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USANZ 2018: Melbourne

G’day! The 71st  annual USANZ Congress, was held in Melbourne and had the biggest attendance on record for the past 6 years. The Urological Nurse’s congress: ANZUNS ran concurrently, encouraging multi disciplinary learning. An excellent and varied educational programme was masterminded by Declan Murphy, Nathan Lawrentschuk and their organising committee. Melbourne provided a great backdrop and soon felt like home with a rich and busy central business district, cultural and sporting venues, the Yarra river flowing past the conference centre, edgy graffiti and hipster coffee shops, plus too many shops, bars and restaurants to visit.

The programme included a day of masterclasses on a range of subjects, including: urological imaging, advanced robotic surgery with a live case from USC, metastatic prostate cancer and penile prosthetics. These were well attended by trainees and consultants alike. The PCNL session (pictured) with Professor Webb was popular and he generously gave his expertise.  The session was supported by industry and provided an opportunity to use the latest nephroscopes on porcine models and innovative aids to realistically practice different puncture techniques.

Two plenary sessions were held each morning covering the breadth and depth of urology and were well attended. Dr Sotelo is always a highlight; he presented, to an auditorium of collective gasps, a unique selection of ‘nightmare’ cases  His cases gave insight in how intraoperative complications occur and how they can be avoided.  Tips, such as zooming out to reassess in times of anatomical uncertainty during laparoscopy or robotic surgery have great impact when you witness the possible consequences. Tim O’Brien shared his priceless insights on performing IVC thrombectomy highlighting the need for preoperative planning, early control of the renal artery and consideration of pre-embolisation.  His second plenary on retroperitoneal fibrosis provided clarity on the management of this rare condition highlighting the role of PET imaging and, as with complex upper tract surgery, the importance of a dedicated team.

Tony Costello’s captivating presentation covered several myths in robotic prostate surgery, plus the importance of knowing your own outcome figures and a future where robotics will be cost equivalent to laparoscopy. Future technology, progress in cancer genomics and biomarkers were also discussed in various sessions.  One example of new technology was Aquablation of the prostate; Peter Gilling presented the WATER trial results suggesting non-inferiority to TURP.  A welcome addition to the programme was Victoria Cullen (pictured), a psychologist and Intimacy Specialist who provides education, support and strategies for sexual  rehabilitation. She described her typical consultation with men with sexual dysfunction and how to change worries about being ‘normal’ to focusing on what is important to the individual.

Joint plenary sessions with the AUA and EAU were a particular highlight. Prof Chris Chapple confirmed the need for robust, evidence guidelines which support clinical decision making; and in many cases can be used internationally. He suggested collaboration is crucial between us as colleagues and scientists working in the field of urology. Stone prevention and analysis of available evidence was described by Michael Lipkin; unfortunately stone formers are usually under-estimaters of their fluid intake so encouragement is always needed! Amy Krambeck presented evidence for concurrent use of anticoagulants and antiplatelets during BOO surgery and suggested there can be a false sense of security when stopping these medications as it isn’t always safe. She championed HoLEP as her method of BOO surgery and continues medications, although the evidence does show blood transfusion rate may be higher. She also uses a fluid warming device which has less bleeding and therefore improved surgical vision; importantly it is preferred by her theatres nurses! MRI of the prostate was covered  by many different speakers, however Jochen Walz expertly discussed the limitations of MRI in particular relating negative predictive value (pictured). He eloquently explained the properties of cribiform Gleason 4 prostate cancer and how this variant contributed to the incidence of false negatives.

Moderated poster and presentation sessions showcased research and audit projects from the UK, Australia, New Zealand and beyond, mainly led by junior urologists. The best abstracts submitted by USANZ trainees were invited to present for consideration of Villis Marshall and Keith Kirkland prizes. These prestigious prizes were valiantly fought for and reflected high quality research completed by the trainees. Projects included urethral length and continence, no need for lead glasses, obesity and prostate cancer, multi-centre management of ureteric calculi, mental health of surgical trainees and seminal fluid biomarkers in prostate cancer. This enthusiasm for academia will undoubtedly stand urology in good stead for the future; this line up (pictured) is one to watch!

The Trade hall provided a great networking space to be able to meet with friends and colleagues and engage with industry. It also hosted poster presentation sessions, with a one minute allocation for each presenter – which really ensures a succinct summary of the important findings (pictured)! It was nice to meet with Australian trainees and we discussed the highs and lows of training and ideas for fellowships. Issues such as clinical burden and operative time, selection into the specialty, cost of training, burn out and exam fears were discussed and shared universally; however there is such enthusiasm, a passion for urology and inspirational trainers which help balance burdens that trainees face. Furthermore, USANZ ‘SET’ Trainees were invited to meet with the international faculty in a ‘hot seat’ style session which was an enviable opportunity to discuss careers and aspirations.

In addition to the Congress I was fortunate to be invited for a tour and roof-top ‘barbie’ at the Peter Mac Cancer centre; plus a visit to Adelaide with Rick (Catterwell, co-author) seeing his new hospital and tucking into an inaugural Aussie Brunch. Peter Mac and Royal Adelaide Hospital facilities indicated an extraordinary level of investment made by Federal and State providers; the Peter Mac in particular had impressive patient areas, radiotherapy suites and ethos of linking clinical and research. However beyond glossy exteriors Australian public sector clinicians voiced concerns regarding some issues similar to those we face in the NHS.

Despite the distance of travelling to Melbourne and the inevitable jet lag the world does feels an increasingly smaller place and the Urological world even more so. There is a neighbourly relationship between the UK, Australia and New Zealand as evidenced by many familiar faces at USANZ who have worked between these countries; better for the new experiences and teaching afforded to them by completing fellowships overseas. The Gala Dinner was a great chance to unwind, catch up with friends and celebrate successes in the impressive surrounding of Melbourne Town Hall (pictured); the infamous organ played particularly rousing rendition of Phantom of the Opera on arrival.

The enthusiasm to strive for improvement is similar both home and away and therefore collaboration both nationally and internationally is integral for the progress of urology. The opening address by USANZ President included the phrase ‘together we can do so much more’ and this theme of collaboration was apparent throughout the conference. The future is bright with initiatives led by enthusiastic trainee groups BURST and YURO to collect large volume, high quality data from multiple centres, such as MIMIC which was presented by Dr Todd Manning. Social media, telecommunications and innovative technology should be used to further the specialty, especially with research and in cases of rare diseases – such as RPF.  Twitter is a tool that can be harnessed and was certainly used freely with the hashtag #USANZ18. Furthermore, utilisation of educational learning platforms such as BJUI knowledge and evidence based guidelines help to facilitate high quality Urological practice regardless of state or country.

So we’d like to extend a huge thank you to Declan, Nathan and the whole team, and congratulate them for a successful, educational and friendly conference; all connections made will I’m sure last a lifetime and enable us to do more together.

Sophie Rintoul-Hoad and Rick Catterwell


Highlights from the 6th International Neuro-Urology Meeting

The world’s leading experts in Neuro-Urology met in Zürich, Switzerland, from 25-28 January 2018 at the 6th International Neuro-Urology Meeting (INUM) and provided an overview on the latest advances in research and clinical practice of this rapidly developing and exciting discipline. The INUM, organized under the umbrella of the Swiss Continence Foundation (www.swisscontinencefoundation.ch), is the official annual congress of the International Neuro-Urology Society (INUS, www.neuro-uro.org), a charitable, non-profit organization aiming to promote all areas of Neuro-Urology at a global level. This unique meeting combines state-of-the-art lectures, lively panel discussions, and hands-on workshops with emphasis placed on interactive components. In addition, there are many opportunities to exchange thoughts, experiences and ideas and also to make new friendship.

An important aim of the Swiss Continence Foundation (www.swisscontinencefoundation.ch) and International Neuro-Urology Society (INUS, www.neuro-uro.org) is the promotion of the next generation of outstanding young researchers and clinicians who represent the future of Neuro-Urology. Therefore, the prestigious Swiss Continence Foundation Award of 10’000 Swiss francs was awarded for the 5th time to the best contribution from a young Neuro-Urology talent who presented the current yet unpublished research at the young talents session of the INUM on Saturday 27 January. This year, An-Sofie Goessaert from Ghent, Belgium, convinced the international jury with the presentation of her project entitled “Nocturnal polyuria in spinal cord injury patients and the effect of conservative measures on urine production” and reached the highest scoring. She demonstrated in a prospective study on patients with spinal cord injury that compressive stockings have an effect on nocturnal urine production, increasing diuresis during daytime and decreasing it during sleep to nearly normal bladder capacity, which might allow to have undisturbed sleep and higher quality of life.

Swiss Continence Foundation Award Winner 2018 An-Sofie Goessaert (middle), Chairman of the Foundation Board Thomas M. Kessler (left) and Vice-Chairman of the Foundation Board Ulrich Mehnert (right).

Three of many other highlights were the “Nightmare session”, the state-of-the-art lecture by Karel Everaert on “Nocturia and nocturnal polyuria” and the surgery in motion presentation by Urs E. Studer on “Cystectomy”.

The Icon of Swiss Urology, Urs E. Studer (middle) with the INUM organising committee Ulrich Mehnert (left) and Thomas M. Kessler (right).

Finally, we are delighted to announce the 7th International Neuro-Urology Meeting to be held in Zürich, 24-27 January 2019. Save the date! For details please visit: www.swisscontinencefoundation.ch. We are looking forward to seeing you in Zürich!


Ulrich Mehnert & Thomas M. Kessler


The challenge with systematic reviews of non-randomised studies in urology

In this issue, BJU International has made the conscious decision to publish a systematic review (SR) and meta-analysis (MA) by Guo et al. [1]to inform the question of whether patients undergoing nephrouretectomy for upper tract urothelial carcinoma are at increased risk of worse oncological outcomes. This question was also the topic of a similar review by Marchioni et al. [2] published earlier this year in this journal. Both studies were submitted around the same time and underwent independent, parallel peer review that resulted in different editorial decisions. Given their similarity in methodological quality they both deserved similar consideration for publication, which the journal is hereby honouring.

At the same time, this provides the unique opportunity to reflect on methodological developments in the field and BJU International‘s efforts to raise the bar of the methodological quality of SRs, which include the provision of an Assessment of Multiple Systematic Reviews (AMSTAR) rating [3]. AMSTAR is a validated tool to assess the components of a SR on an 11-point scale (0–11), with higher scores reflecting higher methodological rigor. An updated version of this tool has recently been provided, which offers greater clarity in interpretation [4]. Another related instrument that has become available is the Risk of Bias in Systematic Reviews (ROBIS), which assesses the study limitations in SRs (i.e., the relevance of the review, concerns with the review process, and potential bias introduced during the review) [5]. Meanwhile, while it would be premature to claim success, it is our impression that BJU International’s initiative to provide AMSTAR ratings is making a valuable contribution in raising awareness for such methodological issues and improving the transparency of published reviews.

As BJU International takes a lead in promoting high-quality SRs in urology, the journal has seen a considerable increase in the number of submissions, including SRs of non-randomised studies (NRS). Whilst much of what we practice on a day-to-day basis is based on evidence from NRS, studies of those designs have infrequently been included in the Cochrane Library, which has pioneered much of the underlying methodology. This is for a few reasons: First, the ‘garbage in–garbage out’ phenomenon; if the underlying individual studies only provide very low-quality evidence, combining these studies will rarely enhance the confidence we place in their results. Second, the need for methodological advances in the assessment and analyses of NRS. Third, when high-quality evidence from randomised controlled trials (RCTs) is available, it may be inefficient to review the NRS literature.

However, progress is being made on the methodology front. Members of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group are credited with having developed an approach for rating the quality or certainty of evidence from randomised and NRS to inform decision making [6]. While a body of evidence from RCTs, which starts as high-quality evidence, may be downgraded for study limitations, a body of evidence from NRS, which starts as low-quality evidence, may be upgraded for one of three reasons, most commonly for large magnitude of effect [7]. The underlying assumption is that, whilst we have to assume that bias is likely to be present in these studies, it is unlikely to explain the entire observed effect.

It nevertheless remains critical to assess the risk of bias of NRS. While the Newcastle-Ottawa scale (as used in both of these SRs) is a widely used instrument to evaluate risk of bias in NRS, it has critical limitations that the recently developed Risk Of Bias In Non-randomised Studies – of Interventions (ROBINS-I) seeks to overcome [8]. ROBINS-I evaluates NRS by using a standardised comparison to an RCT (i.e. target trial) [9]. In this way, ROBINS-I captures the bias inherent to studies without proper randomisation or allocation concealment, namely the lack of a balance of known and unknown confounders and selection of participants. ROBINS-I allows users to fundamentally start all studies at the same quality level, providing the transparency requested by some SR authors conducting SRs of NRS.

While ureterorenoscopy before nephroureterectomy may indeed increase the risk of intravesical recurrence as the authors suggest, additional exploration would be needed to make a statement about the causality of the relationship. Guo et al. [1] conducted sensitivity analyses to describe the potential for bias introduced by confounders of previous bladder tumour history and bladder-cuff management, thereby increasing our confidence that the observed effect may be closer to the truth. It seems equally important to note that Guo et al. found no increased risk in cancer-specific, recurrence-free or overall survival, which are other outcomes of potentially greater patient importance.

Understanding the inherent limitations of NRS, and placing their findings into appropriate clinical context are critical to the conduct of SRs. Moving forward, BJU International will continue to seek out the highest quality reviews that make use of the best, up-to-date methodology. We hope that these efforts will both serve as a beacon for the research community, but more importantly, result in improved evidence-based care for our patients.

Philipp Dahm*, Jae Hung Jung† and Rebecca L. Morgan
*Department of Urology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN, USADepartment of Urology, Yonsei University Wonju College of Medicine,
Wonju, Korea and Department of Health Research MethodsEvidence, and Impact, McMaster University, Hamilton, ON, Canada






3 Dahm P. Raising the bar for systematic reviews with Assessment of Multiple Systematic Reviews (AMSTAR). BJU Int 2017; 119: 193



5 Whiting P, Savovic J, Higgins JP et al. ROBIS: a new tool to assess risk of bias in systematic reviews was developed. J Clin Epidemiol 2016; 69: 22534


6 Guyatt GH, Oxman AD, Vist GE et al. GRADE: what is quality of evidence and why is it important to clinicians? BMJ 2008; 336: 9958


7 Guyatt GH, Oxman AD, Sultan S et al. GRADE guidelines: 9. Rating up the quality of evidence. J Clin Epidemiol 2011; 64: 13116


8 Deeks JJ, Dinnes J, DAmico R et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003; 7: iiix, 1173


9 Sterne JA, Hernan MA, Reeves BC et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919


Editorial: Viewpoint – Rationing and Surgical Care

Limitation in the provision of surgical care has many causes. In a nationalised healthcare system, this often reflects lack of funds, leading to rationing of clinical services. Rationing itself takes a number of forms. Deliberate exclusion of specific operations (usually elective) or specific patient groups (smokers, obese) are the most common examples, but strategic extension of waiting times by the removal of ‘target’ times can also be used as a rationing tool.

Many surgeons are dismayed by these decisions. They feel that the surgical patient is unfairly targeted as the clinical and cost-effectiveness of many planned surgical interventions have been well characterised. Surgeon and institutional outcomes are freely available – unlike the situation in many non-surgical specialties, so how can it be fair to pick on the surgical patient?

The idea that non-urgent elective surgery falls into neat categories where delay has no adverse consequences for the patient mystifies many surgeons. Whilst all would advocate a healthy diet, exercise, weight loss and smoking cessation, decisions to withhold surgery from the obese or those who smoke is rarely evidence-based. Rationing based on such prejudice soon becomes illogical. Why should the obese cancer patient receive an operation when the obese incontinent patient cannot?

In the long term, the absence of a substantial volume of ‘routine’ surgery damages training as exposure to such procedures is limited. Surgery has become the soft target for rationing clinical services. Surgeons should make their patients aware of how this process will affect them. Healthcare planners need to hear a public voice as well as that of the clinicians.

Just occasionally, an apparent limitation can be beneficial. In this issue of the BJUI, the National Institute for Health and Care Excellence (NICE) provides clear guidance on preoperative testing. This is based on sensible recommendations such as: avoiding routine urine dipstick testing, routine chest X-rays, and glycated haemoglobin (HbA1c) in non-diabetic patients. All surgeons irrespective of their specialty would benefit from paying close attention to these important guidelines [1].

Derek Alderson

President of the Royal College of Surgeons of England; Emeritus Professor of Surgery, University of Birmingham; Editor-in-chief of BJS Open.

Read the full article


1 National Institute of Health and Care Excellence (NICE). Routine preoperative tests for elective surgery: © NICE (2016) Routine preoperative tests for elective surgery. BJU Int 2018; 121: 12–6


Highlights from the 6th International Alliance of Urolithiasis annual meeting 2017

There is absolutely no doubt that #urolithiasis is a truly global disease. It is extremely rare in medicine to have a single disease entity with enough breadth and variety to generate such immense interest across the world that it merits a 3 days meeting on its own.

The International Alliance of Urolithiasis (IAU) was founded by Professor Zhangqun Ye, Professor Guohua Zeng (both from China), and Professor Kemal Sarica (Turkey, current chair of #EULIS) in 2010. The aim of the association is to provide a platform for urologists across the world to exchange knowledge on urinary tract stone disease, and to establish professional links for research.

Famous for the fine yellow rice wine produced in the region, Shaoxing in Southeast China was chosen as the host city of this year’s 6th IAU annual conference. This was our first time attending the IAU, and we were both honoured to be invited to speak at the conference. We must congratulate the association and the organising committee in putting together a truly excellent program, which included many thought-stimulating and inspiring talks by eminent local and international stone experts, provocative debates, and many live surgeries demonstrating latest endoscopic techniques in the management of challenging stone diseases.

Professor Guohua Zeng and @WayneLam_Urol

#IAU17 Day 1

#IAU17 started off with the Young Urologists sessions. These sessions not only provided an opportunity for young urologists from all over the world to present their work, but also set a stage for debates on controversial stone topics and a platform to interact with experienced and established eminent stone surgeons.

One of the first sessions were talks on #PCNL. All speakers agreed choice and accurate access is key to a successful and effective #PCNL. It is interesting to know that in China, the vast majority of punctures are performed by urologists. And with experience due to high prevalence of stone disease in particular in the southern part of the country, the practice of pure ultrasound-guided puncture has gained popularity in the past decade. Dr Zhiyong Chen and Dr Xiao Yu, both from China, provided some tips and tricks on pure ultrasound-guided puncture for access for #PCNL, in particular when treating patients with complex or staghorn stones. Both sagittal and coronal planes should be used to assess all major and minor calyces, and they also interestingly showed that the benefit of aiming stones with multiple branches as the most effective first puncture point in patients with complex or staghorn stones.

Position of #PCNL has been a regular debate in stone conferences, and few speakers in the young fellow sessions presented their findings and reviews on the topic. Both #supine and #prone positions have their pros and cons but all presenters agreed that surgeon’s preference to offer best chance of achieving best outcome is the most important determining factor.

Another eye-catching presentation of the day was a randomised study conducted in China comparing standard #PCNL against mini-PCNL in the management of 2-4cm renal stone. The study randomised 800 patients and demonstrated that mini-PCNL was superior in terms of reduced bleeding, post-operative pain, shorter hospital length of stay, and more patients were ‘tubeless’ after the procedure. It is a well-designed study that will add much-needed high-quality data to the argument on #PCNL sizing.

#Sepsis remains one of the most worrying complications during endoscopic surgery for urolithiasis. Optimal method of culture technique was discussed, with Dr Kremena Petkova of Bulgaria arguing that renal, pelvis, urine and stone cultures are more specific and sensitive in predicting post-op complications. Both are superior to #MSU, with higher concordance between pathogens and antibiotic sensitivities. However, their results are not often available pre-operatively, and it’s best to use them as guidance on choice of anti-bacterial treatment if sepsis develops post-operatively. However, in patients with high risk of post-operative sepsis despite peri-operative prophylaxis; renal, pelvis, urine and stone culture should be considered.

Another very interesting study was a randomised trial presented by Dr Wei Zhu from Guangzhou, China, on investigating dosage required for prophylactic antibiotics for patients undergoing retrograde intrarenal surgery for stones. Their study suggested that stone size is a determining factor of whether patients require prophylactic antibiotics, with risk of post-operative sepsis being low if <200 mm2.

In the stone prevention session chaired by Professor Hans-Goran Tiselius from Sweden, Dr Guohao Li from China presented a study on reduction of urinary oxalate. Diet in general contributes to urinary oxalate concentration, and they discovered the use of a mushroom powder is able to reduce oxalate contents by degradation in traditionally oxalate-rich things such as spinach and tea. Their study found that the mushroom product is able to reduce urinary oxalate in stone-formers by up to 33%!

@Mattbultitude, representing @BJUinternational, was invited to give a talk on tips for submitting manuscripts to the journal to maximise the chances of publication. An interesting fact was that China submitted more papers to @BJUinternational in 2016 than the UK, and came second only to the USA. There are now services from the Journal’s publisher,Wiley, to help improve fluency of manuscripts for papers written by authors whose first language isn’t English, and perhaps this may further increase acceptance rates from countries such as China in the future (https://wileyeditingservices.com/en/translation-service/).

Heavy weights in #urolithiasis closed the last session of the first day of #IAU17. Professor Pal from India, with over 30 years of experience in PCNL, offered tips to young urologists on a procedure not often talked about in textbooks. Short, straight puncture track through a papilla into the most peripheral calyx harbouring or leading to the stone is what we should be aiming for when performing the puncture, and he suggested that meticulous alignment of the C-arm is crucial to provide the spatial information to guide us to do that. This was followed by Professor Jean de la Rosette from the Netherlands, who gave a provocative but strong arguments on why he felt #MET should not be recommended. This discussion came as a heated debate has been going on with regards to the recent publication of a very large, multi-centre randomised controlled trial from China suggesting the use of MET is beneficial in patients with larger distal ureteric stones, and of course much debate was initiated after his talk amongst the audience and on social media (see The Drugs Don’t Work … Or Do They? https://www.bjuinternational.com/bjui-blog/drugs-dont-work/).

As we all know, 24-hour urine work-up is dreaded by most recurrent stone-formers.  It takes up a lot of the patient’s time and thus may result in incomplete collection or just simply be forgotten.  Professor Hans-Göran Tiselius described an abbreviated form of the 24-hour urine work-up that he uses in order to reduce patient inconvenience when collecting the urine samples. The first 16 hours are used to collect most of the common urine biochemistry of calcium, oxalate, citrate, etc while the last 8 hours are used to measure for urate and pH. Each portion is then extrapolated to achieve the final data. Through three examples, Professor Tiselius shows how it is easy to apply the results from the 24-hour urine to give specific dietary instructions and treatment to the patients in the prevention of stones.

One of the final talks of the day was presented by Professor Thomas Knoll from Germany on the use of miniaturised PCNL. Various high-quality comparative studies have demonstrated the benefit of miniaturised equipment for PCNL (in particular reduced morbidities), and interestingly the availability of miniaturised systems appeared to have increased the use of PCNL instead of using RIRS and ESWL for patients with renal stones.

This final session, with master stone surgeons sharing their experience and knowledge in the Young Urology Section, allowed the up-and-coming urologists a chance to pick the mind of the masters.  It set a great tone for the first day and created anticipation for the coming two days of the conference!


#IAU17 Day 2

Day 2 of the conference was full of exciting talks and live surgery, spanning over 12 hours from 07:50 in the morning to 20:00 in the evening!

This year @BJUinternational became an Affiliated journal of the IAU. To celebrate this, a virtual issue comprising the 10 best stone papers published in the journal over the past 2 years was published online (Best of Urolithiasis VI), and @mattbultitude, Consultant Urologist and head of stone unit at @guysurology, was invited to present these selected papers in the meeting.

Professor Alberto Trinchieri from Italy then provided an informative talk on the role of acid load in citrate excretion. Hypocitraturia is a common feature in up to 68% of calcium stone-formers. He argued that the acid load of the diet could decrease renal citrate excretion, and the LAKE score, could be a useful tool to be used as a food screener for acid load of diet.

The LAKE score by Professor Trinchieri.

He also argued that the use of oral alkaline citrate can potentially treat uric acid stones by dissolution and prevent calcium oxalate renal stones formation.

Dr Ravi Kulkani from the UK gave an interesting talk on the management of stones in the elderly population. He presented a study conducted at his institution of 60 patients with a median age of 84.6 years with low morbidity, post-op ITU stay and a median length of stay of only 1 day for the cohort. Complete stone clearance rate was still high in the elderly population studied. It is important to assess co-morbidity pre-operatively and optimise them before any surgical treatment, together with extensive anaesthetic input and assessment. Patient selection is crucial and a good outcome can still be achieved in the ever-growing geriatric population.

Following live surgery session demonstrating various tips and tricks of RIRS, the afternoon session on day 2 of #IAU continued to be comprehensive and informative. Professor Peter Alken from Germany gave a provocative talk on the underuse of chemolysis in treatment of patients with uric acid stones, of which most of the audience were in agreement. He argued that evidence suggests it is effective and should be recommended in the guidelines!

Professor Peter Alken from Germany on chemolysis for treatment of uric acid stone.

Professor Guohua Zeng, inventor of super-mini PCNL (SMP), gave a lecture on his experience using the second generation SMP. With the modified sheath enabling efficient irrigation-suction system, he found that the intrarenal pressure intraoperatively remained stably low, with shorter operative time and good stone clearance rate. Undoubtedly, SMP is useful in particular in the management of stones up to 3cm in size, and can be used as an adjunct to standard PCNL when multi-tracts are required. He has also presented his experience in using the technique in the paediatric population with good stone clearance rate and safe. (See The new generation super-mini percutaneous nephrolithotomy (SMP) system: a step-by-step guide)


Professor Guohua Zeng on the use of second generation SMP, with an improved
irrigation/suction system.

Another interesting study from Professor Gonghui Li revealed that post-endoscopic lithotripsy septic shock was heralded by a White Cell Count of <2.85 x 109/L at 2 hours post-operation, with sensitivity & specificity over 90%.  Stepping up the antibiotics and aggressive fluid resuscitation at this point could stave off significant hypotension or even mortality in his study.

Professor Gonghui Li of China on early detection of risk of septic shock post-surgery with White Cell Count at 2 hours post-op.

In the evening, the conference became heated with various debates. Management of calyceal diverticulum stones has always been challenging. Mr Simon Choong from UCLH in London, UK, presented good arguments in the use of PCNL with high success rates, but Dr Yi Zhang also showed good clearance rate in experienced surgeons’ hands. And in selective cases, both minimally invasive and open surgery may have a role, presented by Dr Gang Zhu from China and Dr Zinelabidine Abouelfadel from Africa.

Debate on optimal management of 1-2cm lower pole renal stone has been a hot topic for years. Brian Eisner (@BEendourology) from the USA argued that with experience, RIRS stone clearance rate is approaching that of PCNL but with lesser morbidity. However, seeing a live surgery of clearing a >3 cm stone with a miniaturised PCNL technique on day 3 of the meeting, with the patient left completely tubeless post-operatively, may have changed his mind!


#IAU17 Day 3

The final day of the conference included 13 live #PCNL surgeries, demonstrating various puncture techniques, tips on how to improve accuracy for access, and advanced surgical techniques including various miniaturised #PCNL by local and international experts.

Professor Guohua Zeng from Guangzhou Medical University First Affiliated Hospital in China demonstrated the treatment of a 3.5cm lower pole renal stone using the second generation super-mini PCNL (SMP), which he invented. With its innovative sheath, which provides effective irrigation and controlled suction, he completed the surgery within 20 minutes. It was bloodless and tubeless, with visually complete stone clearance. Stones were completely extracted via its suction system for stone analysis.

Professor Qu Chen of China demonstrated the use of ultra-mini-PCNL, effectively clearing a medium sized renal stone in a matter of minutes. Interestingly, many surgeons in China prefers to use the ureteric catheter as inflow for irrigation, which generates a flow pressure to help flush stone fragments out – great tip!

13 live stone surgeries were broadcasted to the audience on day 2 of IAU2017

Mr Matt Bultitidue @mattbultitide (left) with Professor Guohua Zeng (middle) and
Dr Christian Seitz @SEITZ_C_C (right)

We must congratulate the #IAU17 organisers’ incredible effort in making the conference an inspiring and valuable learning experience to all who attended. The short duration (8-15mins) of presentations ensured that all the meaty details were packed in with very little fluff!  It was also a great opportunity to build bridges to network and collaborate research in #urolithiasis. We thoroughly enjoyed it and would definitely recommend any urologist with an interest in #urolithiasis to attend its future meetings, and we very much look forward to #IAU18 in Istanbul!



Dr Wayne Lam

Assistant Professor in Urology, Queen Mary Hospital, University of Hong Kong

Twitter: @WayneLam_Urol




Dr Brian Ho

Associate Consultant in Urology, Queen Mary Hospital, University of Hong Kong


A Lifetime of Giving – Donald S Coffey (1932-2017)

For those who knew Donald Coffey (the “Chief’”), the inquisitive smile says it all. Don spent his professional life sharing his knowledge, wisdom, humor, and encouragement to everyone that he encountered and mentored –and the list is very, very long. It would be difficult to measure the impact Don had on the field of urology and cancer research, given the countless clinicians and scientists that he mentored and inspired to pursue academic careers.

Born in Bristol, VA in 1932, his life story is not in the least traditional including chemist, engineer, laboratory director, prostate cancer researcher, and cancer center director. During college, he worked as a chemist for the North American Rayon Company and after attending King College in Bristol, Tennessee and the University of East Tennessee, Don worked as an engineer at the Westinghouse Electronic Corporation. He eventually decided that he wanted to spend his life working on cancer, and ended up at Johns Hopkins on the advice of a mentor, where he spent more than 50 years giving to others.

Don spent his early years at Johns Hopkins in the Brady Urology Research labs washing glassware for graduate students and taking classes. In 1959 when the Brady Urological Institute was chaired by William Wallace Scott, Don was named the director of the Urological Research Laboratory for 1 year to fill the spot of Charles Tesar who was on sabbatical. He impressed Dr. Scott who encouraged him to obtain a graduate degree. A year later he entered the biochemistry graduate program at Johns Hopkins University School of Medicine. He earned his PhD in physiological chemistry in 1964, and was named the director of the Brady Laboratory for Reproductive Biology in 1969. In 1974, the lab merged with the Brady Research Laboratory and Donald Coffey was made director of the merged laboratories, a position he held until 2004. Together with Patrick C Walsh, Coffey built what would be considered by many as the premier training ground for surgeon scientists, many becoming distinguished academic leaders in urology.

During his tenure at Hopkins he became the Catherine Iola and J. Smith Michael Distinguished Professor of Urology, Professor of Oncology, Pharmacology, and Pathology; and a member of the professional staff of the Applied Physics Laboratory. He was chair of the Department of Pharmacology having never taken a course in pharmacology, and he helped found the Cancer Center without an MD degree. Don was fond of saying that he flunked out of college and never took a course in a department where he was a full professor. He told this to mentees not bragging, but as encouragement that anything is possible with passion –a trait that he embodied to the very end of his life. He simply seemed never to tire of teaching and mentoring students, inspiring in them his passion and love for discovery and life in general. He was one of the most positive forces I have ever met, and his infectious enthusiasm characterized both his professional and personal life. Don Coffey was one of Johns Hopkins greatest teachers and in recognition of this he was the recipient of the Dean’s Distinguished Mentoring Award.

Dr. Coffey had many interests, but primary among them were his curiosity and fascination on the origins of human creativity and homo sapiens’ place in the world. His annual St. Patrick’s Day lecture on this topic was legendary at Johns Hopkins and was delivered to many audiences beyond Hopkins. Don’s early research involved descriptions of a nuclear scaffolding or matrix that was the organizational structure for DNA regulating genetic function. His research focus involved changes in the nuclear structure and shape that he believed could explain the biology of prostate cancer and provide markers of lethal disease.

Don Coffey achieved much during his life that most of us would regard as epaulets; President of the American Association for Cancer Research (AACR), Fuller Award and Lifetime Achievement Award from the American Urological Association, an American Cancer Society Distinguished Service Award from the American Cancer Society, the AACR Margaret Foti Award for Leadership and Extraordinary Achievements in Cancer Research. He minimized these accomplishments as natural fall out from pursuing his passion in life to “work on cancer.” But those who knew him well would agree that he would -without hesitation- say that his greatest award was witnessing the success of his colleagues and students.

Like all of his mentees and those fortunate enough to work with him, I spent countless hours with Don during a 2-year fellowship as an AUA Scholar. These sessions would go on for hours and could often devolve from science to the meaning of life, evolutionary biology, religion, relationships, etc; the one predictable was the unpredictable during an encounter with Don. They always ended the same way after hearing him say “and just one more thing and we are out of here”; have you eaten yet?” So off he would go with his student(s) in tow to enjoy a meal together and continue talking science.

It is difficult to capture in words the rich life that was Don Coffey over 85 years. Drs. Kenneth Pienta and Alan Partin probably said it best in written and spoken word; “For all of us who knew him and loved him, our grief is deep but our memories of the Chief bring joy that is boundless.”

To learn more about Donald Coffey’s life, take a look at the Donald Coffey story as told by his lovely and devoted wife Eula, his students, and himself (https://vimeo.com/122939259).


Bal Carter

Bernard L. Schwartz Distinguished Professor of Urologic Oncology, Johns Hopkins School of Medicine


The Drugs Don’t Work … Or Do They?

The Verve made millions out of the hit single “The Drugs Don’t Work” … I doubt they would have made any money if they called it “The Drugs Don’t Work … Or Do They ?” but that is where we are in 2017 with medical expulsive therapy (MET) for ureteric stones.

In 2015, “The Drugs Don’t Work” was the most read blog of the year and for that won the “Best Blog of the Year” award at the BJUI Social Media awards. And it was all about SUSPEND. The trial that changed everything. We had been giving MET out like smarties. We loved it. Patients loved it. But many of us had doubts. The evidence was weak. “Large randomised trials are needed to confirm” the authors of small trials said. And so we did it in British Urology and it did change practice for many people. Doubts crept in around the world. More trials confirmed this. The Furyk study … MET doesn’t work in Australia (apart from a small advantage on small subgroup analysis). It doesn’t work in America either. Silodosin … promising but little benefit. But wait … the NIH are doing a trial. This will confirm once and for all. And as I was about to debate John Hollingsworth at the Rock Society at #AUA17 – thrown into the lion’s den of believers – it was released, a late breaking abstract – The STONE study and NO BENEFIT TO MET. Game over … MET is dead. Even non-believers were convinced in another debate with John in Vancouver at #WCE17.

So imagine the surprise as this month in European Urology, the largest study ever conducted was released. 3450 patients. A good quality double-blind placebo-controlled RCT. The headline … Overall MET does work (86% vs. 79%). And this was judged on a fairly hardcore follow-up schedule of CT scans weekly for 4 weeks – how many people do that in their practice? On subgroup analysis stones >5mm show greatest benefit (87 vs. 75% stone passage). Stones ≤ 5mm showed no benefit (88% vs 87%) although there is some advantages for time to passage (148 vs.249 hours), colic episodes (1.9 vs.9.4%) and analgesia requirements (89 vs.236mg). So what do we do now? Firstly I suspect this has just cemented the current position of the 2017 #EAUGuidelines which already states “the greatest benefit might be among those with large (distal) stones”. I do also feel this trial requires greater scrutiny – does this really change everything again?

Some facts: 3296 patients included in the analysis. Only 15 patients declined entry to the study – that is amazing! Recruited in 30 centres in China over 2 years which finished in 2013. The inclusion criteria was for distal ureteric stones from 4-7mm (interestingly a fact not expressed in the abstract). Not 3mm; not 8mm; 4-7mm only. So a narrow window which probably represents the potential target benefit for MET. There are lots of exclusion criteria – diabetes, previous stone on that side, previous ureteroscopy on that side and ‘severe hydronephrosis’. So if the emergency departments are to follow this study they need to select stones of 6 or 7mm in longest diameter, only in the distal ureter and without “severe hydronephrosis” whatever that means. I’m not sure I totally know and I’m a urologist. Good luck to the ED docs with that one!

I need to ask, why has it taken 4 years for this to be published? There is no long-term follow-up required in this study. Outcomes should be known within 28 days. With such international controversy surely this should have been a priority to publish? Only the authors can answer this question but such delayed publication suggests to me some issue with the data. This was a company sponsored trial – so why weren’t they pushing for publication? Only they know. Company involvement to me automatically introduces a degree of murkiness about the outcomes in any trial – just look at the problem with oncology trials. Even more so when they are “involved with preparation of the manuscript”. That gives them a controlling interest in the publication of the outcomes and that really concerns me. It probably shouldn’t … the results are the results … but it still concerns me. It’s one thing supplying the medications for a trial but having control of the manuscript? What data is missing? For example, how many people in each group complied with the imaging protocols? We don’t know. How many patients didn’t undergo any follow-up imaging at all? We don’t know. How many patients did not attend (DNA) for follow-up at each stipulated week (as DNA rates are often high for colic patients)? We don’t know. Any small differences between the groups might explain the differences in final outcome. How many returned the analgesia and pain questionnaires? We don’t know. What were the compliance rates with medication? We don’t know. Importantly, why were the side-effects the same in both groups in such a big sample? That worries me a lot. This trial is powered to show small differences and even the most ardent MET supporters will concede that MET comes with a tolerable increase in side-effects – other studies have clearly shown that. That concerns me. Is that actually a surrogate marker of quality for this study?

Don’t get me wrong, other studies definitely have their limitations as well. Furyk – underpowered for larger stones. STONE – confounded by small stones? SUSPEND – real-life follow-up without mandated imaging. There is no doubt this trial will shift the balance in the debate. I thought MET was dead but, as per the EAU guidelines, MET may confer benefit for stones >5mm but in reality only those measuring 6 or 7mm – an absolute benefit of 12% for that specific group. It definitely doesn’t help stone passage for ≤ 5mm stones. It is interesting that whilst SUSPEND was criticised for having such high stone passage rates of ~ 80% – that is exactly what is seen in this paper and in a more select larger stone group. That is curious. Placebo did very well again. It’s a shame we can’t prescribe that!

What will I do? I might use MET a bit more for the carefully selected and counselled “larger stone” – I did anyway – but I certainly don’t feel we are back to giving this out to everyone who walks through the door.


Matthew Bultitude

Consultant Urologist, Guy’s and St. Thomas’ Hospital

Associate Editor, BJUI


Urolithiasis around the world

Stone disease is a highly prevalent condition that unites all countries around the world, although surgical management will depend on many factors including availability of different technologies. However, percutaneous nephrolithotomy (PCNL) remains the cornerstone for the management of larger renal stones in all parts of the world, and Rizvi et al. [1] report on a huge cohort of PCNL procedures – 3 402 to be precise from Karachi. This is a single-centre series, over an 18-year period, reporting real-life data and showing a stone clearance rate of ~80%, as assessed by plain abdominal radiograph of the kidneys, ureters and bladder, and ultrasonography (US). Whilst the definition of stone-free and imaging modality used to judge it remains a contentious issue, this paper reflects the excellence of high-volume surgery in specialist centres.

Recently, the BJUI became the affiliated journal for the International Alliance of Urolithiasis (IAU), whose annual meeting takes place in Shaoxing this month. To celebrate this, we are proud to publish a ‘Best of Urolithiasis’ issue, which features some of the top stone papers published in the BJUI over the last few years [2]. Choosing articles for this was quite a task given the quality and whilst we have attempted to recognise submissions that potentially change practice, the geographical diversity of the work shows not only the global nature of stone disease but also the excellent research that is being done worldwide and in different healthcare systems to improve care and outcomes. Of particular importance are randomised trials that are often lacking in surgical areas. One such paper from China addressed the question of US vs fluoroscopy for PCNL access during mini-PCNL [3]. Whilst the truth is that surgeons should use whatever gives the best outcomes, the authors in a very high-volume centre were able to demonstrate the effectiveness of US-only punctures, although a combination may be better in complex stone burdens. Another randomised controlled trial (RCT) of clinical importance was from the USA, where the authors conducted a good quality double-blind RCT of NSAID use before ureteric stent removal under local anaesthesia [4]. Whilst a small study, the incidence of severe pain in the 24 h after stent removal was 55% in the placebo group vs 0% in the NSAID group – as such this simple study should have changed practice for all who perform this procedure.

Other papers worthy of inclusion include a single-centre experience of the conservative management of staghorn calculi, which challenges the dogma that all staghorn stones should be treated [5]. This single-centre series showed a conservative policy could be adopted in highly selected patients. Is this practice changing? Maybe … but it certainly gives an evidence base for stone surgeons in making decisions in very high-risk patients. Manoj Monga and his group recently reported on the accuracy of US for the detection of renal stones [6]. This again is a very important topic and a question that commonly arises. In a series of >500 patients with US-detected stones who subsequently underwent CT scanning, 22% of patients would have been inappropriately counselled about their stone based on US alone. Again, the message is clear … US is a good screening tool but do not rely on it for treatment decisions.

I hope you take the time to check out the virtual issue on urolithiasis and read the other papers I could not mention here. Please continue to send your high-quality stone papers to the BJUI and maybe your submission will feature in our next ‘Best of Urolithiasis’ issue.

Matthew Bultitude, BJUI Associate Editor


Guys and St Thomas NHS Foundation Trust, London, UK




1 Rizvi SA, Hussain M, Askari SH, Hashmi A, Lal M, Zafar MN. Surgical outcomes of percutaneous nephrolithotomy in 3402 patients and results of stone analysis in 1559 patients. BJU Int 2017; 120: 7029


2 BJU International. Virtual Issues Page. Available at: https://bit.ly/BJUI-VIs. Accessed September 2017



4 Tadros NN, Bland L, Legg E, Olyaei A, Conlin MJ. A single dose of non-steroidal anti-inammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-  controlled trial. BJU Int 2013; 111: 1015


5 Deutsch PG, Subramonian K. Conservative management of staghorn calculi: a single-centre experience. BJU Int 2016; 118: 44450


6 Ganesan V, De S, Greene D, Torricelli FC, Monga M. Accuracy of ultrasonography for renal stone detection and size determination: is it good enough for management decisions? BJU Int 2017; 119: 4649


Publons – Now Part Of Your Verifiable Online Digital Curriculum Vitae

Last year I introduced Publons via a BJUI Blog . It is pleasing that Wiley, the publishers of the BJUI, have now partnered with Publons to make digital archiving and verification of reviewer (and editorial) work easily accessible with a mouse click once a review is completed.

So, what is Publons again? Perhaps a brief reminder:  Just as PubMed collates publications, Publons collates peer reviews you have performed and verifies you did them. With one hyperlink you may go to all of your reviews listed by date and under sections of journals. In addition, Publons also allows you to showcase to what editorial boards you belong. It also now allows editorial board work to be collated and rewarded.

I can do this all myself, can’t I? Well yes you can but this service is free and offers third party verification of peer reviews. This is important in the era of fake news. You also find out when an article you reviewed is published.

Publons is important because until now it has been difficult to track and quantify the hard work done by reviewers that is all pro bono. Getting credit for reviews is important and this website finally acknowledges that fact. Finally you can compete with other colleagues (all friendly of course). For those with editorial roles for journals the handling of manuscripts can also be collated to again get credit. A final side point is that making your reviews public is possible should you choose to do so (and gets your more points) but that is an individual (and sometimes journal) decision.

Reminder how to access and use Publons:

1) The journal may be aligned with Publons (as BJUI now is) so just click the box at time of review (see example here):

2) Simply forward your official thank-you receipt email as below to [email protected] and they will do the rest (example here):

3) I can’t find the emails- is there any way of back tracking to reviews done over the years?  Yes- take screen shots of   your “Official Journal Dashboard “like this de-identified one below and send to [email protected] (I have done this and it works quite well but you may need to take more than one screen shot per page to make it more easily digestible)

4) You can ask a journal to email you a summary and provided they send enough detail Publons will look at it and probably accept it (I have not done this but heard it may work)

So there you have it. The variety of methods is straightforward. A new Publons dashboard will be created and is easy and documents well which journals you have reviewed for and when.

What are the Publons awards? We can see here in the example of Prof Henry Woo (urologist, Australia) whom has reviewed many papers (see his total score and review numbers). Publons also ranks overall reviewer status and within different reviewers topic sections. It also gives “awards” each quarter to the best reviewer overall, best from your university etc. The value of such awards is likely to rise each year as more people use the Publons platform.

Are there other benefits? Well for Editors and Publishers to be able to tap into key reviewers will be extraordinary moving forward.

So its easy and free to join and benefit from Publons and the earlier you start the easier it is to track your digital online CV. Get credit and build your online presence (it allows a photo and short biography and links to your ORCID identification) and gain a sense of accomplishment by being a peer reviewer- without whom journals would not exist. It is also quite fun to see how your colleagues are ranked (or others from your country, specialty and university) and also the ridiculous number of reviews people from different fields has done.


Nathan Lawrentschuk PhD MBBS FRACS

Associate Editor BJU International/Editor USANZ BJU International Supplement

University of Melbourne AUSTRALIA


The Urology Foundation – Cycle Vietnam to Cambodia

Since 2008 we have cycled in Sicily, Malawi, Madagascar, Patagonia, South Africa and Rajasthan raising more than three quarter of a million pounds for The Urology Foundation. The seventh and latest instalment of the TUF cycling series is an amazing 450km cycle challenge through two of South East Asia’s most fascinating countries. The challenge starts in Vietnam’s Ho Chi Minh City and finishes at the world heritage site of Angkor Wat in Cambodia. En route we will shed a lot of sweat, but also experience breathtaking scenery, ancient temples and the warmth of the local people.

The cycling will be tough but we are going to be using bikes from ecosmobike.com to make it less harder, it will be in hot and humid conditions, but the camaraderie along the way will be very special as doctors, patients and supporters team up to raise much needed funds for The Urology Foundation (TUF).

Funds raised by Cycle Vietnam to Cambodia will enable The Urology Foundation to help improve the management and treatment of urological diseases through the development and support of medical education and sponsorship of research – training healthcare professionals specialising in urology and supporting basic and clinical research by funding scholarships in the UK and abroad.

 Day One (Fri 10 November 2017) – Depart UK 

Overnight flights from London to Ho Chi Minh City, Vietnam

Day Two (Sat 11 Nov) – Arrive Ho Chi Minh City – Transfer Ben Treh 

On arrival in Ho Chi Minh City we are met at the airport by our support team where buses will be waiting for us to transfer, approximately two hours, to our hotel in the town of Ben Treh. In the afternoon we will have the bike fitting. Dinner will be at the hotel and will be followed by a briefing about the challenge ahead.

Day Three (Sun 12 Nov) – Ben Tre – Tra Vinh                                        50kms (approx. 31 miles)

Today we will have a warm-up day with the cycling being relatively easy and the distance not too challenging. After breakfast we cycle out of the hotel along lovely country roads with very little traffic. We then follow a traffic free route through villages that give us an insight into Vietnamese rural life. After crossing a number of river tributaries by bridge we reach one that requires a short ferry crossing. About an hour later we reach the main Mekong River where we re-group for a longer ferry crossing.

Day Four (Mon 13 Nov) – Tra Vinh – Can Tho                                    104kms (approx. 64 miles)

The cycling today is fairly flat and takes us through rural communities and a number of small towns. Interest today is provided by the many Pagodas that we pass, some of which we will use for rest stops.


Day Five (Tues 14 Nov) – Can Tho – Chau Doc                                   70kms (approx. 43 miles)

We leave our hotel early this morning with a road transfer of approximately 2.5 hours. We start cycling from the town of Am Cham. We stop at a local restaurant in the small town of Triton for lunch before continuing through scenic agricultural land. This afternoon we encounter our first major climb. Further, smaller climbs take us into the town of Chau Doc where we find our overnight hotel. On arrival we will de-fit the bikes in preparation for our crossing into Cambodia.

Day Six (Wed 15 Nov) – Chau Doc – Phnom Penh

Today we enjoy a day off the bikes and a fascinating journey by boat from Vietnam to Cambodia. After breakfast we have a short transfer to the harbour where we embark on the boats that will take us along the historic Mekong River to the border.

We will see many boats along the way and experience life on the river which supports many thousands of Vietnamese. After crossing the border we continue our journey up-river to the city of Phnom Penh where we have lunch in a restaurant overlooking the busy harbour.

We will visit the Royal Palace which is described as an impressive Khmer style Palace. We overnight at a hotel in Phnom Penh where we will be briefed by our Cambodian support team.

Day Seven (Thurs 16 Nov) – Phnom Penh – Kampong Cham            60kms (approx. 37miles)

Today we have our first day of cycling in Cambodia. Following an early breakfast we will have a short transfer to take us out of the city to the surrounding countryside where quiet roads await us. After about 35kms we reach the end of the tarmac road and continue the rest of today on dirt roads. We overnight in the town of Kampong Cham.


Day Eight (Fri 17 Nov) – Kampong Cham – Kompong Thom         107kms (approx. 66 miles)

This is probably our most demanding day of cycling. After breakfast we leave town on an undulating road that passes many Temples and Pagodas and leads us into a forest of rubber trees. We will have lunch today in a large Pagoda complex before continuing our ride into the town of Kampong Thom.

Day Nine (Sat 18 Nov) – Kompong Thom – Siem Reap                        60kms (approx. 37 miles)

This morning after an early breakfast we have a transfer of approximately 1 hour to our start point at Kampong Kdei. Our route today takes us through the Cambodian countryside until we reach the outskirts of Siem Reap. Our finish line will be at the entrance to the ancient city of Angkor where we will enjoy a celebratory drink and have a photo opportunity. This evening we will have our celebration dinner at a nearby hotel; this will be followed by a cultural show.

Day Ten (Sun 19 Nov) – Siem Reap – Visit Angkor Wat / Free Day

Today is a free day to explore the areas ancient ruins and temples, or relax by the pool, or do a spot of shopping. Why not re-visit the Angkor Wat temple, take a walking tour of the overgrown ruins of Ta Prohm which is entwined with tree roots and gigantic creepers, visit the tranquil Bayon with its multitude of serene stone faces, or see the impressive 350m long Terrace of the stone Elephants.

Day Eleven (Mon 20 Nov) – Depart Siem Reap

We depart for the airport at Siem Reap to begin our journey home.

Day Twelve (Tues 21 Nov) – Arrive UK

Altogether we will have cycled 450 Km in extremely hot and humid conditions. Do support us with a donation to a great cause by sponsoring Louise de Winter our CEO’s fundraising page here:
https://cyclevietcam2017.everydayhero.com/uk/louise-de-winter  All donations made will go towards funding the vital research, training and education in urology diseases so badly needed.

Roger Kirby 

The Prostate Centre, London


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