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Article of the Week: NSS Across a Nation

Every Week the Editor-in-Chief selects an Article of the Week 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 Archie Fernando and Tim O’Brien, discussing their paper.

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

Nephron-sparing surgery across a nation – outcomes from the British Association of Urological Surgeons 2012 national partial nephrectomy audit

Archie Fernando*, Sarah Fowler* and Tim OBrien*, on behalf of the British
Association of Urological Surgeons (BAUS) 

 

*BAUS, The Royal College of Surgeons of England, and The Urology Centre, Guys and St Thomas NHS Foundation Trust, London, UK

 

BAUS-2012-national-partial-nephrectomy-audit-infographic-clipped

 

Click on image for full size infographic

 

Objective

To determine the scope and outcomes of nephron-sparing surgery (NSS), i.e. partial nephrectomy, across the UK and in so doing set a realistic benchmark and identify fresh contemporary challenges in NSS.

Patients and Methods

In 2012 reporting of outcomes of all types of nephrectomy became mandatory in the UK. In all, 148 surgeons in 86 centres prospectively entered data on 6 042 nephrectomies undertaken in 2012. This study is a retrospective analysis of the NSS procedures in the dataset.

Results

A total of 1 044 NSS procedures were recorded and the median (range) surgical volume was 4 (1–39) per consultant and 8 (1–59) per centre. In all, 36 surgeons and 10 centres reported on only one NSS. The indications for NSS were: elective with a tumour of ≤4.5 cm in 59%, elective with a tumour of >4.5 cm in 10%, relative in 7%, imperative in 12%, Von Hippel–Lindau in 1%, and unknown in 11%. The median (range) tumour size was 3.4 (0.8–30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4%. The histology results were: malignant in 80%, benign in 18%, and unknown in 2%. In patients aged <40 years 36% (36/101) had benign histology vs 17% (151/874) of those aged ≥40 years (P < 0.01). In patients with tumours of <2.5 cm 29% (69/238) had benign histology vs 14% (57/410) with tumours of 2.5–4 cm vs 8% (16/194) with tumours of ≥4 cm (P = 0.02). In patients aged <40 years with of tumours of <2.5 cm 44% (15/34) were benign. The 30-day mortality was 0.1% (1/1 044). There were major complications (Clavien–Dindo grade of ≥IIIa) in 5% (53/1 044). There was an increased risk of complications after extended elective NSS of 19% (19/101) vs elective at 12% (76/621) (relative risk [RR] 1.54; P < 0.01). Margins were recorded in 68% (709/1 044) of the patients, with positive margins identified in 7% (51/709). Positive surgical margins after NSS for pathological T3 (pT3) tumours were found in 47.8% (11/23) vs 6.1% (32/523) for pT1a, tumours (RR 5.61; P < 0.01). In all, 14% (894/6 042) of the patients underwent surgery for T1a tumours: 55% (488/894) by NSS, 42% (377/894) by radical nephrectomy (RN), and in 3% (29/894) the procedure used was unknown. Major complications after occurred in 4.9% (24/488) of NSS vs 1.3% (5/377) of RN (P < 0.01). Limitations included poor reporting of renal function data and no data on tumour complexity.

Conclusions

In its first year, mandatory national reporting has provided several challenging contemporary insights into NSS.

Editorial: SRMs – Where is the Wisdom We Have Lost in Knowledge?

The perceived wisdom that a small enhancing mass in the kidney represents a surgical lesion that automatically requires excision without the need for a preoperative biopsy has been challenged by Fernando et al. [1] in this issue of BJUI.

The authors are to be congratulated in bringing these data to publication to provoke debate on the treatment paradigm for small renal masses (SRMs) by reviewing nationally collected data on the main therapeutic surgical option: nephron-sparing surgery. As anyone who has attended a renal multidisciplinary meeting can testify, the predominant presentation of renal cancer is the incidentally detected SRM, often in elderly patients with significant comorbidity.

As the authors emphasize, these data are unique in representing a national picture encompassing both high- and low-volume centres, as opposed to the majority of the studies in the literature, which report data from high-volume tertiary referral centres.

Drawing conclusions from data requires a clear understanding of the source and quality. Most importantly, as these data only refer to patients undergoing nephron-sparing surgery, we need to be cautious about extrapolating to infer information on the management of SRMs in general.

For instance, a striking finding of the present study is the high incidence of benign lesions in the younger age groups. We have no knowledge of the numbers of patients with SRMs within the study period who had biopsy-proven benign disease and thus avoided surgery. It is probable that the true incidence of benign disease would be even higher if these cases had been recorded and included in the analysis.

An inherent difficulty with self-reported data is the issue of compliance, and this is clearly evident in the present study, with, for example, almost a third of cases missing data on surgical margin results. It would perhaps be helpful for future audits if the BAUS dataset had a clear definition of positive surgical margin in recognition of the surgical drift to enucleation rather than excision with a margin of renal parenchyma.

The variation in caseload between reporting centres raises important questions, as does the finding that two fifths of patients with T1a tumours underwent radical nephrectomies. As the authors concede, with the numbers involved and the absence of any measure of tumour complexity, it is difficult to draw firm conclusions; however, the study does highlight the need to examine this issue in future analyses and to consider including some form of renal scoring system in future audits.

Where do we go from here and what can we do with this information? First, we need to rethink our discussion with patients with SRMs. Can we justify performing major surgery with a one in 20 chance of a significant complication for a possible benign lesion without at least a pragmatic discussion of the role of renal biopsy with the patient? Indeed, one may argue, could it really be an ‘informed’ decision without it?

Second, we need to improve the quality of the data by encouraging robust data reporting, increasing the completion rate and considering adding data fields which will allow us to draw clearer conclusions on surgical margin and surgical outcome and volume relationships.

Third, we need to recognize that nephron-sparing surgery is only one component of the management of SRMs, which represents a major contemporary challenge in terms of health resources and, most importantly, in deciding the best treatment paradigm for our patients. If BAUS can carry out this audit, could we not extend this to all patients with SRMs, whether they have surgery, ablation or surveillance, and establish greater clarity on these treatment methods?

Michael Aitchison, Consultant Urological Surgeon and Maxine Tran, Senior Lecturer in Renal Cancer Surgery and Honorary Consultant Urological Surgeon

 

Renal Cancer Service, Royal Free NHS Foundation Trust, London, UK

 

Reference

 

Video: Nephron-Sparing Surgery Across the UK

Nephron-sparing surgery across a nation – outcomes from the British Association of Urological Surgeons 2012 national partial nephrectomy audit

Archie Fernando*, Sarah Fowler* and Tim OBrien*, on behalf of the British
Association of Urological Surgeons (BAUS) 

 

*BAUS, The Royal College of Surgeons of England, and The Urology Centre, Guys and St Thomas NHS Foundation Trust, London, UK

 

Objective

To determine the scope and outcomes of nephron-sparing surgery (NSS), i.e. partial nephrectomy, across the UK and in so doing set a realistic benchmark and identify fresh contemporary challenges in NSS.

Patients and Methods

In 2012 reporting of outcomes of all types of nephrectomy became mandatory in the UK. In all, 148 surgeons in 86 centres prospectively entered data on 6 042 nephrectomies undertaken in 2012. This study is a retrospective analysis of the NSS procedures in the dataset.

Jun AOTW Results Image 4

Results

A total of 1 044 NSS procedures were recorded and the median (range) surgical volume was 4 (1–39) per consultant and 8 (1–59) per centre. In all, 36 surgeons and 10 centres reported on only one NSS. The indications for NSS were: elective with a tumour of ≤4.5 cm in 59%, elective with a tumour of >4.5 cm in 10%, relative in 7%, imperative in 12%, Von Hippel–Lindau in 1%, and unknown in 11%. The median (range) tumour size was 3.4 (0.8–30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4%. The histology results were: malignant in 80%, benign in 18%, and unknown in 2%. In patients aged <40 years 36% (36/101) had benign histology vs 17% (151/874) of those aged ≥40 years (P < 0.01). In patients with tumours of <2.5 cm 29% (69/238) had benign histology vs 14% (57/410) with tumours of 2.5–4 cm vs 8% (16/194) with tumours of ≥4 cm (P = 0.02). In patients aged <40 years with of tumours of <2.5 cm 44% (15/34) were benign. The 30-day mortality was 0.1% (1/1 044). There were major complications (Clavien–Dindo grade of ≥IIIa) in 5% (53/1 044). There was an increased risk of complications after extended elective NSS of 19% (19/101) vs elective at 12% (76/621) (relative risk [RR] 1.54; P < 0.01). Margins were recorded in 68% (709/1 044) of the patients, with positive margins identified in 7% (51/709). Positive surgical margins after NSS for pathological T3 (pT3) tumours were found in 47.8% (11/23) vs 6.1% (32/523) for pT1a, tumours (RR 5.61; P < 0.01). In all, 14% (894/6 042) of the patients underwent surgery for T1a tumours: 55% (488/894) by NSS, 42% (377/894) by radical nephrectomy (RN), and in 3% (29/894) the procedure used was unknown. Major complications after occurred in 4.9% (24/488) of NSS vs 1.3% (5/377) of RN (P < 0.01). Limitations included poor reporting of renal function data and no data on tumour complexity.

Conclusions

In its first year, mandatory national reporting has provided several challenging contemporary insights into NSS.

Best bits of BAUS 2014

By Archie Fernando

As the friendliest taxi driver in the world dropped me off outside the vast BT centre in Liverpool he asked “if you’re all in there, what’s going to happen to the rest of us?” I wasn’t sure whether he was envisaging an epidemic of priapism, but I reckoned we’d be ok for a few days.

Inside the specious and well-designed conference centre (below) there was an overwhelmingly positive vibe as old friends caught up, new acquaintances were made and a packed scientific program rolled out.

Of course there was really too much to be able to capture all the highlights but here are some of the headlines.

BOO women?

Chris Harding highlighted that female bladder outlet obstruction (BOO) is more common than we think and Tamsin Greenwell talked about the management of female urethral strictures.

Question time

Several MDTs /case studies tested the application of theory to clinical practice. Online, real time voting increased audience interaction and interest.

Taking control of the men

Urologists need to feature more prominently in infertility clinics. It appears that couples are being pushed towards donor sperm prior to discussing their options with a urologist.

Can you find it?

Increasing problems with obesity and the penis – ED, buried penis, sexual dysfunction, and phimosis. Metabolic syndrome and psychological unrest are highly prevalent in this population and should be addressed alongside the andrology. (See the BJUI free Virtual Issue for more on obesity in urology).

Two birds, one stone

ED and LUTS often co-exist to a degree in men of a certain age. Tadalafil has now been licensed for the treatment of both.

On the shoulders of giants…

Mark Soloway gave a fantastic talk in the Perspectives of Oncology session that had a very original Beatles theme this year. He reflected on his career and paid homage to many of the people who have contributed to the modern management of bladder cancer, without whom we wouldn’t have BCG, cisplatin, mitomycin, fibreoptics….

The surgeon is the most important factor

Shahrokh Shariat drove home that there is no salvage therapy for poor surgery in muscle-invasive bladder cancer.  Brausi et al. have shown that the surgeon is the most important factor in non-muscle invasive bladder cancer and this was also re-enforced throughout the bladder cancer sessions.

Sniffing out bladder cancer

Chris Pobert introduced the Odoreader™. It all began with the discovery that dogs could sniff out melanoma, and subsequently TCC! The Odoreader™ uses a small sample of urine to produce a trace that represents the composition of gas detected by the sensor.  The trace produced by patients with bladder cancer is different to those without. It has an accuracy of approximately 96%. Will surveillance cystoscopy become a thing of the past?

Look up

The location of upper tract TCC does not appear to influence outcomes but tumours in the renal pelvis are picked up later than ureteric tumours. Distal ureterectomy is becoming a popular and safe alternative to nephro-ureterectomy in selected patients.

No stone left unturned

Metabolic work up for stones should ideally include serum chemistry, stone analysis and 24-hour urine. A third of 24-hour urine samples show variability and so two samples upfront with a possible 3rd prior to intervention increases the accuracy of the test.

Tailored metabolic advice for stone formers can reduce recurrence rates by up to 60%.

What’s in a stone?

Sri Sriprasad looked at new insights into stone aetiology. Calcium oxalate monohydrate is oxalate dependent whereas calcium oxalate dihydrate tends to be calcium dependent. Metabolic advice should include lowering phosphorous intake from soft drinks, weight loss, reduced salt and protein, and maintaining a urine output of >2.5 L/day.

Is tamsulosin the new ‘vitamin C’ in stone disease?

There are more alpha-receptors in the obstructed kidney. It appears that tamsulosin is not only effective in increasing the rates of spontaneous stone passage, but also in increasing stone passage rates following laser fragmentation and shock-wave lithotripsy. Get prescribing.

Size matters

Steve Nakada suggested that we should be measuring stone volume rather than diameter to provide a more accurate measure of stone size and guide management.

How small can you go?

Martin Schonthaler talked about the evolution of the ultra-mini PCNL. Mini-, ultra-mini and micro PCNL work and are safe. The question now is when should we be using these techniques?

You can’t fight your genes

David Neal gave The Urology Foundation guest lecture on ‘The Genomic Landscape of Prostate Cancer’.

“Cancer is a disease of genomic chaos”. He had a very interesting perspective on focal therapy – if prostate cancer is in your genes, will targeting the single focus of prostate cancer cure you or simply buy time until the rest of the prostate starts to turn malignant?

Is prostate MRI the next Franz Gsellmann world machine?

Gsellmann is an Austrian farmer who over 23 years built a machine made up of hundreds of different parts including a ship’s propeller, two gondolas and 25 motors. When powered up it becomes a spectacle of colour, sound and light but doesn’t actually do anything. Karl Pummer compared MRI of prostate to the world machine –pretty but useless! He argued that the sensitivity of prostate cancer varies hugely from 30-90% and only 31 of the 4687 references matching ‘prostate cancer imaging’ met sufficient criteria to be considered for the German prostate cancer guideline.

Six prostates a day keeps the cancer away

Jay Smith does six prostatectomies in a day. Is this the level all surgeons should be striving for or is it the start of a slippery slope to replacing clinician with technician? Whatever your view, you have to admit it’s pretty impressive!

Has the robotic train left the station?

Striking at the source

David Neal suggested that there may be a role for prostatectomy in the context of metastatic prostate cancer because the primary may continue to drive the disease.

Biopsy or not to biopsy?

No, this is not about prostate biopsy! Benign histology remains a challenge in the management of the small renal mass. As biopsy and pathological techniques improve should we be doing more biopsies to help guide decision-making? Steve Nakada certainly made a convincing case for this, which was hotly debated on twitter.

Freeze!

Small renal masses have a good prognosis overall therefore minimizing morbidity should be a priority. Ablative techniques have been shown to be safe technically and oncologically in selected cases.

“Uncontrolled variability is the enemy of progress”

John McGrath used the enhanced recovery program as an example of the enormous variability in practice across UK centres that cannot be explained by case mix alone. This makes it difficult to deliver consistent service and training. We need to develop  protocols that allow us all to sing from the same hymn sheet.

E-Z-learning

Henry Woo introduced an exciting new CME platform, BJUI Knowledge, in the BJUI International Guest lecture. He also explained that at present there is a gap between user expectations of e-learning (any time, anywhere, any device) and what it can deliver. Follow @BJUIknowledge on Twitter for updates.

Private training

How are trainees going to get experience with operations such as vasectomy reversal and microsurgery that are not available on the NHS?

Changing of the guard

After four years of dedicated service to BAUS, Adrian Joyce hands over the baton (aka large shiny necklace) to Mark Speakman. We wish them both the best of luck.

 

Tweet tweet

Being a very new addition to the uro-twitterati I was a little sceptical about how twitter would enhance a meeting like BAUS. However, I was impressed by the content and activity that goes on. Congratulations to BAUS for adding twitter screens this year, which kept everyone entertained and up-to-date creating a community feel. I’m definitely a convert!

And the stats agree with me. #BAUS14 analytics at time of posting: 268 participants; 1,363 tweets with 1,209,617 digital impressions. This is a stark improvement on #BAUS13 which attracted only 90 participants with 564 tweets, and one that will surely continue. Tweet away folks!

 

Until next time

What a fantastic meeting this year with the almost perfect mix of basic science, clinical research, and expert perspectives, topped off with a smidgen of nocturnal merriment. The best of British urology.

I was feeling a little low in energy as I left the Albert Dock on the final day until I got this text – same again next summer? 🙂

Hope to see you all in Manchester!

 

Archana Fernando is a urologist at Guy’s Hospital, London. Follow her on Twitter @fernando_archie

 

 

 

 

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