to be much sicker than the average patient. What makes this paper different, and thus more significant, is that it only analyzed elective procedures and is the first paper to suggest that with each successive weekday, patients are at increased risk of mortality, culminating with the highest risk on Fridays.

Data on urologic cases within this study remain unknown, as urologic procedures were not selected for sub-analysis. However, overall analysis included all elective procedures, which must have included high-risk urologic procedures such as cystectomy, nephrectomy, partial nephrectomy, prostatectomy, RPLND, and endourologic procedures on infected stones. Therefore, this data should still have relevance for urologists performing such high-risk procedures.

Why is this happening? We know that major complications from elective surgeries happen within the first 48 hours postoperatively (Cavaliere F, et al.). Therefore, patients that have surgery on Friday or over the weekend are at their most vulnerable when the hospital is most short staffed. Additionally, there has been concern that the more junior faculty and trainees bear the majority of weekend coverage, and are therefore most often the primary points of care over weekends, leading to potential failure to rescue due to inexperience. Finally, there is the issue of cross coverage and dialogue between hospital staff during the week and the weekends. How much can a covering physician truly learn about a potentially complicated patient from a simple sign-out?

More importantly, what can we do? Ideally, major cases should be scheduled earlier in the week to allow the patients to have care while all hospital staff are available during the remaining week or so of recovery. Endoscopic and same-day procedures should be scheduled later in the week. However, is this realistically possible? OR time can often come at a premium and is difficult to come by in some busy hospitals, especially for junior faculty. Therefore, such a change would have to come from the top hospital administrators and likely would meet resistance from more senior faculty.

When asked by The Guardian regarding these results, Sir Bruce Keogh, cardiac surgeon and director of the NHS, downplayed the results, stating that when he performed open heart surgeries he would often intentionally operate on patients later in the week to get more time in the ICU over the weekend. With all due respect to Sir Keogh, I just do not see the logic in this approach, and feel we should take these results more seriously rather than downplay them. The data presented by Aylin et al. seems pretty convincing to me: while overall mortality is low, patients getting surgery later in the week and on weekends are getting inferior care leading to inferior outcomes. We need to acknowledge this data, not ignore it or diminish it, and come up with some kind of reasonable and fair solution to the problem.

What say you, Urology community? If any field can come up with a solution, it’s us. Somehow, we need a system that allows all surgeons, young and old, to perform higher risk surgeries earlier in the week to prevent potential complications happening under the watch of an undermanned, inexperienced hospital staff over the weekend. In the meantime, I will try to use my free weekends for spending time with my wife, golf, and watching sports while trying my hardest to perform major surgery earlier in the week. Not only will this please my wife, it will likely improve the care of my patients.

Keith J. Kowalczyk, MD
Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA. @KeithKow

 

 

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Creativity, Faster Horses, and Future Medicine

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I was at an international cricket match, when during one of the very few lulls in the action I noticed a camera operator.  He was riding a Segway around the field in order to get close to the action and vary his angle for the viewers at home. After observing the function of this Segway-Human-Camera complex, it struck me that the only superfluous component in the system was the man with the beer gut and ill-fitting shorts.  All he did was point, focus, and zoom a camera. This can just as easily be done by a director in a control room, or even independently by a smart enough camera. It is not a stretch to imagine a computerized mobile field camera that can track a ball, and “intuitively” widen and tighten shots. The only thing keeping our man on the ground in employment is that at present, he is cheaper than the technology to replace him. His days are numbered. Taking the example of manufacturing, human workers are already replaced or reduced when lifting, welding, or assembling robots become as cost-effective as their flesh-based competitors.  Machines don’t fatigue, take breaks, or form unions, and so are an attractive alternative to, well, us.

With accelerating technology at declining cost, any job that is based around performing concrete tasks is at threat. Fast food restaurants are almost there, car wash services have been there for years, we only have pilots in aircraft because we don’t fully trust computers, and what next? Postal services? Car mechanics?

Lucky for us, doctors could never be replaced. Right?  Actually wrong. There are already electronic systems that in some situations make faster and more accurate diagnoses and management plans [https://www-03.ibm.com/innovation/us/watson/]. Perhaps the role of the physician will soon be giving a “human” face to explaining why the computer has ordered this course of treatment. That is, until technology can generate an adequately “human” face.

We may be relatively protected in surgery at present due to such things as appreciating variable tissue structures, making complex decisions based on unexpected findings, and adapting the surgical plan based on our understanding of the patient’s priorities. Technology will get there eventually. Even now it is conceivable that a computer could control an endoscope in the collecting system of a kidney, identify and then vaporize a stone as well as a human surgeon. A computer removing an organ is surely just further along this same scale.

The best protection we have is creativity. At present, computers have mastered managing vast quantities of data rapidly, and performing physical tasks within specific guidelines. We just cannot compete in this arena. Our advantage is in the abstract. We are still better at thinking of creative solutions, unexpected improvements, and more pleasant alternatives. A quote attributed to Henry Ford points out that if he had asked his customers what they wanted, they would have said “faster horses”. A binary brain would have worked tirelessly to give them this.

In the long term, doctors may only be researchers, generating ideas for computers to assimilate data on, but even then machines will be snapping at our heels. Why can’t a computer generate combinations of chemotherapeutic agents for a randomized trial? Even our last bastions of humanity, the arts, are not guaranteed safety. A computer can understand the mathematics of music, learn what is and is not palatable to the human ear, and “create” music. The same could be said of agreeable angles and architecture. One has to wonder, however long it takes, if the era of the human healer is approaching its end?

 

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

 

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Midurethral tape surgery for incontinence; a possible victim of the vaginal mesh crisis?

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Type 1 mesh is used in vaginal surgery for pelvic organ prolapse repair, along with the mid-urethral tapes for stress incontinence surgery. Tapes for incontinence surgery are well-established and systematic review shows that retropubic tape is probably more effective than colposuspension, risk of bladder perforation notwithstanding [1]. The various types of mid-urethral tape appear to have broadly equivalent efficacy, but the poor quality evidence-base is an issue. The real problem lies with the major complications that can occur, some of which are highlighted in the recent statement from the US Food & Drug Administration in response to concerns expressed by patients and other stakeholders. Mid-urethral tape itself is recognised to be at risk of important complications in the long term, and mesh exposure in the vagina is a major issue with considerable detrimental impact. Patient groups have become organised in recognition of this and they are setting up online dialogues and websites accordingly, for example “tvt-messed-up-mesh.org”. The surgical professions have to agree how best to manage the difficult problems, dealing with the exposed mesh and handling the further procedures needed to re-establish continence [2].

 

Litigation
These in themselves are serious issues, but another threat is looming; the potential that litigation arising in prolapse mesh surgery may extend to midurethral tapes. A huge number of court cases related to mesh prolapse repair has been established, affecting most of the major device manufacturers and key products, with such a volume of workload that multidistrict litigation has been established. A recent award to one claimant against Johnson & Johnson was more than $5 million. With the number of claimants running into thousands, many device companies are taking decisions on these products which will substantially affect their availability and use in the future. How this will affect mid-urethral tape is uncertain, but many companies will have strategic concerns in this area as well. Reporting of mesh-related adverse events has reasoned exponentially in the last few years [3], presumably resulting from increasing use and increasing awareness of potential problems. Self-reported complications to the FDA’s MAUDE database have risen for all forms of mesh including mid-urethral tapes. Particularly worrying is the potential that tape-related complications after tape placement can happen many years postoperatively [4].


A key aspect of the litigation relating to mesh use in vaginal prolapse surgery is the lack of premarketing testing of these devices and the weak evidence base [5]. Legal arguments involve the responsibility of the companies to demonstrate safety before marketing, and the urological profession has expressed the desirability of more stringent approaches to the development of surgical devices – especially given the highly stringent requirements for pharmaceutical companies in marketing new drugs. The professionals themselves are not blameless; preoperative counselling on risk, judicious selection of surgery according to the patients’ individual requirements, surgical training, careful follow-up and engagement where problems arise have caused difficulties in many cases previously. These points are expectations of professional practice, and the professions need to adhere to them – if necessary with input from governing bodies to ensure adherence is demonstrable. The area is rapidly changing and we can be sure that substantial dialogue and developments are predictable in the near future.
Approaches to management of tape complications
The management of mesh and tape-related complications is specialised and centralisation of management of these cases appears appropriate in order to have the best chance of acceptable outcome and to develop the necessary skills which would not be possible in centres handling only small numbers of cases. Potential complications include voiding dysfunction, mesh exposure, pain, LUTS, and persisting or recurrent incontinence. Voiding dysfunction is particularly likely if a woman already has a preoperative history of voiding symptoms, previous retropubic surgery, or if other reconstructive procedures are undertaken at the time of tape placement [6]. Voiding dysfunction can occur as a result of urethral compression by the tape – which will usually be palpable as an indentation of the urethra at its midpoint. Alternatively, voiding dysfunction arises from elevation of the endopelvic fascia – in which case, the urethra tends to be drawn upwards towards the retropubic space. In the first case, a tape incision can be effective, but in the latter case, an abdominal procedure to release the endopelvic fascia to its normal configuration might be needed. It is important to avoid instrumenting the urethra and levering the urethra downwards with an instrument placed into the urethra – this carries the risk of crushing the urethra against the tape, and is likely a major potential factor for subsequent erosion into the urethra.
The assessment of women with the tape complication needs to be comprehensive and fastidious. The considerations require awareness of tape exposure, incontinence, voiding dysfunction, proximity of adjacent structures, pain points and the state of the vagina/ labia/ pelvis. If mesh is exposed, it is essential to remove the unwanted material, though it may not be necessary to remove the entire tape. The excision of the material may leave a defect within the urethra, bladder or vagina, which needs to be closed- bearing in mind the principles for avoidance of subsequent fistula formation (i.e. watertight closure and interposition of healthy tissue between repaired structures). The woman will seek continence postoperatively and to deliver this, both the bladder outlet and the reservoir capacity of the bladder will need to be considered. If necessary, the woman may need to self-catheterise afterwards, and whether the patient will find this practical and acceptable must be confirmed preoperatively. The possibility that the planned operation may fail has to be considered, and accordingly steps taken to ensure that subsequent options are not excluded. For example, excision of mesh may best be achieved with placement of a flap of omentum into the area of the defect, to keep open the subsequent possibility of artificial urinary sphincter placement. It is very clear that extensive experience in all aspects of reconstructive urology are needed in order to get the best outcome in this context.
The looming threats
The immediate future sees several key challenges, including:
1. Training of surgeons in primary incontinence surgery to minimise risk of complications arising
2. Training of surgeons to manage complications
3. Regulatory arrangements as authorities come to grips with major complications occurring with significant incidence
4. Strategic concerns as device companies change their view of the merit of this indication for their profitability
5. The need for proper data on device use, outcomes and adverse consequences
6. The ongoing need to find new management options for improving efficacy and safety in surgical management of incontinence

Professional consensus and dialogue is clearly a high priority to ensure a good outcome for all.

 

Dr Marcus Drake is Consultant Surgeon at the Bristol Urological Institute, Bristol, UK, subspecialising in Female and Reconstructive Urology, Neurourology and Urodynamics He is Chairman of the International Continence Society’s Standardisation Steering Committee

References
1. Novara, G., et al., Updated systematic review and meta-analysis of the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes in the surgical treatment of female stress urinary incontinence. Eur Urol, 2010. 58(2): p. 218-38.
2. Smith, A.R., W. Artibani, and M.J. Drake, Managing unsatisfactory outcome after mid-urethral tape insertion. Neurourol Urodyn, 2011. 30(5): p. 771-4.
3. Shah, H.N. and G.H. Badlani, Mesh complications in female pelvic floor reconstructive surgery and their management: A systematic review. Indian journal of urology : IJU : journal of the Urological Society of India, 2012. 28(2): p. 129-53.
4. Jones, R., et al., Risk of tape-related complications after TVT is at least 4%. Neurourol Urodyn, 2010. 29(1): p. 40-1.
5. Abrams, P., et al., Synthetic vaginal tapes for stress incontinence: proposals for improved regulation of new devices in Europe. Eur Urol, 2011. 60(6): p. 1207-11.
6. Molden, S., et al., Risk factors leading to midurethral sling revision: a multicenter case-control study. Int Urogynecol J Pelvic Floor Dysfunct, 2010. 21(10): p. 1253-9.

 

 

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No Classical Music In My Operating Room Please

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For as long as I have been operating independently, music has been an essential part of my operating theatre environment. If there is no music playing in the background, it is to me as if there is a missing component of the “time out” check list that is carried out by surgical teams prior to each procedure.

For many years, I was trapped in the 70s and 80s with my choice of music. Bowie, Stones, R.E.M. and Pink Floyd were some of the artists that were on high rotation. It provided education to the growing numbers of nurses and medical students who had never heard of classic albums such as Dark Side of the Moon. These days I am lucky to find a medical student who can volunteer the names of the four Beatles – I don’t even bother asking if they know anything about Pete Best who was ousted in favour of Ringo. Sometimes they almost believe my suggestion that the next Pope will be named John Paul George Ringo I, which of course is a perfectly reasonable suggestion. The music played in my theatre therefore actually has an important educative role that makes up for parenting deficiencies with the failure to teach their children about classic rock acts of the 70s and 80s.

 

Over the past couple of years, I have been encouraged to explore contemporary music, which has led to a change in the music played in my operating theatre to performers such as the XX, The Vaccines, First Aid Kit, The Hives, Regina Spektor, Mumford & Sons and Laura Marling just to name a few. This has been a positive move in that I not only have come to appreciate some of the great new music that will one day become classic material, but it also receives a high approval rating from other staff within the operating room. I do admit that I have the latest David Bowie album on order in the vinyl format though an EBay seller.

Why am I telling you all about this? This month, a systematic review by authors Moris and Linos was published in the journal Surgical Endoscopy entitled Music meets surgery: two sides to the art of “healing”. Using fairly limited search terms, a literature search identified 28 relevant articles that were included for review. These papers covered a mix of subject matter including effects of music in the operating theatres on patients, surgeons and theatre staff.

As a surgeon, I will leave discussion of effects of music on patients to our anaesthetic colleagues and it is for them to debate whether there is any beneficial effect of music on induction and upon waking up. Our interaction with music occurs when the patient is asleep so our interest as surgeons lies primarily with its effects on ourselves and other members of staff in the operating room.

Having your anaethetist ‘on board’ with your attitude to music is essential. In the private sector, this is unlikely to be an issue given that you will generally choose to work with somebody who has some compatibility with your own personal tastes. The public sector can at times be challenging where the anaesthetist feels equally entitled and at times more entitled to determine the choice of music or even absence of music in the operating room– this requires tactful negotiation. The principle reason I tend to back off from a fight over this type of issue is that I hate going into an operation feeling cranky. The only time I may make a stand is when classical music is being played – the swings between the calms and storms of some pieces are a little too stressful for my liking.

So what do operating room staff prefer to listen to? Only a couple studies examined this but the bottom line is that classical music is not a clear majority choice – in one study it was favoured amongst 1.2% of respondents and in another it was 45%, they prefer to listen to a type of music that’s a bit more fun . With the latter, my personal inclination is that they were asking non-urologists who are no way as cool as urologists in general. My thoughts, as you may have gathered, are to drop the ‘al’ and choose classic music over classical music.

 

Summary of relevant studies extracted from Table 1 of the Moris study published in Surgical Endoscopy.

 

I am not sure I entirely agree with one conclusion of the review, which states: “With regard to its effect on surgical staff, music is thought to be distracting, reducing the staff’s ability to cooperate and coordinate”. Only one retrospective study is insufficient to reach the general conclusion about the effects of music on staff in operating theatres. My admittedly biased perspective has been in total agreement with the second conclusion that states “From a surgeon’s point of view, music facilitates achievement of higher speed and accuracy of task performance.”

 

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

 

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