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#UroJC July 2014 – Is there a place for laser techniques in our current schema of bladder cancer diagnosis and management?

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This month’s International Urology Journal Club (@iurojc) truly engaged a global audience with participants from ten countries including author Thomas Herrman (@trwhermann) from Hannover, Germany.  A landmark 2000 followers was reached during July, nearly two years since @iurojc’s conception in late 2012. In fact, since this time nearly 1100 people have participated in the journal club from around the world.

Bladder cancer was up for debate for the first time this year and @iurojc trialled the discussion of two complementary articles recently published online ahead of print in the World Journal of Urology.  The first article provided an update of the current evidence for transurethral Ho:YAG and Tm:YAG in the endoscopic treatment of bladder cancer, and the second was a randomised controlled trial (RCT) comparing laser to the gold standard transurethral resection of bladder tumour (TURBT).  Authorship groups were from Germany and China respectively; our Chinese authors unfortunately unable to join the dialogue due to restriction on all twitter activity in the country.

Initial conversation focussed on the methodology, results and limitations of the RCT, however this soon extended to a more general discussion around the current difficulties with the diagnosis and management of bladder cancer and the pros and cons of using laser for this purpose.  Key themes debated over the 48-hour period included the importance of accurate staging, current standards of TURBT, advantages of en bloc resection and the learning curve, cost and usefulness of laser technology.

Both studies reiterated one of the major goals outlined in the EAU guidelines for non-muscle invasive bladder cancer (NMIBC), to achieve correct staging with inclusion of detrusor muscle and complete resection of tumours.  This is important in limiting second resection and consequently has a resulting cost offset.  In the review article, only 3 studies commented on staging quality and another two commented that laser was suitable for staging but did not specify if detrusor muscle was identified.

@ChrisFilson and @CBayneMD expressed their concern over the RCT by Chen and Colleagues

@linton_kate astutely pointed out another limitation

and author of the review article @trwherrmann summed this up nicely

In the RCT by Chen et al. there was a significantly greater number of pT1 tumours detected with laser than TURBT, the authors suggested this might be due to better sampling.  It remains unclear if this would impact on management and this did not enter the arena for discussion during this @iurojc.

Many argued that TURBT techniques and practices should be optimised before newer techniques are introduced.

‘En bloc’ was touted as the new trendy word in endourology.  EAU guidelines recommend en bloc resection for smaller tumours.  The articles suggested that en bloc resection of bladder tumours should provide more accurate staging however conclusive data is missing to substantiate this in the current literature. 

@DrHWoo discussed potential advantages of the laser technique

@linton_kate pointed out that en bloc resection is not limited to the laser technique

Further to this, the lack of obturator nerve reflection with laser was emphasised in the RCT.  Obturator kick was noted during TURBT in 18 patients and none during laser resection, however none of these patients suffered bladder perforation.  The significance of this was debated and usefulness of obturator block in this context discussed.

The pendulum seemed to the swing out of favour of laser during the discussion, with several limitations outlined including reduced ability for re-resection, cost and the presence of a learning curve.

Regarding additional cost, the host rebutted

The flow of academic dialogue was interrupted midstream (pardon the pun) by a light-hearted discussion around the ergonomics of TURBT.

Below are some of the key take home messages that arose from the usual culprits in this month’s @iruojc discussion

Kindly author @trwherrmann invited us to his upcoming en bloc resection workshop.  Keep an eye out for this.

@iurojc would like to thank Prostate Cancer Prostatic Diseases who have kindly provided the prize for this month which is a 12 month on line subscription to the journal. @nickbrookMD’s made efforts to sway the vote his way.

Whilst usually the Best Tweet Prize is reserved for some incisive comment, the repeated complaints from @nickbrookMD for his failure to ever win the Best Tweet prize has seen for the first and final time that the @iurojc has bowed to pressure. Congratulations to @nickbrookMD for finally having made it with the above tweet.

If you haven’t tuned into @iurojc, follow future journal club discussions via the hashtag #urojc, on the first Sunday/Monday of each month. 

 

Dr Marnique Basto (@DrMarniqueB) is a USANZ trainee from Victoria who recently completed a Masters of Surgery in the health economics of robotic surgery and has an interest in SoMe in Urology.

 

 

 

 

Social media @BJUIjournal – what a start!

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When Prokar Dasgupta assumed the role of new Editor-in-Chief of the BJUI in January 2013, he outlined his vision and some of the major changes that the Journal would make as it transitioned to a new editorial team. After 10 years of progress under John Fitzpatrick, it was clear that we are now working in a much-changed publishing landscape, one which will change even more in the next few years. In particular, the way in which medical professionals receive information and interact with colleagues, patients, journals and other professional groups is unrecognisable from what it was just 2 or 3 years ago.

Social media is the driver of much of this change. It has transformed the way in which the current generation of trainees interact—Facebook, Twitter, YouTube, LinkedIn, Urban Spoon, Expedia, Trip Advisor, Instagram – all of these platforms are key conduits for how Generation Z experiences life. This generation will find the idea of a printed journal arriving in the post every month to be anathema. In a world with an ever-increasing amount of content being produced, and much competition for our limited attention span, Gen Z live their lives through mobile platforms capable of delivering the precise content they want, immediately to their devices. Not just that, this content, whether that be breaking news via Twitter, friend status updates on Facebook, job opportunities via LinkedIn, is delivered through vibrant media that allows them to engage and respond by liking, sharing, favourite-ing, re-tweeting and commenting, even as the content reaches them. All of this activity is done through convenient and increasingly pervasive mobile platforms while on the train to work, while queuing for a coffee, between cases in theatre, during a lecture, first thing in the morning, last thing at night. Gen Z will not seek out this type of content – it will seek them out and be delivered straight to their timeline/twitter-feed.

The BJUI is the first surgical journal to introduce an Associate Editor for Social Media. The aim is to devise and implement a strategy to ensure that the BJUI evolves in this new world; to ensure that the next generation of trainees find us a meaningful organisation to engage with and be informed, educated and entertained by. Our fellow Associate Editor, Matt Bultitude (Web) plays an important role here as do our publishers, our Executive team and Editor-in-Chief.

 

Our social media platforms

So what have we done? If you are on Twitter or Facebook you will have noticed that BJUI has come to life on these key social media platforms.

Between January and April 2013, our followers on Twitter have grown from by one third to over 1300, and continue to grow at over 100 followers per month. Through Twitter alone, we have generated huge traffic back to our website with over 3500 link clicks from the hundreds of interactions we have had during this period.

 

 

Advanced social media metrics allow us to measure all of this activity against other organisations active in urology. For example our Klout score has increased from 46 to 55 with a corresponding increase in our Peerindex rating. We are leading the field across all of the key domains we have targeted to date and continue to make progress as we introduce further changes at www.bjui.org in 2013.

Our Facebook site is now highly engaging and is constantly updated with news and content from our website.

 

 

We have recorded over 133 000 page impressions by 23 000 Facebook visitors in the first 3 months of 2013, a huge rise from previously, and all of this traffic gets directed back to content at www.bjui.org, whether that be a Journal article, blog, picture quiz or our new ‘Poll of the Week’.

 

 

Our YouTube site is updated with videos from authors and other multimedia content to complement citable articles published in the Journal. You will see a lot more content added here in coming months.

 

Blogs@BJUI

But perhaps the most talked-about area we have introduced is Blogs@BJUI. And although we are the first mainstream urology journal to introduce a blog site, other journals have done so with great success. In September, we visited the social media team at the BMJ to get some tips on how they had developed their social media strategy into the very successful multi-platform spectacular, which they now oversee. Juliet Dobson, Blogs Editor and Assistant Web Editor at the BMJ offered some excellent advice to help us get up and running and their former Editor, Richard Smith, remains one of the bloggers we most admire. BMJ Blogs is well worth a visit for aspiring bloggers to read some of the best.

We launched our new web journal on the 2 January 2013 to coincide with the new Editor taking the helm, and also published our first blog that day. From then until April 2013, Blogs@BJUI has featured the following:

  • 51 blogs contributed by 25 authors on three continents
  • 193 comments from all over the world, including opinion from some household names in academic urology
  • 16 editorial blogs from our specialty Associate Editors
  • 4 blogs from major urology conferences
  • Multidisciplinary contributions from both authors and comment-leavers

The topics have included everything from urology humour, through the European Working Time Directive, reality TV and an eminent urologist describing his recent personal experience of robotic radical prostatectomy. Our contributors have included many of the key opinion leaders in social media in urology, many of whom are rising stars or already established in academic urology. Also established urology opinion-leaders who are rather new to social media but enjoying the challenge! Other contributors are young trainees who have proved themselves to be talented bloggers already. Blogs@BJUI has been highly successful at driving traffic to the Article of the Week as improving quality remains our main objective.

Also of note is the impact that social media has made at urology conferences in the past few months. As part of a planned strategy, the BJUI social media team has been very active posting updates on Twitter, Facebook and YouTube from major urology conferences, thereby increasing the reach of these meetings to a much larger audience and also allowing those following on social media to engage pro-actively with the conference. This has been a very successful strategy; social media metrics confirm that the BJUI team has been leading the social media revolution at this year’s Annual European Association of Urology (EAU) Congress:

 

 

We had set a target that by the end of the first quarter we would have 1000 readers per month visiting Blogs@BJUI. By the end of the February, we had already had over 9000 visits to our blog site! Each reader spent over 3.5 min reading the web journal and many of them left comments or pushed out links using Twitter or Facebook. We have had many comments posted by readers from every corner of the world and have enjoyed some very humorous posts. For us, social media is all about engagement. We want to use these platforms to allow readers to passively engage with us by liking, sharing, tweeting content that they enjoy whether that is a full paper in the BJUI, a blog post, YouTube video, weekly poll or Picture Quiz of the Week. And for those who want to engage more actively, we strongly encourage you to join the conversation and add a comment.

So we have had a great start to our social media push at the BJUI. And there will be a lot more to come in the coming months. For those of you who are new to social media, we encourage you to dip your toes in by reading a blog or two and adding a comment. Before you know it you will have downloaded the Twitter app to your smartphone and you’ll be off and running! For the Twitterati, we thank you for all your enthusiasm in helping us get social media up and running at the BJUI and we look forward to your blogs, mentions, re-tweets and podcasts over the coming months. Social media is all about engagement – join the conversation @BJUIjournal.

Declan G. Murphy and Marnique Basto

Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia


Declan Murphy is Associate Editor for Social Media at the BJUI.
Follow him on Twitter @declangmurphy

Blog report from USANZ ASM, Melbourne

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Dr Marni Basto & Dr Sarah Wilkinson

G’day from the Annual Scientific Meeting of the Urological Society of Australia & New Zealand, easily identified globally this week using its hashtag, #USANZ13. This year’s meeting has taken place in Melbourne – the city of lane-way lattes, sport, lifestyle and culinary delights!  It has certainly been a jam-packed four days of academic content led by a stellar International Faculty – 23 key opinion leaders from every corner of the globe covering every aspect of urology. Almost 1000 delegates were registered and were joined by an additional 250 delegates from the Asia Pacific Prostate Society who convened their 3rd Annual Scientific Meeting as a conjoined event. There were a lot of urologists in Melbourne!

This year’s Annual Scientific Meeting convened by Professor Damien Bolton and Associate Professor Nathan Lawrentschuk (@Lawrentschuk) kicked off with an emotional Oration by Moira Kelley discussing her inspiring work with Mother Teresa and flying sick children to Western countries to undergo lifesaving medical treatment.  Tears were soon dried however as USANZ acknowledged Professor Anthony Mundy with an honorary membership for his profound achievements and long association with USANZ. The welcome reception provided a great opportunity for delegates to mingle and try the rich assortment of wines Australia has to offer.

Visiting American Professor James Eastham was full of praise for the manner in which approximately 1 in 6 men in Australia and New Zealand are managed by active surveillance compared to around 10% of eligible patients in the US.  Professor Eastham from Memorial Sloan Kettering Cancer Centre in New York went to press saying “Australia and New Zealand are among the best places in the world to be diagnosed with prostate cancer”.

Certainly active surveillance, focal therapy and the use of MRI in prostate cancer were hot topics of debate throughout the meet.  Prof Eastham’s was not alone in his reservations for focal therapy stating his view that “it should be considered experimental”.  Others on the International faculty such as Professor Mark Emberton argued in its defence in the appropriate setting. Dr Emberton also delivered the BJUI Lecture on “Best practice in prostate cancer imaging”. Other BJUI highlights included Editor-in-Chief Prof Prokar Dasgupta who delivered a wonderful overview of the “Scientific Advances in Robotic Surgery” as well as delivering some excellent tips for how to get published during the Surgical Authorship session. This very well attended session also featured Dr Annette Fenner, Editor-in-Chief of Nature Reviews Urology (and a prolific tweeter), who gave a masterful overview of how to write a review paper. BJUI Chairman Dr David Quinlan, challenged our assumptions by asking “Are men pursuing sexual function following radical prostatectomy”. Professor Dasgupta also announced the inaugural BJUI Global Prize Winner, accepted by Dr Yen-Chuan Ou.

The @BJUIJournal and its editors @prokarurol, @declangmurphy & @drhwoo were once again leading influencers throughout this year’s meeting showing form consistent with #EAU13 depicted by the metrics supplied by Symplur (@healthhashtags).  Around 135 participants got involved in the #USANZ13 discussion including many from around the world who joined the conversation.

A special mention to Toronto’s Dr Rajiv Singal (@drrksingal) who even made the list of top 10 influencers! And to our many other Twitter-mates who joined the conversation from all over the world.

It is safe to say social media, or what the Urology twitterati refer to as ‘SoMe’, has now cemented a definitive and purposeful place in engaging and reaching out to the International Urology community.  @Urologymeeting was the official handle with tweets also coming from the primary @USANZUrology official account.  The #USANZ13 hashtag was an obvious option and it appears despite last year’s AUA meeting hashtag controversy with the use of #Uro12 instead of #AUA12, we have now firmly set the hashtags for Urology meets around the world; #EAU13, #USANZ13, #AUA13, #BAUS13, #ERUS13, #ACU13 etc.

A select group of our young talented research and clinical registrars were challenged at the podium battling for the prestigious Keith Kirkland and Villis Marshall prizes.  These were awarded to Dr Isaac Thyer and Dr Sandra Elmer respectively at the Gala evening.  Located at the elegant Grand Ball Room at the Regent Theatre, the Gala evening was certainly an event to behold.  Professor Stephen Ruthven, current President of USANZ handed over the reins to Dr David Winkle who will hold the post for the next two years.

For the first time a dedicated “Social Media & Education” session was chaired by @declangmurphy and @drhwoo with presentations from some of the well known Aussie Uro-twitterati; @isaacthagasamy, and @wilko3040. The SoMe session saw our session chairs with their heads deep in their computers, ipads and iphones creating traffic Internationally with the USA, Canada, the UK and mainland Europe, while monitoring the Tweetchat stream. This traffic generated the largest peak of the conference as seen in the tweet activity graph with close to 400 tweets in the hour.

BJUI Associate Editor Declan Murphy wowed the crowd by abandoning Powerpoint in favour of Prezi to showcase the social media landscape. By way of emphasis, he demonstrated the utility of social media by Tweeting a link to his Prezi which at the time of writing had been viewed by well over 200 people (most from outside Australia). Social media revolution!

We are already looking forward to USANZ 2014 which will take place in Brisbane from 16-19th March 2014. Put the date in your diary – fun to follow on social media but much better in real life!

 

Marni Basto is  a Uro-Oncology Research Fellow at Peter MacCallum Cancer Centre, Melbourne, Australia

Twitter: @Dr MarniqueB

Sarah Wilkinson is a post-doctoral research fellow at Monash University, Melbourne. She is interested in how the prostate tumour microenvironment can be targeted as a therapeutic treatment for prostate cancer.

Twitter: @wilko3040

 

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Humour and the doctor-patient interaction: thoughts from a urological perspective

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Marni Basto

The Urologist cursed with contempt at his finger in the air, discussing with me his practice of prostatic massage, “I’ve had to learn to use my left pointer, the right one developed osteoarthritis”. A moment of silence, then laughter!

From medical school I observed the different ‘phenotype’ of consultant between the specialties and noted the way certain personality types appeared attracted to particular fields. Whilst plastic surgeons displayed a dichotomy of perfectionism and relaxed demeanor, Urologists always struck me as the happy bunch. Witty, personable and sharp with the ability to laugh at themselves and the very nature of the specialty. The sensitive side of some urological conditions makes the doctor-patient interaction and rapport building all the more important. Humour has the ability to enhance communication, break down barriers, develop a therapeutic alliance and improve patient satisfaction. An Urologist’s judicious use of humour may provide the impetus to enter sensitive and personal areas of discussion.  However used without caution can be counterproductive and jeopardise the relationship. As a student and resident I recall some inspiring but also abysmal attempts at humour in the clinical encounter which made me think about how best we can utilise this powerful tool.

Interestingly, the etymology of humour is medically derived from Latin meaning ‘moisture’ or ‘fluid’. It was believed the proportion of four bodily fluids: Blood, phlegm, yellow bile and black bile each conferred unique personality traits and temperament. An imbalance of humours therefore made a person eccentric or odd. With time the word came to refer to those who provoked laughter at the oddities and incongruities of life. Clearly the ancient philosophers were not Urologically inclined –  Two shades of bile?!

Freud noted that the best humour often stems from taboo topics which is perhaps why Urology lends itself well to its use in a clinical encounter.   It’s a tool that can be used by both doctors and patients as a coping mechanism and to reduce the effect of stress.

Here this was exemplified, as I overheard an Urologist discussing with his British patient the TRUS Biopsy he was about to have,

Patient: ‘I am a little nervous, do you think I’ll feel it at all?’

Urologist: ‘No, no, you’ll be off to sleep. But if you did it looks and feels somewhat like the Gherkin in the London Skyline……. Hideously awkward!’

To which the patient almost fell off the bed in tears of laughter. Granted however the Urologist had known this patient for many years and was ‘au fait’ with his style of humour. Another important learning point. Lack of familiarity can cause humour to be ineffective particularly at first consult or in cross cultural encounters. Although we’d say most aspects of humour are broadly trans-societal, one can’t always assume. If unsure always err on the side of caution.

Patient-generated humour can be the most bonding of all in its ability to empower the patient and unite a medical team. ‘Nota bene dic doc’ a recent article published in the Canadian Urological Association Journal by Associate Professor Nathan Lawrentshuck describes a patient who strategically placed a poem in his underpants for the team to see prior to his prostatectomy. This is well worth accessing for the full read however ends along the lines of; “But my sex life is on the upwards curve, So hey there buddy can you spare a nerve?” This had the effect of uniting the team to achieve the best outcome for the patient, who was rapt with the positive response from the staff.

Developing this type of bond with your patients can be extremely rewarding for everyone involved and again Urology lends itself well to this interaction given patients are commonly followed up for years. It takes a while however to get to this point for example;

Patient to long term Urologist regarding recurrent bouts of renal colic: “Can’t you just prescribe me some cyanide?” 

Urologist: “I would except it’d be bad for business – I wouldn’t get any more follow-up visits out of you”. Both laugh!

In a world that is time poor and litigation crazy, humour also can be a tool to ameliorate risk. A US study looked at practice behaviours that helped to decrease the risk of a malpractice suit. It was found that physicians who’d never had a claim against them laughed more and used humour more often during visits. Perhaps this shows once and for all that laughter really is the best medicine!

So for this bunch of plumbers the opportunities for toilet humour are pretty damn concentrated, here’s a great reference! Some food for thought;

• Humour is a useful vector for developing a doctor-patient relationship and can lead to a more rewarding interaction for both parties.

• Humour is best developed with familiarity.

• Learn to use humour to create a healing environment.

• It may assist in entering sensitive areas of discussion.

• Judicious use of humour is appropriate always.

• Externally-focused humour (E.g. weather, parking) carries the least risk in miscommunication and is a good starting point.

• Beware of cross cultural barriers.

• Sole reliance on humour in an interaction can be perceived as flippant.

• Humour may assist in decreasing the risk of malpractice suits.

So even if you’re a medical student, like I was, whose only knowledge of Urology is the great catfish Candiru that swims up the urine stream against gravity and lodges in the urethra; feel free to share any comments, words of wisdom and your own funny experiences for everyone’s enjoyment below.

 

Marnique Basto is a Uro-Oncology Research Fellow at Peter MacCallum Cancer Centre, Melbourne, Australia.

@DrMarniqueB

 

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