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EAU19 Barcelona – Highlights from days 3-5 of the 34th Annual EAU Congress

The early Sunday morning start did not deter delegates from attending one of the three packed plenary sessions of the day. They covered a broad range of rapidly changing areas in urology from imaging in prostate cancer, an update on renal cell carcinoma (RCC) and the breaking news session discussing the potentially game changing results from the recent ARAMIS study and new research into fast bi-parametric MRI.  The role of imaging in prostate cancer is swiftly evolving, with the plenary discussion focusing on recent changes in the diagnostic pathway of localised prostate cancer, particularly with the use of MRI. Next door in the RCC plenary, the speakers debated ‘knife, needle or nothing?’ for the small renal mass in the young patient followed by an update on the very recent and potentially guideline-changing advances in systemic therapy for RCC.

The mid-morning thematic sessions covered the full spectrum of urology from semi-live surgery, the newest advances in immunotherapy, imaging and even how to run a urology office in Europe.

The 7th BJUI social media awards on Sunday night were again the social highlight of the EAU. A view of the Museu Nacional d’Art de Catalunya provided a stunning backdrop to the packed event, with the stars of #UroSoMe recognised for their outstanding work. The night kicked off with the award for the most read blog going to social media champion Professor Declan Murphy.

The awards highlighted the far reaching and valuable impact of social media, recognising a number of important achievements in the field such as Nature Reviews Urology for ‘Both sides of the scalpel: the patient and surgeon view’ with a special guest video appearance from Stephen Fry.

However, for me the most special part of the night was seeing my friend Daniel Christidis remembered and honoured with the most ‘social’ trainee award. Dan was a leader in the real and #UroSoMe world (and had personally set up my Twitter account, and those of many of the other young attendees that night) and I know would have been proud to be remembered for one of the things he did so well.

After the BJUI social media awards, it was time for a little black-tie glamour with the EAU19 Friendship Dinner at the historical Casa Llotja de Mar. The night started with a welcome from Professor Christopher Chapple underlining the importance of international partnerships in urology, followed by a fantastic night of good food, wine and enjoying the beautiful Catalan Gothic architecture.

The Monday morning plenary sessions delivered another jam-packed morning of a mix of cutting-edge science, quality of life issues in cancer survivorship and prostate cancer. The breaking news session discussed the primary results from SAUL, confirming tolerability and safety of atezolizumab in real-world mUC patients, and the results of ARCHES, which investigated the efficacy of androgen deprivation therapy with enzalutamide or placebo in metastatic hormone-sensitive prostate cancer. The controversies in prostate cancer were again debated in an interactive and diverse way between ‘jury members’ including a geriatrician, psychologist, radiation oncologist and urologist.

The last day of the thematic sessions of the congress again provided a smorgasbord of topics in urology. Later in the day, the expert-guided poster tours gave delegates a chance to navigate the huge number of posters from guidelines to local treatment of prostate cancer.

The closing plenary on Tuesday morning to a full auditorium gave a sweeping overview of the top contributions to EAU19 leaving us with a free half day to explore our generous host city and take in the stunning architecture, food and sunshine!

 

Bustling Barcelona provided the perfect backdrop to a well organised, action packed conference which featured world leading urologists and scientists from around the world presenting practice changing new data. Cannot wait for EAU 2020 in Amsterdam! #EAU20 #Amsterdam #UroSoMe

by Jiasian Teh, Urology Registrar, PhD Candidate, Peter MacCallum Cancer Centre

@JiasianTeh

EAU19 Barcelona – Highlights Days 1 and 2

The European Association of Urology Congress brings together delegates from across the globe to showcase cutting-edge urological research, and the 34th EAU Congress in Barcelona was no different. With a record high number of 5,500 abstracts submitted, over 1,600 presentations were due to be presented over five days. Adding to that a dizzying selection of 79 courses and hands-on workshops, this year’s EAU Congress was set to be one of the biggest to date.

After missing my flight here, I also missed the lines:

and swiftly registered to join a sea of red and yellow bags, coloured appropriately for the Spanish setting. With a big day ahead, the Catalonian capital had turned up the weather and the Fira Gran Via was humming with excitement.

The scientific program was already off to a flying start with a number of Urology beyond Europe sessions. These showcased the links between EAU and international urological societies, including USANZ, SIU and the CAU to name a few, and offered a chance to discuss regional differences in practice patterns and cutting-edge work from all corners of the globe.

Laser focus during a hands-on flexible ureteroscopy workshop

The evening approached rapidly, leaving no time for a siesta, as delegates made their way to the official opening ceremony. Prof Christopher Chapple welcomed delegates from around the world to make the most of what EAU19 had in store over the next four days. Presentation of EAU awards ensued, including the Crystal Matula and award for Best Prostate Cancer Research.

The end of formal proceedings had us seeing red, literally, as the Red area set alight with song and dance over a fiery backdrop in a vibrant performance from the opera Carmen.

This was soon to be eclipsed by two aerial silk acrobats accompanying an emphatic rendition of Freddie Mercury’s 1992 Olympic classic, Barcelona.

As the ceremony came to a close, it was time to network with colleagues and enjoy some Catalonian cuisine.

Court was in session early on Saturday morning, as a plenary on nightmares in stone disease chaired by Tim O’Brien and Thomas Knoll kicked off Day 2. With a medico-legal theme, Palle Osther spoke about the forgotten stent and sung the importance of leaving no stone unturned.

He was followed by horror stories of bowel injury during PCNL.

The mood was very different across the hall, however, as delegates geared up for a live surgery session courtesy of the Section of Uro-Technology, including a number from Barcelona’s own Fundació Puigvert Hospital.

Presenting and learning from live surgery is always a privilege, and all were grateful to those patients who generously agreed to participate.

With no shortage of residents at this year’s congress,

the European Society of Residents in Urology and Young Urology Office ran the extremely useful YUORDay19, covering ‘need to know’ information for residents, with topics ranging from the recent PRECISION and POUT trials to career advice and surgical tips and tricks.

EAU Guidelines also proved hugely popular once again, with delegates lining up to collect their copy of the brand new edition.

No meeting would be complete without a plethora of debates, and EAU19 was no different. The Controversies in Guidelines sessions covered a range of contentious topics in areas such as MRI-guided prostate biopsy, TURBT and adjuvant chemotherapy in UTUC. It was often standing room only, forcing a one-in one-out policy with some lines wrapping around the presentation rooms.

Pitting subspecialty heavyweights against each other, these sessions brought out a fighting spirit in all, even threatening to turn colleagues into enemies.

Fortunately, all ended well as another riveting day came to a close.

Barcelona has been the perfect setting to reunite with old friends and meet new ones at EAU19. Days 1 and 2 were a brilliant start to my first EAU congress, leaving me excited to see what the next three days have to offer.

by Arveen Kalapara, Research Fellow, Department of Urology, University of Minnesota

@ArveenKalapara

 

Highlights from the Irish Society of Urology Annual Meeting 2018

 

Dr Kent T. Perry Jr. delivers a lecture on minimally invasive kidney surgery

The Irish Society of Urology annual meeting has a strong tradition of attracting world class guest speakers, and this year was no different. We were joined by Dr Kent T. Perry Jr. (Co-Director of the Minimally Invasive Surgery Program & Associated Professor at Northwestern University Chicago), Professor Hendrik Van Poppel (Adj. Secretary General of EAU for Education), Mr Jeremy Ockrim (Honorary Lecturer and Consultant Urologist at University College London), Mr Kieran O’Flynn (Immediate BAUS past president and Consultant Urologist at Salford Royal Foundation), and Dr Matthias Hofer (Assistant Professor at Dept. Urology, Northwestern University Chicago). The excellent programme of guest speakers started on Friday afternoon with Dr Matthias Hofer’s talk on urethral reconstruction-a ‘no frills’ overview of a complex topic which surely inspired several trainees in the room to consider a career in Reconstructive Urology.

The historic Strokestown House, Co. Roscommon

The Saturday formal dinner was held in the historic Strokestown House in Roscommon-the former home of the Packenham Mahon family, built on the site of a 16th Century castle, which was home to the O’Conor-Roe Gaelic Chieftains. It is now the site of the National Famine Museum. We were treated to a fascinating tour of the house on arrival, before enjoying a wonderful dinner, and some fantastic harp-playing. The presidential chain was conferred to the incoming president, Mr Paul Sweeney of The Mercy University Hospital in Cork, and the society are already looking ahead to exciting things during his tenure as president.

 

About the authors:

Dr Clare O’Connell is a first year Urology SpR in the Department of Urology & Transplant in Beaumont Hospital, Dublin (@oconnellclare).

 

 

 

Dr Sorcha O’Meara is a second year Urology SHO in the Department of Urology in The Mater Misericordiae University Hospital, Dublin (@sorchaOm).

 

 

 

ERUS 2018 – Marseille

Robotic Heaven

The EAU Robotic Urology Section (ERUS) is unabashedly a Robotic surgery conference. We have all drunk the Kool-Aid and we have all come for the robot. There is no need to rush between rooms deciding which session to attend. 3D Glasses are donned, we sit back and the education comes at you on the Cinemax style screen, three live surgeries at a time. This year, the 15th Annual Meeting of ERUS took place in Marseille from 5-7th September 2018 and was convened by Dr Jochen Walz, Director of GU Oncology at the Institut-Paoli Calmettes Cancer Centre. Over 650 delegates from all over the world attended what is the world’s leading robotic surgery conference in urology.

 

 

Three reasons you should have been there

The Rise of the new Robots

In a world exclusive we saw the first cadaveric prostatectomy using the Versius from CMR surgical (aka the Cambridge Robot)

In a candid presentation Prof Dasgupta gave his personal feedback on his experience. This helped grow the enthusiasm for this robotic platform that has been gaining widespread media exposure in recent times.

https://www.bbc.com/news/health-45370642

Invariably the talk of new robots spilled over into social media with a wish list and critique of the current landscape of robotic surgery.

ERAS at ERUS

If we are doing surgery minimally invasive then we should maximise recovery for our patients. A multi-disciplinary team of speakers highlighted the pathways for our patients. We should all be adopting these programs in our own centres. Rather then re-inventing the wheel in each centre we should utilise the great resources already available.

erus18.uroweb.org/wp-content/uploads/ERAS-Protocol-070718.pdf

Live Surgery

Surgeons like surgery and to watch ones craft is undoubtedly a form of education.

All of the 16 live surgery cases were performed by experts to an elite standard and were extremely informative. As per the EAU guidelines we were given updates from both the previous years patients and also the follow up of those performed during the conference.

But live surgery does walk a tightrope of ethics for surgeons and again we must be mindful of the sanctity of the surgeon – patient relationship and above all else patient safety comes first.

 

#Ilooklikearoboticsurgeon

Hopefully the ERUS committee have a long-term diversity plan to ensure more (any) female surgeons are in the live surgery and on the podium. It is very much not for lack of high quality world class female surgeons, many who I have had the privilege to train or work with.

Make Friends not Robots

For all the robotic contact we got, we all crave that human touch and herein lies the key reason to consider ERUS2019 in sunny Portugal.

Prof Dasgupta editor of the BJUI tweeted it best and I wholeheartedly agree. The friends through out the world that I got to catch up with make all that travel worthwhile.

 

The 16th ERUS takes place in Lisbon from 11-13th September 2019 and will be convened by Dr Kris Maes. Check out Kris’ promo video here


 

 

Simon van Rij (@sivanrij) is a Urologist based in Auckland, New Zealand.

 

 

BAUS 2018 Highlights Day Three

BAUS Day 3—Going home images and snippets…

On the final night of BAUS, I had the honor of giving a dinner talk to the IBUS group—International British Urology Society.  With BAUS contracting from 4 to 3 days, some of the previous joint sessions fell by the wayside, but IBUS president Subu Subramonian put together a nice evening program for the group.

The Day 3 morning session started with what is likely an original debate topic: “Consenting to Death.”  The pro/con centered around whether or not every circumcision operation should be consented for the possibility of death.  The idea was nominated by Jonathan Glass who also did a Twitter poll on the subject, which was similar to this audience poll—around 90% saying no.

The general flow of the debate was whether or not the rare incidence of a complication should be left off, so as not to alarm/concern the patient with minutia.  On the other had, severe complications and death should potentially be consented even if rare.

 

Note the risk of everyday life compared to surgery: soccer was 1: 50,000.  Mr. Glass had a nice display on how choices of driving routes to the hospital could affect the risk of dying.  Turns out the bus is safest.

At the end of the debate, the voting shifted slightly to around 30% saying they would consent for death for a circumcision.

As Mr. O’Brien asked—do you also have to show the patient some horrific picture of gangrene so they are truly informed as to the risk of serious infection?

My favorite phrase on the serious but rare event is “its low risk, but never zero…perhaps a lightning strike.” Never say “routine surgery,” as that is always what the newspaper says: “ He died after routine surgery.”  Routine sounds like zero risk.  I must say also that the risk of “bleeding, infection, cardiac event, stroke, and death” is on almost every U.S. hospital template consent.  So I think patients are used to it and will not freak out.  Also vis-a-vie the Day 2 Blog on Dr. Wachter’s talk, an unintended consequence of the EPIC EMR is that we rarely print consents for patient review—rather we shows them on a screen and they digitally sign.  But I bet they read the details less often than before.  Oddly, they are not able to view their consents with their personal accounts, yet they can read clinic notes, diagnostics, imaging, path ,etc.  Need a solution here.

Always good to have some humor in the slides.

Next, we heard a lecture from a truly unique individual. Mr. David Sellu gave us his personal account of how he was brought before a criminal court for manslaughter when a patient had a bowel perforation after a knee operation—he was in call coverage.  He served time but won his appeals to drop charges and clear his name.  I’m sure there were errors in the case, but in the U.S. this would likely have been a malpractice/civil court case and the hospital would have been co-defendant (system errors). Roger Kirby has tweeted the progress of this case for years, so it was interesting to hear from him personally.

Look at the multiple layers of jeopardy his case took him through over a 6 year period.

Here is a link to a previous blog on the case:

https://blogs.bmj.com/bmj/2018/03/20/the-case-of-david-sellu-a-criminal-court-is-not-the-right-place-to-determine-blame-in-complex-clinical-cases/

The Urology Foundation sponsored a session.  They recognized a recent research scholarship awarded to Mr. David Eldred-Evans “The PROSTAGRAM trial: a prospective cross-sectional study assessing the feasibility of novel imaging techniques to screen for prostate cancer.

Roger Kirby then gave a guest lecture on his personal journal with prostate cancer as a surgeon and patient.  He highlighted his actual biopsy specimens and RP path.  He is 5 years disease free.  He also showed some great nostalgia as he was being interviewed  >20 years ago at the launch of Proscar to the market.  He had 2 interviewers trying to gang up on him on conflict of interest and trying to make the drug sound toxic.  I wonder how he would have handled those two in this era.

Some highlights of his slides on advice to surgeons.  Thanks for all you do Roger.

 

 

 

 

 

 

Finally, there was an interesting session on the Global practice of urology with emphasis on training pathways and what has changed over the decade.   Alan Partin presented his department’s approach to urology training at Johns Hopkins and the US perspective.  James N’Dow outlined how diverse urologic training and credentialing is organize across Europe.  Sanjay Kulkarni gave in Indian perspective—noteworthy that the urologist does not have such constraining credentialing pathways, and often will have private practice across multiple hospitals.  He has attended over 60 and now owns one for his urethroplasty cases.  Times are changing globally for urologic training, and Dr. Partin summed it up well by pointing out that the process of training is highly scrutinized now and seemingly higher priority than the final trained product.  Does anyone think that a urology graduate in 2018 is better trained than 1998?

Ok—time to get back to work in Houston.

John W. Davis, MD, FACS

Associate Editor, BJUI.

 

BAUS 2018 Highlights Day Two: The 2018 BJUI Guest Lecture

Achieving the Promise of Digital Health: Are we There Yet? If Not, When…and How? Dr. Robert Wachter

Day 2: The 2018 BJUI Guest Lecture: Dr. Robert Wachter.  Achieving the Promise of Digital Health: Are we There Yet? If Not, When…and How?

Image 1: Q&A with Dr. Robert Wachter, moderated by BJUI Trustee Chair, Prof. Krishna Sethia.

For Day 2 of BAUS18, the BJUI team invited a very unique expert to the podium. Dr. Robert Wachter is chief of medicine at the University of California San Francisco. He is more than an international guest flown across the pond for a keynote speech. Rather he is an expert in the digitization of health care and has consulted with the NHS in the past and extensively toured UK facilities. In a prior era of his career, he is credited with inventing the term “hospitalist” as internal medicine trained doctors who only service hospital-based points of care rather than the traditional outpatient clinic.

As a preface, he showed U.S. statistics that in ten years, we transformed from a < 10% to > 90% rate of electronic medical record (EMR) adoption—much of it spurred by financial incentives from the federal government. We all assume EMRs are more accurate and cut down on medical errors—queue the picture of the poor penmanship resulting in wrong drug/wrong patient/wrong dose. Yet he showed a post digitization era mistake where a drug was given 39 times rather than once due to mg vs mg/kg confusion—somehow the error made it through the whole system of EMR check points, robotic pharmacy dispensing, bar coders, and administration. The patient somehow survived. The take home point is the unintended consequences of the EMR.

What drives the EMR? Familiar themes of safety, accuracy, and low cost. At my hospital, we went through the famous EPIC EMR transformation in 2016. We lost so much money in the transition, it was fodder for articles in our national press and it certainly had an impact of several administrators’ careers. But even > 2 years later, I can say that I can make EPIC work at the level I worked before. But am I any faster? Definitely not. And the InBasket feature is a never-ending taskmaster of clinic results and messages and notifications.

Dr. Watcher showed a nice children’s drawing of a visit to her pediatrician. Everyone in the family is drawn, and she is on the exam table. The doctor? Back turned to the patient and clicking away at the EMR. So true and I’m as guilty as anyone. The only mistake made by the 7-year-old artist was that the doctor is smiling while clicking away on the computer! You can see the image yourself (copyrighted) in the article by Toll E, JAMA 2012 PMID 22797449. He pointed out that in most industries, digitization and automation would normally contract the work force and reduce or transfer out job positions. But not in health care—the popular solution to the physician’s back to the patient is to hire a “medical scribe” to do all of the EMR work while the doctor returns to the face to face role. In another talk on Global trends in health care and education, Dr. Allan Partin pointed out that it is increasingly popular in the USA for undergraduate students to take a “gap” year after graduation and before medical school, where they often do research, travel, work in the field, etc. Both trends are now part of my household—my older daughter graduated Baylor University with Health Sciences Studies degree and is both taking a gap year and taking a job as a medical scribe while applying to medical school.

Next is really the key point to where we are now in health care—yes we have converted to the EMR, and yes we have a few tricks like voice recognition software, medical scribes, and *** template phrases to speed up or at least maintain the pace of the pre-EMR era. However, what lies ahead is how to unlock the mystery of how to increase productivity. As far as we know, no one is more productive with an EMR across the board. In some cases, it can still be the opposite—the EMR became such a temptation for hospitals to “tack on” more tasks while they have us in there: not just an H&P but lets add TMN cancer staging, and a problem list, and reconcile meds, and an enormous review of systems, and review outside problems, and do all of the coding and billing. And at least in the EPIC version of the EMR, if any members of your extended team (nursing, trainees, advanced practice providers, etc.) make a mistake in their documentation, you usually can neither correct the error yourself nor close the encounter. So you have to chase them down by email to finish the work. At our center they now want encounters done by 7 days and promise to fine us starting day 14.
So that might be the future—improvements to EMRs or use of artificial intelligence to make our work better and more efficient. A quick example was an endocrine service where the chief could use the EMR to screen hospitalized patients at risk for hyperglycemic complications. He could send alerts to the nursing team on how to further assess and avoid problems. He can scan the whole hospital to flag 20 cases, and send 10 messages—all in the course of an hour. If any one of those 20 cases became a consult, it would probably be an hour each—so that’s the efficiency multiplier.
Overall it was an excellent and thought-provoking lecture. It fits thematically with the prior 2 blogs in the sense of looking at the effects of “mandating” quality improvement projects or “mandating” MDT discussion of all cancer cases—what are the unintended consequences and where is the next paradigm shift.

As I sign off, I think everyone of a certain age’s favorite example of unintended consequences was the story of the radiology film room attending who commonly sat in a dark office in the basement of the hospital. You would go down there with your team of residents, students, and attending and looks through the films and discuss face to face who has pneumonia and who was fluid overloaded, etc. Once we went digital, that whole interaction disappeared for better or worse. As a funny recollection, the other key staff down there when I was a resident were the guys organizing the film library—once a day you had to give them a list of cases to pull from the stacks. They were your friends and could make you look good at conference time. As I recall, once we went digital that job when away quickly. Seems like many of them found employment at our local airport as TSA security agents. I guess the experience with x-rays was a good prerequisite.

 

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

Image 2: Key Slide. The latter point of digitization of health care is the next point of emphasis, following pressure to deliver high value care.

 

 

BAUS 2018 Highlights Day Two

BAUS Day 2. The Multidisciplinary Team Debate. Which way are you headed?

BAUS is certainly a UK-centric meeting. But we all share most of the same challenges in healthcare, and as an international urologist in attendance, the learning experience is often gaining insight into how different health systems tackle common problems with solutions and evolutions.

During day 2 prime time, the agenda tackled the current and future situation with MDTs in cancer treatment—multidisciplinary team meetings. For the USA, we might use the term Tumor Board. At MD Anderson we just say, “Urological Multidisciplinary Case Conference.” So yes, MDT is much more efficient.

The goals are straightforward in principle: 1) increase the quality and standardization of care, 2) improve access to expert imaging/pathology, 3) provide a “group” decision which may be more experienced than any 1 person. In the United States, each center is left on its own how to organize and conduct MDTs, although there may be requirements for inclusion as an NIH designated comprehensive cancer center. In the UK, it appears that MDTs are more of a compulsory element. Another key decision is what patients will be presented—all or selected. In the UK, it appears the goal has been to present everyone.

The first speaker was Hashim Ahmed who showed how the “present everything” model has increasingly become impossible, as half of all cases are presented/discussed in < 2 minutes and few go beyond 3 minutes. A national strategy is being discussed and likely piloted in prostate cancer whereby “routine” cases might be listed as a statistic but not discussed; and time reserved for more complicated cases where discussion might be more fruitful. This model will require the MDT chair to spend more pre-meeting time triaging the meeting agenda.

Jo Cresswell expanded the topic by compiling the UK real world experience with MDTs in terms of what has worked well and where it has been lacking.

The “good” might include:

  • Building working relationships with colleagues
  • Mentorship interactions
  • Challenging old practices—evolving from eminence based to evidence based decisions
  • Calling out bad practice/minimize rouge decision making
  • Comforting patients that their case has been heard by a group—sort of a free 2nd opinion

The “bad” or “Pet Hates” list is interesting:

  • The cost of running the MDTs—actual and effort
  • Reduced ownership of the patient—notes where the plan just reads “refer to MDT”
  • Waiting on the MDT
  • MDT Tennis—i.e. referring back and forth between different MDTs
  • Fatigue—going through 120 cases in a session—is anyone awake at the end? Some providers have to attend multiple MDTs per week
  • Loud voices can overrule others (queue the photo of Trump)
  • Agenda effect—if you always present in the same order then whoever goes last on the agenda probably gets less quality discussion.

What is the best middle ground? Again,the concept of discussion reserved for complex cases, and routine cases are under the MDT but not given time.

The final speaker was Bill Dunsmuir. He started by challenging the assumption that the MDT make up of 10-20 experts in oncology will produce wiser decisions than any single provider. Case and point was the 1996 climbing expedition to Mount Everest where the group decision making of expert climbers led to the deaths of the many. Maybe group thinking is not so wise? Problems might include group thought with the same ideas, hierarchy that minimizes dissent, and false debates.

From the Emperor of All Maladies book, he channeled the similar questions, “What is Cancer, why does cancer kill?” One trainee responded in a survey “A cancer killed because they were unfortunate enough to have their cases discussed at an MDT.”   So why do we have MDTs?

His proposal was to consider MDTs as not only dedicated to group decisions, which may or may not always be right. Rather consider them as multidisciplinary professional education. As an example, if the group encounters a specific problem, there would be a pool of short video clips to review the evidence and guidelines—and then discussion could flow off of these standardized points. Ambitious for sure and would need funding and buy in.

In conclusion, this was a well-done session, and highlights the natural history, so to speak, of compulsory MDTs including all patients.   At MD Anderson, we went the other way: select presentations. Each case takes 10-20 minutes, so we usually only get through 3-5 in an hour session. Attendance is optional and there tends to emerge faculty personalities who like MDT interaction, and some who never go. Cases are nominated by a fellow or faculty and you would probably be criticized for presenting a patient where we already have a treatment protocol in placed, i.e. “put them on the protocol, next case.” As a fellow in 2001-2002 I observed there are 3 popular categories of MDT case presentation that are always worthwhile:

  1. I dare you to operate on this patient (co-morbidity, prior surgery, obesity etc.)
  2. How to manage multiple cancers
  3. Look what they screwed up on the outside. Now what?

Please use our comment section—where do you stand on MDTs at your center and what is in the future?

 

John W. Davis, MD, FACS

Associated Editor, BJUI

 

Figures: Slide highlights on current and future of MDTs

 

BAUS 2018 Highlights Day One

Day one at BAUS gets started with society meetings and the John Blandy Prize and Lecture delivered by Editor Prokar Dasgupta.  The winner was from Pisano et al from Turin, Italy on “The role of re-transurethral resection in the management of high risk NMIBC (PMID 26469362).

But I had to miss this event as I was having my first patient encounter with the NHS.  I have 4 days of severe pain in my left foot after a lot of walking/running around as a tourist on a Baltic Sea cruise.  I went to the nearby NHS walk in clinic—there for an hour and saw the nurse practitioner and left with new scripts for NSAIDs, pain, etc.  And no bill?  Not in the USA!

So now that I can walk (sort of—but only with my running shoes—looks great with a suit) I made it to the teaching course on quality improvement (QI).  I am interested in the topic as I am a Quality Officer for Urology at MD Anderson Cancer Center.  One of our new directives has been to help with fellows organizing a new mandatory “quality improvement” initiative as part of their training.  From the course, I learned that the UK has similar programs but also similar challenges in implementation and standardization.  In the UK, it sounds like medical students are being taught quality improvement in the curriculum.  But if you are like me and finished school > 20 years ago, you likely missed this content.  A consensus opinion was that educational materials on quality improvement science will be created and hopefully will land on the BJUI Knowledge website.  This will help trainees but also trainers catch up on terminology, goals, and how to coach trainees on project development.

The next strong consensus was that quality improvement projects be listed on a website—likely BAUS—so that they could be indexed and searched.  Similar to clinicaltrials.gov or the PROSPERO website that catalog clinical trials and meta-analyses, respectively, the BAUS site could be searchable for projects that were successful as well as those that failed for some reason (perhaps with lessons learned).  Indexing could help with project selection as some QI ideas are unique to urology versus all specialties, and QI projects may emphasize different practice environments such as clinic, operating theatre, or diagnostic departments.

Overall, QI is an emerging field and we are struggling with the same barriers on both sides of the Atlantic.  Principle questions include 1) how to differentiate a clinical study from QI, 2) the role of statistics, evidence-based medicine principles, and ethics committees in QI, 3) how QI should be taught in medical school and post graduate programs, and 4) how QI projects can be published.  On the latter point the Journal of Clinical Urology has expressed interest in publishing QI projects.

The course was directed by Mr. James Green from Barts Health, and also taught by Prof. Nick Sevdalis.  Congrats to both on a job well done.  From my perspective, this field will continue to grow and for some young academic minded urologists will develop into a legitimate academic niche to go along with established pathways such as laboratory investigations, health services research, and surgical education.

Figure: My favorite slide—so may sources of inspiration for a Quality Improvement Projects

John W. Davis, Associate Editor.

 

AUA 2018 highlights days 3 and 4

AUA 2018

As a first-timer to the AUA, I did not know what to expect from this meeting but one thing for sure was that San Francisco would put on a show. I have always been told that everything is big in America so let’s see: plenty of big names present (check), big conference centre (check), big smiles everywhere (check), big news (check)! (but a diminutive author, to put this all together).

It may have been half-way across the world but the royal wedding brought a buzz of excitement, since they prepare everything for this event, including the use of red table linen for decoration on this special day. They are some special things, which kept secret due to royal family. The most important excited thing which is kept secret from media is hens nights of the Meghan Markle, As per sources from the royal house then hens party was arranged with the special hens packages, arranged by the wedding planner by hiring world’s best hens party company.

On Sunday, we were treated to one of the city’s quintessential experiences: The Bay to Breakers race. Getting to the Moscone centre may have been a bit difficult as a result of all the road closures but the runners offered plenty of entertainment on the commute.

Some of the male runners decided to bare it all and one wonders whether their boldness comes from having read the ‘biggest paper” at AUA2018!

At the conference centre, there was no shortage of excitement with the annual AUA residents bowl challenge happening over the weekend culminating in the final between South Central – Pirates of the Perineum vs Western – California Streamin’. This was a tense battle that went into overtime with the Western – California Streamin’ taking out the overall prize.

A recurring theme at the meeting was ‘the rise of the machines’. A few abstracts presented suggested the role of artificial intelligence (A.I) to not only interpret MRI but also to determine who needs an MRI! Should clinicians be worried about losing their jobs to machines? The hope is that A.I does not replace clinicians but aids in improving the diagnostic accuracy. Ralph Clayman also mentioned the potential use technology in surgical rehearsal and even true automation!

A Japanese group also presented their work on the potential role of A.I in screening for STI’s – the possibilities are truly endless!

On Sunday, we were treated to the BAUS-BJUI-USANZ joint session at Marriott Marquis. This was a great session with talks ranging from prostate cancer genomics to tissue engineering for reconstruction. During the session, Dr Ballentine Carter paid tribute to Donald Coffey before presenting the Coffey-Krane prize to Dr Xiaosong Meng.

I should also point out that Dr Bal Carter himself won an award at AUA2018 and the legitimacy of this award cannot be questioned as this was voted for by one of the top social media influencers! I shall say no more…

Dr Caroline Moore presented the results of their landmark PRECISION trial. However, following on from the spine-tingling “Court is in session” case on post-TRUS biopsy sepsis and the comment earlier in the meeting on the superiority of a well done ultrasound over MRI, it was not surprising that the crowd here was still a bit sceptic about the benefits of MRI.

The issue of gender diversity in leadership positions also came up at the meeting. The presidents’ reception photo only showed two female presidents and there was a call for improvement in this regard. It was encouraging to note that there were sessions at the meeting that focussed on how to bridge the gender gap and a few articles have been published recently in the literature looking at exactly this issue.

Away from the conference, I got to experience a bit of what San Francisco had to offer including the NBA Western conference finals (Go Warriors!!!), Napa wine region, a ride across the bridge, Alcatraz island, Tiburon, drowned in the shopping experience at the Livermore outlets. San Francisco has some great restaurants showcasing food from all around the world which I got to enjoy. Overall, this was a great meeting in a great host city and my first AUA experience definitely lived up to the hype and am already looking at what Chicago 2019 has in store!

Dr. Tatenda Nzenza,University of Melbourne, Department of Surgery, Austin Hospital, Melbourne; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne; and Young Urology Researchers Organisation (YURO), Australia

Twitter: @DrTNzenza

AUA 2018 highlights days 1 and 2

The American Urological Association meetings always offer a plethora of stimulating sessions. Forget about the flowers in your hair, if you were going to San Francisco for the 2018 AUA meeting, an early morning coffee and good walking shoes were your best shot at getting to as much of the action as possible.  As best that I tried, I could not make it to all of the places that I wanted to be, so apologies must be made in advance if I fail to mention some of the great work that is being done in our field.

After registration and carefully dissecting the daily content in the phone book sized program, the day kicked off as early as 7am. Poster and video presentations touted new technologies and put forward ideas that met critical peer review and applause in several concurrent sessions. Also flourishing in number was the amount of instructional courses that were offered to attendees. From nocturia management to business models in medicine, the AUA courses added some active involvement to the osmotic learning process.

So often the term “defensive medicine” is used in describing practice that protects a practitioner from punitive or litigious claims. As uncomfortable an idea as this is, the AUA stage show titled “Court is in Session” was a great portrayal of the risk management process that occurs in clinical decision making for all of our patients. The brutal cross examination of on stage “witnesses” delivered by close colleagues (given away by a wry smile or two) had a few people shuffling in their seats and pulling at their collars. All in all, this was a great example of the use of best current evidence base for common choices made in urological care. Interestingly, when debating the case of a post-TRUS biopsy sepsis patient, transperineal biopsy did not even score a mention from the prosecution!

 

A complex case discussion of Prostate cancer was to follow with John Davis doing an excellent job at moderating and driving the discussion. A common theme in the court cases and case studies was the increasing relevance of pre-biopsy multiparametric MRI, with an argument being made by many that it is the evolving standard of care to image before biopsy.

To break up the day, a stroll around the science and trades hall is always welcome. The new devices and systems on offer surely raised some questions and some eyebrows! Some of the virtual reality simulators gave a great feeling for being actually present in the OT as seen in the picture below of me performing a prone PCNL puncture with my arm over the shoulder of my virtual consultant.

 

An interesting presentation was to follow called “The survivor debate” in which a case was made for different treatment options in a male patient with low- intermediate risk prostate cancer. The showdown of cases presented by Klotz’ 13 – each a passionate experts in the field – revealed some convincing arguments for therapies that I would not have previously considered. If anything, it was a lovely chance for the salesmanship of senior clinicians to come out!

AUA President Brantley Thrasher delivered an address with some future insight. The issue of clinician burnout was addressed, being particularly high in the US. This was tied in with the rise of artificial intelligence, technology in medicine and the need for future proofing of the electronic medical record and data systems to help us better care for patients and ourselves. A slide and brief description on each new technology had my head swimming after learning about Bluetooth urinalysis chips to put in patient’s underwear to beam UTI info straight to your smartphone and electromagnetically driven “sperm-bots” that delivered a genetic payload to an ova.

Just when I thought I couldn’t be more impressed, a presentation from Dr. Atul Butte blew the lid off the plenary. In an engaging oration, he described the access that already exists to large data sets such as genomic and tissue samples and how easily these kinds of sets can be used to create innovative solutions to current healthcare dilemmas. To cap it off, a very effective visual “patient illness moving-map” was displayed showing data from tens of thousands of patients who had suffered myocardial infarction. By finding the end point of these patient journeys (most likely to die of sepsis years down the track) this can lead to the creation of a truly accountable model for healthcare outcome prediction and improved patient care. Definitely a lecture to re-visit if you get the chance!

After the lecture on clinician burnout, I thought it best to heed the advice regarding taking some time out for you. Luckily, only a 10min walk from the convention center, you could find yourself amidst the Seal Docks and waterside. If you were lucky enough to jump in to the baseball game at AT&T Park, you may have enjoyed some ballpark American classics (hotdogs, nuts and crackerjacks) as well as a sea of black and orange clad SF Giants fans cheering their home team to victory.

Other stress relief events throughout the conference were a great chance for peers to mix and mingle, old alumni to catch up and for new relationships to be forged. The Urological Society of Australia and New Zealand’s annual AUA reception is a great event on the calendar that performed this role perfectly. With attendees encouraged to bring international guests, it was as multi-national as Australia’s home population.

It seems that an overarching theme for our future directions is one of large-scale change. The sheer size of the AUA 2018 meeting was enough to out that idea into our heads initially, but considering the global impact of the growing population and the limitation to our resourcing, we will need to start to consider some changes to future proof our systems of care. A quote that stuck with me that I had caught along the conference: Progress is impossible without change, and those who cannot their minds, cannot change anything. This meeting definitely changed presented enough to change my mind about quite a few things!

For my first AUA it was a fantastic experience! It is always a great chance to catch up with peers and mentors and also to meet international experts in the field to gain exposure to their work. Looking forward to Chicago! #AUA19

 

Dr. Daniel Christidis, Peter MacCallum Cancer Centre, Melbourne, Australia

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