Tag: #urojc

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The Urology Tag Ontology Project

September 1, 2015/by Alexander Kutikov

This blog was first posted at https://www.symplur.com/blog/the-urology-tag-ontology-project/

Urologists have been on the forefront of harnessing Social Media for professional use. Urological Organizations and Journals have used Social Media to lower barriers for information dissemination [1,2] [3] [4]. Meanwhile, Social Media engagement at Urological meetings has been used to augment the experience of attendees and allow remote “attendance” for those not able to physically be present at the meetings [5,6] [7]. Academic exchange through a formal Twitter-based Journal Club on the #urojc hashtag has enjoyed international participation [8]. Social Media has also been employed to assess the Media’s and the Public’s responses to news events in the Urologic clinical space [9], and guidelines for responsible and effective Social Media use now have been developed [10] [11]. Moreover, an extremely active patient advocacy voice has been growing louder on a number of the Social Media channels.

The Urology Tag Ontology Project aims to align hashtag use for this burgeoning Urological Social Media community. Utilizing this standardized list of Social Media communication descriptors, the project hopes to facilitate communication and promote collaboration in the healthcare provider and patient communities.

In creating the list, we crowd-sourced the Urologic Social Media community at large and were fortunate to receive buy-in from key stakeholders (Table 1).

Effective and standardized hashtag use remains an organic process that clearly cannot be dictated by a simple creation of a list. Indeed, the current list attempts to strike a balance between existing hashtags that enjoy heavy use and those descriptors that key opinion leaders in a particular urologic sub-specialty would like to see gain traction. As such, we hope for the Urology Tag Ontology Project to remain a “living document,” which is reassessed and updated on a regular basis.

Alexander Kutikov, MD, FACS @uretericbud
Associate Professor of Urologic Oncology
Fox Chase Cancer Center, Philadelphia, USA @FoxChaseCancer
Associate Editor for Digital Media
European Urology @EUPlatinum

Henry Woo, MD @DrHWoo
Associate Professor of Surgery
University of Sydney, Sydney, Australia
Founder and Manager
International Urology Journal Club #urojc @iurojc

James Catto MB, ChB, PhD, FRCS @JimCatto
Professor in Urological Surgery
University of Sheffield
Editor-in-Chief
European Urology @EUPlatinum

Table 1: Urological Social Media Stakeholders Supporting Urology Tag Ontology Project

Organization	Hashtag / Twitter Handle
European Association of Urology (EAU)	@UroWeb
American Urological Association	@AmerUrological
EAU Guidelines Committee	#EAUGuidelines
AUA Social Media Committee	N/A
Society of Urologic Oncology / Young Urologic Oncology Committee	@SUO_YUO
Urological Society of Australia and New Zealand	@USANZurology
British Association of Urological Surgeons	@BAUSurology
Endourological Society	@EndourolSoc
European Urology Journal	@EUPlatinum
Journal of Urology	@JUrology
BJUI	@BJUIjournal
Urology Gold Journal	@UroGoldJournal
Nature Reviews in Urology Journal	@NatRevUrol
Prostate Cancer and Prostatic Diseases Journal	@PCAN_Journal
Journal of Sexual Medicine	@JSexMed
Bladder Cancer Journal	@BladderCaJrnl
Journal of Clinical Urology	@JCUrology

References

[1] Loeb S, Catto J, Kutikov A. Social media offers unprecedented opportunities for vibrant exchange of professional ideas across continents. European Urology 2014;66:118–9. doi:10.1016/j.eururo.2014.02.048.

[2] Cress PE. Using Altmetrics and Social Media to Supplement Impact Factor: Maximizing Your Article’s Academic and Societal Impact. Aesthetic Surgery Journal 2014;34:1123–6. doi:10.1177/1090820X14542973.

[3] Nason GJ, O’Kelly F, Kelly ME, Phelan N, Manecksha RP, Lawrentschuk N, et al. The emerging use of Twitter by urological journals. BJU Int 2014:n/a–n/a. doi:10.1111/bju.12840.

[4] Loeb S, Bayne CE, Frey C, Davies BJ, Averch TD, Woo HH, et al. Use of social media in urology: data from the American Urological Association (AUA). BJU Int 2014;113:993–8. doi:10.1111/bju.12586.

[5] Matta R, Doiron C, Leveridge MJ. The dramatic increase in social media in urology. The Journal of Urology 2014;192:494–8. doi:10.1016/j.juro.2014.02.043.

[6] Canvasser NE, Ramo C, Morgan TM, Zheng K, Hollenbeck BK, Ghani KR. The Use Of Social Media in Endourology: An Analysis of the 2013 World Congress of Endourology Meeting. J Endourol 2014:140715142757008. doi:10.1089/end.2014.0329.

[7] Wilkinson SE, Basto MY, Perovic G, Lawrentschuk N, Murphy DG. The social media revolution is changing the conference experience: analytics and trends from eight international meetings. BJU Int 2015;115:839–46. doi:10.1111/bju.12910.

[8] Thangasamy IA, Leveridge M, Davies BJ, Finelli A, Stork B, Woo HH. International Urology Journal Club via Twitter: 12-Month Experience. European Urology 2014;66:112–7. doi:10.1016/j.eururo.2014.01.034.

[9] Prabhu V, Lee T, Loeb S, Holmes JH, Gold HT, Lepor H, et al. Twitter Response to the United States Preventive Services Task Force Recommendations against Screening with Prostate Specific Antigen. BJU Int 2014;116:65–71. doi:10.1111/bju.12748.

[10] Rouprêt M, Morgan TM, Bostrom PJ, Cooperberg MR, Kutikov A, Linton KD, et al. European Association of Urology (@Uroweb) recommendations on the appropriate use of social media. European Urology 2014;66:628–32. doi:10.1016/j.eururo.2014.06.046.

[11] Murphy DG, Loeb S, Basto MY, Challacombe B, Trinh Q-D, Leveridge M, et al. Engaging responsibly with social media: the BJUI guidelines. BJU Int 2014;114:9–11. doi:10.1111/bju.12788.

Could Urolift stand the test of time for LUTS management?

August 4, 2015/by admin Z.9

Several new surgical technologies have been assessed during the last decades in order to improve the management of LUTS (Lower Urinary Tract Symptoms): HoLEP (Holmium laser enucleation of the prostate), HoLAP (Holmium laser ablation of the prostate), TUMT (transurethral microwave therapy), TUNA (transurethral needle ablation), HIFU (high-intensity frequency ultrasound) and more recently Greenlight laser vaporization. All these techniques have been compared to TURP (transurethral resection of the prostate), which it is currently considered as the surgical standard procedure for men with mid-size prostate gland associated with moderate-severe LUTS and obstruction.
This month, the #urojc tribe discussed a multicentric randomized trial of a new surgical treatment option for LUTS caused by prostate enlargement: the Prostatic Urethral Lift (PUL), which supposedly reduces the negative effects of other surgical therapies on sexual function. One important controversy of the article is the use of a composite end-point, the BPH6 that includes the assessment of 1) LUTS relief, 2) postoperative recovery experience, 3) erectile function, 4) ejaculatory function, 5) urinary continence preservation and 6) safety, a concept that may resemble the Pentafecta from the surgical treatment of prostate cancer.
The PUL vs TURP – BPH6 study seems to be a well done RCT that accurately follows the CONSORT
statement.

Despite of this, #urojc participants showed reluctance to accept the main outcomes of the study. Interestingly, comments about COI (conflict of interest) and the impact of the industry in manuscripts were mentioned…

People were not completely convinced about using a novel endpoint to compare TURP and PUL… the BPH6 seems to balance the impact of the 6 elements… or perhaps it gave more magnitude to the sexual side effects…

As usual in this #urojc, urologists mentioned specific details about the design and methods of the study…

And participants questioned about why authors emphasized in the manuscript specific points that may favor PUL over TURP…

Good discussion went throughout the 48 hours session, constructive comments about the study, and some other tweets revealed skepticism at this new technique….

And then, @sivanrij evoked the truth about LUTS (by the way, one of the most retweeted/favorited comments)…

Despite being something completely related to the type of health care system, and the specific conditions of each continent or region, costs were compared…

Some experts in PUL shared their thoughts…
Final thoughts were mentioned…

Only time will determine the real success of this novel therapy…

But some questions remain unanswered…

… And helpful references were mentioned…

https://www.bmj.com/content/326/7400/1167

#urojc Commentary on #BPH endpoints “Patients not p-values” by Rees @MattBultitude @CanesDavid @antnoah @soph_cash https://t.co/IMVK6DbAvL — Stacy Loeb, MD (@LoebStacy) July 6, 2015

https://www.ncbi.nlm.nih.gov/pubmed/?term=25885560

Classic Barry paper-BPH minimum clinically important difference #urojc @MattBultitude @CanesDavid @antnoah @soph_cash https://t.co/KDdzc0uZpy

— Stacy Loeb, MD (@LoebStacy) July 6, 2015

https://www.ncbi.nlm.nih.gov/pubmed/7563343

At this time we do not have any treatment options for LUTS/BPO that preserves the ejaculatory function, and PUL may be an option in selected cases; we should accept that it is another option to increase our therapeutic armamentarium…
#urojc demonstrates that Twitter is a powerful tool to share our scientific thoughts all over the world. #urojc gives the opportunity to discuss articles with world-wide experts and authors of the published articles. Following and participating in these discussing definitely opens our minds, expands our medical knowledge and contributes to offer better health care to our patients.

Daniel Olvera-Posada (@OlveraPosada) is a Mexican Urologist, trained at @incmnszmx, currently in his second year of the Endourology Fellowship (@EndourolSoc) at @westernu, in London Ontario, Canada.

Give the pill, or not give the pill. SUSPEND tries to end the debate

June 22, 2015/1 Comment/by Christopher Bayne

June 2015 #UROJC Summary

News of a landmark paper on medical expulsive therapy (MET) for ureteric colic swirled through the convention halls on the last day of the American Urological Association’s Annual Meeting in New Orleans, Louisiana. I watched the Twitter feeds evolve from my desk at home: the first tweets just mentioned the title, then the conclusion, followed by snippets about the abstract. As time passed and people had time to read the manuscript, discussion escalated. Without data to prove it, there seemed to be more Twitter chatter about the SUSPEND trial, even among conference attendees, than the actual AUA sessions.

Robert Pickard and Samuel McClinton’s group utilized a “real-world” study design to publish what many urologists consider to be the “best data” on MET. The study (SUSPEND) randomized 1167 participants with a single 1-10 mm calculi in the proximal, mid, or distal ureter across 24 UK hospitals to 1:1:1 MET with daily tamsulosin 0.4 mg, nifedipine 30 mg, or placebo. The study’s primary outcome was the need for intervention at 4 weeks after randomization. Secondary outcomes assessed via follow-up surveys were analgesic use, pain, and time to stone passage. Though the outcomes were evaluated at 4 weeks after randomization, patients were followed out to 12 weeks.

Some of the study design minutiae are worth specific mention before discussing the results and #urojc chat:

Treatment allotment was robustly blinded. Participants were handed 28 days of unmarked over-encapsulated medication by sources uninvolved in the remaining portions of the study
Medication compliance was not verified
The study protocol didn’t mandate additional imaging or tests at any point
Participants weren’t asked to strain their urine
Secondary outcomes assessed by follow-up surveys were incomplete: 62 and 49% of participants completed the 4- and 12-week questionnaires, respectively

The groups were well balanced, and the results were nullifying. A similar percentage of tamsulosin- , nifedipine-, and placebo-group patients did not require intervention (81%, 80%, and 80%, respectively). A similar percentage of tamsulosin-, nifedipine-, and placebo-group participants had interventions planned at 12 weeks (7%, 6%, and 8%). There were no differences in secondary outcomes, including stone passage. There was a trend toward significance for MET, specifically with tamsulosin, in women, calculi >5 mm, and calculi located in the lower ureter (see image taken from Figure 2).

The authors concluded their paper was iron-clad with results that don’t need replication.

“Our judgment is that the results of our trial provide conclusive evidence that the effect of both tamsulosin and nifedipine in increasing the likelihood of stone passage as measured by the need for intervention is close to zero. Our trial results suggest that these drugs, with a 30-day cost of about US$20 (£13; €18), should not be offered to patients with ureteric colic managed expectantly, giving providers of health care an opportunity to reallocate resources elsewhere. The precision of our result, ruling out any clinically meaningful benefit, suggests that further trials involving these agents for increasing spontaneous stone passage rates will be futile. Additionally, subgroup analyses did not suggest any patient or stone characteristics predictive of benefit from MET.”

Much of the early discussion focused on the trend toward benefit for MET in cases of calculi >5 mm in the distal ureter:

Journal Club participants raised eyebrows to the use of nifedipine and placebo medication in the trial:

A few hours in, discussion shifted toward the study design, particularly the primary endpoint of absence of intervention at 4 weeks rather than stone passage or radiographic endpoints. The overall consensus was that that this study was a microcosm of “real world” patient care with direct implications for emergency physicians, primary physicians, and urologists.

The $20 question (cost of 4 weeks of tamsulosin according to SUSPEND) is whether or not the trial will change urologists’ practice patterns. Perhaps not surprisingly, opinions differed between American and European urologists.

We owe SUSPEND authors Robert Pickard and Sam McClinton special thanks for their availability during the discussion. In the end, the #urojc banter for June 2015 was the largest and most-interactive monthly installment of International Urology Journal Club to date.

Christopher Bayne is a PGY-4 urology resident at The George Washington University Hospital in Washington, DC and tweets @chrbayne.

Transarterial Embolisation of Angiomyolipomas – Not so Cut and Dry

May 29, 2015/by Anthony Noah

The month of May 2015 saw the International Urology Journal Club #urojc Twitter discussion move away from a cancer topic to a benign one. The discussion centred on the recent Journal of Urology paper entitled ‘Transarterial Embolization of Angiomyolipoma – A Systematic Review’. In this paper Murray et al presented a review of 524 cases of transarterial embolization (TAE) for AML in 31 studies (published between 1986 and 2013) with a mean follow up of 39 months.

The authors reported technical success of the procedure in 93.3% of cases with a mean AML size reduction of 3.4cm (38.3%). Post-procedural mortality was reported in 6.9% and unplanned repeat procedures in 20.9%.

The conversation kicked off on Sunday 3rd May at 22:00 (BST) with a flurry of tweets from around the world. Initially there were brief questions about the sample size and clarity of the results in the paper.

A few contributors were not convinced by the overall efficacy of embolisation in the study.

Post-procedure embolisation-related morbidity was reported in 6.9% of patients.

The suggestion of low morbidity moved the conversation away from the paper itself and on to the risks of AMLs if left untreated. The most significant risk of renal AML is bleeding.

There is also the important issue of misdiagnosis

Oesterling et al (1986) published a key paper suggesting that 82% of patients with symptoms had AMLs >4cm. This and other similar papers from the 1980s and 1990s form the basis of treatment protocols for renal AML. The lack of further literary knowledge regarding the natural history of AML became a key sticking point.

Cue the introduction of some more recent literature, suggestive that <2cm AMLs can be ignored (https://www.ncbi.nlm.nih.gov/m/pubmed/24837696/).

This caused further debate about the appropriate screening and management of AMLs. It became apparent that opinions on surveillance vary.

Growth is the important factor. Rate of growth is perhaps more important than actual size in small AMLs.

However there will be data published further supporting this approach to small AMLs.

Are we being overcautious?

Or are we shifting our anxieties to the patient?

There was the inevitable discussion of surgical treatment (partial nephrectomy preferred) instead of embolization. The reasoning for embolization versus surgery was sought out.

Partial nephrectomy allows for definitive treatment of the AML with preservation of renal function and acceptable complication rates.

Embolisation is less invasive without the risks of major surgery and so provides first line treatment for many.

Therefore local complication rates are important to consider, especially when considering nephron-sparing surgery.

CT angiography findings may aide in treatment choice if the vascular supply is amenable to a successful embolisation with minimal non-target embolisation.

Mammalian target of rapamycin (mTOR) is a protein which regulates cell growth, proliferation and survival. Everolimus, an oral mTOR inhibitor, has been shown to reduce the size and growth rate of Tuberous Sclerosis related AML.

As AMLs are benign tumours with significant potential complications, there may be wider variations in management protocols than would be seen with a malignant tumour. Perhaps patient preference, or urologist preference plays much more of a role in individual cases.

As always the debate was interesting and raised a number of key points. Discussion focussed more on overall issues around the management of angiomyolipoma following a brief discussion of the paper itself. The literature is lacking recent high level evidence for treatment of angiomyolipoma. Whilst most follow classical teaching of intervening in symptomatic and larger tumours (>4cm), there is wide variation in the follow up and surveillance of small tumours.

More recent data suggests smaller tumours may not require close follow up. Perhaps rate of growth, much like PSA dynamics in prostate cancer, is more important than the actual size of the tumour. There is also evidence lacking in the direct comparison of embolization versus nephron-sparing surgery for angiomyolipoma.

This draws to a conclusion the summary of the May #urojc summary blog. Please follow @iurojc on Twitter for updates and to get involved on the first Sunday/Monday of each month.

Anthony Noah

Urology Speciality Trainee, West Midlands, UK

Twitter: @antnoah

AML Poll Results

May 22, 2015/by admin Z.9

Following on from the recent #urojc discussion, it is clear opinions on managing AML’s vary widely. You are referred a fit and well 40 year old with incidental solitary 4cm AML. What is your treatment of choice?

Is maintenance BCG an unnecessary evil? Summary of the April 2015 #urojc

May 1, 2015/by Sophia Cashman

The current BCG shortage, and the effect this is having on our bladder cancer patients, is an issue that continues to weigh heavily on many urologists. With no immediate solution in sight, and limited availability, a variety of tactics are being advocated to optimally use the current supply.

The April 2015 International Urology Journal Club #urojc debate focused on the timely paper by Martínez-Piñeiro et al¹. This paper reported the results of a randomised trial evaluating the outcomes of BCG induction followed by a modified three year maintenance regimen versus standard BCG induction alone in patients with high-risk non-muscle-invasive bladder cancer. The investigators concluded there was no observed decrease in recurrence and progression rates in those receiving just induction compared to induction and maintenance regimen.

This very topical debate kicked off on Sunday 12^th April.

Coinciding with the USANZ Annual Scientific Meeting, this month’s debate gave both those who were live tweeting at the conference, and those learning about the benefits of social media as a new concept, the opportunity to see the #urojc debate in action.

One of the first points of discussion raised was the difference between the maintenance protocol used in the study, consisting of one BCG installation every three months for three years, and the standard SWOG schedule.

The lack of difference in outcome between the two groups raised the question as to whether this indicated that their modified maintenance protocol is less effective that the current strategies.

The theme of alternative maintenance schedules continued, with some variation in practice noted.

Some of the variability in maintenance may be due to the tolerability and side effects experienced.

Although there may be a degree of acceptance amongst patients if there is thought to be a chance of improvement in risks of disease recurrence or progression.

The reason for the variability of response to BCG therapy between patients remains unclear.

For the patient, the lack of understanding of why this is the case may be a cause of distress, especially when faced with adverse effects and toxicity.

Inevitably it was not long until the key on-going issue of the lack of available BCG was raised.

This issue continues to cause a lot of angst for both patients and their treating urologists, with no immediate solution evident. There may however be light at the end of a somewhat long tunnel with the restarting of production by Sanofi.

In the mean time, the downstream effects of the production delay continues to compromise the treatment options for bladder cancer patients.

As the availability remains largely outside of clinicians’ hands, perhaps our focus at present needs to be on other factors we can control in order to improve the outcomes for our bladder cancer patients.

This debate surrounding this paper has raised a number of key points that, in the face of the BCG shortage, are worth considering. Until the supply is re-established, the BCG we have needs to be optimally used – however perhaps the most effective maintenance schedule needs further investigation. Or perhaps, due to the variation in tolerability and effectiveness between individuals, maintenance therapy needs to remain a more fluid concept.

As always, the #urojc debate involved healthy international discussions. This gives the unique ability to understand the global viewpoints on the study findings, and the current BCG crisis. Analytics of the debate using the #urojc hash tag from the website www.symplur.com again demonstrated the excellent involvement from participants, with over 180,000 unique impressions.

Thanks to all of those who participated this month. We look forward to the #urojc May debate – I am sure it will be as lively as ever.

1. Martínez-Piñeiro L, Portillo JA, Fernández JM, et al. Maintenance Therapy with 3-monthly Bacillus Calmette-Guérin for 3 Years is Not Superior to Standard Induction Therapy in High-risk Non-muscle-invasive Urothelial Bladder Carcinoma: Final Results of Randomised CUETO Study 98013. European Urology March 2015 (Article In Press)

Final Analysis of RT+ADT versus ADT alone in locally advanced CaP

March 23, 2015/by Chris Hillary

The March 2015 international urology journal club #urojc twitter discussion focused on a paper by Mason et al [1]. This article, published in the Journal of Clinical Oncology (Feb 2015), reports on the preplanned final analysis of the randomized trial of radiotherapy (RT) and androgen deprivation therapy (ADT) versus ADT alone in patients with locally advanced prostate cancer between 1995 and 2005.

The authors have previously reported on the survival benefits of RT added to ADT in this cohort of patients and the final analysis demonstrates a sustained longer-term survival outcomes of RT+ADT over a median follow-up of 8 years as compared to ADT alone.

As ever the discussion was lively with some polarized views. The feed commenced at 12:00pm PST on Sunday 1^st March 2015 for a 48-hour period. Initially debate focused on staging and the under-reporting of DRE findings:

Which was perhaps addressed by issues during the screening process…

Despite this, other aspects of staging were discussed, particularly the methods for node staging:

For N staging, the authors included either a clinical assessment (70.5% of patients), Imaging (8.5%) or surgical dissection (2.4%). Meanwhile, the accuracy of ‘clinical’ nodal staging was questioned.

Consideration of the patient inclusion criteria was followed by a discussion over the use of ADT in this patient cohort

In this context, ADT consisted of either BSO or lifelong LHRH agonists

However, the question was asked of ADT in addition to RT ‘is lifelong ADT appropriate?’

While for high-risk disease, evidence suggests that long-term (2-3 years) ADT should be used following RT [2, 3], for intermediate risk cancers, 8 weeks of adjuvant ADT remains the standard of care as highlighted in the recent RTOG 9910 data [4].

The rationale behind RT and ADT was noted:

While the results of the study came as no shock to some:

The addition of RT to ADT significantly improved OS and DSS. The study reports that ‘there was no evidence of any differences in deaths from other causes’, however, the issue of secondary malignancies with RT was ‘highlighted’:

Ultimately, the role of surgery for these patients was questioned. A point highlighted in the paper was not shared by some:

To conclude the March #urojc, some final comments were provided by @_TheUrologist:

Thanks to all those who participated in this months discussion. We look forward to the April #urojc.

References

[1] Mason, M.D., W.R. Parulekar, M.R. Sydes, et al., Final Report of the Intergroup Randomized Study of Combined Androgen-Deprivation Therapy Plus Radiotherapy Versus Androgen-Deprivation Therapy Alone in Locally Advanced Prostate Cancer. J Clin Oncol 2015;.

[2] Horwitz, E.M., K. Bae, G.E. Hanks, et al., Ten-year follow-up of radiation therapy oncology group protocol 92-02: a phase III trial of the duration of elective androgen deprivation in locally advanced prostate cancer. J Clin Oncol 2008;26:2497-504.

[3] Bolla, M., G. Van Tienhoven, P. Warde, et al., External irradiation with or without long-term androgen suppression for prostate cancer with high metastatic risk: 10-year results of an EORTC randomised study. Lancet Oncol 2010;11:1066-73.

[4] Pisansky, T.M., D. Hunt, L.G. Gomella, et al., Duration of androgen suppression before radiotherapy for localized prostate cancer: radiation therapy oncology group randomized clinical trial 9910. J Clin Oncol 2015;33:332-9.

Chris Hillary @chrisjhillary

Clinical Fellow in Urology, Sheffield, UK

Radical cystectomy for bladder cancer – is there a changing trend?

January 23, 2015/by Greg Nason

The first #urojc instalment of 2015 discussed the recent European Urology paper ‘Trends in operative caseload and mortality rates after radical cystectomy (RC) for bladder cancer in England for 1998-2010’. Hounsome et al., examined a total of 16,033 patients who underwent RC – over the study period 30-day and 90-day mortality rates decreased and 30-day, 90-day, 1-year and 5-year survival rates significantly improved.

Henry Woo (@DrHWoo) suggests this paper is breaking the mould in comparison to other series.

Analysis of the SEER database would suggest otherwise – there has been little or no change in the incidence, survival or mortality rates with respect to bladder cancer over an even longer study period (1973-2009). Likewise, Zehnder noticed no survival improvement in patients undergoing RC over the last three decades (1980-2005).

However, Jim Catto (@JimCatto) and Alexander Kutikov (@uretericbud) were quick to point out the differences between survival rates and mortality rates, although Hounsome et al., reported beneficial outcomes in both parameters.

In the UK, the Improving Outcomes in Urological Cancers guidance (IOG) recommends patients be considered for RC for muscle invasive bladder cancer (MIBC) and high risk recurrent non-muscle invasive bladder cancer (NMIBC). Key aspects of this guidance include – a minimum caseload requirement for performing RC, an MDT approach and specific 30day mortality rates of 50% despite no change in the incidence of bladder cancer. The reasoning for this is multifactorial but in part due to designated cancer centres are offering surgery to more candidates as a result of service improvements that include service reconfiguration, improved surgical training, neoadjuvant chemotherapy, enhanced recovery principles, and continued improvements in peri-operative care.

The on-line debate moved towards discussing the effect of centralisation of cancer services as a causative factor behind these positive results.

Rather intuitively, in a systematic review in 2011, Goossens-Laan et al., postoperative mortality after cystectomy is significantly inversely associated with high-volume providers.

Although the benefits of being treated in a cancer centre of excellence are undoubted- high volume fellowship trained surgeons, a multidisciplinary approach and improved peri-operative conditions; the impact of distance from central services was broached. O’Kelly et al., postulated a higher stage of prostate cancer based on distance from a tertiary care centre, other studies have shown for a variety of cancers (lung, colon)that distance from a central provider can impact outcomes. Outside of the impact on oncological outcomes, the impact on the patient’s lifestyle as well as the economic consequences were not discussed.

While contrary to this, Jim Catto (@JimCatto) highlighted the deskilling associated with centralisation.

A further significant implicating factor in the positive results seen in this study is due to the use of neo-adjuvant chemotherapy, a question often posed by the patient.

Rather contentiously, David Chan (@dytcmd) remarked that optimal surgical results have already been achieved, a statement challenged by Jim Catto (@JimCatto).

This study although examining a vast number of patients over a lengthy time period is not without its limitations. Specifically the lack of tumour stage, smoking status and the use of chemotherapy as well as issues surrounding a retrospective study looking at data collected by individual hospital coding systems.

This month’s #urojc attracted substantial coverage on Twitter – keep it up.

Many thanks to those you participated in the debate. We look forward to next month’s #urojc discussion.

Greg Nason (@nason_greg) is a Specialist Registrar in Urology, Beaumont Hospital, Dublin, Ireland

Is active surveillance the way to go for stage I nonseminoma testicular cancer?

December 22, 2014/by Yuigi Yuminaga

The December 2014 international urology journal club on twitter featured the large Danish population study published on Journal of Clinical Oncology. Daugaard et al reported this population based retrospective cohort study of 1226 patients who had been diagnosed with stage I nonseminoma testicular cancer and then managed by active surveillance from 1984 to 2007. Followed up was up to 2012 with a median follow up of 180 months (range, 1 to 346 months).

As usual, contributions to the discussion were on a global scale including Australia, United States, Canada, United Kingdom, Ireland, France and the Netherlands. It was great to see participation from trainees and their interactions with leading experts.

Initial discussion focused on the inclusion of the patients, and questions were raised regarding the changing sensitivity of relapse detection due to improved imaging standards over the study period.

However @urorao made a good point regarding exclusion criteria:

The ‘King of Twitter’ felt the strength of study was a high 96.1% compliance rate among Danish men.

The management of stage I nonseminoma testicular cancer in terms of risk factors and appropriate treatment was nicely summarized by @drphil_urology

@dycmd chimed in on the risk factor discussion. Traditionally, with vascular invasion, the risk of relapse is thought to be 50% however it was interesting that this paper revealed that vascular invasion alone resulted in a risk of only 18%. The presence of three risk factors (embryonal carcinoma, rete testis invasion, and vascular invasion) was shown to have the historical 50% relapse rate.

The discussion then moved onto finer points of management in this group of patients,

In terms of management of Stage IA patients, participants all agreed that active surveillance is appropriate with risk of relapse being 12%.

In terms of management of stage IB patients, there were two schools of thoughts. One group saw the glass half full (@uretericbud, @nickbrookMD) and the other group saw the glass half empty (@RFowlr, @drphil_urology).

@uretericbud and @RFowlr had a somewhat contrary views on the matter.

There was a discussion regarding appropriate selection for RPLND and the conclusions of this exchange was nicely summarised by @scientistatlrge

Overall, this was a high quality discussion for our first ever journal club paper on testicular cancer. The Best Tweet Prize was supported by the European Association of Urology (@uroweb) who have kindly offered a complimentary registration to the #EAU15.

The winner was @nickbrookMD who nicely put forward his argument for surveillance

We look forward to seeing you join us for the next #urojc which commences on 4/5 January 2015 depending upon your time zone. Do follow @iurojc for updates.

Yuigi Yuminaga @Yyuminaga is an advanced urology surgical trainee at the Sydney Adventist Hospital in Sydney, Australia.

BCG – An all or nothing treatment for NMIBC?

November 27, 2014/by Zachary Klaasen

November 2014 ushered in the third year of the international urology journal club (@iurojc) and also marked the 2500th follower of @iurojc.

This month’s article was published in European Urology (@Uroweb) on October 10, 2014, Sequential Combination of Mitomycin C Plus Bacillus Calmette-Guerin (BCG) Is More Effective but More Toxic Than BCG Alone in Patients with Non-Muscle-Invasive Bladder Cancer in Intermediate- and High-risk Patients: Final Outcome of CUETO 93009, a Randomized Prospective Trial.

The discussion was once again well attended by many of the Urology twitter gurus and leaders in the field of intravesical chemotherapy for non-muscle-invasive bladder cancer (NMIBC) (@davisbj, @JimCatto, @DrHWoo, @jimmontie, @uretericbud, @shomik_s, @UroDocAsh, etc).

Given the recent worldwide shortage of BCG, this article proved timely for discussion @iurojc. The authors from Spain conducted a prospective, randomized trial including 407 patients with intermediate- to high-risk NMIBC – 211 patients were allocated to receive mitomycin-C (MMC) and BCG, and 196 patients to receive BCG-alone. At 5 years, the disease free interval significantly improved with sequential MMC and BCG compared to BCG alone (HR 0.57, 95%CI 0.39-0.83, p=0.003), and reduced the relapse rate from 33.9% to 20.6%. However, sequential treatment lead to increased toxicity even after lowering the MMC dose to 10mg (p<0.001). The authors concluded that due to higher toxicity, sequential MMC and BCG therapy should only be given to patients with high likelihood of tumor recurrence (ie. recurrent T1 tumors).

The discussion started with the point being made that BCG strain may influence outcomes, with reference made to the @Uroweb article discussing the outcomes of NMIBC and BCG strain.

Subsequently, we were reminded that patients with recurrent T1 tumors are at high risk for disease progression and mortality, and that appropriately fit patients should be offered aggressive treatment (radical cystectomy).

@uretericbud also made the point that we aggressively treat T1 prostate and T1 kidney cancer, which have low cancer specific mortality, however cystectomy is the last resort for T1 bladder cancer (mortality >30%).

The reality of the worldwide BCG shortage was also highlighted during the discussion, ultimately affecting other ongoing MMC and BCG trials.

This month’s discussion concluded with a conversation regarding treatment options during the BCG shortage. The conclusion among the discussants was for MMC during the induction phase of treatment.

Overall, the consensus was that although the results of MMC and BCG in sequence are encouraging, appropriately fit patients may still benefit from radical cystectomy for recurrent T1 disease. With the worldwide shortage of BCG, perhaps this decision will be easier to make. Happy #movember everyone.

The winner of the Best Tweet prize is Vincent Misrai who will receive a complimentary registration to the USANZ Annual Scientific Meeting to be held in Adelaide, Australia in March 2015.

Thank you to the Urological Society of Australia and New Zealand (USANZ) for providing this generous prize. Thanks also to European Urology for enabling this paper to be open access for the November #urojc.

Zach Klaassen is a Resident in the Department of Surgery, Section of Urology Georgia Regents University – Medical College of Georgia Augusta, USA. @zklaassen_md