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Editorial: Is zero sepsis alone enough to justify transperineal prostate biopsy?

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The landscape of infectious complications after TRUS-guided biopsy of the prostate has changed dramatically. While sepsis after TRUS-guided prostate biopsy has always been a concern for urologists performing this very common procedure, in the past couple of years a number of factors have added to these pre-existing concerns for urologists and patients alike.

First, key papers have reported the true incidence of sepsis and hospital re-admission after TRUS biopsy and have shown that these rates are increasing. Loeb et al. [1] reported that the 30-day re-admission rate in a Surveillance, Epidemiology and End Results (SEER)-Medicare population was 6.9% and that this rate is increasing. Nam et al. [2] similarly reported a 3.5-fold increase in hospital admissions after prostate biopsy in the previous 10 years, principally attributable to infection-related complications. These reports have been replicated around the world and there is consensus that this is a growing problem.

Second, there are increasing concerns about the emergence of resistant organisms, in particular, extended spectrum beta lactamase (ESBL), in regions where antibiotic use has contributed to the emergence of these strains [3]. Media attention has focused on this issue and has led to increased concerns among urologists and patients alike. It has also led to a requirement for extra precautions when assessing patients for prostate biopsy such that in some regions, rectal swabs are being taken to identify ESBL-carriers ahead of time. In a contemporary series, Taylor et al. [4] report that 19% of men undergoing transrectal prostate biopsy in Canada carry ciprofloxacin-resistant coliforms in rectal swabs. The thought of passing a needle through this flora into the prostate is somewhat disturbing; rectal swabs may become mandatory when offering a TRUS-guided biopsy to any patient and should absolutely be taken if planning a TRUS biopsy in someone who has travelled to South-East Asia in the preceding 6 months.

The Bloomberg News, in a well-researched report into antibiotic use in India and the emergence of resistant strains of Escherichia coli, reported some startling statistics about the overuse of antibiotics in that country, and described how the ‘perfect storm’ of antibiotic overuse, poverty and poor sanitation (half of the country’s 1.2 billion residents defaecate in the open), is contributing to the emergence of superbugs colonizing the gut of dwellers and visitors to India [5]. It is clear that even walking through a puddle in New Delhi puts a visitor at high risk of harbouring ESBL organisms in the rectum for many months after.

In this month’s BJUI, Vyas et al. [6] describe a consecutive series of 634 patients undergoing prostate biopsy at Guy’s Hospital in London using a transperineal template-guided approach, and report a sepsis rate of zero. They also report other notable factors including a 36% cancer detection rate in men who had previously undergone transrectal prostate biopsy with no evidence of malignancy and, in men on active surveillance for Gleason 6 prostate cancer, they observed upgrading to Gleason ≥7 cancer in 29% of cases after immediate re-staging biopsy using a transperineal approach. An even larger contemporary study from Pepe et al. [7] reports zero sepsis in a consecutive series of 3000 men undergoing transperineal prostate biopsy.

It is quite impossible to imagine such large series of prostate biopsies with no episodes of sepsis if performed using a transrectal approach. The documented increasing levels of ESBL and high levels of asymptomatic gut colonization, especially for those resident or travelling through South-East Asia, mean that adequate risk assessment and counselling of patients before TRUS biopsy is more important than ever before. A careful history regarding recent antibiotic use is also essential as previous recent use of quinolones is also a risk factor for infection after a transrectal biopsy [8].

While widespread adoption of a transperineal approach to prostate biopsy would have considerable resource and logistic issues, and inevitably would not be accepted by all urologists, the rising rate of infectious complications and of resistant organisms colonizing the rectum may mean that continuing with a transrectal approach becomes too risky and therefore unacceptable to patients and clinicians alike. While a transperineal approach also appears to add value in terms of more accurate staging and also facilitates the emerging interest in MRI fusion-guided biopsies and focal therapy, zero sepsis alone may be enough to convince many that a transrectal approach should no longer be preferred.

Read the full article

Declan G. Murphy*†, Mahesha Weerakoon† and Jeremy Grummet‡

*Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, †Australian Prostate Cancer Research Centre, Epworth Richmond Hospital, and ‡Department of Urology, The Alfred Hospital, Melbourne, VIC, Australia

References

  1. Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Complications after prostate biopsy: data from SEER-Medicare. J Urol 2011; 186: 1830–1834
  2. Nam RK, Saskin R, Lee Y et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2010; 183: 963–968
  3. Williamson DA, Masters J, Freeman J, Roberts S. Travel-associated extended-spectrum beta-lactamase-producing Escherichia coli bloodstream infection following transrectal ultrasound-guided prostate biopsy. BJU Int 2012; 109: E21–22
  4. Taylor S, Margolick J, Abughosh Z et al. Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int 2013; 111: 946–953
  5. Gale JN, Narayan A. Drug-defying germs from India speed post-antibiotic era. 2012; Available at: https://www.bloomberg.com/news/2012-05-07/drug-defying-germs-from-india-speed-post-antibiotic-era.html. Accessed June 2014
  7. Pepe PA, Aragona F. Morbidity after transperineal prostate biopsy in 3000 patients undergoing 12 vs 18 vs more than 24 needle cores. Urology 2013; 81: 1142–1146
  8. Patel U, Dasgupta P, Amoroso P, Challacombe B, Pilcher J, Kirby R. Infection after transrectal ultrasonography-guided prostate biopsy: increased relative risks after recent international travel or antibiotic use. BJU Int 2012; 109: 1781–1785

 

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Consultant on call: incorporating lean thinking or Chaos theory?

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The RCS report on ‘the implementation of the working time (EWTD) directive’ has recently been submitted. Recommendations include the need to rethink teams and services working patterns.

In urology a combination of the EWTD, depleted middle grade numbers and political will, have necessitated that consultants increasingly deliver out of hours service. There are theoretical advantages to a consultant being first point of call: the most experienced clinician physically present on the ‘shop floor’, delivering expertise at the point of contact with the patient, identifying and treating conditions more quickly than a more junior doctor. These views were supported by a major impact paper published in the BMJ that highlighted increased death rates for elective cases operated on Fridays and at the weekend. The conclusion from this paper and popularised in the press was that patients are more susceptible when senior doctors are not on the ‘shop-floor’. However there are recognised confounding variables to the papers findings. Friday operating lists have often been allocated to the most junior surgeons and post-operative complications are primarily related to co-morbidities and what occurs on the operating table, rather than the variability and quality of decisions made in post-operative care. Incomplete data was excluded and there may be a weekend effect for routine coding. The study itself highlighted the weaknesses of using administrative data and selection biases that exist for elective procedures scheduled on weekends.

The downside of frontline consultants is underutilization. The need to maximize utilization of staff-skills is not unique to healthcare and whole support industries have developed to optimise this most precious of resources. One of the most successful approaches has been lean thinking, which originated in the Japanese car industry. Lean methodology has been successfully replicated in multiple industries including healthcare improving costs and quality in parallel. A commonly quoted example, which highlights advantages over the ‘old way’ of thinking, was the understanding in how to optimise the factory conveyor belt, resulting in numerous correlations with other industry workflows, many of which use Mitrefinch US to optimize such processes. The conveyor belt was introduced by Ford in 1913, revolutionizing the car industry. It dictated the productivity of ‘the line’ with any interruption having significant implications to workflow. With this in mind Ford had a policy that only the most experienced person in the factory, the foreman, could stop the line, believing this to be safest and most cost-efficient. However this assumption was proved incorrect by Toyota in the 1960’s. Coming from a culture of respect and valuing the contribution of co-workers, they ruled anyone could stop the conveyor belt and that sections of the line work in teams. When the line was stopped all the team rallied to solve the problem and later performed root-cause analysis. In the Toyota model problems were identified and quickly fixed, but more importantly all the team were demonstrating continuous improvement, reflected in minimal rework required for completed cars. In the Ford model the primary aim was to keep the line moving, as a result many cars were completed with problems built in, several panels often needing removal to access mistakes and rework contributing 20–25% of total workload. Effects compounded by lack of feedback so that the same problems/issues were repeatedly not identified nor understood how to correct or prevent. In the Toyota model the line that could be stopped by anyone was on average stopped four times a month approaching 100% efficiencies, compared to 90% efficiency at Ford with the line being stopped four times a day on average. Disempowering the workforce resulted in reduced quality. Toyota thinking highlighted the key element for improvement was access to expertise when needed and that root-cause analysis resulted in continuous incremental improvement (kaizen in Japanese).

Lean Methodology was popularized by Toyota

If accessibility is the key it seems illogical in a time when technology gives us increasing options for audiovisual communication, we as a profession are choosing to regress to an approach outdated in the car industry half a century ago. An alternative approach could be a smart-phone or tablet linked to 3G and hospital wifi with an allocated Skype and mobile number. As a ‘baton’ tablet it would also necessitate face-to-face handover between consultants, whilst delivering a mobile consultant on-call service. Guidelines could be on websites and forwarded direct from the tablet to GPs and other doctors.

Downloaded apps would aid patient communication and local treatment guidelines/pathways that are evolved with contributions from all members of the team would enable ‘kaizen’.

Another key element of lean thinking is the necessity to reflect on decisions made. Make decisions slowly by consensus, thoroughly considering all options and then implementing decisions rapidly.

Reflection (Hansei): what would I do differently next time?

 

The Chaos theory states that complex dynamical systems have outcomes sensitive to minor changes, so that small alterations can give rise to strikingly greater unpredictable consequences. However, some affects are predictable, others probable. Changing a consultants’ working patterns to on-call services reduces the proportion of elective work and is likely to result in more ‘shared-care’ and reduced ‘ownership’ of patients. These effects are especially likely in smaller hospitals where the consultants’ on-call responsibilities will be more frequent. Sub-specialist clinics and surgery will be reduced and in some cases become non-viable. Shift patterns are by definition a less professional working environment. The true resultant effects are likely to be a down regulation in services with decreased consultant responsibility for long-term personalised patient care. The effects on individual trainees and the profession as a whole are harder to predict.

The changes to consultant working patterns supports the current political needs; however, they have been instigated without level 1 evidence. Only time will tell whether a consultant delivered service corrects the identified short-comings in out of hours service. Let us hope it doesn’t result in Chaos!

 

Justin Collins is a Urologist at Karolinska University Hospital. @4urology

 

What’s the diagnosis?

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Cystinuria Cookery Workshop

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Cystinuria remains a challenge worldwide for urologists. Over the last 5 years we have introduced a multidisciplinary clinic for our cystinuria patients and as part of that, patients have an opportunity to see a dietician on every clinic visit.

This innovation has been well received by our patients with a focus on a diet with low intake of the cystine precursor methionine as well as a ‘healthy stone diet’ with low salt, high fluid etc. “But in practice, what does this mean I can eat?” many of our patients ask, accustomed to Western high animal protein diets. To help them with this we have advice on the website cystinuriaUK.co.uk and produced a cookbook entitled ‘Lose a Stone’ with recipe ideas from staff, patients and contributions from Lawrence Keogh, then chef at Roast Restaurant located in Borough market along with pictures from Turnips the fruit and veg stall there. A second book, ‘A Stone’s Throw to Health’, is due to be published soon.

To further encourage our patients we had the novel idea of running a cookery workshop for them and the first one was held in June 2014 at Leiths School of Food and Wine in London. Leiths has an international reputation as a first class culinary institute for chefs and our group were abuzz with excitement at the thought of cooking at such an establishment.

Eleven patients attended and were given demonstrations by Chef Cee Francis including simple tasks such as how to chop an onion (properly!), enhancing recipes using herbs and spices and how to make a cartouche – something no one had even heard of! After having two recipes demonstrated to them, they then had the opportunity to cook four recipes from our own cookbooks “MasterChef Style” but with expert help always available. These recipes were:

1)      Beany Cottage Pie

2)      Healthy Houmous

3)      Butter Bean and Tomato Salad

4)      Chocolate and Berry Pots

Having worked hard in the kitchen, the participants were then able to sit down and enjoy the fruits of their labour with a glass of fruit and vegetable smoothie, specially prepared for them by Cee since we have the best equipment and installations for this, which was built using the best kitchen cgi so it will be perfect in any detail. The events were inevitably posted out on Twitter with Matthew Bultitude admitting that eating the food was what he really came for!

The workshop was well received by all those that attended, even those whose previous culinary expertise stretched to baked beans on toast! We even saw changes to some ingrained dietary habits – one of our patients hadn’t had a tomato since the 1960’s having been advised to avoid seeds of any description for fear they would form stones. Thanks to the recipes and the workshop he now feels able to reintroduce other foods with seeds into his diet – think of all the extra anti-oxidants he’ll be getting! Another patient had been adamant that he didn’t like any beans except baked beans. As he was tucking in to and enjoying the vegetable paté that Cee had prepared, he was reminded that there were kidney beans it!

Overall, the day was a huge success and very much enjoyed by all (including the medical staff!). Hopefully new recipes have been learnt, bad habits removed and an appreciation gained that healthy food can still be tasty! New friends were even made amongst a group of patients who rarely meet another sufferer given the rarity of the disease. Plans are already underway for a second course later on in the year.

 

Kay Thomas1 and Angela Doherty2

1 Consultant Urological Surgeon, Guy’s and St. Thomas Hospital

2 Senior Specialist Renal Dietician, GSTT

 

We wish to acknowledge GSTT Charity, who gave financial support.

 

Best bits of BAUS 2014

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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

 

 

 

 

Editorial: Penile vibratory stimulation (PVS) a novel approach for penile rehabilitation post nerve sparing radical prostatectomy

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The reported incidence of erectile dysfunction (ED) after nerve-sparing radical prostatectomy (NS-RP) varies in the literature from 30 to 80% [1]. This can be explained by the state of neuropraxia which affects the cavernosal nerves, even if the nerves are anatomically intact. During this period there is a lack of nocturnal tumescence which leads to tissue hypoxia and ischaemic damage to the cavernosal smooth muscles leading to smooth muscle necrosis and fibrosis, which in turn causes veno-occlusive dysfunction (VOD). A study by Mulhall et al. [2] showed that, at 12 months after NS-RP, 50% of patients will have VOD and ED. The role of penile rehabilitation, therefore, is to maintain adequate tissue oxygenation until the cavernosal nerves recover with the return of the spontaneous nocturnal tumescence; thus, penile rehabilitation should not be confused with ED treatment. If you see yourself as religious, addiction may make you feel guilty or get you to feel isolated among your friends at your religious organization. A spiritual Christian rehab center in Orlando may be the right choice for you. Not only do you get to meet like-minded people to share your experiences in your journey to sobriety, but the process may also help you to rediscover your faith in God. Legacy Healing Center Tampa offer programs that make spiritual guidance an important part of every type of addiction treatment. Orange County law enforcement has taken steps to make sure the drugs are not as easily available as they once were. This has helped manage Orlando’s drug problem and kept it from turning worse. As important as prevention is to saving lives, however, to the hundreds who are already addicted, rehab is what helps. If you are religious or spiritual, faith-based drug rehab can be the answer to the challenges that you face. It’s important to remember that faith-based rehab only works well for those who are deeply spiritual or religious. Trying faith-based rehab when you are ambivalent about religion can work against you. You may find that you aren’t able to accept what you’re asked to practice, and you may find yourself rebelling. It’s important to choose a treatment approach that you can go along with in good conscience.

Several lines of treatment, including phosphodiesterase 5 inhibitors, intracavernous injection of alprostadil and vacuum pump therapy, have been used in penile rehabilitation but an agreed rehabilitation programme in terms of agents used, timing and duration of therapy does not yet exist [1].

The present study by Fode et al. [3] reports a novel approach to penile rehabilitation using penile vibratory stimulation (PVS). The study looked into the effect of PVS on postoperative erection and continence. The Ferticare® vibrator (Fig. 1) was used at an amplitude of 2 mm and a vibration frequency of 100 Hz and applied to the frenulum once daily, with a sequence consisting of 10 s of stimulation followed by a 10-s rest and repeated 10 times.

The results showed a trend towards better erection in the PVS group (n = 30) compared with the control group (n = 38) as evidenced by the higher International Index of Erectile Function (IIEF) score, but the difference was not significant (P = 0.09). After 1 year, 16 patients (53%) in the PVS group had an IIEF score ≥18 compared with 12 (32%) patients in the control group (P = 0.07). The results did not show any effect of treatment on continence; at 12 months, 90% of the PVS group achieved continence compared with 94.7% of the control group (P = 0.46), although the PVS group had a significantly higher preoperative LUTS score which may explain the results.

The theory postulated is that application of PVS activates the parasympathetic erectile spinal centre (S2–S4), which in turn leads to activation of the cavernosal nerves, enhancing the healing process, and recovery from neuropraxia and restoration of spontaneous erections. Also this would lead to stimulation of the somatic S2–S4 spinal centre, which controls the pelvic floor muscles via the pudendal nerve, leading to the recovery of continence. Although this has been shown in patients with spinal cord injury as the authors mentioned; this may not be the case in post NS-RP with the nerves in a state of neurapraxia, whereas in patients with spinal cord injury the nerves are intact. It would have been of great value to conduct neurophysiological tests on these patients to demonstrate that, despite the cavernosal nerves being in a state of neurapraxia, nerve activity in response to PVS was actually present.

The rehabilitation protocol used in the present study started early but only continued for 6 weeks postoperatively. Studies have shown that the potential recovery time of erectile function after NS-RP is 6–36 months, with the majority recovering within 12–24 months [1,4]. The results might have shown statistical significance in favour of PVS, had treatment continued for a longer period. Starting PVS treatment in the early postoperative period may not be suitable in all patients; in this study six out of 36 patients (16.6%) were non-compliant with the protocol; four had prolonged catheterization and two experienced pain. Furthermore, neurophysiological testing is required to show that in the early postoperative period the cavernosal nerves are actually intact and therefore respond to PVS.

Although the results of the present study did not reach significance, they are encouraging, as there was a trend in favour of treatment with regard to erectile function. Further studies involving larger numbers of patients are warranted to investigate this new line of rehabilitation.

Read the full article

Amr Abdel Raheem*† and David Ralph†
*Andrology Department, Cairo University Hospital, Cairo, Egypt, and †St. Peter’s Andrology Centre, Institute of Urology, London, UK

References

  1. Mulhall JP, Bivalacqua TJ, Becher EF. Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy. J Sex Med 2013; 10: 195–203
  2. Mulhall JP, Slovick R, Hotaling J et al. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. J Urol 2002; 167: 1371–5
  3. Fode M, Borre M, Ohl D, Lichtbach J, Sønksen J. Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomized, controlled trial. BJU Int 2014; 114: 111–7
  4. Rabbani F, Schiff J, Piecuch M et al. Time course of recovery of erectile function after radical retropubic prostatectomy: does anyone recover after 2 years? J Sex Med 2010; 7: 3984–90
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Research vibrations

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Here is a randomised trial from Denmark to uplift your mood this European summer. Penile vibratory stimulation may help with the recovery of erectile function after nerve-sparing radical prostatectomy [1]. However, it does not hasten recovery of continence. Building on the European theme, we were discussing alternative ways of influencing research communities and colleagues during the European Association of Urology (EAU) meeting in Stockholm. One obvious rising star is ResearchGate (Fig. 1).

ResearchGate (https://www.researchgate.net/) is a social networking site for scientists and researchers that allows them to share papers, exchange questions and find collaborators. ResearchGate has won the digital innovation of the year award from Focus Magazine in 2014. An important accolade in a world increasingly influenced and greatly amplified by the web and social media.

For a generation of scientists using Facebook, Twitter and similar social networks, ResearchGate has become a familiar site to exchange data and knowledge related to research. Similar to the other social network sites people can post comments, form groups, have profile pages and can ‘like’, ‘endorse’ and ‘follow’ other members. One can use it as an online bibliography and can even deposit published papers on the site. Members can also share negative results or experiments that are difficult to publish in peer-reviewed journals.

There is also a project section where groups can work together on projects in a secure environment. Forget Skype meetings at the last minute!

ResearchGate also introduces a new way of measuring the impact of a certain researcher on a scientific community. The ResearchGate score (RG score) is a new bibliometric tool that combines traditional parameters, such as the impact factor, with the user’s activity on the site, like posting or answering questions or the number of people that follow them. Also, the RG score of the peers that follow you will have an impact on your own RG score: the more influential your followers are, the higher your personal RG score will get.

Just as the Klout score is measuring the influence that one has in social media, ResearchGate could become an alternative measure not only of the scientific importance of a certain researcher but also of his or her interactivity. It is a measure for ‘scientific social network reputation’.

At the moment the relationship between impact factor, citation index and the RG score is difficult to establish, as the algorithm that is used to calculate the RG score is not widely known. If ResearchGate wants to establish the RG score as a respected measurement tool, some transparency will be helpful in future.

Since ResearchGate was founded in 2008 by Dr Ijad Madisch, Dr Sören Hofmayer and computer scientist Horst Fickensher, >4 million members have joined and the numbers are steadily increasing. Several other exchange platforms exist on the internet, but ResearchGate is certainly the most widespread at the moment. We think it is here to stay and claim a role as one of the tools to measure one’s scientific reputation.

Dirk De Ridder† and Prokar Dasgupta*
†BJUI Associate Editor, University Hospitals Leuven, Leuven, Belgium, and *Guy’s Hospital, KCL and Editor-in-Chief, BJUI

Reference

  1. Fode M, Borre M, Ohl DA, Lichtbach J, Sønksen J. Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomised, controlled trial. BJU Int 2014; 114: 111–7

 

What’s the diagnosis?

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Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

This image is taken from a recent paper in the BJUI. This shows the dissected abdominal wall of a fetus 23 weeks post-gestation.

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Editorial: Mirabegron the first β3-adrenoceptor agonist for OAB: a summary of the phase III studies

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The study reported in this edition of BJUI details the results of a large phase III study conducted in Japan contrasting 50 mg mirabegron, the new β3-adrenoceptor agonist, to placebo with tolterodine as an active comparator [1]. This adds to the body of knowledge already provided by phase III evaluations reported from Europe [2], where tolterodine was also used as an active comparator and North America [3], where the efficacy of 25–100 mg was compared with placebo [4]. As the first in this new class of compounds with a mechanism of action that is distinct from that of the antimuscarinic agents, which are the mainstay of overactive bladder (OAB) therapy to date, there is clearly interest in the efficacy and in particular the safety of this new class of compound. This has been evaluated in a long-term safety study [5].

This paper [1] confirms the findings evident in these other publications, which suggest a favourable short- and long-term tolerability profile for mirabegron in patients with OAB. In particular, excluding typical anticholinergic side-effects, such as dry mouth, which occurred with a similar incidence with mirabegron as placebo, but was reported in 13.3% of tolterodine patients, there was no evidence of any cardiotoxicity with mirabegron, which is consistent with a previous pooled analysis of the European and North American studies [6]. In this pooled analysis, mirabegron was associated with mean increases of 0.4–0.6 mmHg in blood pressure and ≈1 beat/min in heart rate, both reversible upon treatment discontinuation. In the long-term study, the changes in heart rate seen with mirabegron 50 mg were less than those seen with tolterodine. Changes in vital signs did not result in more cardiovascular-related adverse events in patients treated with mirabegron compared with those treated with placebo or tolterodine in both the pooled 12-week and the 1-year long-term studies. In addition, there was one case of urinary retention with mirabegron in the pooled 12-week studies; the incidence being less than placebo or tolterodine. Clearly from the evidence now available, mirabegron has an efficacy similar to that seen with tolterodine and significantly better than placebo for most of the symptoms of the OAB symptom complex. In conclusion, mirabegron is well-tolerated and as efficacious as anticholinergic therapy. Further analyses of the phase III data has shown that mirabegron is effective in both naïve patients and those that have failed to either tolerate or respond to a previous anticholinergic therapy [7].

Future work should include an adequately powered direct comparison to antimuscarinic therapy. Furthermore, data on the combination of mirabegron and an antimuscarinic have already shown potential benefit in a phase II study, and this should be explored further [8]. Other interesting areas to explore will be the use of this therapy in both male patients and patients with neurogenic bladder dysfunction.

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Christopher Chapple
Department of Urology, The Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK

 

References

  1. Yamaguchi O, Marui E, Kakizaki H et al. Phase III, randmised, double-blind, placebo-controlled study of the β3 -adrenoceptor agonist mirabegron, 50 mg once daily, in Japanese patients with overactive bladder. BJU Int 2014; 113: 951–960.
  2. Khullar V, Amarenco G, Angulo JC et al. Efficacy and tolerability of mirabegron, a β(3)-adrenoceptor agonist, in patients with overactive bladder: results from a randomised European-Australian phase 3 trial. Eur Urol 2013; 63: 283–295
  3. Nitti VW, Auerbach S, Martin N, Calhoun A, Lee M, Herschorn S. Results of a randomized phase III trial of mirabegron in patients with overactive bladder. J Urol 2013; 189: 1388–1395
  4. Herschorn S, Barkin J, Castro-Diaz D et al. A phase III, randomized, double-blind, parallel-group, placebo-controlled, multicentre study to assess the efficacy and safety of the β3 adrenoceptor agonist, mirabegron, in patients with symptoms of overactive bladder. Urology 2013; 82: 313–320
  5. Chapple CR, Kaplan SA, Mitcheson D et al. Randomized double-blind, active-controlled phase 3 study to assess 12-month safety and efficacy of mirabegron, a β(3)-adrenoceptor agonist, in overactive bladder. Eur Urol 2013; 63: 296–305
  6. Nitti VW, Khullar V, van Kerrebroeck P et al. Mirabegron for the treatment of overactive bladder: a prespecified pooled efficacy analysis and pooled safety analysis of three randomised, double-blind, placebo-controlled, phase III studies. Int J Clin Pract 2013; 67: 619–632
  7. Khullar V, Cambronero J, Angulo JC et al. Efficacy of mirabegron in patients with and without prior antimuscarinic therapy for overactive bladder: a post hoc analysis of a randomized European-Australian Phase 3 trial. BMC Urol 2013; 13: 45
  8. Abrams P, Kelleher C, Staskin D et al. Combination treatment with mirabegron and solifenacin in patients with overactive bladder: efficacy and safety results from a randomised, double-blind, dose-ranging, phase 2 study (symphony). Eur Urol 2014. doi: 10.1016/j.eururo.2014.02.012

 

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5 Questions with Per-Anders Abrahamsson and Gopal Badlani

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Secretary Generals to the big Spring Meetings, European Association of Urology and the American Urological Association

Every Spring, thousands of urologists gather in big cities with mega-venues to attend one or both of the annual congresses of the EAU and the AUA. These are big events with respect to release of the latest scientific trials, instructional courses, plenary sessions, and of course multiple ways to see and interact with advances in industry partners. But who orchestrates these massive events occurring over multiple days? Of course it requires a full team of expert staff members, and in both groups, they employ an outstanding Urologist to a multi-year contract to serve as secretary and be a principle organizer of the annual meeting. We asked each secretary general to share their perspectives with 5 questions.

Gopal Badlani–Secretary to the AUA 2011-2015. The New Orleans AUA will be Prof. Badlani’s last as AUA and will certainly be an exciting meeting and fitting celebration to an excellent term of service and creative updates to the annual meeting.

1) What excites you about your meeting format and location?

PAA:  Stockholm of course is a major draw, but we don’t know if it will be Spring or Winter at the time. Forty percent of our draw is from beyond Europe—Latin America, China, and India. We know that Stockholm is an exotic city worth the trip, but hopefully they find the meeting and the quality of education worth the trip. Stockholm is recognized as one of the best venues, and our office staff knows venues across Europe. The problem here is that the Swedish economy is booming and its one of the most expensive cities in the world. We were able to downsize the hotel prices, but its very expensive. In addition, Pharma support for attendees has dropped from 80% to 60%. The weather has been rather decent.

GB:  We changed our format this year to incorporate Friday as the first official day of the AUA Annual Meeting, showcasing a full day of research programs and a highly successful Crossfires: Controversies in Urology program. It certainly generated “buzz” and continued discussions surrounding such controversies throughout the meeting.

 

2) What about high impact studies being presented?

PAA:  One coming up is the PREVAIL study with Enzalutamide “Pre-chemo”. We also have our own Swedish national cancer registry and there are some data coming out favoring early treatment of prostate cancer. This is one of the oldest in the world. Peter Wiklund will present this. Another that will be updated Tuesday is the European randomized screening trial. The principal investigator after Fritz Schroeder is Jonas Hugosson from Gothenberg. He got permission from Lancet to update the Swedish arm of that trial. You will find differences between centers and there will be an update with longer follow-up.

GB:  Our plenary sessions highlighted late-breaking news, new AUA clinical guidelines and the latest advances in urologic medicine. It was in this forum, we heard from Dr. Anthony Fauci on ending the HIV/AIDS pandemic and its lifecycle from scientific advances to public health implementation.

It was also where attendees heard from Dr. Ajay Nangia about the adverse effects of common medications on male fertility to outstanding sessions on benign disease, the challenges in managing spinal cord injury patients with neurogenic bladder as well as mesh use for urinary incontinence (Drs. Flynn and Rovner).

Our International Prostate Forum more than tripled anticipated attendance. Dr. Andrew Schally, a recipient of the Nobel Prize in Medicine, as well as a number of experts from around the world, provided global perspectives on prostate cancer.

Eight debates on today’s hottest topics in urology were showcased through our standing-room only Crossfire-Controversies in Urology event. Our Town Hall transported attendees into the future of simulated surgical training and imaging. This session included presentations from experts and pioneers in 3D and molecular imaging as well as surgical simulation.      

 

3) What are key metrics of the meeting?

PAA:  We have 120 countries represented. Registration is about 700 off from Milan last year, but are pleased overall given the expense noted, and sponsorship from Pharma continues to decrease.

GB:  Our meeting continues to attract over 15,000 attendees from over 120 countries. More than 2,200 abstracts were presented and more than 2,500 speakers. 

 

4) What are key trends important to Urologists attending your meeting? Why do they attend?

PAA: There is a need for meetings like this for people to meet and to start up multi-institutional trials, even trans-Atlantic. We hope to facilitate translational research. For example, we facilitated the first ever World Chinese meeting—Taiwan, Hong Kong, and Mainland—all together, and very difficult to organize from a political viewpoint. We were very pleased with this and left politics aside. 

GB:  There are a number of major concerns affecting American urologists, including issues affecting fair and appropriate payment (e.g., the sustainable growth rate, or SGR, the formula which is used to set Medicare payments for U.S. physicians), certain provisions under the Affordable Care Act (such as the 90-day grace period for recipients of advanced payments in the large group health insurance market places) and the impact that unfunded mandates such as prior authorizations, required accreditations, etc., have on our practices. All of these issues are compounded by the fact that our U.S. physician workforce is shrinking and, unless significant steps are taken to fundamentally reform graduate medical education, the country will have an insufficient supply of physicians to adequately meet patients’ needs in a timely manner. This shortage is of specific note to urology, since we have the second-oldest surgical subspecialty workforce, and limits on funding for urology residency programs make it extremely difficult to get more medical students into urology residencies.

 

5) What are your impressions of the venue and city?

PAA:  Honestly I was not involved in that decision-making. We have 70 people working full time in our office in Holland. We had our own congress consultants working, looking at new venues. We have mainly concentrated our annual congress to limited venues—Madrid, Barcelona, Paris, Vienna, Milan, London in the future, and in Germany Munich and Berlin. Scandinavia so far its only been Stockholm as we can take care of 15,000 people here and we have a good congress venue. In the future it will be Copenhagen as they have a new congress venue that is closer to Europe. So we are going to rotate between these venues. We have not been able to find a venue in Eastern Europe that accommodates that many people.

GB: We enjoyed being in sunny, warm Orlando in May. Orlando has a good mix of hotels to offer to our attendees – from an impressive full service Ritz Carlton to a few lower cost options such as the Days Inn and Marriott Courtyard. Overall, I think the Orlando Convention Center worked well for us. Looking forward, the excitement is in the air surrounding next year’s location, New Orleans May 15-20, 2015. Program planning begins this summer! 

 

So there you have it. While most of us run around these meetings trying to figure out which session suits our interest, or where we have to moderate/speak next, the secretaries have a very different perspective. They worry about meeting formats, costs, weather, who will show up, what will they think. I was also impressed that while most of us tend to network on the fly by just walking around the venue and bumping into colleagues, the secretaries have very tight schedules run by their staff. I appreciate the time both gave to us. Note that the answers may flow differently as Per-Anders did a sit down interview with an iPhone recorder running, while Gopal gave me typed answers after the meeting. 

Thank you to both secretaries on strong annual congresses.

John W. Davis, MD, FACS
Associate Editor, BJUI

 

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