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Editorial: Radical cystectomy: how do blood transfusions affect oncological outcomes?

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Kluth et al. [1] have conducted a large retrospective study from several institutions in North America and Europe to assess the impact of blood transfusion on oncological outcomes after radical cystectomy (RC) for bladder cancer. The hypothesis for a negative impact of transfusion on oncological outcomes stems from the observation that renal allograft survival is prolonged after pre-transplant blood transfusions because of its immuno-modulatory effects [2]. This finding prompted Gantt [3] to express concern about the possible adverse effects of transfusions in patients being treated for cancer. Since then, there have been numerous publications addressing this issue in various surgical journals including those of urology with conflicting messages.

Sadeghi et al. [4] queried the Columbia University Urologic Oncology Database. This included 638 patients undergoing RC between 1989 and 2010. Of these, 209 (32.8%) received perioperative blood transfusions. On univariate analysis, the number of units transfused was inversely related to overall and cancer-specific survival. However, on multivariate analysis, it did not prove to be an independent predictor of cancer-specific survival.

As the authors highlighted in this paper, Linder et al. [5] reported a large series of patients from the Mayo Clinic, which included 2060 patients undergoing RC over 25 years. Of this large cohort, 1279 (62%) received perioperative blood transfusion with adverse outcomes, not only in terms of overall and cancer-specific mortality, but also postoperative tumour recurrence.

RC is one of the most major surgical procedures performed in urological surgery. The vast majority of patients with bladder cancer requiring RC are in their mid-sixties, overweight and have several co-morbidities. Some of these patients present late and are anaemic at presentation.

Blood loss during open RC varies depending upon surgeons’ experience, patients’ body mass index, disease stage and availability of modern equipment, e.g. LigaSure™ or stapling devices. Blood transfusion may be required because of pre-existing anaemia or excessive blood loss during surgery. Variations exist in thresholds of anaesthesiologists and the surgeons for transfusions. All of these factors account for variation in reported frequency of transfusion rates for this operation and this is well reflected in many large series of RC.

As there are many confounding factors that may influence overall and cancer-specific survival in patients undergoing RC including stage of the disease, histological nature of the tumour, lymph node status and competing co-morbidities, it is very challenging to control for these factors in retrospective series. Hence, prospective well-controlled multicentre studies are the only way forward to answer this question.

While we await robust evidence on the influence of perioperative transfusion on oncological outcomes, several potential options could be explored to avoid homologous blood transfusion. These include preoperative optimisation of haemoglobin levels through iron infusions, administration of erythropoietin where appropriate, and preoperative autologous-banking. Intraoperatively meticulous surgical technique, use of modern devices, e.g. LigaSure/stapler and Cell Savers, could be used to avoid homologous blood transfusion.

Fortunately, these studies aimed at raising awareness of potential risks of transfusions are appearing in the urological literature at a time when urologists are moving away from open to minimally invasive oncological surgery with a steady decline in the need for perioperative blood transfusion. This is one of the important steps in the right direction and will have a major impact on the need for blood transfusion in foreseeable future.

Muhammed S. Khan
Department of Urology, Guy’s Hospital and King’s College London School of Medicine, London, UK

Read the full article

References

  1. Kluth LA, Xylinas E, Rieken M et al. Impact of perioperative blood transfusion on the outcome of patients undergoing radical cystectomy for urothelial carcinoma of the bladder. BJU Int 2014; 113: 393–398
  2. Opelz G, Sengar DP, Mickey MR, Terasaki PI. Effect of blood transfusions on subsequent kidney transplants. Transplant Proc 1973; 5: 253–259
  3. Gantt CL. Red blood cells for cancer patients. Lancet 1981; 2: 363
  4. Sadeghi N, Badalato GM, Hruby G, Kates M, McKiernan JM. The impact of perioperative blood transfusion on survival following radical cystectomy for urothelial carcinoma. Can J Urol 2012; 19: 6443–6449
  5. Linder BJ, Frank I, Cheville JC et al. The impact of perioperative blood transfusion on cancer recurrence and survival following radical cystectomy. Eur Urol 2013; 63: 839–845
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Future Proofing Urology – Conference Highlights from the USANZ ASM 2014

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Dr Marnique Basto (@DrMarniqueB) 

 

 

Delegates of #USANZ14 received a sunny welcome at this year’s 67th annual scientific meeting in Brisbane, affectionately coined by Aussies as ‘Bris-vegas’ attributed to a love of Elvis and the city’s growing live music scene. The reins were passed from Professor Damien Bolton and A/Professor Nathan Lawrentschuk (@lawrentschuk) who convened last year’s ASM in Melbourne to Greg Malone (@DrGregJMal) and Eric Chung. @BJUIjournal Editor-in-chief Prokar Dasgupta (@prokarurol) praised the USANZ organising committee for their tremendous hospitality.

A star studded international faculty made the long-haul down under including Shahrokh Shariat, Alan Partin, Gerry Andriole, James Eastham, Rainy Umbas, Per-Anders Abrahamsson, Monique Roobol, Hein Van Poppel, Jean de la Rosette, Gerald Brock, Brad Leibovich, Gary Lemack, Tom Lue, Jonathan Coleman, Michael Jewett, Oliver Traxer, Eric Small, Adrian Joyce, Roger Kirby, Gopal Badlani, Sunil Shroff, Eila Skinner, Jaspreet Sandhu, Matthew Rettig, Pilar Laguna, Jaime Landman, Irwin Goldstein, Todd Morgan and Gregor Goldner.

The hype around #USANZ14, however, had kicked off well before conference doors opened with @USANZUrology mounting the largest pre-conference social media (SoMe) campaign of any Urology conference internationally to date. Over 200 tweets were generated in the five-day lead-up from the @Urologymeeting account, doubling last year’s efforts of the social media team at the Prostate Cancer World Congress in Melbourne. It’s fair to say Australia is setting a blazing pace in the use of SoMe to amplify the Urology conference experience and generate international engagement and global reach.

“Future proofing urology” was the conference theme this year to promote and foster multidisciplinary collegiality and evidenced urological practice. The theme was entwined throughout the four-day conference with the final day showcasing a multidisciplinary forum with international experts discussing complex cases. Additionally the Australian and New Zealand Urological Trials (@ANZUPtrials) session highlighted the interplay between urology, radiation and medical oncology and the current trials underway. 

USANZ president David Winkle officially opened conference proceedings and we had the honour of Scottish-born Australian Scientist Professor Ian Frazer AC, the mastermind behind the Human Papilloma Virus vaccine and the fight against cervical cancer, deliver the Harry Harris oration. Professor Frazer’s ongoing dedication to implementing vaccination programs in low GDP countries such as Vanuatu and Butan was truly inspirational. Harry Harris was the first full time Urology specialist in Australia, and suitably the award of the seven newest fellows of the USANZ collegiate followed. Congratulations to all.

A lively point-counterpoint debate on the viability of prostate cancer prevention then ensued between Shahrokh Shariat (@DrShariat) on the negative and Gerald Andriole (@uropro) on the affirmative. Interestingly both parties used the same sets of data to reach opposite conclusions. The ability to use the opposition’s prior publications against them became the clincher in several of the debates throughout the conference; however, it was the ‘no show’ of hands from the audience when asked “who currently uses chemoprevention?” that reinforced the inevitable conclusion.

The BJUI session was then underway and A/Prof Nathan Lawrentschuk, Associate Editor of the BJUI USANZ supplement, outlined his vision for the journal going forward. The winner of the BJUI Global Prize awarded to a trainee who significantly contributed to the best international article went to Dr. Ghalip Lidawi for his paper titled ‘High detection rate of significant prostate tumours in anterior zones using transperineal template saturation biopsy’. In an Oscar-style award ceremony Dr Lidawi was broadcast from Tel Aviv. Professor Alan Partin (@alan_partin) went on to deliver a brilliant and balanced rationale behind why Gleason 6 IS prostate cancer and potentially coined the alternative name PENIS (‘Prostatic epithelial neoplasm of indeterminate significance’).  News of ‘PENIS of the prostate’ hit social media channels instantly with Urologists chiming in from the US to give their opinion within minutes and before Dr Partin had even stepped down from the podium.

Dr. Ghalip Lidawi accepting his BJUI Global Prize via video message (photo courtesy of Imogen Patterson).

After the opening plenary each morning, the 950 delegates were treated to a range of concurrent sessions from the faculty, which included localised prostate cancer, endourology, andrology/prostheses, high risk prostate cancer, LUTS/BPH, prostate cancer multidisciplinary forum, urology general, bladder cancer, kidney cancer and abstract poster presentations. There was a concurrent nursing program also running during the USANZ schedule that proves year after year to be a huge success.

A stand out session of the meeting was on high-risk prostate cancer section on Monday afternoon. Professor James Eastham (who is rumoured to have just joined twitter!) discussed the role of pelvic lymph node dissection (PLND) for diagnostic and therapeutic purposes with reference to the Memorial Sloan Kettering (MSK) experience and the role of salvage PLND after radical prostatectomy for choline PET detected retroperitoneal or pelvic node recurrence. Professor Hein van Poppel went on to support the role of surgery in high-risk disease in this session, while Drs Shariat and Per Anders Abrahamsson discussed the latest in hormonal adjuvant therapy. 

What makes USANZ special?

The abstract submissions this meeting far superseded last year in volume and quality requiring two concurrent poster presentation sessions running most of the conference. The use of transperineal template biopsy was a prominent theme again in the abstract series, as was active surveillance for low risk prostate cancer. Pleasingly we saw the development of large international collaborations involving Australia such as the Vattikuti Global Quality Initiative on Robotic Urologic Surgery where Mr Daniel Moon has collaborated with nine hospitals throughout Europe, North America and India on their growing robotic partial nephrectomy series. 

Each year a select group of our young talented trainees compete for the prestigious Keith Kirkland (KK) clinical and Villis Marshall (VM) basic science prizes. This year Dr Kenny Rao (@DrKennyRao) was awarded the VM prize from a field of five candidates for his work titled ‘Zinc preconditioning protects the rat kidney against ischaemic injury’. Dr Helen Nicholson (@DrHLN) took out the KK prize over 10 other candidates for her work; ‘Does the timing of intraoperative non-steroidal anti-inflammatory analgesia affect pain outcomes in ureteroscopy? A prospective, single-blinded, randomised controlled trial’. These were awarded at the gala ball located at the Brisbane townhall, a venue soon to be filled by some of the most prominent in the world for the G20 summit. Other awards on the night included the Alban Gee for best poster to Shomik Sengupta (@shomik_s), the BAUS trophy (@BAUSUrology) to Michael Holmes and the Abbvie Platinum award to Niall Corcoran.

Unlike any other Urology meetings worldwide, the USANZ ASM is compulsory for all trainees from their third year on and is encouraged in the first two years. Trainees were treated to a breakfast meeting with Dr Shahrokh Shariat who imparted 14 career tips and then assisted @lawrentschuk in grilling trainees on difficult case studies in preparation for their fellowship exams. A brilliant learning opportunity! Trainees also got to meet one-on-one with international faculty members of their choice to facilitate potential future fellowships in somewhat of a staged ‘speed-dating’ affair – 10 minutes chat, then move on. To top off the trainee program, the @BJUIjournal delivered an extremely practical and useful workshop focussed on getting published in the digital and social media era where blogs are encouraged, tweets are citable and your CV now contains a social media section.

A SoMe session attracted a lot of attention from international delegates and twitter activity on the #USANZ14 hashtag skyrocketed as we were joined by Stacy Loeb (@LoebStacy) in Moscow, Alexander Kutikov (@uretericbud) in the US and Rajiv Singal (@DrRKSingal) in Canada. Declan Murphy (@declangmurphy), Henry Woo (@DrHWoo) and Todd Morgan (@wandering_gu) put on a masterful (and non-nauseating) prezi display with the audience taken on an e-health journey of novel gadgets and devices including one that measured tumescence and sends the file automatically to the physician records. The possibilities are endless! Twitter boards were back in force; a sign of a quality and successful conference according to @declangmurphy. The wifi at the conference venue could not be faulted!

Controversial areas of SoMe were also broached including the APRAH Advertising Guidelines that came into effect this week, Monday March 17. Australian Plastic surgeon Jill Tomlinson (@jilltomlinson) has actively opposed the guidelines that will see physicians responsible for all testimonials associated with them on the internet. The policy mandates this information be removed otherwise a fine of up to $5000 is possible, many feel this places an unreasonable burden on health practitioners to be responsible for content that they may potentially be unaware of. Read Jill Tomlinson’s letter to APRAH here.

The @BJUIJournal and its editors @prokarurol, @lawrentschuk, @declangmurphy and @alan_partin (left to right below) and off screen @drHwoo were prominent SoMe influencers of the meeting two years running. We were also delighted to have Mike Leveridge (@_theurologist) from Canada attending, one of the pioneering uro-twitterati. A mention goes out to fellow countryman @drrksingal who was again mistaken for being at the conference due to his strong SoMe presence from afar. The twitter activity for the conference period March 16 (00:00) to March 19 (23:59) generated nearly 1.4 million impressions and 2,326 tweets or approximately 344K impressions and 581 tweets per day. Based on the study conducted by our team examining metrics of all eight major urological conferences of 2013, #USANZ14 would comparatively rate second only to the AUA in the international engagement and global reach attained. Congratulations to @USANZUrology and @Urologymeeting for enhancing our conference experience and sending our message out to almost 1.4 million potential viewers in just a 4-day period. 

The BJUI Workshop featured Editor-in-Chief Prokar Dasgupta and Associate Editors Nathan Lawrentschuk, Declan Murphy and Alan Partin.

In 2015 we take a trip to Adelaide for the 68th Annual Scientific Meeting of USANZ with experts already confirmed including Steven Kaplan, Martin Koyle, Morgan Rupert, Matthew Cooperberg and Glenn Preminger. See you all there!

 

Dr Marnique Basto (@DrMarniqueB) is a USANZ trainee from Victoria who has recently completed a Masters of Surgery in the health economics of robotic surgery and has an interest in SoMe in Urology.

Check out the new BJUI Instagram feed for more photos from #usanz14 www.instagram.com/bjui_journal

 

 

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.

Image from Sabnis et al. BJU Int 2013; 112: 355–361. doi: 10.1111/bju.12164

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Editorial: mTOR-related non-infectious pneumonitis: a potential biomarker of clinical benefit?

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The study by Atkinson et al. [1] published in the present issue of the BJUI is the largest study to date to address the role of non-infectious pneumonitis (NIP) as a predictive biomarker in patients with RCC who are treated with mammalian target of rapamycin (mTOR) inhibitors. It is also the first article to correlate mTOR-related NIP with improved overall survival (OS). Until now, only radiological response as measured by RECIST and progression-free survival (PFS) had been correlated to the onset of NIP in two small retrospective studies [2, 3], but the results obtained in those studies were contradictory and, therefore, this correlation remains controversial.

While the predictive relationship between NIP and OS needs to be further investigated in well-designed prospective clinical trials, the implications of such a relationship may be significant because no predictive biomarkers for mTOR inhibitors have been validated to date. In the era of targeted therapies, the detection of biomarkers of treatment efficacy is crucial to differentiate the subpopulations of patients who are most likely to benefit from treatment. Several biomarkers, such as the development of arterial hypertension and hypothyroidism, have been correlated with improved outcomes in patients with advanced RCC treated with vascular endothelial growth factor pathway inhibitors [1]; however, there are currently very limited data regarding the potential predictors of the clinical efficacy of mTOR inhibitors. A recent study by Lee et al. [4] showed that greater increases in serum cholesterol levels from baseline in patients with advanced RCC treated with temsirolimus were significantly associated with longer PFS and OS. Interestingly, temsirolimus-related hypertriglyceridemia and hyperglycaemia were not associated with improved clinical outcomes. Although NIP or hypercholesterolaemia must still be validated prospectively to ascertain whether they are true surrogate biomarkers of pharmacodynamic effect or just confounding epiphenomena, these promising findings may be the first steps in the identification of predictive biomarkers in mTOR inhibitor therapy.

Other important aspects addressed by Atkinson et al. [1] are the uncertainty of the pathogenesis of mTOR-related NIP and the lack of clinical predictive factors. Older age and treatment with everolimus were the only significant predictive factors of onset of NIP in their multivariate analysis. Similarly, a retrospective study by Dabydeen et al. [2] showed a statistically nonsignificant higher incidence of NIP in patients with RCC treated with everolimus compared to those treated with temsirolimus. Interestingly, in a randomized phase II study testing three different dose levels of temsirolimus (25,75 and 250 mg/week) in patients with advanced RCC, none of the six patients diagnosed with NIP were in the highest dose group of 250 mg/week [5], suggesting that mTOR-related NIP might have a non-dose-dependent pathogenesis. Similarly, a meta-analysis of 2233 patients affected by different tumours including RCC treated with an mTOR inhibitor failed to show any relationship between median treatment duration and incidence of NIP [6]. Finally, underlying respiratory conditions before treatment, such as the presence of lung metastases [6], chronic obstructive pulmonary disease or smoking habit [2], were not shown to be predictive factors of development of mTOR-related NIP. Another study by White et al. [3] showed that the development of pneumonitis in patients with RCC treated with everolimus was not associated with more impaired baseline pulmonary function tests, indicating that pulmonary function tests may not help identify patients with an increased risk of pneumonitis nor predict its severity. At present, there are therefore very few pretreatment clinical predictive factors to help clinicians identify patients at higher risk of developing mTOR-related NIP.

In conclusion, given the potential value of NIP as a predictive biomarker of survival in patients with RCC treated with mTOR inhibitors, Atkinson et al. [1] suggest that efforts should be made to avoid dose reductions and treatment discontinuation whenever possible. However, predictive factors of the severity of lung toxicity are needed to identify those patients at risk of developing life-threatening NIP as the maintenance of dose intensity may be crucial for maximizing clinical benefit.

Read the full article

Alejo Rodriguez-Vida, Noan-Minh Chau and Simon Chowdhury
Department of Medical Oncology, Guy’s Hospital, London, UK

References

  1. Atkinson BJ, Pharm D, Cauley DH et al. mTOR inhibitor-associated non-infectious pneumonitis in patients with renal cell cancer: management, predictors, and outcomes. BJU Int 2014; 113: 376–382
  2. Dabydeen DA, Jagannathan JP, Ramaiya N et al. Pneumonitis associated with mTOR inhibitors therapy in patients with metastatic renal cell carcinoma: incidence, radiographic findings and correlation with clinical outcome. Eur J Cancer 2012; 48:1519–1524
  3. White DA, Camus P, Endo M et al. Noninfectious pneumonitis after everolimus therapy for advanced renal cell carcinoma. Am J Respir Crit Care Med 2010; 182: 396–403
  4. Lee CK, Marschner IC, Simes RJ et al. Increase in cholesterol predicts survival advantage in renal cell carcinoma patients treated with temsirolimus. Clin Cancer Res 2012; 18: 3188–3196
  5. Atkins MB, Hidalgo M, Stadler WM et al. Randomized phase II study of multiple dose levels of CCI-779, a novel mammalian target of rapamycin kinase inhibitor, in patients with advanced refractory renal cell carcinoma. J Clin Oncol 2004; 22: 909–918
  6. Iacovelli R, Palazzo A, Mezi S, Morano F, Naso G, Cortesi E. Incidence and risk of pulmonary toxicity in patients treated with mTOR inhibitors for malignancy. A meta-analysis of published trials. Acta Oncol 2012; 51: 873–879

 

Wearable Technology in Urology

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Wearable Technology

Everywhere I look these days, it seems like I am reading more and more about wearable technology. Earlier this year, I started using Fitbit to “quantify myself” in an effort to improve my overall health. As a urologist, I started wondering about the technology our patients might be wearing in the near future.

I did some research, and found some interesting examples of wearable technology in urology.

Diapers that Warn of Infection


We all have incontinent patients in our practice who are prone to developing recurrent urinary tract infections. When these patients begin to develop an infection, their symptoms are not always readily recognized.

Pixie Briefs are diapers with an embedded patch that tests urine for evidence of urinary tract infection. When the patient voids into the diaper, the patch on the front of the Pixie Brief is scanned with a mobile device. The data collected is automatically entered into an algorithm. When the algorithm detects evidence of a urinary tract infection, or dehydration, an alert is made. This technology is already available for infants and toddlers in the form of the Smart Diaper.

Leg Bags that Empower Patients

Foley catheters and suprapubic tubes are used in a wide variety of patients for the management of urinary retention. Many of these patients have mobility issues, I suggest the use of a high quality Folding Power Wheelchair, as due to their condition we can’t allow them to make any kind of physical effort using a traditional wheelchair, specially with their arms or their abdominal zone, otherwise the patient would be unable to sit out of bed. For these patients, day-to-day living with a leg bag can present a significant challenge.

The Melio leg bag system is designed to help these patients better manage themselves. The system consists of a leg bag with an embedded sensor, a patient controller, and a pump with extension tubing. The sensor within the Melio leg bag begins alerting the patient when the leg bag is two-thirds full of urine.  Once alerted, the patient uses the controller to activate the pump.  The pump pushes the urine out of the leg bag and into extension tubing that the patient can easily reach and readily control. The device allows patients who may have previously required assistance to empty their leg bag to have complete control over the emptying process.

Ostomy Bags with Benefits

As urologists, we are all very familiar with the surgical steps involved in creating an ostomy.

I think it’s fair to say, however, that most of us are far less familiar with the day-to-day challenges that accompany living with an ostomy.

The Ostom-i-Alert system is the brainchild of ostomate Michael Seres. This product is a sensor that clips onto any standard ostomy bag. The sensor collects data as the ostomy bag fills with urine, or bowel contents, and transmits the data to an application on the patient’s mobile phone.

The app then alerts the ostomate when the ostomy bag needs to be drained. Output data acquired by the sensor is securely stored and, if necessary, can be e-mailed to the surgeon, ostomy nurse, or any other member of the health care team.

Wearable Technology – A Growing Trend

Recently, there has been a tremendous  amount of investment, research and development, and direct patient marketing in the field of wearable medical technology. In the next couple of years, we are likely to see many more products being introduced into the marketplace.

Some of these products will undoubtedly be of help to our patients. Other products will probably just be fancy gadgets with very limited, if any, real clinical value.

As urologists, I believe we need be aware of these devices. We also need to start seriously thinking about how we are going to partner with our patients and their families to appropriately interpret, and responsibly act upon, quantified-self data.

 

Dr. Brian Stork is a community urologist who practices in Muskegon and Grand Haven, Michigan, USA.  He is a member of the American Urological Association Social Media Committee and is the Social Media Director at StomaCloak. You can follow Dr. Stork on Twitter @StorkBrian.

 

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.

Atkinson et al. BJU Int 2014; 113: 376–382. doi: 10.1111/bju.12420

These images are of patients with metastatic renal cell carcinoma who developed this complication:

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Editorial: Renal functional recovery after radical nephrectomy

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In their publication ‘Trends in renal function after radical nephrectomy: a multicentre analysis’, Chung et al. [1] suggest that after radical nephrectomy (RN), renal functional recovery in patients who have RCC occurs even in states of baseline renal functional compromise (pre-existing stage III chronic kidney disease, CKD). These findings bolster other recent reports, which suggest that surgically induced CKD may not be associated with the same degree of renal functional decline as CKD that may be caused by medical factors [2, 3]. While the incidence of de novo stage III CKD (36.1%) and delta estimated GFR between preoperative and postoperative values are lower than reported by most other groups, which may be attributable to national and demographic trends that are different from North American and European trends [2-4], the findings are nonetheless important and show that in the short-to-intermediate term (median follow up of 33 months) continued renal functional stabilisation and recovery occurs after RN. Also, performing a RN in a patient does not sentence him or her to invariable or inevitable renal functional decline in the short-to-intermediate term. Furthermore, they establish, in the short-to-intermediate term at least, a reasonable timeline of renal functional recovery for patient counselling and physician expectations in the postoperative follow-up period. Interestingly, and perhaps more disturbingly, the authors noted minimal and no functional recovery in the elderly and diabetic groups, underlying the importance for consideration of nephron-sparing approaches in these higher risk subgroups, even in the setting of normal renal function, and particularly with a lower risk lesion, e.g. a clinical T1a renal mass [5]. What we are missing from this analysis are longer term data, and a more thorough analysis of the incidence and impact of potential metabolic and cardiovascular sequelae during this period [4, 6], and a comparative analysis that examines the timeline of renal functional recovery after partial nephrectomy. Because of these reasons, the reader should be cautioned not to over-interpret these findings, and to conclude that because RN is associated with renal functional recovery, performing a RN may not pose increased long-term risk compared with a nephron-sparing method, particularly in a patient with pre-existing medical drivers towards CKD (diabetes, obesity, hyperlipidaemia, etc.). These findings are nonetheless important and provocative, and should spur further investigation and may provide an important adjunct in the counselling of patients about the functional impact of RN.

Read the full article

Ithaar H. Derweesh
Department of Urology, University of California San Diego Health System, La Jolla, CA, USA

References

  1. Chung JS, Son NH, Byun SS et al. Trends in renal function after radical nephrectomy: a multicentre analysis. BJU Int 2014; 113:408–415
  2. Van Poppel H, Da Pozzo L, Albrecht W et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2011; 59:543–552
  3. Lane BR, Campbell SC, Demirjian S, Fergany AF. Surgically induced chronic kidney disease may be associated with a lower risk of progression and mortality than medical chronic kidney disease. J Urol 2013; 189: 1649–1655
  4. Sun M, Bianchi M, Hansen J et al. Chronic kidney disease after nephrectomy in patients with small renal masses: a retrospective observational analysis. Eur Urol 2012; 62: 696–703
  5. Campbell SC, Novick AC, Belldegrun A et al. Guideline for management of the clinical T1 renal mass. J Urol 2009; 182:1271–1279
  6. Woldrich J, Mehrazin R, Bazzi WM et al. Comparison of rates and risk factors for development of anaemia and erythropoiesis-stimulating agent utilization after radical or partial nephrectomy. BJU Int 2012; 109: 1019–1025

 

To TVT or TVT-O, does it even matter?

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The March, 2014 edition of twitter-based international urology journal club discussion experienced a change of scenery as incontinence took center stage. The discussion focused on the five-year results of a randomised controlled trial (RCT) comparing retropubic versus transobturator midurethral slings for stress incontinence. The platinum priority article by Laurikainen et al. was made available open access thanks to European Urology. Special mention is also given to senior corresponding author Carl Nilsson, whose contributions were relayed via the #urojc guest account.

The prospectively registered, independent RCT was conducted across several Finnish centers. The study reported that at five-year follow up there was no difference in cure rate between the two procedures and that patient satisfaction was high. Initial discussion comments focused on the impressive length of follow up. Furthermore, the study reported that 94.8% of women (254 of 268) returned for five-year follow up.

 

The question of whether or not urodynamics should form part of the pre-operative workup of urinary incontinence was also raised. The study reported that urodynamics to investigate urgency incontinence was not performed.

The study defined a negative 24hr pad test as being <8g leakage/day. An interesting point was raised as to how this compares with the definition used post radical prostatectomy.

A limitation in the study’s methodology was highlighted.

At this point it became obvious that the usual heavyweight #urojc contributors were missing. Even the ‘King of Twitter’ was unusually silent.

The thirst for knowledge was also evident amongst practicing urologists.

 

To further shed light on the differences in complications between the two procedures, we were directed to the study’s shorter-term results. While higher complication rate following transobturator sling was statistically significant, it was not regarded as clinically significant.

We were also directed to an excellent review of the surgical management of female stress urinary incontinence.

While the results of the study show no difference between retropubic versus transobturator midurethral slings, the generalisability of this data across various populations was questioned. The mean age and BMI of patients in the study was 53 and 26 respectively.

Surgeon expertise in vaginal/prolapse surgery was an important issue especially in light of litigation.

A few take home messages
 

While this month’s #urojc discussion did not have the usual level of participation it was nonetheless a valuable conversation concerning two common sling procedures for the management of stress incontinence. Best tweet prize was an iPad app subscription thanks to BJU International which goes to Helen Nicholson (@DrHLN) for above tweet. We look forward to the next installment of #urojc in April.

Isaac Thangasamy is a second year Urology Trainee currently working at the Royal Brisbane and Women’s Hospital, Brisbane, Australia. He is passionate about education and social media. Follow him on Twitter @iThangasamy

 

 

The Urology Foundation SpRUCE course

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Last weekend, The Urology Foundation held the Specialist Registrar in Urology Consultant Education (SpRUCE) course in Birmingham. It was spread over 2 days with a networking dinner held in the evening. The course fills a significant void in higher surgical training – that which involves high quality training in interview and communication skills.

In the evening, we were joined by a faculty of senior urologists and professors and were able to network with them over dinner and drinks in a relaxed and informal way. We had an inspiring after dinner speech from BAUS vice-president, Mark Speakman, who stressed the importance of making the most of the connections we make with other urologists. He pointed out that this was not only good for personal career development, but also for patient care. Unlike communication skills trainers I have met in the past, Anna Raine and Jonathan Lermit kept the audience of 22 SpRs captivated throughout the course. They used several techniques to expose where our communication skills were deficient and then introduced us to techniques to improve them. After teaching us about the differences between making a good and an excellent first impression, we moved on to communication styles in interview scenarios. The sessions were highly interactive and our trainers involved the entire group.

The second day was more or less devoted to mock consultant interviews by a panel of urologists and nurses. This was the real highlight of the course. We were split into 4 small groups and each of us was interviewed for approximately 20 minutes. We got a realistic idea of what questions were actually asked in consultant interviews and received detailed feedback from the panel. This was invaluable as it gave a real insight into how others perceived our performance. The interviews were also filmed and we were given the discs to take home and review.

The Urology Foundation provided this course to us for free and it is an excellent example of the good work this charity does in fostering trainees. We all left having learnt a great deal about ourselves and each other and the small size of the group meant we were able to make new friends from all over the UK. I can thoroughly recommend the course to senior trainees and hope TUF continue to run SpRUCE in the future.

Ravi Barod has completed his urological training in London and is about to start a robotic surgery fellowship in the USA. @RaviBarodUrol

 

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