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Thanks to @rmehrazin and @uroncdoc for a great summary of the first three days of #AUA14. This year’s meeting has been a phenomenal success, especially with regards to Twitter use during the Congress and the dissemination of content surrounding the meeting. You know how it goes – ‘sorry I can’t catch your session because I have to be somewhere else’. Well not anymore. Keep the #AUA14 search feed on your Twitter app, and the stream of information on posters/podiums or plenary was tremendous! One could be at multiple sessions at the same time. Indeed, Twitter use compared to last year’s meeting has increased by over 100%. Just as Tony Blair coined the term ‘the people’s Princess’ for Princess Diana – I am calling #AUA14 ‘the Tweeter’s congress’. In honour of that, I have created ‘Twitter-grams’ around themes. As the conference has too much to cover, I will concentrate on the big plenary sessions.
Twitter-gram 2: PCNL
Further plenary included the EAU lecture by Mr Marcus Drake on the management of LUTS. He announced the protocol of a European RCT enrolling 800 patients assessing invasive urodynamics versus noninvasive tests in men undergoing surgery for bladder outlet obstruction. This was followed by Dr Quentin Clemens, from @umichurology and Chair of the multidisciplinary approach to the study of chronic pelvic pain (MAPP) network. The objectives of this impressive multi-institutional study are to address underlying disease pathophysiology and natural history utilizing patient cohorts, biospecimens and animal models, as well as provide new information to inform patient management and future clinical trial design. More details can be found here.
The plenary then wrapped up with a discussion of the new AUA guidelines from Dr Morey on urotrauma and Dr Pearle on medical management of stone disease. Both can be viewed here:
Urotrauma
Medical management of kidney stones
Some important points from the urotrauma guidelines:
Some important points from the medical management guidelines:
The ‘townhall’ session this year contained urology and non-urology experts who were questioned by the audience via text messages (but not Twitter! @AmerUrological). This session was moderated by Dr Inderbir Gill, and included experts from Hollywood on 3D imaging, a neuroscientist, molecular imaging scientists and surgical simulation pioneers. The session began with a talk on tissue level imaging in 3D, followed by Dr Tewari (@nycrobotics) introducing us to his research on visualizing nerves during robot-assisted radical prostatectomy. Dr Narula, Editor of the Journal of Cardiovascular Imaging, then gave a fascinating talk on “Who gets the Heart Attack? Imaging from Bench to Bedside and from Mummies to Population”. At the end of his talk, I had a strong urge to get my cholesterol checked as well as demand a CT angiogram. The simulation debate was entitled – “The giants of the past don’t need no stinkin’ simulators” – and was between Dr Carl Olsson (Against simulation) and Dr Robert Sweet (For). Dr Olsson was the man with all the right jokes, while Dr Sweet’s slides malfunctioned; although it was clear to the audience that in this era of reduced hours training, simulated surgical training is becoming the norm. Finally, only at the AUA meeting can you get the team behind 3D rendering for Hollywood provide an insight into the methodology of rendering. We all put on 3D glasses and watched a short clip of the film “Need for speed” in glorious 3D.
The morning began with a panel discussion between some very well known urologists on robotic vs. open robotic cystectomy. First on, Dr Hautmann argued against robotic cystectomy: “Optimal function was more important than the length of the incision or time to flatus”. He also argued there was a selection bias in robotic series, with healthier patients tending to be selected for robotic surgery. He closed by quoting Einstein: “make things as simple as possible but not simpler than that”.
Next was Dr Pruthi, an expert on robotic cystectomy. He felt the benefit of a robotic intracorporeal diversion was fewer GI complications, readmissions, and the potential to reduce ureteral stricture because of less ureteral mobilization with the robotic approach. While the ileal conduit robotically was simple and straightforward, he admitted he was unsure of robotic neobladders as this was more complex. The session closed with a frank statement by Dr Jay Smith, “It is unlikely any substantial difference in outcome will emerge between robotic vs open cystectomy”. However, he felt robotics was here to stay, as it was doubtful if the next generation of urologists would have the skills to obtain high-level open cystectomy results.
The plenary then resumed with the theme on PSA testing, and started with a panel discussion on tests to distinguish aggressive from non-aggressive prostate cancer before biopsy. Dr John Wei (@jtwei88) from @umichurology, spoke about the Michigan Prostate Score (MiPS) – a composite score consisting of three tests: PSA, urine T2:ERG gene fusion, and urine PCA3 level. Later on, to a jam jam-packed hall, Dr Penson (@urogeek), from Vanderbilt, delivered a state-of-the-art lecture on PSA testing guidelines. This excellent talk generated lots of Twitter traffic, which is illustrated in the Twitter-gram.
Wednesday – take home messages and wrap-up
The final day was not as busy as the other days as most delegates and all exhibitors had left. I too had to get back to work, but I was still able to catch up with #AUA14 via the twittersphere (thanks @chrisfilson). The best of the tweets from this last day are depicted in the final twitter-gram. I also recommend @cbayneMD for his top 5 conference highlights.
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Twitter-gram 4: final day
Overall, #AUA14 has been a fantastic conference, where records were set for Twitter participation and engagement in a urological meeting. I am still recovering!
Khurshid Ghani
University of Michigan, Ann Arbor, USA
@peepeeDoctor
Social media traffic broke all records at #AUA14 with over 1100 participants sending over 10,000 tweets and making almost 14 million digital impressions.
Kamran Ahmed and Oliver Brunckhorst
Surgical simulation has advanced tremendously over the last two decades with the development of laparoscopic and robotic surgery. Because these procedures have a steep learning curve and because of the reduced training times experienced by trainees, safe adjuncts to operating room training are required [1]. Simulation training is a novel approach to surgical training and has been validated as a training and assessment tool and has been shown to improve a surgeon’s performance in the operating room.
In the present paper, Ramos et al. [2] evaluate the face, content, construct and concurrent validity of robotic dry laboratory (dry lab) exercises. They developed similar tasks to those included in the validated virtual reality da Vinci Skills Simulator using the da Vinci Surgical System in a dry lab environment. They also explored the applicability of Global Evaluative Assessment of Robotic Skills (GEARS) to assess dry lab performance. Good responses from the expert cohort with regard to realism and usefulness as a training tool confirmed the face and content validity of the dry lab exercises, whilst concurrent validity was also established, with experts outperforming novices in all but one of the individual metrics. Finally the simulator composite score achieved from the virtual reality simulator and GEARS scores from the dry lab exercises moderately correlated, thereby also establishing concurrent validity.
The present study raises an interesting question about the definitions of what constitutes an expert in robotic surgery. There are no consistent definitions of a ‘novice’ or an ‘expert’. A recent review has shown that the learning curve in the literature varies from 80 to 250 cases in robot-assisted laparoscopic prostatectomies, depending on previous open or laparoscopic experience and the outcome measures used [1]. With this in mind, Ramos et al. classified ‘experts’ as those performing >30 cases as the primary surgeon. This should be taken into consideration as the experts were so vital in establishing the face, content and construct validity of the dry lab curriculum. Additionally, although it has been shown that simulation models are valid and reliable for the initial phase of training and assessment in urological procedures, this is not the case for advanced and specialist level skill learning.
The present study provides validated dry lab exercises which could be incorporated into a robotic surgery training curriculum. With several simulators now having been validated for robotic surgery, integration of these within a structured robotic surgery curriculum is required. Steps have been taken to set out an effective curriculum similar to that which exists for laparoscopic surgery. The Fundamental Skills of Robotic Surgery is a simulation-based curriculum which has been validated and has a proven educational impact [3]. The Fundamentals of Robotic Surgery curriculum has also recently been laid out, but this is still in the process of validation [4]. One of the biggest initiatives in urology, however, was recently announced by the European Association of Robotic Urology Section Congress 2013 [5]. A multinational push to implement a standardized curriculum set out a multi-step curriculum which uses various techniques, including online theoretical training, simulation and observation and finally fellowship prior to certification, then allowing the surgeon to perform independent surgery. The next step for these curricula is for them to be fully validated and implemented, with the patient outcomes then being analysed.
Another aspect worth considering is the integration of non-technical skills within these curricula which has occurred in few of them. Full-immersion simulation (Fig. 1) offers the opportunity for training surgeons to develop critical skills such as communication, coordination and leadership. For the more experienced surgeon, at the later stages of a curriculum, full crisis simulation can help develop decision-making and team-working skills in difficult situations. It has been shown that integration of full-immersion simulation in simulation training is feasible and effective [6]. Surgeons performing robotic surgery need to develop the non-technical aspects alongside their technical skills, and full-immersion simulation certainly has a role to play in this and needs to be integrated within the curricula. The development of the Distributed Simulator offers a validated and low-cost method [7] of introducing full-immersion simulation into robotic surgery curricula and is an option that requires further investigation for its effectiveness in urology.
Figure 1. Aspects of non-technical skills developed through full-immersion simulation [8, 9].
In conclusion, the present study offers further examples of tasks that could be incorporated into robotic surgery training curricula. Whilst curricula exist, implementation and analysis of their effect on patient outcomes are the next steps. The integration of non-technical skills within these is important, and full-immersion simulation has an important role to play within robotic training curricula.
Kamran Ahmed*† and Oliver Brunckhorst*†
*MRC Centre for Transplantation, King’s College London, King’s Health Partners, and †Department of Urology, Guy’s Hospital, London, UK
References
As my flight descends into the home of Walt Disney and make believe in sunny Borelando, I can’t help wonder how #AUA14 will compare to the outstanding #EAU14 meeting held just one month ago. A great meeting requires equal parts place and content, and although Stockholm is without peer, there must be a reason Orlando is the third most visited city in the U.S., right? The solution to that mystery is for another day; ask elsewhere, as I have no idea. Review of the agenda on the #AUA14 app gives hope for this meeting. There is more quality scientific content than one can possibly absorb, and highlights include the new “Crossfire” program to address controversies in urology, the John K. Lattimer Lecture by Dr. Anthony Fauci (director of the National Institute of Allergy and Infectious Diseases), the Town Hall on imaging, simulation and animation (with speakers from Hollywood who make make-believe a reality and a living), #SUO14, and the release of three new AUA Guidelines on urotrauma, medical management of stones, and cryptorchidism.
Friday afternoon kicked off with the new “Crossfire” section featuring debates on a number of heated urology controversies. Debate topics included the use of synthetic slings for stress urinary incontinence (SUI), the role of urologists in administration of therapy for advanced and metastatic prostate cancer, and the probably overly discussed topic of open versus robotic surgery (for both partial nephrectomy and radical prostatectomy). In favor of synthetic mid-urethral slings for SUI, Drs. Kennelly and Rovner presented a wealth of data showing the efficacy of slings in both the short and long term. Drs. O’Connell and Blaivas countered that the pubovaginal fascial sling provides a safer alternative, with less potentially significant complications that far outweigh the benefits of having the operation.
Drs. Nelson and Lepor then argued in favor of open prostatectomy, which drew some colorful tweets:
Drs. Tewari and Menon presented compelling arguments for robotic prostatectomy, and while it is hard to declare a winner, the majority of urologists in the U.S. perform robotic assisted prostatectomy; the panelists stressed that outcomes depend more upon the surgeon than the technique, and people should perform whichever approach they are most comfortable with.
The robotic versus open debate then shifted to kidney surgery, with distinguished faculty Drs. Gill and Uzzo debating “minimally invasive partial nephrectomy is the new gold standard for renal cancer”, while Drs. Blute and Libertino argued in favor of open surgery. Although both sides had thought provoking arguments, presented data were all limited by their retrospective designs, institutional experience, or lack of validation. In my opinion, even with high volume surgeons, most patients with highly complex tumors or a renal mass in a solitary kidney undergo open surgery, which implies selection bias that limits the generalizability of robotic or laparoscopic partial nephrectomy. As contemporary experience with robotic surgery grows, we can anticipate that more complex lesions will be approached via MIS techniques in the future. We always love to throw in “randomized clinical trials are needed”… although I do think that IDEALLY prospective evidence would be great, however a clinical trial comparing MIS partial Nx to open techniques will be fraught with accrual challenges and are most likely not expected in the near future. Until more definitive prospective evidence is available, decisions regarding the optimal surgical approach for the renal mass should be determined by individual patient and surgeon preference, experience and comfort level.
Following the debate, Dr. Todd Morgan nicely summarized audience sentiment:
Dr. Declan Murphy provided perhaps the best sage advice regarding robotic versus open surgery:
Social Media continues to grow in urology, and Friday evening concluded with a wonderful party hosted by the AUA (@Americanurol) for the “UroTwitterati”. There was a great turnout, and #SoMe heavy hitters: @daviesbj, @declangmurphy, @dr_coop, @qdtrinh, @TheUrologist, @LoebStacy, and @Tdave attended along with “wannabe” youngsters (your current bloggers, @UROncDoc and @RMehrazin). The beauty of #SoMe is that it even allows members to participate in the meeting from home, including @uretericbud and @dytcmd. Urologists should sign up for a Twitter account and join. It is very engaging and addictive!
The jam-packed schedule continued on Saturday morning with the annual residents forum, during which the resident teaching award was awarded to Dr. Robert Uzzo from Fox Chase Cancer Center.
A variety of sections and societies also held meetings on Saturday. At the Association of American-Iranian Urologists, panelists Drs. Ghavamian and Samadi discussed the role of focal therapy in prostate cancer.
The remainder of Saturday was largely filled by the Society for Basic Urological Research and Society for Urological Oncology annual meetings. One highlight of the #SUO meeting was Dr. McDermott’s presentation on anti-PD-1 agents in kidney cancer. In a phase 1 RCT, Nivolumab (anti PD-L1 agent) showed efficacy for patients with metastatic RCC (n=34). There was a 29% objective response rate with a median progression-free survival time of 7.3 months. The drug was well tolerated with minimal severe adverse events, and remarkably, treatment free survival was achieved in a few patients. Immunotherapy represents an exciting and novel way target kidney cancer, and may well help usher in the era of personalized targeted therapy.
On Sunday, multiple poster and podium sessions were occurring simultaneously, which makes it hard to attend and see everything. The discussion on Twitter via #AUA14 made it possible to capture highlights from simultaneous sessions. During the Plenary session on Sunday, Dr. Fauci, Director of the National Institute of Health, Allergy and Infectious Disease Division, gave the annual Lattimer lecture. AIDS is an important topic for urologists because several aspects of the disease are specific to urology. “For example, the role of STD’s in increasing the transmissibility as well as the vulnerability of getting infected with HIV, the potential role of HPV vaccine in preventing HIV infection, and the importance of urologist issues associated with the drugs HIV patients are taking, including stones, renal insufficiency, voiding dysfunction, and erectile dysfunction,” remarked Dr. Fauci.
John P. Mulhall, Director of Male Sexual Health and Reproductive Medicine at Memorial Sloan Kettering Cancer Center, delivered the plenary state of the art lecture on radiation induced erectile dysfunction. It is an important topic, because “there are an increasing number of urologists who have hired a radiation oncologist or have a stake in an IMRT unit or do brachytherapy in their practices”, remarked Dr. Mulhall. “The pathophysiology of ED after pelvic radiation is very similar to that after radical prostatectomy based on three factors: nerve injury, arterial injury, and smooth muscle injury”.
The new AUA clinical guideline for cryptorchidism was also presented at the plenary session on Sunday. The highlights of the guideline:
Your bloggers,
Reza Mehrazin, M.D. and Jeffrey J. Tomaszewski, M.D.
Fox Chase Cancer Center, Philadephia, PA
Twitter @rmehrazin and @UROncDoc
Wednesday morning, the 14th May 2014, John M Fitzpatrick passed away aged 65. He left this life the way he lived it, in the fast lane. Taken ill at home in his own gym, where he was honing his fitness with his personal trainer, he was rushed by ambulance to hospital, where he died within hours from a massive subarachnoid haemorrhage. This blog in the BJUI, the journal he edited, championed and loved so very much, is a celebration of his life, and an opportunity for those who knew him to post their own special memory of him, and to contribute a tribute to one of the truly great international characters of urology.
John’s career was an illustrious one. He trained in Dublin, and then in London, where for a time he lived in a house in fashionable Chelsea, just off the King’s Road. He worked with the “greats” of British urology: John Wickham, Richard Turner-Warwick and John Blandy and was always positive and enthusiastic about his time at the famous St Peter’s Hospitals and the Institute of Urology.
Returning to his beloved Dublin, in 1986, aged 38, he successfully applied for the post of Professor of Surgery and proceeded to build up an outstanding department of urology and latterly, with the assistance of the wonderful Bill Watson, created a quite exceptional research unit. He was most proud of his international standing as possibly the world’s best-known urologist (apologies to Dr Patrick Walsh!). He certainly was the most travelled, clocking up untold millions of Air Miles in his favourite seat 2A in the British Airways First Class cabin, and a welcome guest wherever he arrived.
Things, as Richard Turner-Warwick was fond of saying, don’t just happen; they have to be made to happen. Among other things, John did sterling work in helping Bill Hendry and me to create The Urology Foundation (TUF) in 1994, by negotiating £250,000 grants from BAUS and the BJUI. He did a magnificent job as Chairman of the Scientific Committee, Trustee and Patron to help us create a thriving charity. TUF continues to do amazing work to support training and research in urology in the UK and Ireland. He adored being President of BAUS, St Peter’s medal winner and visiting professor to almost 100 academic institutions in North America.
I have too many positive memories of John to regale you with here. Climbing Kilimanjaro (he never tired of reminding me that he reached the summit well before me), trekking in Nepal, cycling in Sicily, Malawi and Madagascar. John was always “up for it”. Another boast of his was that he never misjudged people; but everywhere he went he made friends, took interest in everyone he met and communicated in his own unique, eloquent and quintessentially Irish style.
Sadly, none of us had the opportunity to say goodbye to John. He slipped away from this life, just as he did from so many international meetings, a little early, anxious to move on to the next challenge. My own particular farewell was a few weeks ago at a TUF dinner at the famous and historic Vintner’s Hall in London, where John was in his element talking to Jane MacQuitty, wine correspondent of the Times, about the merits and demerits of a variety of fine wines. With a strange prescience, he told me as he left for the airport the next day that he had enjoyed every moment of his life as a surgeon, scientist and communicator, and that always he really loved the very special world of urology.
Like me, John loved Shakespeare, so I will finish this blog with an apposite quote from the Bard:
His life was gentle, and the elements
So mixed in him that Nature might stand up
And say to all the world, “this was a man!”
When comes such another?
Farewell loyal friend Fitzy, we loved you and we will miss you badly.
Roger Kirby, The Prostate Centre, London
REGISTER FOR THE INAUGURAL JOHN FITZPATRICK IRISH PROSTATE CANCER CONFERENCE
An interview with John M. Fitzpatrick
BJUI December 2012; Volume 110, Issue 11
Click here to see a short video on the challenges the TUF cyclists in India faced https://trendsinmenshealth.com/video/tuf-cycle-india-2016/
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This colourful picture is of a multicolour FISH analysis in non-muscle invasive bladder cancer.
Image from Matsuyama et al. BJU Int 2014; 113: 662–667
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My wife recently dropped and smashed her iPhone screen. She didn’t have insurance, and on consultation with her phone provider was told that her only option was to purchase another phone as she was locked into a lease contract. Our initial annoyance was then amplified when we discovered that we could just have the screen fixed privately for a fraction of the cost and effort, which we duly had done.
I began to think of the old Henry Ford adage (1910) in relation to his legendary Model-T edition car “You can have it in any colour as long as its black”, and wondered how often we as urologists might be criticized of adopting a similar approach with patients in their clinics.
Urology has always been a very progressive surgical specialty. Developed in 1909, TURP was the first successful, minimally invasive surgical procedure of the modern era. The first laparoscopic nephrectomy for a renal mass was carried out in 1991 in Johns Hopkins, surprisingly around the same time as the development in robotic (PROBOT) technology for use in urology (Murphy et al. 2006). As technology advanced, fellows and consultants became more sub-specialized in tandem with this change, leading to the large repertoire of treatment options and modalities available today. However, somewhere along the way with the vast change in the playing field, there appeared a concerning pattern of failure to discuss all treatment options with patients, or to refer them to other institutions which may/may not have provided an alternative treatment path. This trend, which is not oncology-specific, can be seen across a number of sub-specialty areas such as the management of renal masses, PUJ obstruction, radical prostatectomy, reconstruction post cystectomy, and even in paediatric urology with hypospadias repair being a classic example.
The question remains as to the reasons why one would not choose to cross-refer. Allowing for variables such as patient choice or consumerism, non-established or experimental procedures, and for urologists that may be financially or institutionally coerced into only providing certain treatments, the concept of not providing cross-referral brings into question whether this is perhaps down to financial considerations, a belief that referrals will not be reciprocated back, leading to a reduction in patient base and de-skilling, or a strong sense of paternalism where the urologist genuinely feels that they can offer a superior treatment package. This theme has previously been shown by Miller et al. who described how many patients with kidney cancer were offered treatment based on the surgeon’s practice style rather than on the characteristics of their disease.
However, given a choice of a number of options, it has previously been shown many times, that patients are more likely to build a strong rapport with the first specialist clinician they meet, and therefore likely to revert back to the first treatment option. Perhaps a lack of cross-referral is based on a pre-emptive sense of patient autonomy. Often the greatest power of autonomy is relinquishing it, and letting the consultant decide the best course of treatment offers the greatest solace. Despite the optimism and favorability of newer technology and techniques, and a general demand for minimally invasive procedures (Duchene et al. 2011), no-one is simply advocating technology for its own sake, or that a robotic-assisted circumcision could be currently seen as acceptable, however the idea of communication, cross-referral and the confidence in asking for further sensible treatment options should always be embraced.
In many ways, our annoyance with the mobile phone screen could have been avoided had the mobile provider been honest, and provided us with further options. It may not have stopped us from fixing the screen elsewhere due to institutional constraints however; a rapport and confidence would have been maintained.
One would do well to find a specialty in which the addition of a constructive (competitive) second opinion has not driven progress. Cross-referral is not a matter of failure, nor a lack of progress, but a continued determination to ensure the highest level of patient care available, to improve patient perception of the specialty as one committed to open communication, and a means to foster concrete inter-institutional relationships. Should we have to document that a second modality opinion was at least sought by the specialist, or waived by the patient?
“The single biggest problem in communication is the illusion that it has taken place” – G.B. Shaw
Fardod O’Kelly is a Specialist Registrar in Urology at AMNCH, Tallaght, Dublin 24, Ireland. Twitter @FardodOKelly
Over the past several years, with publications of studies evaluating multiple aspects of nephrolithiasis using large databases, our overview of kidney stone disease has vastly expanded. The most recent addition by Armitage et al. [1], published in this issue of BJUI, gives us a view of percutaneous nephrolithotomy (PCNL) outcomes in England that we otherwise would have difficulty seeing without tapping into a database study. Several salient features of this investigation are worth pointing out.
With any study comes the uncertainty of its validity. Evidence-based medicine (EBM) theory dictates we first ask ‘Are the results valid?’ rather than ‘What are the results?’. This study reports similar outcomes to a prior database study of the BAUS, giving us confidence that data from different sources still produce somewhat similar outcomes, hence adding validity to both studies [2]. Moreover, it is further reassuring that the type of epidemiological source of the information was derived from completely different origins, i.e. Armitage et al. [1] used an administrative database from Hospital Episode Statistics (HES) to create their outcomes while the BAUS used a voluntary online prospective database for British surgeons.
The second question that forms the basis of EBM is ‘What are the results?’. The HES data confirmed several findings of PCNL seen in other studies, including in both international series from the Clinical Research Office of the Endourological Society (CROES) as well as American administrative database studies using the Nationwide Inpatient Sample (NIS) [3-5]. Overall complications occur anywhere from 6% to 15% of the time, with the most common complications including infection and bleeding. Compared with these recent studies, the HES study reports lower bleeding, UTI and sepsis rates, which the authors admit could represents an under-reporting phenomenon. Mortality is an exceedingly rare event in all these studies. Overall, complication rates are comparable and give us assurance that they align approximately with other worldwide data. Another important finding with the HES database is the decreased length of stay for patients over time. Lastly, from a physician credentialing standpoint this study has relevant findings. It suggests that the HES administrative database may be a viable source of information to assist in the surgeon validating process.
Weaknesses of administrative database studies include the lack of detail that prospective clinical databases provide. Clinically pertinent PCNL endpoints are inherently absent for both patient and surgical domains. Missing patient information includes stone size, stone-free rates, and patient obesity, which are all reflections of clinical case difficulty. Missing critical surgical information includes where (upper, mid or lower calyx), who (urologist or radiologist) and how (balloon, serial dilators) access is obtained. As mentioned above, the uncertainty of under-coding clinical information always exists.
Why are large database studies, including this article, important? These studies are timely given the recent advocating of retrograde ureteroscopic treatment of large renal calculi [6]. Publication of low complication rates with equal efficacy in an outpatient setting has made ureteroscopic treatment of partial and staghorn renal calculi attractive. Even laparoscopic anatrophic nephrolithotomy has been advocated to further challenge the ‘gold standard’ treatment of PCNL [7]. It is therefore clinically important that British PCNL complication rates are low and that length of stay is decreasing to affirm the role that PCNL has with large renal calculi.
The role of PCNL surgery for renal calculi continues to develop but, more importantly, the value of these large epidemiological studies also continues to grow. They help us to look not only from the ground level but also give us perspective from a different, if not ‘higher’ level, which taken together helps shapes our interpretation of PCNL.
Department of Urology, UC San Diego Health System, San Diego, CA, USA
References
This month’s twitter-based international urology journal club discussed “Impact of Medical Treatments for Male LUTS due to BPH on Ejaculatory Function: A Systematic Review and Meta-analysis”, published online in the Journal of Sexual Medicine. The discussion was enriched by the participation of Asst. Prof. Giacomo Novara (@giacomonovara) of the University of Padua, the senior author of the paper.
There was general consensus that this was a well constructed paper addressing an important and sometimes neglected side-effect of a group of medications that most urologists use commonly. The principal messages of the paper were:
The authors were congratulated on the amount of work that had obviously gone into the analysis. There was a discussion of some of the technical aspects of how to conduct a systematic review (SR) and meta-analysis. The PRISMA guidelines are a mandatory standard, and are recommended to anyone considering undertaking one. @LoebStacy also recommended the Cochrane handbook as a useful source of info. @DrHWoo asked whether Jadad scores had been used to rate RCT quality. They were not used in this study, but are one method of assessing RCT quality for an SR. @chrisfilson and @jleow advocated the Cochrane Collaboration’s tool for risk of bias assessment (found in Section 8.5 of the handbook), as an alternative.
After the technical aspects, discussion focussed on how best to avoid EjD in men who are concerned about it. @linton_kate asked whether PDE5 inhibitors were an option in this regard. General consensus was that they are an option, especially where LUTS and erectile dysfunction (ED) coexist, but concerns were expressed about the cost (which varied country by country, but is generally far in excess of the cost of ABs) and by @nickbrookMD about the uncertainty surrounding their mechanism of action for LUTS improvement.
Several correspondants were using PDE5Is in clinical practice for this indication however, including @VMisrai. It was pointed out however, that alfuzosin also offers a reduced risk of EjD compared to other ABs, and is substantially less expensive than PDE5Is. Alfuzosin was not evaluated in this paper, however @giacomonovara agreed that it was an option in men with LUTS who wish to avoid EjD, especially where ED is not a concern. @DrHWoo pointed out the Rosen data demonstrating the correlation between increasing LUTS and decreasing erectile function, but indeed (as suggested by @JCLinMD) treatment of LUTS, e.g. with an AB, may in itself improve erectile function.
Discussion moved on to 5ARIs. @giacomonovara stated that these agents had a broad spectrum of potential effects on ejaculatory/erectile function. @shomik_S raised the issue of whether 5ARIs could cause irreversible sexual side-effects. This is certainly a medicolegal concern, and undoubtedly some men report persistent effects on libido and sexual function, although a firm causal link has not been established.
The medicolegal theme was further explored with a discussion on what to warn patients of when commencing these medications. All were agreed that patients commencing ABs/5ARIs, including those undergoing medical expulsive therapy for stones should be warned about EjD. There was some discussion however, about whether patients commencing a 5ARI should be warned about the increased rates of high-grade prostate cancer seen in the PCPT and REDUCE trials. This increase may be an artefact of more effective cancer detection, but none-the-less @loebStacy was of the opinion that it should be included in pre-treatment counselling.
But is all the concern about sexual side-effects justified? It was pointed out that many patients are prepared to tolerate sexual side-effects in return for improvement in their LUTS.
Regardless, this paper from @giacomonovara and co-authors provided useful insight and stimulated a valuable discussion. Undoubtedly, some patients are very concerned about EjD and this paper will help all urologists who treat male LUTS to address these concerns.
Winner of the Best Tweet Prize was David Gillatt for his response to the discussion regarding the needs of various nationalities for PDE5I. Special thanks to the SIU for offering a prize of free registration to the 2014 SIU Congress in Glasgow. Also special thanks to Wiley for allowing open access of the article for the May #urojc discussion.
Ben Jackson has completed urological training in the East Midlands, and is now undertaking a fellowship at St. Vincent’s Hospital, Sydney. His principal clinical interest is urologic oncology.
Twitter @Ben_L_Jackson
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