Archive for category: BJUI Blog

Resident’s podcast: Palliative care use amongst patients with bladder cancer

Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:

Palliative care use amongst patients with bladder cancer

Abstract

Objectives

To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

Patients and methods

Using Surveillance, Epidemiology, and End Results‐Medicare data, we identified patients diagnosed with muscle‐invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.

Results

Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+, or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder‐sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.

Conclusions

Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease‐specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician‐, patient‐, and system‐level barriers to this care.

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Why attend Advanced Prostate Cancer Consensus Conference APCCC 2019?

From the 29th to the 31st of August 2019 the next Advanced Prostate Cancer Consensus Conference #APCCC19 will take place in Basel, Switzerland. The consensus conference was inspired by the very successful and pioneering early breast cancer consensus conference that was started in 1978 in St Gallen.

APCCC was initiated in 2015 because of the rapid developments in the field of advanced prostate cancer with the aim to discuss the clinical management of men with advanced prostate cancer, with a special focus on situations with a lack of or only weak evidence from the literature or conflicting evidence. Prostate cancer is such a common disease that the majority of men across the globe are not treated in expert centers but rather in smaller hospitals or community-based practices. APCCC wants to help the process of knowledge translation by assembling a large group of international prostate cancer experts that hold highly educational lectures summarizing the available literature and evidence, and discussing controversial questions.

The recommendations from the previous two conferences in 2015 and 2017 have been published open access in renowned scientific journals and have been widely read:

APCCC 2015 report

APCCC 2017 report

The expert panel in action at APCCC 2017

The following topics have been chosen for discussion at the 2019 conference:

  1. Locally advanced prostate cancer
  2. Biochemical recurrence of prostate cancer after local therapy
  3. Management of primary tumour in the metastatic situation
  4. Newly diagnosed metastatic prostate cancer, including oligometastatic prostate cancer
  5. Management of nmCRPC
  6. Management of mCRPC
  7. Bone and bone metastases
  8. Molecular characterization: tissue and blood
  9. Heterogeneity of men with prostate cancer (ethnicity, elderly)
  10. Side effects of hormonal treatments and their management

Difficult questions at APCCC17

Importantly all participants of APCCC can attend the consensus discussion and voting on Saturday morning. The questions and voting results will again form the basis for a report that will be published soon after the conference.

Why attend APCCC 2019?

The management of men with advanced prostate cancer keeps changing rapidly. Practice changing results have been recently presented and controversially discussed at ESMO (e.g. radiation therapy of the primary in the metastatic situation) and important new data will be presented at ASCO 2019 (e.g. results of standard-of-care therapy with or without enzalutamide or apalutamide for metastatic hormone-sensitive prostate cancer), making the choice of treatment in this situation even more challenging.

There are many reasons to attend APCCC 2019:

  • A unique opportunity to focus on the important topic of advanced prostate cancer management for two and a half days and be updated on current standards and state of the art of the care of men with advanced prostate cancer
  • Be involved in a global discussion on questions relevant to daily clinical practice but not investigated well

Expert interactions at APCCC17

  • Help to translate the outcomes from clinical trials into the management of men with prostate cancer in daily practice especially for men treated outside of large prostate cancer centers.
  • Be inspired and organize an APCCC satellite meeting for your country or region as has been done after the previous consensus conferences, with manuscripts published here in the BJUI.
    • Chiong et al. The Asia-Pacific Satellite of the APCCC BJUI 2019
    • Ma WK et al. Consensus statements on the management of clinically localized prostate cancer from the Hong Kong Urological Association and the Hong Kong Society of Uro-Oncology BJU Int. 2019
    • Omlin A, Gillessen S. The Advanced Prostate Cancer Consensus on a regional level – what can we learn? BJU Int. 2019
  • And of course, enjoy a few wonderful summer days in the beautiful city of Basel!!!

Further information and links

APCCC 2019

Preview of APCCC 2019: Silke Gillessen, in conversation with Alicia Morgans, discusses many of the changes we have experienced in clinical practice since the last APCCC in 2017


APCCC on the THE “NEW” PROSTATE CANCER INFOLINK

 

by Dr Aurelius Omlin

Twitter: @apccc19
 

June 2019 – About the cover

 

The Article of the Month for June (In‐hospital cost analysis of prostatic artery embolization compared with transurethral resection of the prostate: post hoc analysis of a randomized controlled trial) is on work carried out by urologists from St Gallen and Zurich in Switzerland.

The city of St Gallen is located in Eastern Switzerland, south of Lake Constance (Bodensee) and on the border of four countries. It is best know for its UNESCO World Heritage listed Abbey precinct and library, which contains an impressive collection of medieval books. In the past it was an important centre for textiles and embroidery; now it is a university town specialising in Economic Sciences.

 

 

 

Residents’ podcast: Vaccines for preventing recurrent UTIs


Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:

Vaccines for the prevention of recurrent urinary tract infections: a systematic review

 

Read the full article

Abstract

Objectives

To systematically review the evidence regarding the efficacy of vaccines or immunostimulants in reducing the recurrence rate of urinary tract infections (UTIs).

Materials and Methods

The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), PubMed, Cochrane Library, World Health Organization (WHO) International Clinical Trials Registry Platform Search Portal, and conference abstracts were searched up to January 2018 for English‐titled citations. Randomised placebo‐controlled trials evaluating UTI recurrence rates in adult patients with recurrent UTIs treated with a vaccine were selected by two independent reviewers according to the Population, Interventions, Comparators, and Outcomes (PICO) criteria. Differences in recurrence rates in study populations for individual trials were calculated and pooled, and risk ratios (RRs) using random effects models were calculated. Risk of bias was assessed using the Cochrane Collaboration’s tool and heterogeneity was assessed using chi‐squared and I2 testing. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence (QOE) and summarise findings.

Results

In all, 599 records were identified, of which 10 studies were included. A total of 1537 patients were recruited and analysed, on whom data were presented. Three candidate vaccines were studied: Uro‐Vaxom® (OM Pharma, Myerlin, Switzerland), Urovac® (Solco Basel Ltd, Basel, Switzerland), and ExPEC4V (GlycoVaxyn AG, Schlieren, Switzerland). At trial endpoint, the use of vaccines appeared to reduce UTI recurrence compared to placebo (RR 0.74, 95% confidence interval [CI] 0.67–0.81; low QOE). Uro‐Vaxom showed the greatest reduction in UTI recurrence rate; the maximal effect was seen at 3 months compared with 6 months after initial treatment (RR 0.67, 95% CI 0.57–0.78; and RR 0.78, 95% CI 0.69–0.88, respectively; low QOE). Urovac may also reduce risk of UTI recurrence (RR 0.75, 95% CI 0.63–0.89; low QOE). ExPEC4V does not appear to reduce UTI recurrence compared to placebo at study endpoint (RR 0.82, 95% CI 0.62–1.10; low QOE). Substantial heterogeneity was observed across the included studies (chi‐squared = 54.58; P < 0.001, I2 = 84%).

Conclusions

While there is evidence for the efficacy of vaccines in patients with recurrent UTIs, significant heterogeneity amongst these studies renders interpretation and recommendation for routine clinical use difficult at present. Further randomised trials using consistent definitions and endpoints are needed to study the long‐term efficacy and safety of vaccines for infection prevention in patients with recurrent UTIs.

Read more Articles of the week

 

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Four Seasons – Spring 2019’s top reviewer

 

This month, BJUI continues the Four Seasons Peer Reviewer Award recognising the hard work and dedication of our peer reviewers. Each quarter the Editor and Editorial Team select an individual peer reviewer whose reviews over the last 3 months have stood out for their quality and timeliness.

 

 

 

 

The Spring Crown goes to Dr Janet Kukreja.  Prokar Dasgupta, Editor-in-Chief of the BJUI, presented her with the award at the AUA conference in Chicago.

 

Dr Kukreja is an Assistant Professor at the University of Colorado in Denver, CO, USA. She specializes in urologic oncology with a specific interest in bladder cancer. She currently works on research in surgical recovery and bladder cancer in both clinical and translational research.

 

May 2019 – About the cover

The Article of the Month for May (Evaluation of axitinib to downstage cT2a renal tumours and allow partial nephrectomy: a phase II study) has been written by urologists/oncologists from across France.

The cover picture shows La Basilique de Sacré Coeur de Montmartre, Paris’s second most famous church.  It was designed by architect Paul Abadie, in the Romano-Byzantine style and construction began in 1875.  This year marks 100 years since it was consecrated, at the end of the First World War.

 

 

 

Residents’ podcast: In utero myelomeningocele repair and urological outcomes

Giulia Lane M.D. is a Fellow in Neuro-urology and Pelvic Reconstruction in the Department of Urology at the University of Michigan; Kyle Johnson is a Urology Resident in the same department.

In this podcast they discuss the following BJUI Article of the Week:

In utero myelomeningocele repair and urological outcomes: the first 100 cases of a prospective analysis. Is there an improvement in bladder function?

Abstract

Objectives

To evaluate the first 100 cases of in utero myelomeningocele (MMC) repair and urological outcomes in a prospective analysis aiming to define possible improvement in bladder function.

Patients and methods

We used a protocol consisting of a detailed medical history, urinary tract ultrasonography, voiding cystourethrography, and urodynamic evaluation. Patients were categorised into four groups: normal, high risk (overactive bladder with a detrusor leak‐point pressure >40 cm H2O and high filling pressures also >40 cm H2O), incontinent, and underactivity (underactive bladder with post‐void residual urine), and patients were treated accordingly.

Results

We evaluated 100 patients, at a mean age of 5.8 months (median 4 months), classified as high risk in 52.6%, incontinent in 27.4%, with underactive bladder in 4.2%, and only 14.7% had a normal bladder profile. Clean intermittent catheterisation was initiated in 57.3% of the patients and anticholinergics in 52.6%. Antibiotic prophylaxis was initiated in 19.1% of the patients presenting with vesico‐ureteric reflux.

Conclusion

The high incidence of abnormal bladder patterns suggests little benefit of in utero MMC surgery concerning the urinary tract.

 

Read the full article

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IP2 – ATLANTA is launched!

IP2 – ATLANTA is launched! ATLANTA is a phase II randomised controlled trial that will explore sequential multi-modal treatment using systemic therapy, local physical cytoreduction and metastasis directed therapy in men with newly diagnosed metastatic prostate cancer against a comparator of standard of care alone.

All men with new histologically diagnosed hormone sensitive metastatic prostate cancer, within three months of commencing androgen deprivation therapy (ADT), and of performance status 0 to 2 are eligible.  No upper limit on metastatic burden will apply, although men must be fit to undergo all trial interventions at point of randomisation.

Men will be randomised to: Control (Standard of Care) OR Intervention 1 (Minimally Invasive Ablative Therapy [MIAT] +/- pelvic lymph node dissection [PLND]) OR Intervention 2 (Local Radiotherapy +/- Lymph Nodes OR Radical Prostatectomy +/- PLND). Randomisation stratified by metastatic burden (CHAARTED definition), intent to treat pelvic lymph nodes, intent to treat metastasis and intent to commence chemotherapy.

Systemic therapy in all arms includes ADT +/- Docetaxel. Radical prostatectomy will be with or without PLND. Local radiotherapy will be 60Gy/20Fr OR 74-78Gy in 2Gy per fraction over a minimum of 27 days, with or without simultaneous nodal radiotherapy. MIAT will be cryotherapy or focal HIFU. Men in both intervention arms will be eligible for metastasis directed therapy in the form of stereotactic ablative radiation (SABR) or surgery.

Men will be recruited over a two year period and followed up for a minimum of two years. Primary outcome will be progression free survival (PFS). ATLANTA is commencing in 17 UK trial centres with a target recruitment of 80 patients in the internal pilot, rising to 918 patients in full phase across 30 UK trial centres from November 2019.

ATLANTA is entirely charity funded (Wellcome Trust) and available on the NIHR CRN portfolio. Follow-up trial visits are not in excess of routine practice and extra burden is minimal. If you would like to join the main phase of ATLANTA as a site, please contact Mr Martin J. Connor ([email protected]) www.imperialprostate.org.uk/ATLANTA.

Prof. Hashim U. Ahmed (ATLANTA PI & CI),

Mr. Martin J. Connor (ATLANTA Doctoral Clinical Research Fellow)

Mr. Taimur T. Shah (Urology SpR & Research Fellow)

 

ATLANTA Surgeons Board: Mr Mathias Winkler, Mr Tim Dudderidge, Prof. Chris Eden, Mr Paul Cathcart, Prof. Naeem Soomro, Mr Adel Makar

ATLANTA Radiotherapy Board: Prof. John Staffurth, Dr. Alison Falconer, Dr. Stephen Mangar, Dr Olivia Naismith, RTTQA team

ATLANTA MIAT Board: Prof. Hashim U. Ahmed, Mr Stuart McCracken, Mr Raj Nigam, Mr Tim Dudderidge, Prof Iqbal Shergill

ATLANTA SABR Board: Dr Vincent Khoo, RTTQA team

ATLANTA Medical Oncologists: Dr. Naveed Sarwar, Dr Michael Gonzalez

ATLANTA Trial Sites: Imperial College Healthcare NHS Trust, The Royal Marsden Hospital, Guy’s & St Thomas’ NHS Foundation Trust, London North West Healthcare NHS Trust, Royal Surrey County (Guildford) Hospital, University Hospital Southampton, Clatterbridge Cancer Centre & Arrowe Park Hospital, Newcastle Freeman Hospital, King’s Lynn (Cambridge), Norfolk & Norwich (Cambridge), Sunderland Royal Hospital, Frimley Park Hospital, Royal Devon and Exeter Hospital, Wrexham Park Hospital, West Middlesex University Hospital, Royal United Hospital Bath, Betsi Calderwar Health Board, Lister Hospital, Hampshire (Basingstoke) Hospitals, University Hospital Coventry, Worcestershire Royal Hospital.

Trial Sponsor: Imperial College London

Trial Funder: Wellcome Trust

ClinicalTrials.gov Identifier: NCT03763253

See more infographics

 

Encouraging future urologists: BAUS Section of Trainees (BSoT) goes to ASiT Conference

The Association of Surgeons in Training (ASiT) is a trainee-led, pan-specialty, independent body that aims to promote the highest standards of surgical training. The highlight of their calendar is the ASiT Conference, this year held at the ICC Belfast from 22nd to 24th March 2019. It attracted over 700 delegates of all grades.

ASiT invites representatives of all surgical specialty groups to be part of their council. It is a reciprocal relationship as many surgical training issues affect us all and together we have a great influence. Urology’s BAUS Section of Trainees ‘BSoT’ (formerly SURG) Representative, Clare Jelley (ST5, Oxford Deanery), has done an incredible job over the last 3 years and it is these shoes that I now attempt to fill as the new BSoT/ASiT Rep.

Are you a urologist and desire to find a good job offer? Check out vacancies on Jooble.

The ASiT Conference weekend included pre-conference courses run by surgical specialty groups, plenary lectures with notable speakers, breakout sessions and an impressive exhibition hall.  Unsurprisingly the plenary session on curricula, credentialing and regulation was full; Charlie Massey and Prof Colin Melville (GMC) were put under fierce questioning by the ASiT Committee and the audience. The plenary talks also included a range of topics: innovation, leadership, burnout, fatigue and overcoming adversity. The latter was poignantly given by John Peter, RAF pilot and POW in Iraq (pictured).

The scientific programme included research and audit project presentations. Successful abstract submissions were invited for poster presentation (grouped and marked by specialty) and the highest scoring, prize-worthy abstracts were invited for oral presentation. Accepted abstracts are published in the British Journal of Surgery. There were also social events including a 5km charity run, welcome drinks and the inaugural black-tie Gala Dinner held at the stunning Belfast City Hall.

 

Clare and I flew the flag for Urology during the conference! The pre-conference course ‘Basic Urology Skills’ was full; we taught 16 very keen delegates interested in a career in urology from all over the UK (pictured). We included practical stations to teach skills such as: cystoscopy, ureteric stenting, scrotal exploration (using medical meat), circumcision and supra-pubic catheter insertion. We are very grateful for reps from Cook, Stryker and Coloplast for providing the equipment and to our urological trainee faculty which included  Mr Trevor Thompson, urological consultant and Head of the School of Surgery in Belfast, UK.

The ‘Specialty Fair’ was another opportunity to showcase urology (and promote it as the best career choice!). The room was packed. Delegates met speciality representatives and trainees, enabling conversations and questions about their surgical specialty in an informal manner. Special thanks to urology registrars Tharani Mahesan and Katie Chan who helped spread the positive message (pictured).

 

The abstract presentations were of a high standard; there were over 50 urology-themed posters showcased. Of particular note there were at least 4 oral presentations reflecting projects within urology – including IDENTIFY preliminary results presented by Tara Sibartie on behalf of all the collaborators, which won the Society of Academic and Research Surgery (SARS) prize. Another urological highlight was the Edinburgh Surgical Sciences Qualification prize being awarded to Katie Chan for her presentation of the #DontPayToStay campaign. This Freedom of Information request exposed that 18% of English hospitals charge for non-resident on call accommodation at a median rate of £25/night. i.e. trainees are left with a financial burden in order to maintain a safe emergency practice. By highlighting this issue and gaining support from ASiT and the Junior Doctors Committee it is hoped that these charges can conclusively be removed during the renegotiation of the junior doctor contract. Katie also brought along the youngest Conference delegate, baby Orla, who enjoyed the use of the ASiT crèche (free of charge!).

BSoT is committed to representing current urology trainees but also to inspire and mentor medical students, foundation and core trainees who may be interested in a career in urology. Therefore it was a privilege to be able to represent the newly rejuvenated BSoT; perhaps even encouraging some future urologists!

Overall it was an exciting and interesting weekend; ASiT Conference 2020 will be held at the ICC Birmingham from 6th to 8th March; it promises to be bigger and better than ever and BSoT will be there! I’d thoroughly recommend all those interested in a career in surgery (and urology) to submit their projects, attend and get involved with ASiT. BSoT will also be organising events for those interested in a career in urology – so watch this space!

by Sophie Rintoul-Hoad, ST5 Urology trainee in South London Deanery and recently elected ASiT representative for BAUS Section of Trainees Committee (BSoT).

Acknowledgements: Clare Jelley and Luke Forster (BSoT President)

 

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