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BAUS 2013 Conference Report – Day 1-2

This year’s BAUS Annual Meeting was held in Manchester’s International Convention Centre and attended by almost 1200 delegates from all over the world. There has been a lot of anticipation this year following great attendance and atmosphere at the USANZ13, EAU13 and AUA13; much of the success and excitement coming from those conferences was echoed by the delegates on Twitter.

This was my first BAUS conference and I was particularly excited about my place on a urology skills course using fresh frozen cadavers, along with teaching sessions on Paediatric Urology and Urogenital emergencies and a “Walk with Experts” session around the academic posters.

The conference started with 3 parallel sessions on Monday morning:

  • Andrology and Genito-Urethral surgery key updates were discussed with a joint academic session in the afternoon to include the latest basic science research into Peyronie’s pathophysiology, artificial sperm, post-prostatectomy ED and genital tissue Bioengineering.
  • The BAUS Female, neurological and Urodynamic Urology Section focused mainly on the latest updates for urological fistulae, with other Keynote addresses over the following day covering mesh erosions and recurrent stress incontinence.
  • The Academic Session consisted of presentations from the six best abstracts submitted to BAUS this year. As our chairman Professor Dasgupta pointed out, all these presentations were based on clinical research rather than basic science. Is this a bias towards the clinical or is the standard of clinical work higher? The session finished with the awarding of the prestigious BJUI John Blandy Prize, received by the best and most cited BJUI article over the last two years. This year Dr Jérémie Haffner from France won the prize and £5000, for his work titled [the] “Role of MRI for Prostate Cancer Screening”, which he presented in fluent English.

In the afternoon the Exhibition arena provides the opportunity to see some of the latest innovations from the pharmaceutical and equipment industry representatives, and even have a play with 3D laparoscopy. However most trainees are understandably drawn to the Da Vinci stand where a robotic console is the main attraction. Delegates got the chance to use the robot to test their basic skills. 

My walk with the experts was really informative; each group consisted of approximately six trainees and two consultants. It was comfortable to ask questions and really maximised how much you can learn from the posters.

Day two started with a great update on laparoscopy, followed by the BAUS President, Mr Adrian Joyce, who gave his official address and awards as follows;

  • St. Peter’s Medal was awarded to Mr Malcolm Lucas, Swansea, UK.
  • St. Paul’s Medal was awarded to Professor Glenn Preminger, Durham, USA.
  • The BAUS Gold Medal was awarded to Mr Justin Vale, London, UK.

Social media is increasingly present in professional conferences allowing worldwide coverage and dissemination of all the conference content. Recent success was publicised from other Urology conferences, see other BJUI blogs.

BAUS has embraced this emerging technology and the “uro-twitterati” by establishing a twitter hashtag #BAUS13 and having updates throughout the conference. Furthermore a sold-out teaching course on Social Media run by Associate Professor Declan Murphy (@declangmurphy) and Professor Dasgupta (@prokarurol), was held at BAUS this year, which must surely be one of the first at any surgical conference? The session aimed to raise awareness of social media and advise delegates on the safe and best uses of social media in light of the recently drawn GMC guidance on the issue. Members were also helped by the unveiling of a set of BJUI guidelines on social media.

A range of experience was shown by the group, with about 50% using Twitter and other social media professionally at the present time.

Teaching new things in new ways

The BJUI supports BAUS regarding social media and demonstrated their rapid uptake of social media by posting the highest “influence” of any urology journal with a Klout score of 56.
 

During the conference BAUS president Mr Adrian Joyce, blogged his response to a newspaper article demonstrating that BAUS are developing an interest in social media and are using the expertise of their friends at BJUI to help them get their message out. It is an exciting time for all and I think we will see much more activity in social media in urology.

Other changes for the future were raised at the BURST session, where simulation in Urology training was discussed. Simulation will be used more in training and may not just include surgical skills but extend to non-technical skills including leadership, and working with distraction and disruptions.  

The conference has a great educational element, produced by Miss Tamsin Greenwell, with numerous small skills and teaching sessions running on every day of the conference. This allows every delegate to tailor their experience to their interests and needs. In particular the skills session gave us the rare chance for realistic surgical simulation using fresh frozen cadavers, with significant sponsorship at a fraction of the cost. These courses ranged from PCNL access and TURP to basic cystoscopy, ureteric stenting and supra-pubic insertion.

The BAUS social programme is rightly famous, with great events planned every night. The main event from Day 1 was the regional football competition, which was again competitive and well attended with congratulations to the Newcastle Trainees for winning the Cup.

With so much to do and see I am sure that many had a completely different experience to me and I am already looking forward to next year.

Dr Nishant Bedi is a Core Surgical (Urology) Trainee in the West Midlands Deanery, UK.
@nishbedi

 

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A Letter from the President of BAUS to the Daily Telegraph

19th June 2013

Sir,

Laura Donnelly’s article (Daily Telegraph Sat 15th June) contains some factual inaccuracies. She estimates that if all men referred with suspected prostate cancer received an MRI scan prior to a prostate biopsy, a quarter of them could be reassured without the need for a biopsy. This is fundamentally misleading because as yet there is insufficient evidence to support this assertion.

The article further claims that an initial MRI could halve the number of men who would be diagnosed with significant cancer incorrectly by biopsy and subsequently receive unnecessary treatment.

Similarly, this has not yet been confirmed by rigorous clinical research. Validation, via the PROMIS trial – https://www.controlled-trials.com/ISRCTN16082556 is currently being undertaken at UCLH by Professor Mark Emberton’s team. Should evidence emerge of the usefulness of MRI in identifying men with prostate cancer the process would need to be standardised by protocols endorsed by The Royal College of Radiologists and significant training would need to be undertaken by radiologists nationally.

MRI scans are expensive, as each scan costs £400, thus there are significant resource implications. This diagnostic pathway would need to be funded by Primary Care Commissioners for both an initial scan plus any repeat scans that may be required if biopsy is not deemed necessary. Regretfully currently such funding is not confirmed.

BAUS fully supports all endeavours to improve the diagnosis and treatment of prostate cancer for men in the UK but evidence of effectiveness needs to be in place before new modalities can be introduced nationally.

 

Adrian D Joyce MS FRCS(Urol)

Consultant Urological Surgeon & Hon Senior Lecturer

St James’ University Hospital

Leeds LS9 7TF

 

President, British Association of Urological Surgeons

[email protected]

[email protected] or [email protected]

https://www.baus.org.uk

 

 

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The Best of British

We live in a world that is getting smaller mainly because of global friendship, the Internet and the ease of travel. The British contribution to this should be a matter of pride for every UK urologist. Many friends and colleagues say that the BJUI has gone global, a decision that was made during the editorship of Hugh Whitfield and promoted under John Fitzpatrick. It was the correct move and has allowed British urology to maintain its prominent position in the rapidly changing world of academic publishing.

During BAUS 2013 we wanted our readers to know that the B in BJUI remains vital to the journal. We continue to publish and promote the best papers from UK for the benefit our local and international audience.

So here is the Best of British virtual issue, a selection of the most cited papers from UK in the BJUI in 2012-13. There are articles from every part of the British Isles proving that geography is not a barrier to quality.

It came as a surprise to me that Functional urology is the most cited section of the BJUI. We have highlighted a controversial but real life follow-up of patients having Botulinum toxin A injections for overactive bladder (OAB), a multicentre trial of a mini-sling and the natural history of urinary symptoms amongst ketamine users.

This is complemented by a Translational Science paper on the inhibition of stretching-evoked ATP release from bladder mucosa by anticholinergic agents. High-quality basic research with rapid translation is becoming real, thanks to the growth of Biomedical Research Centres in UK and overseas. We want to publish the best science papers and make them relevant to surgeons through Science Made Simple, a section that explains why our readers should care about science in a “dummies” fashion. The term “autophagy” is set to become as important as apoptosis.

Urological oncology is the largest section of the BJUI. There is considerable interest in prostate biopsies through the transrectal and transperineal routes and attempts at better imaging through MRI and perhaps Histoscanning. The role of surgery in high-risk prostate cancer is of particular relevance to British urologists within multidisciplinary teams as a number of our patients have aggressive, palpable and locally advanced disease. It is becoming clear that robotics can achieve oncological outcomes as robust as open surgery even in these patients. The Robotics and laparoscopy section of the BJUI has some of our most cited papers. We have given it prominence by featuring beautiful illustrations of  these common and evolving procedures in a Step by Step fashion on the front cover of our paper journal. Finally, a randomised controlled study evaluating the effects of metformin and lifestyle intervention on patients with prostate cancer receiving androgen deprivation therapy, has an important message.

While a number of new modalities of resection such as blue light and narrow band imaging are emerging, good quality white light resection by experienced endoscopists must not be ignored. It is not just about resection, however; adjuvant intravesical gemciabine found its way into a systematic review in patients with non-muscle invasive disease.

The Upper urinary tract often suffers at the hands of the bladder and prostate but is equally important. We have highlighted systematic reviews of ureteroscopic and percutaneous management of upper tract urothelial carcinoma, its surgical management by other modalities and the changing trends in stone disease that will be of interest to our endourological colleagues.

We have introduced a new Surgical Education section and bring to your attention the first results from the BAUS SIMULATE project, which combines technical and non-technical skills. This will be of great importance to every British trainee and indeed we are the international standard bearers in this field, thanks to your active participation.

We thoroughly enjoyed selecting this issue for your reading pleasure. A number of these articles have already been free downloads on www.bjui.org as articles of the week, and are now free to everyone as part of this virtual issue. They are further promoted internationally through our social media network and we are hoping to see a number of you at the BJUI SoMe course during BAUS.

Enjoy the highest quality, most cited articles from Britain. And be very proud, you deserve it!

Prof. Prokar Dasgupta, Editor in Chief, BJUI, Guy’s Hospital, King’s College London. @prokarurol

Scott Millar, Managing Editor, BJUI. @BJUIjournal

Editorial: Multiparametric MRI in active surveillance – time to rethink our current strategy?

Active surveillance for low-risk prostate cancer is gaining increasing acceptance. Indeed, many would argue that it is now the primary management strategy for men who have little to gain from radical therapy but who may incur some harms. However, active surveillance is far from a perfect pathway. First, many men and their physicians find it unacceptable to not treat a known cancer. Second, the burden of follow-up with clinical examinations and serum PSA testing on both men and healthcare systems is far from cost-neutral. Third, the need for repeat transrectal biopsies, which many advocate, carries harms of complications and the difficulties of inaccuracy. Fourth, there is some concern that the window of curability may be lost when men eventually go on to have radical therapy, although overall and disease-specific survival is in fact reassuringly high in the medium term.

Mullins et al. have attempted to address some of these issues by evaluating the role of multi-parametric MRI (mpMRI) in men followed using active surveillance. The results, albeit preliminary, are very encouraging. The ability of mpMRI to exclude clinically significant prostate cancer found on repeat biopsies reflects those results we have seen from other groups (J Urol 2012, BJU Int 2011). Further, they show that the presence of a lesion on mpMRI more often predicts reclassification on repeat biopsy. This has been supported by others who have demonstrated that the inclusion of mpMRI findings into a nomogram was able to predict clinically insignificant prostate cancer better than models without imaging. Mullins et al. have been appropriately guarded about their own results and point out the weaknesses of their cohort in an open manner so readers can judge the external validity of their findings; however, the significance of these results for the urological community cannot be underestimated, particularly as they point us in the direction of important research questions and clinical trials that need to be formulated to give us the answers we need to improve patient care.

There is an increasing body of evidence pointing to TRUS-guided prostate biopsy as being one of the major problems in the current prostate cancer pathway. As a test, it is both inaccurate, unreliable and has harms. It is inaccurate because about one-third of men with low-risk disease have grade or burden reclassification when a better test (template biopsy) is used. It is unreliable because the status of ‘cancer’ and ‘no cancer’ fluctuates from one biopsy to the next. It is harmful not only because it can cause complications (bleeding, sepsis and pain), but also because it detects clinically insignificant disease the treatment of which the man gains little benefit from. So, the problems with active surveillance do not stem from the fact that surveillance per se is flawed, but rather from its heavy reliance on a deeply flawed diagnostic test.

So, what are the key questions for the field of active surveillance that require a coordinated effort to deliver in a timely fashion? First, could the use of mpMRI before biopsy avoid unnecessary diagnosis of clinically insignificant prostate cancer? Second, if low grade and low-volume lesions were found on an accurate biopsy (template mapping and/or MRI-targeted), could we re-designate these lesions as something other than ‘cancer’? Combined, these two changes could in effect, make active surveillance unnecessary. Third, if mpMRI has a predilection for detecting clinically significant lesions, should the presence of a lesion on imaging lead to a man being excluded from active surveillance? Thus, should all men who are considering active surveillance undergo mpMRI and possibly template mapping biopsies? Fourth, can repeat mpMRI, as opposed to repeat transrectal biopsy, detect disease progression in men on active surveillance, and how is progression defined on imaging? Fifth, is the tissue-preserving strategy of focal therapy an alternative for men suitable for active surveillance or an alternative for those men with intermediate- and high-risk disease who stand to benefit from treatment but wish to minimise the harms of treatment?

It is clear that amongst all of these elements of research we will need to embed health economics to ensure that novel strategies are both clinically and cost-effective. Nonetheless, these are exciting times for those of us who work to innovate in clinical practice and research and improve the care of men with localised prostate cancer.

 

Hashim U. Ahmed
MRC Clinician Scientist and Clinical Lecturer in Urology, Division of Surgery and Interventional Science, University College London, London, UK

A beer a day keeps stones away

This month the Twitter-based International Urology Journal Club #urojc made a bold move away from cancer to discuss kidney stones. The paper entitled ‘Soda and other beverages and the Risk of Kidney Stones’ by Ferraro et al. was published online on 15th March 2013. Open access to the article was generously provided by the Clinical Journal of the American Society of Nephrology. The lead author, Pietro Manuel Ferraro, was kind enough to actively participate within the Twitter discussion.

This particular study looked at a total of 194 095 participants amalgamated from the Harvard-based Health Professionals Follow-Up Study and The Nurses Health Studies I and II. These individuals all filled in biennial questionnaires regarding their diet, general health and kidney stone pain for a median follow up period of 8 years. It is interesting that the event rate was relatively low with only 4462 cases identified, however it is important to note that the study looked only for new stone formers and persons who had previously had a kidney stone were excluded from the trial. At the outset this begs the question as to whether these results are in any way applicable to the recurrent stone former population.

 

So what did they find? The referent is the consumption of less than one drink per month, so with respect to daily consumption of one or more sugar sweetened colas there was a 23% increased risk in the incidence of renal calculi. Other beverages to show a statistically significant increased risk of stones included:

Sweetened non-cola soft drinks 33% increased risk
Artificially sweetened non-cola soft drinks 17% increased risk (p=0.05)
Punch (sugar sweetened fruit drink) 18% increased risk

 

And what decreases your risk?   % risk reduction        
Coffee 26%                 
Decaffeinated coffee 16%
Tea 11%
Red Wine 31%
White Wine 33%
Beer 41%
Orange Juice 12%          

 

Missing my poison of choice, diet cola? While there was a trend towards a decreased risk, this was not found to be statistically significant. But not an increased risk….so I may just keep drinking it for the time being. I am not alone.


There were certainly more than one of the so called Urological ‘Twitterati’ who seemed delighted that the study findings justified their habits:

   

There are undoubtedly limitations with any cohort questionnaire analysis. The authors have acknowledged that while they tried to control and adjust for variables including age, BMI, diabetes, race, BP and dietary intake, there are variables that simply cannot be accounted for on the basis of a simple questionnaire. Fructose, for example, is purported to be a potential contributor to the increased risk of stones by increasing calcium, oxalate and uric acid excretion. There are many other dietary sources of fructose, including fruits, cereals and processed foods and sauces that are not accounted for and are potential confounders. Along the same lines, coffee is a relatively broad category of beverage. When one compares an espresso with a teaspoon of sugar to a Starbucks Frappuccino the difference in sucrose, and thus fructose, content is extraordinary. The caffeine content of these beverages, while purported to decrease the risk of stones through diuresis, is variable and thus also a potential confounder.

Manuel Ferraro importantly acknowledged that the study observed ‘associations, not causal effects’. Harder evidence such as 24 hour urines, stone analysis and imaging data would be useful to draw more significant conclusions as to causality.
 

The population studied was also somewhat limited. As mentioned by Jason Lee, Henry Woo and Matt Bultitude the study included male health professionals and female nurses, who were generally white, an older population with a relatively low BMI and potentially prone to dehydration. There was also limited control of comorbidities.

As suggested by Christopher Bayne, the only evidence as yet in randomized controlled trials is that water consumption as reflective of hydration status and urinary volume is the only substance known to reduce the risk of stone formation.
 

An astute observation by one of my fellow Australian trainees Janice Cheng noted the relatively dehydrated status of the study subjects.


This won the best Tweet prize, kindly donated by European Urology @EUplatinum.

Increased water intake has been reviewed on the Cochrane Database in 2012, however the consensus drawn was that there is currently insufficient evidence that increased water intake specifically, as opposed to other fluids, prevents the formation of urinary calculi.

So what conclusions should we draw? A patient with his first presentation kidney stone actually asked me yesterday whether he could keep drinking his favourite drink….beer. I simply replied that there was no current evidence that this would increase his risk of stones, however that moderation was key. We must remember that many of these calorific drinks have significant impact on comorbidities outside of the world of kidney stones. #a(lotof)wateradaykeepstheurologistaway

The overall participation in #urojc continues at a solid rate, with 39 participants and 178 total tweets over the 48 hour period. The next #urojc will be on the first Sunday or Monday of July (depending on your time zone).

   

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

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Early Prostate Cancer Detection. One Canadian Urologist’s Perspective

After seventeen years as a practicing urologist and a further six in training, it amazes me that we still regard prostate cancer as a mystical science and view the issue of screening through the opaque prism of controversy. For so long it seems that the advanced stage disease that I learned about in the mid 1980s in medical school was irreversibly altered by early detection and treatment. Of course we now know that much of this early detection was simply a lead-time bias and that many men who were treated required only observation and were left with many potential compromises to quality of life. “Doctor, my cancer is gone, why am I so miserable?”

At the recent annual meeting of the American Urological Association in San Diego, new guidelines on prostate cancer screening were unveiled. In the past, routine testing at age 50 was recommended with age 40 being the threshold for those at risk. Essentially they can be summarized as:

  • Avoid screening under 40
     
  • Do not routinely screen between 40 and 54 for average risk men. For those at risk screening should be individualized.
     
  • For those between age 55 and 69 there is possibly some benefit and shared decision-making with a patient should be the rule.
     
  • Finally no routine screening after 70.
     
  • PSA should be considered every two years

The motivation for this more cautious recommendation stems for the fact that many men have indolent disease. Many of these men don’t require treatment. Treatment brings with it the potential to harm and therefore casts into doubt the value of any treatment.

The problem of course is while that may represent a possible, cost-effective strategy across the wider population, there is little doubt in my mind that this will lead to many younger and even older men falling through the cracks. It will be justified as too high a number needed to treat to make sense to find these men. Policy makers and health economists may shrug. My own experience is that we have much to learn about risk factors and that many men present seemingly without warning with significant disease.

 

This email from a patient illustrates the concern. Identifiers of course are removed. Both men had disease beyond the capsule of the prostate. Neither man had risk factors. Our patients are very wise and quickly become experts in the disease.

In Canada, the Canadian Urological Association has taken the view for some time that we should look at multiple factors as we “build a case” for prostate biopsy. Its own guidelines reflect this. This paper that we published speaks to the use of nomograms to make better biopsy decisions. Many calculators are available on the web.

So what is shared, informed decision-making? The assumption after the AUA meeting is that somehow patients and their primary care doctors will somehow know. What sort of conversation is happening if urologists themselves don’t seem to provide clear guidance? I suspect it will go something like “PSA doesn’t work, prostate cancer is not lethal and you will likely die from something else” Many family doctors have much of their time rightfully diverted to treating important disease entities such as hypertension, depression and diabetes. A not insignificant number of primary care doctors don’t necessarily even do a DRE anymore. If the urological community conveys the message that prostate cancer is not worth the effort it will further fall down the priority list.

In my view I am a little dismayed by the rhetoric that has started since these guidelines were presented. Much of this is well intentioned and a reaction to years of potential over-treatment. This earlier 2012 piece from the highly respected @OtisBrawley of the American Cancer Society illustrates the false promise of screening message that is being told. It will only be amplified after San Diego. In my view PSA itself is a blood test. It is harmless. It is the treatment machinery that it often initiates that potentially gives it a bite and needs careful reflection.

To many, prostate cancer is simply a benign disease in aging males along the lines of male pattern baldness. This would be a disaster in my view. We have definitely shifted the curve to the left but in addition to lowering overall mortality have greatly lessened the burden of disease complications. Men presenting with hematuria, urinary retention and renal failure has significantly diminished. It is rare that we get asked to insert nephrostomy tubes for advanced disease. This was a common clinical scenario when I was a resident in the early 1990s. I think we will see much more of that if we massively abandon screening.

I think as urologists we have a big responsibility to lead within our local communities. This comment from Dr. A Partin speaks to this very well. In the absence of the perfect pre-test conditions that predict meaningful disease my view is that we have to cast a wide net. In doing so we will uncover disease that does not need to be treated. We must then be prepared to separate diagnosis from treatment and carefully counsel our patients in a way that takes much detail and effort. It is not a five-minute discussion you can have in the middle of a busy clinic. Active Surveillance does work for low-risk disease. Our patients are sophisticated and will not blindly ask for treatment out of overwhelming anxiety. In parallel, we must continue to improve. The risk of biopsy, which has greatly increased over fifteen years, must be modified. Biopsy accuracy to find “real” disease can perhaps be improved with technology such as MRI. Techniques that lessen quality of life issues need to be modified. Robotic surgery can’t be a marketing free-for-all. In other words the onus is on us experts to get it right and do better.

Prostate cancer is a very significant disease and the source of pain and suffering for men and their families. We must continue to be vigilant of its implications, respectful of patient desires and hopeful ultimately of a cure. A benign disease it most certainly is not.

Dr. Rajiv K Singal is a Urologist at Toronto East General Hospital and Assistant Professor in the Department of Surgery at the University of Toronto.

Follow him on Twitter at @DrRKSingal

 

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