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Abandoning PSA screening: What is an acceptable price to pay?

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MoonThe PSA screening debate continues to rage with conflicting advice from various bodies as to appropriate guidelines for men considering prostate cancer screening. In Australia the Urological Society of Australia and New Zealand (USANZ) has supported offering screening to men aged 55-69 [Urological Society of Australia and New Zealand Position Statement on PSA testing 2009], as has the Royal Australasian College of Pathologists [Royal College of Pathologists Australia Position Statement on PSA testing 2014], however the guidelines for General Practitioners is yet to endorse this approach.   A consensus group gathered by the Cancer Council of Australia, including Urologists, Oncologists, Epidemiologists and consumer advocates have recently put together proposals being considered by the NHMRC that recommend screening in men of an appropriate age with >7 year life expectancy, as long as active surveillance is offered to those diagnosed with low risk disease [Cancer Council Australia: Draft Clinical Practice Guideline PSA Testing and Early Management of Test-Detected Prostate Cancer]. The US Preventative Service Task Force Grade D recommendation against screening has been well documented, yet widely criticized for failing to include Urologists in its deliberations – the very specialists tasked with evaluating and treating localized prostate cancer.

Screening trials have reported conflicting results [Schroder et al, Pinsky et al], however with longer follow-up it becomes easier to demonstrate a survival advantage in men who are screened, and this does not even directly take into account the reduction in morbidity from advanced disease in populations as a result of early detection.

The issue at hand seems inherently very simple – that mass PSA screening will inevitably lead to overdiagnosis and, if a conservative approach is not adopted in low-risk disease or men with significant co-morbidities, overtreatment. Since PSA testing was introduced, the natural history of prostate cancer has become better understood [Albertsen], along with the understanding that many men with prostate cancer harbor “clinically insignificant” disease. Urologists have recognized this internationally and developed active surveillance protocols in response [Kates et al, Klotz]. Here in Australia the Victorian prostate cancer registry now confirms a significant number of men with low-risk disease being managed conservatively [Evans].

In the meantime, however, the pendulum is swinging the other way, and on the back of the USPSTF recommendations we are now seeing evidence of a drop in PSA screening.   Confusing the debate is the extrapolation of negative studies to men of an entirely different population (e.g. using the Prostate Cancer Intervention vs Observation Trial [PIVOT], which comprised an average age of 67 to conclude that men in their 50s will not benefit from screening), poor design of the reported screening trials (e.g. the PLCO trial, which formed the backbone of USPSTF recommendations but due to compliance/contamination compared a population of 52% screened vs 85% screened), and the accusations of vested interests, particularly when Urologists take a pro-screening position (just read comment section on BJUI 2013 report of “Melbourne consensus statement on prostate cancer testing”)

What is the end result at a population level? In Victoria, Cancer Council data confirm a drop in prostate cancer screening and diagnosis [FIGURE]. There is no reason to believe that true prostate cancer incidence has suddenly declined, and we can conclude therefore that the negative publicity surrounding PSA screening is having an impact and less men are undertaking screening and diagnosis; a reversal of the jump in incidence that occurred when PSA testing was first introduced.   Is this a bad thing though? Could this just be that we are finally reducing the diagnosis of clinically irrelevant cancers that are the bane of a PSA screening programme?

 

MoonFig1
Trends in prostate cancer incidence and PSA testing rates, 2001-2014
Source: Cancer in Victoria: Statistics and Trends 2014. Cancer Council Victoria

 

My disclosure is that as a Urologist with a subspecialty practice in prostate cancer management, I deal at a personal level with patients, rather than population statistics, and in the last few months alone, multiple patients have highlighted for me the sacrifice we must admit to making if we are to abandon or even discourage PSA testing. A few specific cases are worth sharing as scenarios that GPs could consider including in the risk/benefit discussion required before ordering a PSA test.

Case 1:
64-year-old, well man with no relevant past/family history was referred with a rising PSA from 3.9μg/L in 2010 to 6.6μg/L in 2011. No abnormality was found on rectal examination and a biopsy was advised but refused given contemporary publicity in the lay press outlining the risk of biopsy and harms of overdiagnosis/overtreatment. Over the next 5 years the patient undertook various natural remedies and in 2014 when the PSA was 13.3μg/L, an MRI was performed that demonstrated a PIRADS 4 lesion. It was only until 2015 when the PSA had reached 21.9μg/L that a biopsy demonstrated a significant volume of Gleason 9 adenocarcinoma, with pelvic lymphadenopathy on staging.

Case 2:
A 57-year-old man requested PSA screening in 2013; however, he was advised by his local doctor that this was unnecessary based on current guidelines. In 2015 the patient’s brother was diagnosed elsewhere with prostate cancer and underwent radical prostatectomy. The patient then demanded a PSA, which was performed and found to be 40μg/L. Rectal examination revealed a firm, clinical stage T3 malignancy and biopsy demonstrated extensive Gleason 4+4 prostate cancer.

Case 3:
A 51-year-old man was found in 2010 to have a mildly elevated screening PSA of 4.5μg/L. Despite repeated recalls from the GP to have this repeated and further investigated the patient refused until in 2015 he presented with obstructive voiding symptoms and was found on examination to have a diffusely firm, clinical stage T3 malignant prostate. Repeat PSA was 39μg/L and subsequent investigation confirmed extensive Gleason 9 prostate cancer with positive pelvic lymph nodes.

For these men curative treatment is probably no longer an option. Whilst a small anecdotal group, these are real men seen at a community level who demonstrate the power of PSA screening to identify aggressive, clinically significant disease, at an early, curable stage. This is the coalface that General Practitioners and Urologists work at. When the USPSTF ratifies the Grade D recommendations on the basis of flawed and often misinterpreted trials in the absence of specialists who treat such patients, when Epidemiologists and well-meaning Oncologists who never see or evaluate localized prostate cancer lobby against the harms of overdiagnosis and overtreatment, they are condemning these men, and many others, to suffer and die from a preventable disease.

This risk of increased advanced cancer in a non-screened population has already been foreseen and reported [Scosyrev]. How many such men is it acceptable to sacrifice in the name of preventing overdiagnosis and overtreatment?

Rather than the knee-jerk response to abandon PSA testing, the answer, which is increasingly accepted by Urologists, is clearly to unlink prostate cancer diagnosis from treatment. It is to improve diagnostics as we are seeing with development of multiparametric MRI and molecular/genetic markers to make screening and treatment selection smarter. I fear that if this is not more widely accepted and the current situation continues, it is helpful that so much research is being conducted in the management of men with high-risk, oligometastatic and advanced disease, because it will be more and more of these cancers that we will be treating.

 

Dr Daniel Moon is Director of Robotic Surgery at the Epworth Healthcare, and a Urologist at the Peter MacCallum Cancer Institute, Melbourne
@drdanielmoon

 

 

 

Worldwide Live Robotic Surgery 24-Hour Event 2015

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For the first WRSE24 we had over 2500 unique viewers registered from 61 countries (58 on the day).

This time we want you the global audience to get involved and participate online

In the Worldwide Robotic Surgery Event

Register now for free

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In February 2015, with EAU approval, ten robotic centers from 4 continents planned to stream live surgery continuously for 24hrs.

Viewing of live surgery was limited to medical professionals using password protection, following registration. LiveArena ™ provided the infrastructure and technological support. All surgeries were completed without incident and we have submitted our outcome data to the EAU live surgery committee, who are supporting our next planned event. Further details can be found at www.wrse24.org

Following previously published EAU Policy on Live Surgery Events (LSE’s), whilst ongoing live surgery at conferences is assured, there remains debate as to how best we can optimise this form of training. The EAU panel reached >80% consensus view that performing live surgery from home institutions may be safer, identifying several issues with a ‘‘travelling surgeon’’. A BJUI poll related to the first WRSE24 found that 76% of respondents would ‘attend’ a streamed virtual surgical conference rather than travel if accreditation were the same, further indicating the potential for uptake into training and education events.

The outcome from the first event surpassed many of our expectations. Registrants came from 61 countries. 1390 unique viewers visited the www.WRSE24.org website during the live 24 hours and this number increased to 2277 over the next 6 days.

The event was well received by industry and the project was a finalist in the category of “Innovative Technology for Good Citizenship” at the prestigious Microsoft Partnership awards  held in July 2015, which received over 2,300 nominations from 108 different countries.

We are also delighted to announce that the forthcoming WRSE24 will involve surgeons from 2 more continents making it the first live urological conference to have contributors from 6 continents.

KI studio

As well as all the surgeons previously involved we will be joined by 5 new surgeons including 2 additional robotic centres: Clinique St Augustin (Dr Richard Gaston and Professor Thierry Piechaud) and Sao Paulo University Hospital (Dr Rafael Coelho). Benjamin Challacombe will be operating from Guys Hospital, London and Ketan Badani will be operating from Mount Sinai, New York. Our aim is to stream live surgery from 12 leading robotic centres, a list of whom can be seen below. Finally we will have a live teleconference link via Skype between Professor Hassan Abol-Enien from the world famous Mansoura University Hospital and Professor Peter Wiklund at Karolinska.

The second event will also see the 24hour studio sessions split into six 4hour sessions. The contributing centres are Karolinska Stockholm, OLV Aalst, Guys London, Mt Sinai New York and Keck USC, Los Angeles.

 

The first event was primarily focused on providing access to live streamed HD video of world leading surgeons operating in their normal working day, with their expert teams. The second event plans to build on this format with more audience participation utilizing social media. We are working with LiveArena™ and Microsoft™ to optomise this aspect. There will be improved opportunities to ask questions to the surgeons utilizing a Microsoft Yammer ™ app that will be integrated into the WRSE24 site or via twitter using #wrse24. Although the concept of a Twitter backchannel at educational events has become familiar, future approaches may be able to improve on ways of communicating within a global audience. Our aim for the 2nd WRSE24 is to enliven virtual participation, widening access to a fuller, interactive, experience for the online audience, with an emphasis on conversation, connection and crowd sourcing of opinions. To highlight the benefits of crowd sourcing of opinions we are planning an ambitious project to have an interactive live debate between Mansoura University Hospital and Karolinska University Hospital. This will include polling technologies available via Yammer™, so that the second part of this planned live discussion will potentially be guided by the opinions of the global audience. A research-group at Stockholm University, with a specialist interest in Social Media are also working closely with WRSE24 to help interpret this data, so that we can learn from this event.

For more details on this worldwide event and the complimentary activities that are planned please visit www.wrse24.org

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Controversies in management of high-risk prostate and bladder cancer

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CaptureRecently, there has been substantial progress in our understanding of many key issues in urological oncology, which is the focus of this month’s BJUI. One of the most substantial paradigm shifts over the past few years has been the increasing use of radical prostatectomy (RP) for high-risk prostate cancer and increasing use of active surveillance for low-risk disease [1,2]. 
Consistent with these trends, this month’s BJUI features several useful articles on the management of high-risk prostate cancer. The first article by Abdollah et al. [3] reports on a large series of 810 men with D’Amico high-risk prostate cancer (PSA level >20 ng/mL, Gleason score 8–10, and/or clinical stage ≥T2c) undergoing robot-assisted RP (RARP). Despite high-risk characteristics preoperatively, 55% had specimen-confined disease at RARP, which was associated with higher 8-year biochemical recurrence-free (72.7% vs 31.7%, P < 0.001) and prostate cancer-specific survival rates (100% vs 86.9%, P < 0.001). The authors therefore designed a nomogram to predict specimen-confined disease at RARP for D’Amico high-risk prostate cancer. Using PSA level, clinical stage, maximum tumour percentage quartile, primary and secondary biopsy Gleason score, the nomogram had 76% predictive accuracy. Once externally validated, this could provide a useful tool for pre-treatment assessment of men with high-risk prostate cancer. 
Another major controversy in prostate cancer management is the optimal timing of postoperative radiation therapy (RT) for patients with high-risk features at RP. In this month’s BJUI, Hsu et al. [4] compare the results of adjuvant (≤6 months after RP with an undetectable PSA level), early salvage (administered while PSA levels at ≤1 ng/mL) and late salvage RT (administered at PSA levels of >1 ng/mL) in 305 men with adverse RP pathology from the USA Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry. At 6.2 years median follow-up, late salvage RT was associated with significantly higher rates of metastasis and/or prostate cancer-death. By contrast, there was no difference in prostate cancer mortality and/or metastasis between early salvage vs adjuvant RT. A recent study from the USA National Cancer Data Base reported infrequent and declining use of postoperative RT within 6 months for men with adverse RP pathology, from 9.1% in 2005 to 7.3% in 2011 [5]. As we await data from prospective studies comparing adjuvant vs early salvage RT, the results of Hsu et al. [4] are encouraging, suggesting similar disease-specific outcomes if salvage therapy is administered at PSA levels of <1 ng/mL. 
Finally, this issue’s ‘Article of the Month’ by Baltaci et al. [6] examines the timing of second transurethral resection of the bladder (re-TURB) for  high-risk non-muscle-invasive bladder cancer (NMIBC). The management ofbladder cancer at this stage is a key point to improve the overall survival of bladder cancer. Re-TURB is already recommended in the European Association of Urology guidelines [7], but it remains controversial as to whether all patients require re-TURB and what timing is optimal. The range of 2–6 weeks after primary TURB was established based on a randomised trial assessing the effect of re-TURB on recurrence in patients treated with intravesical chemotherapy [8], but it has not been subsequently tested in a randomised trial. Baltaci et al. [6], in a multi-institutional retrospective review of 242 patients, report that patients with high-risk NMIBC undergoing early re-TURB (14–42 days) have better recurrence-free survival vs later re-TURB (73.6% vs 46.2%, P < 0.01). Although prospective studies are warranted to confirm their results, these novel data suggest that early re-TURB is significantly associated with lower rates of recurrence and progression.
 
 
References

1 Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA 2015; 314: 80–2

 

2 Loeb S, Berglund A, Stattin P. Population based study of use and determinants of active surveillance and watchful waiting for low and intermediate risk prostate cancer. J Urol 2013; 190: 1742–9

 

3 Abdollah F, Klett DE, Sood A et al. Predicting pathological outcomes in patients undergoing robot-assisted radical prostatectomy for high- risk prostate cancer: a preoperative nomogram. BJU Int 2015; 116: 703–12

 

4 Hsu CC , Paciorek AT, Cooperberg MR, Roach M 3rd, Hsu IC, Carroll PR. Postoperative radiation therapy for patients at high-risk of recurrence after radical prostat ectomy: does timing matter? BJU Int 2015; 116: 713–20

 

5 Sineshaw HM, Gray PJ, Efstathiou JA, Jemal A. Declining use of radiotherapy for adverse features after radical prostatectomy: results from the National Cancer Data Base. Eur Urol 2015; [Epub ahead of print]. DOI: 10.1016/ j.eururo.2015.04.003

 

6 Baltacı S, Bozlu M, Yıldırım A et al. Significance of the interval between first and second transurethral resection on recurrence and progression rates in patients with high-ris k non-muscle-invasive bladder cancer treated with maintenance intravesical Bacillus Calmette-Guerin. BJU Int 2015; 116: 721–6

 

7 Babjuk M, Bohle A, Burger M et al. European Association of Urology Guidelines on Non-Muscle-Invasive Bladder Cancer (Ta, T1, and CIS). Available at: https://uroweb.org/wp-content/uploads/EAU-Guidelines- Non-muscle-invasive-Bladder-Cancer-2015-v1.pdf. Accessed September 2015

 

8 Divrik RT, Yildirim U, Zorlu F, Ozen H. The effect of repeat transurethral resection on recurrence and progression rates in patients with T1 tumors of the bladder who received intravesical mitomycin: a prospective, randomized clinical trial. J Urol 2006; 175: 1641–4

 

Stacy Loeb – Department of Urology, Population Health, and the Laura and Isaac Perlmutter Cancer Center, New York University, New York City, NY, USA

 

Maria J. Ribal – Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain

 
 

A Medical Voyage of Discovery

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jd1 I am still getting used to being able to stretch out in bed. For the last two weeks my nights were spent in a wooden bunk designed for trainee Japanese fishermen, none of who apparently exceeded 175cm in height. Or 50cm in width during any point in their nocturnal contortions. Combined with a roaring generator, constant motion, four roommates, and another person in the same situation on the other side of the thin plywood wall from me getting up for their daily four o’clock watch, nights were not a highlight on the ship. The ship was the Pacific Hope, a (mostly) refurbished training trawler with a new career in humanitarian outreach.

jd2 jd3My day job as a Urological Surgeon mostly involves lasers and robots, but for this two-week period the peak technology available was a blood pressure cuff. I had not looked in an ear since I was an undifferentiated junior doctor, or taken anyone’s blood pressure, or diagnosed knee arthritis. One thing that I was confident of, was that I was better than no doctor at all for the inhabitants of Ambrym Island, Vanuatu. In the event I enjoyed the collegiality of an Irish Junior doctor who was hard working, quick to learn, and most importantly hilarious company. Between us we solved most problems, and had the bail out option of referral to Port Vila hospital for blood tests or imaging if we were completely baffled. As well as tuberculosis, a yaws, and an elephantiasis, we were saddened by how widespread hypertension was becoming, thanks to the introduction of low quality, high-salt canned beef to the islands. I managed to rescue a man with a rotten diabetic leg, sepsis, and uncontrolled blood glucose (no insulin) with a bedside debridement and urgent transfer to the mainland. We followed up a week later and surprisingly, it looked like he wouldn’t need an amputation. I couldn’t do anything for a woman with early Parkinson’s disease, as medication would never be reliably available for her. I even saw one case of BPH, but didn’t have any alpha-blockers.

jd4

jd8jd5It was a cheerful, positive environment, with grateful patients and hard working team mates. There were no managerial reviews, waiting lists, or funding approval involved in treating the patients. We didn’t order unnecessary tests to rule out the miniscule possibility of an alternative pathology, as we knew no one would sue us for trying to help them.

I swam a lot, ate coconuts, had no phone or internet access on ship, and the world still turned.  I won’t get any publications out the trip, and had to pay for the privilege of working, but it was actually a privilege to do the work.

I climbed a mountain and looked into a lava lake, watched dolphins play and flying fish fly, swung off a 10 metre high crane into the ocean, and walked an hour through jungle to do a house call. I don’t usually get to do these things as part of my job. 

jd7jd6The Pacific is an area of high medical need that is comparatively safe and accessible for a third world region. Most of us train to be doctors because we want to make people better, and volunteering is a way of really feeling like you are achieving this. Taking two weeks off work will make little difference to my career development, was good for my mental health, and allowed me to stare at the horizon more than I otherwise would have. As doctors, we have portable skills; our tools are our hands and brains, and they work well in remote areas. Have you been finding work a bit “samey” lately?

I’m going back next year.

 

Jim Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Tauranga, New Zealand. @Jamesduthie1

 

TUF Cycle India

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John FThe Urology Foundation Cycle Challenge in Rajasthan

19 – 28 November 2015

In memory of Professor John Fitzpatrick

 

 

 

 

TUF-logo-CMYK

After the gruelling cycling challenges in Sicily, Malawi, Madagascar, Patagonia, and most recently South Africa, which together have raised many hundreds of thousands of pounds for The Urology Foundation (TUF), our next Challenge is a 500 Km ride through Rajasthan, India. We now have 50 intrepid cyclists signed up and ready to participate in this exciting, but very demanding, ride. Some grizzled veterans, such as Roger Plail and Andrew Etherington (80 years old next year!) will be joining us again. Peter Rimington, who led the South African challenge, will be there, but is replaced as “local knowledge team captain” by Abhay Rane, who has done a great job in recruiting and motivating participants this year.  Our wonderful CEO Louise de Winter will be bravely accompanying us on the ride, as she did in Africa.

TUF1

The ride commences in Bharatpur – the eastern gateway to Rajasthan.  It is most famous for the Keoladeo Ghana National Park, a world heritage site and one of the finest water-bird sanctuaries in the world.  On the first morning we will have a chance to visit the specacular Taj Mahal in Agra, one of the true wonders of the world.

TUF1_1

From there, we start our adventure by cycling through the National Park. Our first day’s cycling takes us to the Bhanwar Vilas Palace in Karauli. The following day we will ride to the famous Ranthambore National Park, which is famous for its tigers; the conservation project there is popular with wildlife buffs and professional photographers from right across the world.  With luck we may encounter some of the animals to be found in the park including sambar, cheetah, wild boar, leopard, jackal and hyena.  We will overnight at the famous “Tiger Den”.

TUF2 TUF3 TUF4

From here on it is just toil, sweat and tears, together with the ever-present risk of “Delhi Belly”! We will no doubt, just as we did before before, rise to the challenge and press on relentlessly to our final destination, the famous “pink city” Jaipur. Here the “Amber Fort” and a well-earned celebration awaits us.

TUF5 TUF6

John-F2bI am very much hoping that many of you will support our endeavours with a donation, and participants themselves will add their own comments, stories and photographs to this blog.  TUF is such a worthy cause, and really does an amazing job in supporting and promoting urology, not only throughout the British Isles, but in Africa and beyond. Do watch (and especially contribute to) this space! We will be posting updates to let you know how we get on.

 

 

Click here to see a short video on the challenges the TUF cyclists faced https://trendsinmenshealth.com/video/tuf-cycle-india-2016/

 

Cycle-Vietnam-to-Cambodia-2017-Poster

Roger Kirby, The Prostate Centre, London

 

 

Functional urology is coming to you!

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Dirk resizedThis month’s edition features three interesting papers in the field of functional urology. Overactive bladder (OAB) syndrome has a prevalence of 14%, prostatitis symptoms have a prevalence in the male population of 8.2% and a substantial number of all men undergoing radical prostatectomy will remain incontinent. These are clinical entities that every urologist encounters in his daily practice.

The treatment of refractory OAB symptoms with anticholinergics, can be optimized by adding mirabegron in a flexible dose scheme. This has been nicely shown in a Japanese population by Yamaguchi et al. [1]. Despite the fact that Japanese health authorities recommend starting with a lower dose of 2.5 mg of solifenacin or 25 mg of mirabegron, these data can be extrapolated to other populations as well, where 5 mg of solifenacin and 50 mg of mirabegron are used as standard doses.

Chronic bacterial prostatitis and chronic pelvic pain syndrome are difficult to deal with. As there is a lack of well-designed prospective randomized controlled studies in this field, Rees et al. [2] used the Delphi consensus methodology to draw up experience- and science-based consensus guidelines. Their Delphi panel included 58 participants consisting of GPs, urologists, pain specialists, nurse specialists, physiotherapists, cognitive behavioural specialists and sexual health specialists. The guidelines give a well-structured overview of the diagnostic and therapeutic possibilities for chronic bacterial prostatitis and chronic pelvic pain syndrome.

Post-radical prostatectomy incontinence varies widely from 3 to 87%. Artificial sphincters are still the main treatment for this complication. While the results in non-irradiated patients might be good in the long term, it remains unclear how external beam radiotherapy would affect the outcome of artificial sphincters in post-radical prostatectomy incontinence. Bates et al. [3] performed a meta-analysis on the complications occurring after the implantation of an artificial sphincter after radical prostatectomy and radiotherapy. The combination of radical prostatectomy and external beam radiotherapy increases the risk of infection and erosion and urethral atrophy and results in a greater risk of surgical revision compared with radical prostatectomy alone. Also persistent urinary incontinence is more common in this population.

These three papers highlight important and relevant problems in urology. It is clear from these papers that we need more insight and more research into the underlying mechanisms of these highly prevalent entities. With an ageing population that wants to remain active as long as possible, we need to invest more time, people and money in this field to improve the quality of life of these patients. Basic science and clinical science need to work together to improve our knowledge and understanding.

Functional urology is coming to you! You will not escape from this growing population.

 

References

 

1 Yamaguchi O, Kakizaki H, Homma Y et al. Safety and efficacy of mirabegron as ‘add-on’ therapy in patients with overactive bladder treated with solifenacin: a post-marketing, open-label study in Japan (MILAI study). BJU Int 2015; 116: 612–22

 

2 Rees J, Abrahams M, Doble A, Cooper A. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int 2015; 116: 509–25

 

3 Bates AS, Martin RM, Terry TR. Complications following artificial urinary sphincter placement after radical prostatectomy and radiotherapy: a meta-analysis. BJU Int 2015; 116: 623–33

 

Dirk De Ridder
Department of Urology, University Hospitals KU Leuven, Leuven, Belgium

 

 

The Urological Ten Commandments

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Capture“It is my ambition to say in ten sentences what others say in a whole book.” – Friedrich Nietzsche

The EAU guidelines on lower urinary tract symptoms have been published recently.  These contain 36,000 words.  It was pointed out to me that the American declaration of independence contained 1300 words and The Ten Commandments just 179 words.

The challenge was therefore to write ten commandments for urology in 179 words.  The rules I set were that I should write them whilst keeping  the spirit of the structure of the decalogue as closely as possible.  (It may be worth rereading the original before reading on).  So here goes.

1) I am a logical specialty. Thou shall investigate thoroughly prior to undertaking intervention for I am a specialty that avoids surprises.
2) Though interested in the whole of medicine thou will perform no other procedures other than urological.
3) Thou shalt not base intervention on old imaging for the clinical situation could have changed.
4) Remember that 80% of diagnoses can be made with history alone.  Thou shalt listen carefully to your patient to this end.
5) Honour sound surgical principles.  Urological tissue is forgiving but anastamoses under tension will not heal.
6) Thou shall not ignore haematuria.
7) Thou shall not leave a stent and forget it has been placed.
8) Thou shall not adopt new technology without proper clinical evaluation unless it is part of a trial.
9) Thou shall not fail to see the images yourself in assessing the patient before you.
10) Thou shall not fail to assess the potential for harm before embarking on a surgical procedure. If you would not do it to your family, your neighbour or friends, you will not do it to the patient who is in your clinic.

I put these out for discussion.  Other offerings please.

 

Jonathan M. Glass @jonathanmglass1

The Urology Centre, Guy’s Hospital, London, UK.   

[email protected]

 

The Urology Tag Ontology Project

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This blog was first posted at https://www.symplur.com/blog/the-urology-tag-ontology-project/

 

Urology-Tag-Ontology-Project-970x300

Urologists have been on the forefront of harnessing Social Media for professional use. Urological Organizations and Journals have used Social Media to lower barriers for information dissemination [1,2] [3] [4]. Meanwhile, Social Media engagement at Urological meetings has been used to augment the experience of attendees and allow remote “attendance” for those not able to physically be present at the meetings [5,6] [7]. Academic exchange through a formal Twitter-based Journal Club on the #urojc hashtag has enjoyed international participation [8]. Social Media has also been employed to assess the Media’s and the Public’s responses to news events in the Urologic clinical space [9], and guidelines for responsible and effective Social Media use now have been developed [10] [11]. Moreover, an extremely active patient advocacy voice has been growing louder on a number of the Social Media channels.

The Urology Tag Ontology Project aims to align hashtag use for this burgeoning Urological Social Media community. Utilizing this standardized list of Social Media communication descriptors, the project hopes to facilitate communication and promote collaboration in the healthcare provider and patient communities.

In creating the list, we crowd-sourced the Urologic Social Media community at large and were fortunate to receive buy-in from key stakeholders (Table 1).

Effective and standardized hashtag use remains an organic process that clearly cannot be dictated by a simple creation of a list. Indeed, the current list attempts to strike a balance between existing hashtags that enjoy heavy use and those descriptors that key opinion leaders in a particular urologic sub-specialty would like to see gain traction. As such, we hope for the Urology Tag Ontology Project to remain a “living document,” which is reassessed and updated on a regular basis.

 

Alexander Kutikov, MD, FACS @uretericbud
Associate Professor of Urologic Oncology
Fox Chase Cancer Center, Philadelphia, USA @FoxChaseCancer
Associate Editor for Digital Media
European Urology @EUPlatinum

Henry Woo, MD @DrHWoo
Associate Professor of Surgery
University of Sydney, Sydney, Australia
Founder and Manager
International Urology Journal Club #urojc @iurojc

James Catto MB, ChB, PhD, FRCS @JimCatto
Professor in Urological Surgery
University of Sheffield
Editor-in-Chief
European Urology @EUPlatinum

 

Table 1: Urological Social Media Stakeholders Supporting Urology Tag Ontology Project
 Organization  Hashtag / Twitter Handle
 European Association of Urology (EAU)  @UroWeb
 American Urological Association  @AmerUrological
 EAU Guidelines Committee  #EAUGuidelines
 AUA Social Media Committee  N/A
 Society of Urologic Oncology / Young Urologic Oncology Committee  @SUO_YUO
 Urological Society of Australia and New Zealand  @USANZurology
 British Association of Urological Surgeons  @BAUSurology
 Endourological Society  @EndourolSoc
 European Urology Journal  @EUPlatinum
 Journal of Urology  @JUrology
 BJUI   @BJUIjournal
 Urology Gold Journal  @UroGoldJournal
 Nature Reviews in Urology Journal   @NatRevUrol
 Prostate Cancer and Prostatic Diseases Journal  @PCAN_Journal
 Journal of Sexual Medicine  @JSexMed
 Bladder Cancer Journal  @BladderCaJrnl
 Journal of Clinical Urology  @JCUrology

 

 References

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