Archive for category: BJUI Blog

No Heat in the Desert

I am blogging again my friends. Blogging is freedom in the 21st Century; the modern equivalent of standing on a soapbox in Speakers’ Corner in London. Still, only old people write formal blogs now, young people microblog. They use Twitter, Reddit, Tumblr, or Instagram. Blogging is no more modern than an open radical prostatectomy is sexy; actually its old-fashioned and beneath me. Still, I like it. And more importantly, it gives me an easy outpost to write about urology in an informal manner. So off we go – I am going to give blogging its sexy back.

For the past 20 years, my department at the University of Pittsburgh has sponsored and developed a course to aid board-eligible urologists tackle the oral urology boards (or part 2). We locate the course in Scottsdale, Arizona in Maricopa County. Maricopa county was recently in the news for having a controversial sheriff cited by the Department of Justice for engaging in a pattern or practice of unconstitutional policing” and had “a chronic culture of disregard for basic legal and constitutional obligations.” I use this to scare the candidates into submission. If they misbehave I simply release them into the streets and lock the hotel door. Good luck out there!




I have been the supreme leader – or king as my followers call me – of the course for the past 3 years. The onus is on me to develop, curate, prod, shape, and refine the protocols for the exam. Naturally, I do a great job. This year we had an active hashtag following the course #GUMOCK13.

The urotwitterati were in heavy attendance from Dr. Loeb (@LoebStacy) gracing us with her fashionista presence, and the braintrust of Drs. Morgan and Kutikov (@wandering_gu and @uretericbud) were also there. Even my colleague Dr. Averch (@tdave) made a good twitter presence (a breakthrough). The break dancing and karaoke crooner Prof. Cooperberg (@cooperberg_ucsf) also had a defining presence.

The highlight for me was the profound talk from our guest motivational speaker Wayne Sotile. Just calling yourself a motivational speaker makes me yearn for a shotgun. As a non-believer I was thoroughly entertained and – more importantly – actually learned a great deal about the work/family balance. Some highlights with (tongue-in-cheek) twitter reactions as hyperlinks:

  1. It is not the absolute hours you work that impacts your family life it’s the mood you bring home with you. Tweets here….
  2. We work in a high-demand and low-control environment – that is the ultimate stressful situation. Tweets herehere
  3. Levels of intimacy plummet until the 10 year mark in your marriage then they increase markedly. Tweets….here

The course ended with overall good reviews. The candidates appeared well-prepared, fine young doctors and I was impressed. Still – with a fail rate hovering at 11% the stress levels are high for these physicians. It did not help that the hotel seemed unable to provide the comfort we all desire after working all day and drinking all night – a hot shower. Over 50% of the attending participants had to contend with a cold or tepid shower because of a failed water pump that the hotel scampered to fix. I didn’t mind the dishevelled hippie hair look and – luckily – it appeared to keep the Sheriff’s department at bay.



Benjamin Davies is Assistant Professor of Urology at the University of Pittsburgh; Program Director, Urologic Oncology Fellowship and Chief, Division of Urology Shadyside Hospital. His views are his own. @daviesbj


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“It’s a gold mine!” said someone to me once about the Surveillance, Epidemiology, and End Results (SEER).

Most of you are probably aware of the existence of this large observational population-based cohort of the National Cancer Institute in the United States. The quality of the SEER’s data collection and the immense pool of information on patient socio-demographics, morphology, therapeutic treatment and long-term follow-up for vital status (and more) are nothing short of extraordinary.

Officially, the SEER was developed to monitor cancer trends and data on cancer incidence, extent of disease, treatment and survival.

Unofficially, the SEER has become more or less a funhouse for research scientists, comprising urology investigators as well, probably because the advantages of the SEER database are so appealing:

– it is readily available (click and download);

– the number of patients, even after excluding a bunch of people, is colossal (“Wow! You did all those partial nephrectomies?” someone asked me at the American Urological Association two years ago);

– the findings are publishable (except at one famous journal, who rejects all SEER submissions without external review);

– It’s free! – unless you want to use the SEER Medicare-linked database, in which case, a few robotic-assisted prostatectomies performed by a co-investigator can easily cover the cost (thanks Quoc).

Yet, many individuals within the urological community remain skeptical, borderline aversive towards studies relying on population-based cohorts, such as the SEER database, or the

Nationwide Inpatient Sample (NIS), or the Florida Hospital Inpatient Datafile, to name a few.

At first I didn’t understand why. Because some of the highest quality, most well-designed, and widely cited studies that were published in high-end journals like the New England Journal of Medicine, the Journal of American Medical Association, and the Lancet actually originated from large population-based databases.

But then I realized that – put aside a few people who are just old and bitter – some of these aversions towards studies relying on observational cohorts could be because there is quite a bit of redundant, inconsistent, trivial junk out there that has been published using population-based cohorts like the SEER.

In a recent letter of correspondence in JAMA, Quoc and I wrote a little piece that could be considered as a potential remedy against the issue at hand.  Whereas some may think that the proposed principles appear excessively strict, we personally believe that it can help regulate the prevalent redundancy, reduce discrepancies, and improve the overall quality of the work within population-based reports. Well, at least that is what we think the population-based research community should aim for. Until then…the clock is ticking!


Maxine Sun is a urologic-oncological research scientist and co-director of the Cancer Prognostics and Health Outcomes Unit in Montreal. @maxinesun


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

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.



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Anaesthesia for robotic-assisted laparoscopic radical prostatectomy

Richard MoreyHere’s my technique for anaesthetising patients for robotic-assisted laparoscopic radical prostatectomy and I’d be interested to hear any thoughts, comments and ideas.

Pre-op. I try to fast the patients for as short a time as possible and also include pre-operative carbohydrate loading. This is in line with Enhanced Recovery After Surgery (ERAS) Guidelines for major bowel surgery and has been shown to reduce the negative nitrogen balance that occurs following major surgery. I use 200ml cartons of Polycal, which is clear and non-particulate, prescribed 12 and 3 hours pre-operatively. Clear fluids are encouraged up to 2 hours pre-op as this improves gastric emptying and minimises pre-operative dehydration.

Intra-op. I use a mixed technique of both general and regional anaesthesia. The general consists of a fairly standard technique with a Propofol induction and maintenance with Desflurane and a Remifentanil infusion. To reduce post-operative nausea and vomiting I use ondansetron, cyclizine and dexamethasone. The regional part is a spinal anaesthetic using 0.5% Hyperbaric Bupivacaine with additional intrathecal Diamorphine. Regional anaesthesia has been shown to reduce peri-operative DVT formation, probably by blocking sympathetic activity and improving blood flow through the legs, it also produces profound muscular relaxation enabling better pelvic vision and easier insufflation. In addition there is some evidence that appears to suggest regional anaesthesia may reduce the recurrence rate of prostate cancer. As the patients are positioned in a steep trendelenberg they are all intubated and ventilated with a small amount of additional PEEP to reduce pulmonary atelectasis.

Post-op. Intrathecal diamorphine usually provides 12-14 hours of good quality post operative analgesia. Intrathecal opiates act locally producing segmental analgesia and therefore do not produce the systemic side effects to the same degree as intravenous opiates. The ondansetron given peri-operatively may reduce the incidence of opiate induced pruritus as well as acting as an excellent antiemetic. Additional analgesia will be required but usually paracetamol and ibuprofen are sufficient. It is unusual for patients to require any additional stronger opioid medications and this is helpful in ensuring that gastric stasis and reduced gut motility do not occur. This enables the patients to be rapidly progressed on to a light solid diet that in turn further reduces the occurrence of a post-operative ileus.

Fluid Management. Using this starvation policy, patients should commence their surgery with only a minimum degree of dehydration. Remifentanil produces an extremely cardio-stable anaesthetic and with the patients being head down peri-operative hypotension is unusual.  Should this however occur blood pressure should be maintained with the judicial use of vasopressors and fluid if necessary. Post-operative urine output can be maintained if required with plasma expanders and diuretics.


Richard Morey qualified from MHMS in 1987 and has been a Consultant Anaesthetist in SE London since 1997. His particular interests are ERAS/ Laparoscopic Surgery along with ENT and Difficult Airways.



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The X-Factor, Reality TV, and Live Surgery Demonstration

Declan theatreMy first suggestion to my wife was that I enter Pop Idol with my modified, radiation-bashing rendition of American Pie (chorus “bye bye brachytherapy seeds“). She quickly retorted “DIVORCE! YOU CANT SING!” I begrudgingly agreed. Then Britain’s Got Talent came along and I saw an overweight Greek father and son duo, Stavros Flatley, prance around the stage bare-chested, dancing to some traditional Greek music and I thought “YES! There is hope!” I put on Riverdance, grabbed my then three-year-old son and started teaching him the basics of an Irish jig. I pleaded with my wife to allow us enter the X Factor (or whatever reality TV show was auditioning at that time), but she again screamed “DIVORCE!”. It appeared my hopes of finding fame on reality TV were dashed forever (although I expect Masterchef might be interested in my prowess on the BBQ – Murphy’s Marvellous Marinade on a whole eye fillet deserves a wider audience).

At about that time, the vogue of having live surgery demonstrations featuring at clinical meetings was really gaining momentum. The World Robotic Symposium, European Robotic Urology Symposium, European Society for Urological Technology section meeting at the EAU, Challenges in Laparoscopy & Robotics and others, were all featuring live surgery demonstrations as a prominent part of their scientific program. These sessions feature enormous high-definition screens, 3D broadcast in some circumstances, parallel operating rooms, and live interaction with the surgical team, and have proved enormously popular with audiences and sponsors alike. In fact, without live surgery, some of these meetings would be quite dull –there is certainly a commercial value in featuring live surgery as part of the program as is demonstrated by the huge numbers attending these sessions. Whether it is the lure of seeing world-famous surgeons perform robotic prostatectomy, partial nephrectomy or various types of salvage surgery, or the ever-present possibility of seeing a complication and its management, there is a blood-lust which surgical audiences have for this type of entertainment, sorry – education, and which is being met by the organisers of urology conferences. A merry band of surgeon-entertainers roam the world turning up at these conferences with their entourage of assistants and scrub nurses, and turning on the charm for the huge audiences which the big names now attract.

However, some controversy surrounds the ethics and conduct of live surgery. We wrote in the BJUI previously about some concerns we had and questioning the absolute educational value of these demonstrations. Well known leaders such as Dr Arthur Smith have also voiced concerns about live surgery and in some specialties and some countries, live surgery demonstrations are banned. In response, it has been encouraging to see the European Robotic Urology Society (now an official Section of the EAU), whose annual meeting is a live surgery spectacular, work with others to generate guidelines and ethical standards for the conduct of live surgery at scientific meetings. These will be published in the coming months.

So when it dawned on me that the personal price to pay for fame on reality TV was too high, I resigned myself to a life away from the glamour and fame of reality TV. However, I was very interested when Alex Mottrie and Ben Challacombe invited me to do a live robotic radical prostatectomy for the European Robotic Urology Symposium in London a few months ago. I had only ever done live surgery demonstrations for quite small audiences previously (I had done my karaoke version of American Pie to bigger audiences), and I was somewhat daunted and excited by the prospect of doing live surgery for a big audience, especially one full of the “Gods of Robotic Surgery”. The reality TV star inside me was saying ‘YES! I AM GOING TO BE A STAR!!” So I said yes. And the nerves started soon after. By the time it got to the opening morning of ERUS (in stunning post-Olympics London), I was pretty anxious. The case was straight-forward and I had done hundreds already, so why was I nervous? Well the audience was big (>800), and they looked blood-thirsty – I could feel them licking their lips at the prospect of something going badly wrong. I knew that a few of the “good luck mate” wishes that I had received that morning could be interpreted as “I hope you don’t hurt your head when you fall off your pedestal”. And the big guys were all over the place. The live surgery roll included Vip Patel, Richard Gaston, Alex Mottrie, Prokar Dasgupta, James Porter, Ronney Abaza, Mike Stiefleman, Ashok Hemal and Peter Wiklund. Francesco Montorsi was in the operating room next door and we would be operating in parallel. It was somewhat daunting. Even the stars looked nervous before going live with their surgery, some were even quite temperamental as the stress builds, but when they go live to the convention centre, they put on their “TV-face” and the show begins – all sweetness and charm. Quite a show.

Before live surgery at Guy’s

In the “Green Room” before live surgery at Guy’s Hospital in London for ERUS 2012: Ken Palmer, Geoff Coughlin, Jim Porter, Vip Patel, Declan Murphy, Francesco Montorsi and Declan Cahill

For me, I figured out that the reason I was nervous was that I did not want to make a mess of it in front of a big audience. Human nature has a vain streak to it, and much as I am embarrassed to admit it, I realised that some of my anxiety was just that – I wanted to look and sound good on the big screens. There – I’ve said it! Something certainly added a different stress to the normal pressure of wanting to do an excellent job for your patient, and I expect that even the highly experienced live surgery stars who feature at these meetings do feel this extra pressure. Especially when things get a little sticky or you cause some bleeding and someone at the other end is asking “why did you do that?” Thankfully my case went nicely and my patient has done very well – details to be presented at next year’s ERUS as part of their new guidelines which will see feedback from all cases from the previous Symposium – an excellent initiative.

Doing robotic radical prostatectomy at ERUS 2012

Doing robotic radical prostatectomy at ERUS 2012

Doing robotic radical prostatectomy at ERUS 2012

So for now, the reality TV star in me has been sated and life goes on. Although I did hear there may be a new reality TV series in Australia for amateurs who fancy themselves as crocodile hunters. I wonder would she let me do that….

Declan Murphy


Declan Murphy is Honorary Clinical Associate Professor at the Department of Surgery, University of Melbourne, St Vincent’s Hospital and Director of Robotic Surgery at the Peter MacCallum Cancer Centre. He had previously been consultant urological surgeon at Guys & St Thomas’ NHS Foundation Trust in London.


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In 1948 BF Skinner put a pigeon in a box.  Unlike most of Skinner’s birds, this one did not have to learn a behavior, such as pecking a lever, to receive an edible reward. Food was automatically dispensed at fixed time intervals without fail, the pigeon simply had to wait. The fascinating development from this experiment was that after some few hours in the box the bird was performing an elaborate routine of behaviors; turns, head movements, foot raises, all presumably in an effort to bring about the reward. When a number of birds were placed in the same situation, each developed a unique routine to bring about reinforcement, that was forthcoming regardless. Whatever behavior they happened to be performing at the time of feeding was, by chance association, reinforced.

Skinner dubbed this phenomenon “superstitious behavior”. He extrapolated this to human activities that have no bearing on an outcome, but are nonetheless performed in an effort to bring about a favorable endpoint.  Repeatedly pushing the elevator call button to speed its arrival. Using loved ones birthdates when selecting lottery numbers. Wearing lucky socks to a job interview. In these cases decision making is faulty due to misperceived information, that an extraneous behavior will make a significant difference to outcomes.

Much superstitious behavior is harmless, albeit futile.  In surgery, we have the “Goodnight Stitch”. This is the added step in the procedure that maybe unnecessary, but makes us feel we have done something extra for patient safety, and will therefore sleep easier. If the patient does well, the behavior is reinforced. Equally we all know the power of a significant, memorable complication in influencing our behavior.

Real harm arises when, like a pigeon in a box, a surgeon becomes isolated. Sitting alone in the dark, relying on short-term patient outcome feedback, the surgeon may develop a dominant philosophy of “In my hands…”, or “Our experience is…”, that precludes service improvement based on robust evidence. It has been established since at least the mid 1990s that powdered surgical gloves increase the rate of symptomatic abdominal adhesions (Luijendijk R), but do any of us know a surgeon that persists in using them because “This has not been my experience”? At first glance, the geographically isolated surgeon would seem to be particularly vulnerable to this phenomenon, with few colleagues to provide a check on eccentric practice. Perhaps, however, the surgeon that separates themselves from the surgical community, regardless of geography, is of greater concern.

We have conferences, morbidity and mortality meetings, and audit to objectively assess our outcomes, and prevent us from becoming superstitious victims of anecdote. We can vicariously increase our experience through research based on thousands more patients than we will ever treat. If a surgeon avoids or minimizes these activities, they are vulnerable to systematic superstitious decision making.

As surgeons, we fiercely defend our right to autonomous practice, and rightly so. We must not become slaves to policies imposed by misinformed outsiders with agendas other than patient welfare. We must also seek to overcome undue internal influences on our decision making based on fear, lack of knowledge, and superstition.

James Duthie is a Uro-Oncology Trainee (Robot Surgery) at Peter MacCallum Cancer Centre, Melbourne. He is interested in Human Factors Engineering, & making people better through electronic means. @Jamesduthie1


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What prophylactic steps should we take to prevent DVT/PE after RARP?

Deep vein thromboses (DVT) and pulmonary embolism (PE) are rare, but potentially devastating, complications of major pelvic surgery. We have performed more than 1000 robot assisted radical prostatectomy (RARP) procedures in Central London (Lessons learned from 1000 RARP operations BJUI 2013;111(1):9-10.) and to date encountered just a couple of DVTs, as well as a single, non-fatal instance of PE. However, in the case of one of us (RK), a close relative passed away as a result of a PE 10 days after a routine hip replacement performed in Oxford, a very sad event which highlighted the very negative impact on the family of this preventable surgical complication.

Guidance from NICE recommends that evidence-based steps be taken to reduce the risk of venous thromboembolism (VTE). Failure to do so therefore renders us open to criticism if a DVT, or worse a PE, does develop. On the other hand, pelvic haematoma and haematuria are troublesome complications of RARP, the risks of which may be exacerbated by anticoagulation.

What therefore should we be doing to reduce the risk of before and after laparoscopic pelvic surgery? Few would disagree that TED stockings should be worn before and after surgery, but how long should they be retained, as many patients do find them rather uncomfortable? Calf compression boots during surgery and for 12 hours or so post-operatively should also be standard practice.

More contentious is the duration of use of low molecular weight heparin (LMWH). Some surgeons use a single dose immediately prior to the operation; we have used 5000 Units of Clexane post-operatively for 2-3 days. Orthopaedic surgeons are increasingly continuing LMWH for 28 days at home after joint replacement surgery, which carries a significant risk of VTE. Should we follow their lead? A simpler alternative from the patients’ viewpoint is daily use of one of the new oral anti-coagulants such as dabigatran.

Perhaps the most sensible approach clinically is to perform a risk assessment of all RALP candidates pre-operatively. A calf compression device and TED stockings should be used for all patients, together with LMWH, while in hospital. Those considered especially at risk with, for example, a BMI >30 (Becattini CA) (See Box 1), should usually go home for a month with either LMWH injections or daily oral dabigatran, or equivalent oral anticoagulant agent.

We would be most interested in the views, experiences and current practice of the readers of this piece. Please do post your own response.


Roger Kirby, Ben Challacombe and Prokar Dasgupta
The Prostate Centre, London W1G 8GT and Guy’s Hospital, King’s College London, King’s Health Partners


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The self-proclaimed King of the Urology twitter world

Howard Stern proclaimed himself the King of all Media; I have proclaimed myself the King of the Urology twitter world.  There is no basis for my claim.  I certainly do not have the most followers nor do I have regal heritage. If you repeat things often enough they simply become true on the web – so I’m happy to be the king

What is true is that I was the first academic urologist to take to the twitterverse in a persistent, snarky, timely, and – at times- academic manner. I coached the uro-twitterati including Declan (@declangmurphy), Quoc (@qdtrinh),  Alex (@uretericbud), Coops (@cooperberg_ucsf), Tony F (@urooncmd) , Mike L (@_TheUrologist_), and Henry Woo ( @DrHWoo). And I am proud of them.

Many of my most compelling tweets have been published in real news outlets (like on NPR and the Washington Post blog) and even a real article grew from it in Nature Urology. The biotech twitterverse (see Adam Feuerstein) has there hooks in me as well and I have had several consulting jobs as a result.

Like any father I have problems with my kids. They dont listen to my sage advice and they should. To tweet is not to be boring. It is not to be glib and tidy (Hi mom!). That is why we have Facebook. You have several style options for your tweets in the twitterverse and here are a few:

Academic tweets: Boring. These people add pithy tag lines to an interesting article (good example is @drMEisenberg). I have no problem with this approach. It makes for a safe environment and there is no question you have to be safe with your remarks (which I occasionally am not). It is a purely an informational tweet.

Snarky and academic: This is the province of Matt Cooperberg and I. I am vastly more funny. He is what I would describe as almost funny. The strategy is simple – find an article in urology or medicine in general and add a funny comment.  They become strangely profound if done right. Good examples are here ….. or here

Mash-up Tweets: This is hard and rare. It is basically the ability to makes a tweet about a timely topic (could be breaking news) and tie it to something else that is urologic or some other breaking news. Sounds hard? It is. This is an advanced twitter move. My best tweets (judged by RTs) were mashups. Remember my best tweets are actually not available after some time since twitter archives your tweets for a limited time. Here is one ok example

Academic Modified Tweets and/or Snarky Academic Modified tweets:  Modified tweets are taking a tweet and changing it to either to it make shorter or to completely change it to make a funny and/or compelling point. I’m better at funny. This is hard. These are by far my favorite form of tweets. Good one here

Odd ball tweet: I also love just saying something funny totally out of context. Remember do not be boring. This has been championed by @robdelany who is champion tweeter and raunchy comedian. Not everyone likes him but his a great odd ball tweeter. Here is my attempt. It is ok.
There is a lot to teach my people.  Follow good tweeters. Do not tell us about your heartburn, gas, or inlaws (unless its a mashup!). Do not talk to your friends about something silly. Do not add silly hashtags to seem funny. They are never funny. Never. Repeat that over and over until you stop doing it. I will blog frequently about urologic twitter topics now that I am the Senior Consultant and Highly Paid Advisor for Social Media for BJUI. This of course is false but if you keep repeating it…


Benjamin Davies is Assistant Professor of Urology at the University of Pittsburgh; Program Director, Urologic Oncology Fellowship and Chief, Division of Urology Shadyside Hospital. His views are his own. @daviesbj


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Editorial: Is botulinum toxin not the solution to OAB after all?

Dirk De Ridder
Department of Urology, University Hospital Leuven, Belgium

The article by Mohee et al. highlights a problem that is often neglected: the outomes we see in clinical trials do not predict the success of the therapy in real life. We know this from anticholinergics: the study results are good, but the performance in real life is much poorer. Only 20-40% will continue to take the medication.

For botulinum toxin in OAB it is surprising to see that even in experienced hands only 38.7% of patients continued with the treatment at 36 months. The reasons to abandon the treatment were retention, the need for CISC and urinary tract infections. Moreover, 8.6% of the patients had no response at all after the initial injection.

Of course infections could have been avoided by using prophylactic antibiotics, but the other issues remain. How to explain the primary failures? How to manage the risk of CISC?

Given the fact that most patients abandoned the treatment within the first 3 years, more research would be needed on how to increase the treatment adherence of the patients after the initial injection.

This challenging article also stresses the fact that in a time where only RCTs stand a good chance of being published in journals, good retrospective cohort studies can be extremely important too.

Read the full article

Ten stories of 2012, part II

Thanks for all the helpful input regarding my first blog post. Constructive criticism is always helpful, especially if I am to get better at this.

If you haven’t read it, part 1 is here.

So, in no particular order, part 2 of 2:

+ Metastatic prostate cancer – it’s getting complicated…

2012 was a year of hope for metastatic prostate cancer patients.  First, Enzalutamide (also known as MDV3100), in the context of a phase III RCT, was shown to prolong the survival of men with metastatic prostate cancer after chemo. And just when we thought the year was over, Abiraterone, which was previously shown to improve survival in patients with metastatic prostate cancer after chemotherapy, was found to be beneficial even in chemo-naive patients. All this translates into more complicated algorithms for castrate-resistant prostate cancer.  That said, my question is the following: what happens if these drugs are effective at treating localized prostate cancer? It seems that some medical oncologists are trying to figure that out. Prostatectomists, murky waters lie ahead! Oh wait, I’m part of that group.

+ The changing landscape of surgical education

Times They Are a-Changin’. Residents are working less but don’t sleep more. 16-hour work day restrictions. More women are admitted into surgical fields. Protected nap (sleep) time during calls. Residents not covering floor consults during the day (those are actually the rules where I work). Most trainees now value quality of life above anything else, possibly even the quality of their training (do read this beautiful piece by a Urologist in JAMA: Considering Life Before Lifestyle. Yet, the amount of knowledge a resident needs to consolidate during residency is at least 10-fold greater than what the old geezers had to learn back in the days (the current Campbell-Walsh is 134 chapters, 4320 pages). Whether or not you agree with any of the above (which is irrelevant anyways, because it’s happening whether you like it or not), attending surgeons and urologists are finding it hard to adapt or understand. “Honey, things were much harder back when I was a resident…” How do we evolve as a sub-specialty without compromising surgical education (or lengthening residency)? Status quo is not an option.

+ Radiotherapy for prostate cancer – what’s up with that?

A nice observational study from Sheets et al in the JAMA thematic issue on Comparative Effectiveness Research showed that “use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction“. Yet, Jacobs et al, using the same dataset and almost the same study years, showed that the risks of salvage therapy and complications are comparable between the two modalities, for most patients. And let’s not get started about proton-beam therapy. Whilst this costly approach is gaining precedence in the treatment of localized prostate cancer, severe doubts exist regarding its efficacy. The bombshell: another observational study from Yale, based on Medicare data: “Although proton radiotherapy is substantially more costly than IMRT, there was no difference in toxicity in a comprehensive cohort of Medicare beneficiaries with prostate cancer at 12 months post-treatment“. Ouch.  To be perfectly honest (sometimes I’m told I should shut up), it would be hypocrisy for robotic surgery fanboys to condemn proton beam therapy right now. As we all know, it took years before convincing observational data showed that robotic radical prostatectomy is better than open, at some levels. Maybe someone responsible will actually perform a prospective comparative effectiveness assessment between these modalities. As an avid blogger suggests, maybe the proton beams and the robots should fight for world domination.

+ Urology at the forefront of the social media revolution

As a group, we should be proud of how we embraced social media in 2012. In the field of medicine, where anything novel is usually met with smirk and mockery (see: surgery, robot-assisted), social media has been surprisingly well received, thanks to a tight-knit community of twitter champions (if you’re new to twitter, you should definitely follow’s list of key opinion leaders (KOLs) in Urology. Moreover, the first International Urology Journal Club was held in November 2012 and has been a global success ever since. I’m sure that 2012 was only the start. It will be exciting to see the role of social media in upcoming international meetings such as the EAU, AUA and BAUS. Virtual high-five everyone!

+ Be inspired.

OK, so this one has nothing to do with Urology, or Medicine for that matter. Here’s a toast to the events that shook 2012, and let’s hope that 2013 will be a great year!



Quoc-Dien Trinh


Quoc-Dien Trinh is a minimally-invasive urologist and co-director of the Cancer Prognostics and Health Outcomes Unit. His research focuses on patterns of care, costs and outcomes in prostate cancer treatment.


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