This issue’s Article of the Month comes from three Danish institutions including Aarhus University Hospital. The cover shows Aarhus Old Town, an open air museum of traditional Danish buildings dating from the 16th to 19th Centuries
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Research headlines that attract the most publicity are those that show success in benefitting patients, whether it is through new targeted drugs or new immunotherapies. Many funding bodies and charities have also changed their policy toward funding more translational research that has clear economic, clinical and patient benefit. We must remember, however, that the innovations for these transformative publications and translational research projects are imbedded in our fundamental understanding of the molecular and cellular biology of disease investigated at the basic science level. These investigations are the cornerstone of translational research.
The authors of January’s BJUI Article of The Month come from Hamburg and Mannheim in Germany. The cover shows Hamburg’s Speicherstadt, the largest warehouse district in the world and a UNESCO World Heritage Site.
Click here for this issue’s Table of Contents
References
Once again we are approaching the end of another productive year in urological research. The final meeting of the year of the International Urology Journal Club #urojc was held from Monday December 7th to Wednesday December 8th AEDT. This month’s topic was a recent paper published in @JAMAOnc by the well-known STAMPEDE group.
In this new analysis of the STAMPEDE trial, the subject was the control arm. The trial’s definitive primary outcome was to evaluate the overall survival when adding radiotherapy (RT) to the cohort of N0 and N+ M0 high risk prostate cancer patients receiving hormonal therapy. The intermediate primary outcome was the failure-free survival (FFS), which was defined as biochemical failure, progression (locally, lymph nodes, or distant metastases) or death from prostate cancer.
The first comments of the discussion were about the satisfaction of a new study evaluating the beneficial effect of RT in addition to ADT in N+M0 disease. For the N0M0 Sub-cohort, 2 year survival was 97% (95% CI, 93%-99%), and 84% (95% CI, 74%-91%) were still alive after 5 years. On the other hand, for the N+M0 sub-cohort, 2 year survival was 93% (95% CI, 88%-96%), and 71% (95% CI, 56%-82%) were still alive after 5 years.
FFS was better with received RT in both groups: In the N0M0 sub-cohort the adjusted HR was 0.25 (95% CI, 0.13-0.49) with 2 year FFS of 96% (95% CI, 90%-98%) in patients receiving RT compared with 73% (95% CI, 57%-84%) in those not reporting RT (Figure). In the N+M0 the results were similar, with an adjusted HR of 0.35 (95% CI, 0.19-0.65), and a 2-year FFS of 89% (95% CI, 77%-94%) and 64% (95% CI, 51%-75%), respectively.
Since this approach to high-risk N0,+ M0 disease is not a standard of treatment, there were some concerns about urologist opinions, and mainly, about the side-effects of pelvic radiation.
This trial showed the adverse effects associated with RT, split by N0M0 and N+M0. The majority (78%) of N+M0 received conventionally fractionated RT to prostate and pelvis, and of the N0M0, 46% received it only to prostate and 42% to prostate and pelvis. The reported adverse effects were similar for patients with and without nodal involvement, with no grade 4 or 5 adverse effects reported.
Another question during the discussion was about the control group and the different baseline characteristics of the patients if comparing to other countries (mainly previous surgery).
Most urologists conclude that this information contributes to the growing evidence of the different modalities of treatment that should be offered to patients with prostate cancer. Every urologist focused on the importance of determining the risk and stage of the patient to give an appropriate treatment. They also mentioned how these results correlate with other treatment outcomes.
The previous published trials about the subject conclude that this combination reduces the risk of prostate cancer death; however, the population of those studies varies. Most patients were low-risk N0M0 prostate cancer and none were N+M0.
Other thoughts were shared, such as the usefulness of ADT for high-risk M0 prostate cancer, the prostate cancer stage and its relation to treatment response, and the needed collaboration of other specialties for study trials.
We still have to remember that the study has some limitations, though: The study population is drawn from a control arm of a clinical trial. There is no randomization of patients, and those planned for radiotherapy were the ones considered fit for it, so there might be an overestimated benefit biased by a better prognosis.
Indeed this is not the last of the STAMPEDE trials. One of the authors, @Prof_Nick_James mentioned redoing analysis of all the arms to evaluate more parameters about the outcomes of the different treatments.
This topic raises many questions about the treatment approaches to high-risk prostate cancer. As the authors expressed “There is a need for randomized clinical trials within the N+M0 population to address questions prospectively”. So far the results shown seem to be of benefit, and support the routine use of radiotherapy in patients with N+M0 prostate cancer. But as usual, we always need more proof.
This is the last meeting of 2015, so I have to finish this summary with a “Merry Christmas and Happy New Year 2016” to all the Urological twitter family!
Irela Soto Troya is a urologist born and trained in the Republic of Panama, and is a Fellow at Severance Hospital/Yonsei Medical Health System, Seoul, South Korea.
Twitter @irela_soto
After a constant upward trajectory for 3 years, in 2015 the BJUI achieved an impact factor (IF) of 3.53, the highest ever in its history. Complacency is not in our DNA and we hope to achieve much more. We set out to become the most read surgical journal on the web and as part of that initiative have just launched our Android app in addition to the existing iPhone and iPad app. But our true impact beyond the IF, lies perhaps in the Altmetric score.
Altmetric is a score of the impact of (or perhaps better, the attention attained by) articles, based on mentions over a period of time in online channels such as news outlets, science blogs, Twitter, Facebook, Sina Weibo and Wikipedia, amongst others. The automated algorithm’s calculation of an article’s score applies weighting to the sources, such that a mention on a news outlet is weighted 8, or in a science blog 5, whereas a Twitter mention is only weighted 1, and a Facebook mention 0.25. News outlet scores are also tiered by their reach, re-tweets score less than original tweets, and bias is accounted for, e.g. tweets by independent researchers count more than a tweet by the journal that published the article.
The results are visualized as the ‘Altmetric donut’ with the calculated score in the centre. In the donut the different colours represent the different channels; so, for example Twitter is cyan, Facebook is dark blue, Blogs (including Weibo) are orange, News outlets red, Google+ is magenta, Video is pale green, Reddit is pale blue and Wikipedia is dark grey. The proportion of the donut that is shown in each colour generally reflects how much of the score was contributed to by that channel, but when many channels need to be represented then each is given a segment as is seen in the rainbow donut for our ‘Am I Normal’ article [Veale et al].
To give some context to the phenomenal level of interest in the ‘Am I Normal’ article, which at the time of writing boasts a score of 1034, most articles attain a score of 3 or under, and a score of 9 is sufficient to put an article in the top 10% of all 4,386,073 that Altmetric has scored. ‘Am I Normal’ is, perhaps unsurprisingly, in the top 1% of all articles scored.
Our other highly citable innovation is the BJUI Guideline of Guidelines (GOGs), which have made access to, and the understanding of, often conflicting urological guidelines a lot easier. Along with our other guidelines on chronic prostatitis [Rees et al] and continence [Tse et al], they will all be available in early 2016 as a virtual issue of GOGs [Loeb; Ziemba & Matlaga; Wollin & Makarov; Syan & Brucker] in a single repository on our web journal. Completely free, of course!
Prokar Dasgupta, Editor-in-Chief, BJUI
Scott Millar, Managing Editor, BJUI
Jo Wixon, Publisher, John Wiley and Sons Ltd
I landed on a bright sunny Brisbane morning for the Urological Society of Australia and New Zealand (USANZ) Trainee Week 2015 – an annual, 5 day, comprehensive, bi-national conference specifically for trainees. I have much to be grateful for including sponsorship from BAUS, TUF, USANZ and SURG. All these organisations had realised international organisation inter-working is required to foster a higher level of teaching for trainees.
Later that day, I had opportunities to meet trainees from all over Australia and New Zealand (ANZ). The quality of training given is truly remarkable. When looked at in detail, the ANZ system focuses on general surgery training initially, prior to moving to urology as a separate speciality. The result of this are that they are superb open surgeons. This is often a dying art and difficult to gain.
Our first day started with a chance to observe mock FRACS stations. The standard of the candidates was incredibly high, despite it being a mock exam. As part of this, an overview of the FRACS exam was given by one of the FRACS senior examiners, Mr. Neil Smith. The day concluded with meetings of trainees for each region within ANZ – again another fantastic way to support the trainees. I have never seen anything quite like this. This also ensures trainees are receiving adequate training as concerns and issues are relayed directly to the training board chair. The evening concluded with a Welcome reception and barbeque at Brisbane Surf club.
The next day started with a series of lectures on bladder cancer, led by Mr Shomik Sengupta (Melbourne) and Mr. Roger Watson (Brisbane). There were many learning points for trainees to take away, including case based management discussions, role of cystoprostatectomy and role of bladder preservation (Dr Tanya Holt, Brisbane).
Also covered were the roles of neoadjuvant vs adjuvant chemotherapy, (Dr. Niara Oliveira, Brisbane), the pros and cons of urinary diversion (Dr. Sarah Azer), and LND (Dr. Jonathan Chambers, Brisbane). After lunch the most amazing teaching was given on uro radiology, with a focus on nuclear medicine and also on pathology. The FRACS exam is very different from any other end of training exam, as there will be both radiology and pathology stations.
The next day dawned bright and early, with a whole morning of paediatric urology. I can think of many registrars, who would love a whole morning of teaching on this subject- it is not often easy to get access to paediatric urology. Testicular embryology and maldescent were very nicely covered by Mr. Peter Borzi, (Brisbane). Both normal and abnormal conditions were discussed including reasons for orchidopexy with maldescent. Former USANZ President, David Winkle then spoke on translation care. Mr Pete McTaggart, then covered Adolescent voiding dysfunction, a profoundly difficult subject to manage, given the age of the patient and the disease involved.
The next focus was on the adrenal including functions of the adrenal, management of the adrenal mass and investigations and phaeochromocytoma. This again, is another area, which is not often covered or encountered in clinical practice.
The morning concluded with a Board of Urology update addressed by Mr Richard Grills, Board Chair, covering the training programme for urologists. Also covered were training policies and involvement of RACS in governing this. Most impressively, USANZ has negotiated membership for all of its’ trainees with EAU, SIU and AUA. A good step forward regarding international working and fellowship.
The next day started with a breakfast meeting, on how to pass the FRACS exam. This session was chaired by Dr. Matt Winter. Big congratulations also went out to Dr. Tim Smith, who had had a baby the day before and still attended to teach. Topics covered were perspectives of preparing emotionally, physically, and psychologically. This recognised how difficult it can be to prepare. All tips and tricks were given by former trainees, who had passed the exam. Further mock practice also occurred, being taken through a pathology exam.
A whole session was dedicated to renal cancer covering topics such as active surveillance, partial and radical nephrectomy, RFA and cryotherapy. A really fantastic lecture was given by Mr. Simon Wood on management of RCC and cyotreductive nephrectomy, followed by oncological management of metastatic RCC. This is an area, which unless you are in a renal fellowship, may not see.
The next session involved teaching on upper tract and transplant. This was absolutely brilliant at covering donor assessment, management of transplant ureter and assessment of renal function and prognosis. Unless a transplant job were done, this knowledge would not be gained. All of this contributes to making a far better surgeon.
The afternoon focused on mastering difficult interactions with colleagues. Lastly, the day ended, with case based discussions, focused on FRACS viva practice. After having gone through that, I have a greater respect for all candidates going through post graduate exams. The evening was completed by a lovely boat ride through Brisbane and farewell dinner.
The next day, started with a bang, with Prof Samaratunga (Brisbane) talking on prostate grading. It is wonderful to have a lady professor. It shows the forward thinking of the Australia medical field, clearly ahead of others. Next, very valuable teaching was received from Dr. Peter Swindle (Brisbane). This was followed by teaching on PSA screening by Dr John Yaxley (Brisbane). PSMA PET was then covered by Dr. Rob Clarke (Brisbane), and its role in detection of prostate cancer. A fantastic presentation on management of elevated PSA was covered via a balloon debate- much loved by all and a different way of learning.
The conference ended with a quiz- Masters of the Uroverse. Teams from different regions of Australia battled it out for the title. It ended the conference is a very fun and unusual way. After having been to this meeting, my knowledge base has grown.
Our thanks go to Ms. Deborah Klein, the star organiser who is Education and Training Manager of USANZ, the Convener Mr. Stuart Philip and Mr. Richard Grills Chair, Board of Urology for hosting a thoroughly enjoyable event. Also to all the trainees and consultants who made us incredibly welcome.
Sanchia Goonewardene, University of Warwick, UK. @survivorshipuk
The inaugural international joint meeting of BAUS and SLAUS was held two years ago. The second joint meeting has just finished in Colombo, bringing together British and Sri Lankan urologists. We were also joined by excellent Chinese and Indian colleagues.
The meeting commenced on Monday 2nd November with a series of urological workshops. These started with an excellent laparoscopic workshop at Colombo South Teaching Hospital, led by Gordon Kooiman (King’s, UK), Wei Wang, Zhu Gang (Bejing) and Srinath Chandrasekera (Sri Lanka).
The College of Surgeons of Sri Lanka was the chosen venue for the second day of the pre-congressional sessions. This kicked off with a trans-world MDT, with John Kelleher (UK), Gordon Kooiman (UK), Mark Speakman (President of BAUS), Archana Fernando (Guy’s and St Thomas’ Hospitals, London), Sanchia Goonewardene (University of Warwick), Ranga Wickramarachi (National Hospital of Sri Lanka) and Niroshen Seneviratne, (Sri Jayawardenapura, Sri Lanka). Fifteen complex cancer cases were presented, ranging from prostate and bladder cancer to complex renal cases. The intellectual sparks flew as each side vigorously debated their management of each patient, with input from Chinese Professors Zhu Gang and Wei Wang. The MDT was wonderfully organised by Dr Ranga Wickramarachi, who brought together both faculties, with solid science and learning on both sides.
The afternoon was led by Mr Julian Shah (University College London), who presented on medico-legal issues and communication skills, with input from Sri Lankan doctors. There are an ever increasing number of medico-legal situations clinicians may find themselves in, and this workshop provided the tools for how to manage them. Also noteworthy were the acting skills of Dr Manjula Herath (Kandy Hospital, Sri Lanka) and his colleagues, who deserved an Oscar for the excellent case scenarios they enacted as a background for a critique of their communication skills. On a more serious note, these clearly highlighted issues that are becoming more and more significant in today’s practice.
The third day of the pre-congressional sessions was a trip to Galle in the south of the island for a joint meeting with the Galle Medical Association. A 6am start was complemented by teaching on the neuropathic bladder by Ms Jean Macdonald and Mr Julian Shah, as well as a workshop on penile diseases from Mr Suks Minas at the Jetwing Lighthouse hotel. There was also teaching from Galle medical personnel, notably Kareen Hareen on haematuria. Additionally, there was a lecture on LUTS/BOO from Mr Speakman, and wise lessons to all trainees present on the validity of BPH treatment. A wonderful lunch was served, with chances to interact with Sri Lankan trainees and to clearly see differences in training in both countries – although we are not that dissimilar. A relaxed afternoon beckoned, including a wonderful tour of the ancient Portuguese Galle fort and its scenery. This was followed by afternoon tea at the Closernberg Hotel, Galle.
The next day brought live surgery at Lanka Hospital, conducted by Julian Shah, and Suks Minhas (University College London), with a focus on female and functional urology. A complicated ureteric strictures managed by pyeloplasty and a complex female urethral stricture were demonstrated with live surgery. Additionally, there were video operative lectures by EAU Secretary General Professor Chris Chapple (Royal Hallamshire Hospital, Sheffield), on urethroplasty; valuable lessons for all trainees.
There was also a visit to Sri Jayawardenapura hospital from the Faculty. It was brilliant to see Sri Lankan medicine in practice, with lessons to be learnt by all BAUS faculty members. Afterwards a workshop on trauma occurred at the Faculty of Medicine, University of Sri Jayardenapura, composed of all Faculty members. The best lesson learnt was how to manage renal trauma. This was followed by a hands-on skills for ureteric reconstruction. The course, run by Peter Thompson, had been started 20 years before by Prof. Harold Ellis at RCS England. This was run by Mr Thompson, Ms Goonewardene and Prof. Wang (China). It was considered a fantastic opportunity for all trainees, with hands-on experience of anastomoses of the pig urinary system. Its success was justified the next day when, in practice, a trainee was called upon to manage a ureteric injury.
A beautiful inauguration ceremony in front of 200 people was conducted that evening at Kings Court, Cinnamon Lakeside Hotel, with traditional Kandian dancing and lighting of the oil lamp. This was followed by inauguration speeches, given by Prof. Satish Goonesinghe (Colombo), Prof. Chris Chapple (EAU), and Mr Mark Speakman (BAUS). The evening ended with entertainment from Kandian dancers, and singing from Prof. J. Shah, Prof. S. Fonseka and Mr J. Kelleher– the rock band was aptly named ‘The Professors.’
The next day, the full congress kicked off, with a presentation from Mr Thompson on the history of British urology. The audience learned about great legends, including Malcolm Coptcoat, pioneer of laparoscopic surgery at King’s College London. The next section was on urolithiasis, started by Ms S. Goonewardene on metabolic stone analysis, Ms J. Macdonald (North Middlesex Hospital) on PCNL, and finally from Dr Ranga Wickramararchi on open stone surgery. The learning outcomes demonstrated to trainees the importance of being a well-trained general urologist prior to sub speciality training.
The next section was brightened by Mark Speakman, President of BAUS, talking on surgeons’ outcome data — a really valid subject as this can greatly impact surgical practice. Training issues as part of this were also highlighted. At the end of the day, this can also be used as a continuous assessment tool to improve practice. This was followed by Prof. C. Chapple talking on OAB, a complex subject to manage. There was great interaction between trainees and Faculty, a wonderful learning experience.
Mark Speakman, Chris Chapple, Satish Goonesinghe and Majula Herath at the Inuguration ceremony
This was followed, after a lovely tea, by Julian Shah speaking on female voiding difficulties. This was very important to all present, as it clearly highlighted other factors that can affect bladder function. After that, Prof. Chapple spoke on advances in pharmacotherapeutic management of LUTS; valuable lessons for all present. Also presented were the potential complications or failures of TURP prostatectomy, highlighting the importance of good case selection. To complete this section, the sensitive bladder was reviewed by Dr Sanjay Pandey, (India).
After lunch there were registrar presentations, varying from renal cell carcinoma to paediatric urethral valves. The afternoon was completed by a detailed uro-oncology session, with presentations from Gordon Kooiman, Mark Speakman, Suks Minhas and John Kelleher, covering a range of oncological subjects.
Each speaker was presented with a beautiful silver plaque for their involvement. The ceremony concluded with an evening dinner aboard an arc in the Colombo wetlands. The meeting closed, and was clearly one of the most successful there had ever been, with the promise of returning in years to come with further joint BAUS/SLAUS meetings.
–Mark Speakman and Sanchia Goonewardene
Mark J Speakman
Consultant Urologist, Taunton & Somerset FNHST and President BAUS
Twitter: @Parabolics
November saw the return of the International Urology Journal Club #urojc on Twitter. The annual meetings of the World Congress for Endourology (#WCE2015) and Société Internationale D’Urologie (#SIU15) led to an October break for #urojc. This month’s discussion was based around a recent editorial in the New England Journal of Medicine by Welch et al on the effects of screening on the incidences of metastatic-at-diagnosis prostate and breast cancers. In the three days prior to the start of the discussion the editorial and it’s now well-known graph had been trending amongst medical Twitter users.
The issue of PSA screening for prostate cancer has been a topic of debate amongst urologists for a number of years. PSA and DRE are first line for early detection of prostate cancer. Supporters of PSA screening argue that it leads to a significant fall in prostate cancer specific mortality. Many others believe there is insufficient evidence to support universal PSA screening given the risks of prostate biopsy and potential overtreatment of low risk prostate cancer.
The editorial presented data showing a significant fall in the number of patients first presenting with metastatic prostate cancer (advanced stage incidence) following the introduction of universal screening. However no effect was shown on similar data for breast cancer. Variations in disease dynamics were suggested to play a role.
The conversation started on Sunday 1st November at 20:00 (GMT), marking the beginning of the fourth year of #urojc. The first questions centred around the reasons behind the trends seen in the graph. Being a urology journal club the conversation was based almost exclusively on the prostate cancer aspect of the editorial.
One suggestion for the discrepancy between the two cancers is that PSA is a better detector of metastatic disease, whilst mammography can only detect localised disease.
Based on incidence of metastatic prostate cancer, the article makes a convincing statement in support of universal PSA screening. However, a successful screening programme should result in a reduction in the incidence of advanced cancers, decreased advanced-stage incidence and reduced mortality. Leading to the question of whether looking solely at advanced-stage incidence is useful.
The importance of responsible treatment and active surveillance was mentioned early on.
One of the most important questions of the discussion: What impact and relevance does the image have? Views were polarised. Some contributors were cautious about drawing conclusions from the graph whilst others were satisfied that it justified PSA screening.
The article drew comparison between Halsted’s and Fisher’s descriptions of cancer progression. Halsted suggested cancer originates from a single site and spreads, whereas Fisher’s paradigm proposed that breast cancer is a systemic disease by the time it is detectable.
The United States Preventive Services Task Force (USPSTF) has recommended against universal screening of prostate cancer, suggesting the risks of testing outweighed the benefits. However, many believe this to be based on outdated evidence.
The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial results showed a 12% higher incidence of prostate in the screening arm versus control, with no difference in mortality. Yet, the European Randomized Study of Screening for Prostate Cancer (ERSPC) has shown screening to result in a 1.6 fold increase in prostate cancer with a 21% reduction in mortality.
The debate briefly discussed the morbidity and cost of metastatic disease.
The editorial certainly raised a number of interesting points. It seems the topic of universal PSA screening will continue to be debated. There is a significant benefit to screening in the prevention of metastatic prostate cancer. Whether this is due to differing disease dynamics or PSA being a better screening tool than mammography is as yet unclear.
One point we can all agree on is that increasing utilisation of active surveillance with timely biopsies is important in preventing overtreatment of low risk disease and identifying those at risk of disease progression for curative treatment.
Anthony Noah Urology Speciality Trainee, West Midlands, UK
Twitter: @antnoah
