Category: Learning

Editorial: Celebrating BAUS and NICE Guidance

May 31, 2017/by admin Z.9

On behalf of the BAUS Council, I am delighted to write this editorial looking forward to the 73rd annual meeting of the BAUS, which will be held in Glasgow from 26 to 28 June. In response to feedback we had from delegates following BAUS 2016 and the successful European Association of Urology meeting in London this March, we have changed the format and duration of the meeting, ensuring that it has a distinct feel, reflecting the best of British Urology.

With Brexit looming and the precarious state of NHS finances, the continuing challenge for all of us working in the NHS is to deliver high-quality care within available resources, while embracing the latest evidence informing clinical practice. This month’s BJUI sees the first publication of National Institute for Health and Care Excellence (NICE) guidance on urological topics – ‘MTG29 GreenLight XPS for treating benign prostatic hyperplasia’ [1]. NICE has a fantastic track record in publishing highly regarded evidence-based syntheses across the breath of medicine and this guidance will stimulate the development and adoption of Greenlight laser for treating BPH as a day case procedure in the UK.

Assessing and critiquing new evidence are key elements of the annual BAUS meeting and this year is no exception. In all, 535 abstracts were submitted of which 157 will be presented. Whilst much of our clinical practice is of a high quality, analysis of the work done by the ‘Getting it right first time’ (GIRFT) team has shown a wide variation in practice for many common conditions in Urology. Simon Harrison, who leads the GIRFT team, will be giving an update on the progress of the work in a session looking at how standards can be applied in the real world at a session on Tuesday 27 June, entitled ‘Urology standards and the real world’.

On Monday 26 June, Academic Urology, Andrology and Genito-Urethral Surgery (AGUS), and Female, Neurological and Urodynamic Urology (FNUU) will be holding their annual meetings. State of the art lectures include Professor Trinity Bivalacqua speaking on ‘Molecular genetics and the prospect for future treatment strategies in Urology’. The AGUS section will focus on the genital emergencies consultation and the future of andrology in the UK, shedding light on specialist commissioning and training in the speciality. Highlights of the FNUU section meeting will include an update on meshes and tapes and the medicolegal consequences of adverse outcomes.

British urology has played a pivotal role in our understanding of the diagnosis and management of prostate cancer. Reflecting this, a point-counterpoint debate will take place on Tuesday 27 June, with Caroline Moore and Paul Cathcart debating the necessity for prostate biopsy in patients with Prostate Imaging Reporting and Data System (PI-RADS) 1and 2 lesions seen on MRI, drawing on evidence from the recent PROstate MRI Imaging Study (PROMIS) trial. On Wednesday 28, Noel Clarke will report on the latest news from the Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE) study, which to date has recruited >9000 patients. New evidence from the study is likely to herald a change in the care of our patients with metastatic prostate cancer.

In addition to state of the art papers, we are delighted to have a number of key opinion leaders attending the meeting. Reflecting the public’s high expectations and pressures on clinicians, Professor David Speigelhalter, Winton Professor for the Public Understanding of Risk at the University of Cambridge, will speak on the nature of risk and uncertainty in clinical practice. The BJUI Guest lecture will be delivered by David Prior (Parliamentary Under Secretary of State in the House of Lords). With the recent publication of The Long-term Sustainability of the NHS and Adult Social Care report [2], he is uniquely placed to give a perspective on the future direction of the NHS.

For the first time at our meeting there will be a session entitled ‘When things go wrong’. This session will focus on the impact of adverse events and burnout on Urologists, which promises to be insightful and thought provoking. With plenty of science, innovations in urological care and some politics, BAUS 2107 promises to be a fascinating meeting. I look forward to seeing you there.

Kieran O’Flynn

President of the BAUS

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How to Cite

O’Flynn, K. (2017), Celebrating BAUS and NICE Guidance. BJU International, 119: 815. doi: 10.1111/bju.13899

References

1 National Institute for Health and Care Excellence.MTG29 GreenLight XPS for treating benign prostatic hyperplasia.BJU Int 2017;119:823–30

2 House of Lords.The Long-term Sustainability of the NHS and Adult Social Care, 5 April 2017. Available at: https://www.publications.parliament.uk/pa/ld201617/ldselect/ldnhssus/151/151.pdf. Accessed 24 April 2017

Residents’ Podcast: NICE Guidance – GreenLight XPS for treating benign prostatic hyperplasia

May 31, 2017/1 Comment/by Veeru Kasivisvanathan

Veeru Kasivisvanathan

SpR in Urology & NIHR Doctoral Fellow, University College London & University College Hospital London.

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This National Institute for Health and Care Excellence (NICE) guidance is the current, unaltered NICE guidance at time of publication. BJUI publishes selected NICE guidance relevant to urologists to extend their distribution and promote best practice.

Recommendations

1.1
The case for adopting GreenLight XPS for treating benign prostatic hyperplasia is supported in non-high-risk patients. GreenLight XPS is at least as effective in these patients as transurethral resection of the prostate (TURP), but can more often be done as a day-case procedure, following appropriate service redesign.

1.2
There is currently insufficient high-quality, comparative evidence to support the routine adoption of GreenLight XPS in high-risk patients, that is those who:
- have an increased risk of bleeding or
- have prostates larger than 100 ml or
- have urinary retention.
NICE recommends that specialists collaborate in collecting and publishing data on the comparative effectiveness of GreenLight XPS for high-risk patients to supplement the currently limited published evidence.

1.3
Cost modelling indicates that in non-high-risk patients, cost savings with GreenLight XPS compared with TURP are determined by the proportion of procedures done as day cases. Assuming a day-case procedure rate of 36%, and that the GreenLight XPS console is provided at no cost to the hospital (based on a contracted commitment to fibre usage), the estimated cost saving is £60 per patient. NICE’s resource impact report estimates that the annual cost saving for the NHS in England is around £2.3 million. In a plausible scenario of 70% of treatments being done as day cases, the cost saving may be up to £3.2 million.

1.4
NICE recommends that hospitals adopting GreenLight XPS plan for service redesign to ensure that day-case treatment can be delivered appropriately.

Guideline of guidelines: non-muscle-invasive bladder cancer

January 24, 2017/by admin Z.9

Abstract

Non-muscle-invasive bladder cancer (NMIBC) represents the vast majority of bladder cancer diagnoses, but this definition represents a spectrum of disease with a variable clinical course, notable for significant risk of recurrence and potential for progression. Management involves risk-adapted strategies of cystoscopic surveillance and intravesical therapy with the goal of bladder preservation when safe to do so. Multiple organizational guidelines exist to help practitioners manage this complicated disease process, but adherence to management principles among practising urologists is reportedly low. We review four major organizational guidelines on NMIBC: the American Urological Association (AUA)/Society of Urologic Oncology (SUO), European Association of Urology (EAU), National Comprehensive Cancer Network (NCCN), and National Institute for Health and Care Excellence (NICE) guidelines.

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Guideline of guidelines: priapism

December 29, 2016/by admin Z.9

Introduction

Priapism is defined as a prolonged penile erection lasting for >4 h in the absence of sexual stimulation and remains despite orgasm. Current guidelines for priapism have been published after a comprehensive literature review and expert consensus by the AUA and by an evidence review according to the Oxford Centre for Evidence-Based Medicine (OCEBM) by the European Association of Urology (EAU). Although there are both local and regional guidelines available throughout the UK, these tend to be adaptations of guidelines from larger urology organisations and there are currently no guidelines available from the BAUS. However, in the UK the management of complex cases is increasingly undertaken in specialist centres with the basic management following existing guidelines.

As priapism is a urological emergency, which requires immediate detumescence, the condition does not lend itself to randomised controlled trials and the EAU guidelines are based, at best, on Level 3 evidence.

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Article of the Month: Guideline of Guidelines – Thromboprophylaxis for Urological Surgery

September 7, 2016/by admin Z.9

Every Month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Kari Tikkinen, discussing his paper.

If you only have time to read one article this week, it should be this one.

Guideline of guidelines: thromboprophylaxis for urological surgery

Philippe D. Violette*, Rufus Cartwright†‡, Matthias Briel§, Kari A.O. Tikkinen¶ and Gordon H. Guyatt**,††

*Division of Urology, Department of Surgery, Woodstock Hospital, Woodstock, ON, Canada, † Department of Epidemiology and Biostatistics, Imperial College London, London, UK, ‡Department of Urogynaecology, St. Mary’s Hospital, London, UK, §Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland, ¶Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, **Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada, and ††Department of Medicine, McMaster University, Hamilton, ON, Canada

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Decisions regarding thromboprophylaxis in urologic surgery involve a trade-off between decreased risk of venous thromboembolism (VTE) and increased risk of bleeding. Both patient- and procedure-specific factors are critical in making an informed decision on the use of thromboprophylaxis. Our systematic review of the literature revealed that existing guidelines in urology are limited. Recommendations from national and international guidelines often conflict and are largely based on indirect as opposed to procedure-specific evidence. These issues have likely contributed to large variation in the use of VTE prophylaxis within and between countries. The majority of existing guidelines typically suggest prolonged thromboprophylaxis for high-risk abdominal or pelvic surgery, without clear clarification of what these procedures are, for up to 4 weeks post-discharge. Existing guidance may result in the under-treatment of procedures with low risk of bleeding and the over-treatment of oncological procedures with low risk of VTE. Guidance for patients who are already anticoagulated are not specific to urological procedures but generally involve evaluating patient and surgical risks when deciding on bridging therapy. The European Association of Urology Guidelines Office has commissioned an ad hoc guideline panel that will present a formal thromboprophylaxis guideline for specific urological procedures and patient risk factors.

Video: Guideline of Guidelines – Thromboprophylaxis for Urological Surgery

September 7, 2016/by admin Z.9

Guideline of guidelines: thromboprophylaxis for urological surgery

Philippe D. Violette*, Rufus Cartwright†‡, Matthias Briel§, Kari A.O. Tikkinen¶ and Gordon H. Guyatt**,††

*Division of Urology, Department of Surgery, Woodstock Hospital, Woodstock, ON, Canada, † Department of Epidemiology and Biostatistics, Imperial College London, London, UK, ‡Department of Urogynaecology, St. Mary’s Hospital, London, UK, §Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland, ¶Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, **Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada, and ††Department of Medicine, McMaster University, Hamilton, ON, Canada

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Decisions regarding thromboprophylaxis in urologic surgery involve a trade-off between decreased risk of venous thromboembolism (VTE) and increased risk of bleeding. Both patient- and procedure-specific factors are critical in making an informed decision on the use of thromboprophylaxis. Our systematic review of the literature revealed that existing guidelines in urology are limited. Recommendations from national and international guidelines often conflict and are largely based on indirect as opposed to procedure-specific evidence. These issues have likely contributed to large variation in the use of VTE prophylaxis within and between countries. The majority of existing guidelines typically suggest prolonged thromboprophylaxis for high-risk abdominal or pelvic surgery, without clear clarification of what these procedures are, for up to 4 weeks post-discharge. Existing guidance may result in the under-treatment of procedures with low risk of bleeding and the over-treatment of oncological procedures with low risk of VTE. Guidance for patients who are already anticoagulated are not specific to urological procedures but generally involve evaluating patient and surgical risks when deciding on bridging therapy. The European Association of Urology Guidelines Office has commissioned an ad hoc guideline panel that will present a formal thromboprophylaxis guideline for specific urological procedures and patient risk factors.

Guideline of guidelines: follow-up after nephrectomy for renal cell carcinoma

March 9, 2016/by admin Z.9

Abstract

The purpose of this article was to review and compare the international guidelines and surveillance protocols for post-nephrectomy renal cell carcinoma (RCC). PubMed database searches were conducted, according to the PRISMA statement for reporting systematic reviews, to identify current international surveillance guidelines and surveillance protocols for surgically treated and clinically localized RCC. A total of 17 articles were reviewed. These included three articles on urological guidelines, three on oncological guidelines and 11 on proposed strategies. Guidelines and strategies varied significantly in relation to follow-up, specifically with regard to the frequency and timing of radiological imaging. Although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics.

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Urological recommendations from the National Institute for Health and Care Excellence (NICE) Guideline, June 2015: Suspected cancer: recognition and referral

March 9, 2016/by admin Z.9

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Guideline of guidelines: a review of urological trauma guidelines

March 9, 2016/by admin Z.9

Objective

To review the guidelines released in the last decade by several organisations for the optimal evaluation and management of genitourinary injuries (renal, ureteric, bladder, urethral and genital).

Methods

This is a review of the genitourinary trauma guidelines from the European Association of Urology (EAU) and the American Urological Association (AUA), and renal trauma guidelines from the Société Internationale d’Urologie (SIU).

Results

Most recommendations are guided by the American Association for the Surgery of Trauma (AAST) organ injury severity system. Grade A evidence is rare in genitourinary trauma, and most recommendations are based on Grade B or C evidence. The findings of the most recent urological trauma guidelines are summarised. All guidelines recommend conservative management for low-grade injuries. The major difference is for haemodynamically stable patients who have high-grade renal trauma; the SIU guidelines recommend exploratory laparotomy, the EAU guidelines recommend renal exploration only if the injury is vascular, and the AUA guidelines recommend initial conservative management.

Conclusion

There is generally consensus among the three guidelines. Recommendations are based on observational or retrospective studies, as well as clinical principles and expert opinions. Multi-institutional collaborative research can improve the quality of evidence and direct more effective evaluation and management of urological trauma.

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Guideline of guidelines: urinary incontinence

October 19, 2015/by admin Z.9

Abstract

The objective of the article is to review key guidelines on the management of urinary incontinence (UI) to guide clinical management in a practical way. Guidelines produced by the European Association of Urology (updated in 2014), the Canadian Urological Association (updated in 2012), the International Consultation on Incontinence (updated in 2012), and the National Collaborating Centre for Women’s and Children’s Health (updated in 2013) were examined and their recommendations compared. In addition, specialised guidelines produced by the collaboration between the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction on overactive bladder and the use of urodynamics were reviewed. The Appraisal of Guidelines for Research and Evaluation II (AGREE) instrument was used to evaluate the quality of these guidelines. There is general agreement between the groups on the recommended initial evaluation and the use of conservative therapies for first-line treatment, with a limited role for imaging or invasive testing in the uncomplicated patient. These groups have greater variability in their recommendations for invasive procedures; however, generally the mid-urethral sling is recommended for uncomplicated stress UI, with different recommendations on the approach, as well as the comparability to other treatments, such as the autologous fascial sling. This ‘Guideline of Guidelines’ provides a summary of the salient similarities and differences between prominent groups on the management of UI.

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