Tag Archive for: consensus

Posts

Article of the Month: BAUS consensus on priapism

Every Month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

BAUS consensus document for the management of male genital emergencies: priapism

 

Asif Muneer, Gareth Brown, Trevor Dorkin, Marc Lucky, Richard Pearcy, Majid Shabbir, Chitranjan J. Shukl,a Rowland W. Rees & Duncan J. Summerton

BAUS Section of Andrology Genitourethral Surgery

 

 

Abstract

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on‐site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus committee comprising members of the BAUS Section of Andrology and Genitourethral Surgery together with experts from urology units throughout the UK. Priapism requires prompt assessment and treatment and these consensus statements provide guidance for UK practice.

Editorial: The BAUS consensus documents on andrology

In 2018, the BAUS returns to Liverpool and we have taken this opportunity to renew the lasting friendship between the BAUS and the BJUI. We also celebrate a monumental achievement for the city of Liverpool itself – the Knighthood of Sir Ringo Starr. This has finally happened, 50 years after his MBE and is richly deserved. We therefore decided to feature Liverpool and The Beatles on the front cover of your journal.

This year, Duncan Summerton, a well‐respected Urologist and Andrologist, starts his 2‐year term as the President of the BAUS. In our ‘Guidelines’ section, we have featured two BAUS consensus documents from the Andrology Section on priapism [1] and testicular trauma [2]. The former has an excellent flow chart on management of priapism with timelines of presentation, which every urologist will find clinically useful.

We have also included two excellent UK articles on renal trauma [34], which BAUS members and beyond can learn from.

Finally, renal oncocytoma and its management may pose its own challenges as recorded by Neves et al. [5]. We also present the BAUS radical prostatectomy audit, which is publicly accessible and reassures readers (and the public) that the majority of these operations are being performed in high‐volume centres (164/centre) by high‐volume surgeons with good outcomes [6]. Nearly three in four operations are now performed robotically, which was certainly not the case when I started 15 years ago.

We look forward to meeting you at lunchtime on the Monday and Tuesday of the BAUS conference at the BJUI stand. I am particularly excited about the BJUI lecture and the National Clinical Entrepreneurship Programme, led by my friend Tony Young, on the second day of the meeting (https://www.baus.org.uk/agm/programme.aspx).

 

Prokar Dasgupta

MRC Centre for Transplantation, King’s College London, London, UK

 

 

References

 

 

  • Lucky M, Brown G, Dorkin T et al. British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies – testicular traumaBJU Int 2018121: 840–4

 

  • Wong KY, Jeeneea R, Healey A et al. Management of paediatric high‐grade blunt renal trauma: a 10‐year single‐centre UK experienceBJU Int 2018121: 923–7

 

  • Hadjipavlou M, Grouse E, Gray R et al. Managing penetrating renal trauma: experience from two major trauma centres in the UKBJU Int 2018121: 928–34

 

  • Neves JB, Withington J, Fowler S et al. Contemporary surgical management of renal oncocytoma: a nation’s outcomeBJU Int 2018121: 893–9

 

  • Khadhouri S, Miller C, Fowler S et al. The British Association of Urological Surgeons (BAUS) radical prostatectomy audit 2014/2015 – an update on current practice and outcomes by centre and surgeon case‐volumeBJU Int 2018121: 886–92

 

Article of the Month: Gleason Grading in the Spotlight

Every Month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Klaus Brasso, discussing his paper.

If you only have time to read one article this week, it should be this one.

The impact of the 2005 International Society of Urological Pathology consensus guidelines on Gleason grading – a matched pair analysis

Kasper D. Berg*, Frederik B. Thomsen*, Camilla Nerstrøm*, Martin A. Røder*, Peter
Iversen*, Birgitte G. Toft, Ben Vainer† and Klaus Brasso*

 

*Department of Urology, Copenhagen Prostate Cancer Center and Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

 

Objectives

To investigate whether the International Society of Urological Pathology (ISUP) 2005 revision of the Gleason grading system has influenced the risk of biochemical recurrence (BCR) after radical prostatectomy (RP), as the new guideline implies that some prostate cancers previously graded as Gleason score 6 (3 + 3) are now considered as 7 (3 + 4).

Patients and methods

A matched-pair analysis was conducted. In all, 215 patients with Gleason score 6 or 7 (3 + 4) prostate cancer on biopsy who underwent RP before 31 December 2005 (pre-ISUP group), were matched 1:1 by biopsy Gleason score, clinical tumour category, PSA level, and margin status to patients undergoing RP between 1 January 2008 and 31 December 2011 (post-ISUP group). Patients were followed until BCR defined as a PSA level of ≥0.2 ng/mL. Risk of BCR was analysed in a competing-risk model.

JunAOTMResults

Results

The median follow-up was 9.5 years in the pre-ISUP group and 4.8 years in the post-ISUP group. The 5-year cumulative incidences of BCR were 34.0% and 13.9% in the pre-ISUP and post-ISUP groups, respectively (P < 0.001). The difference in cumulative incidence applied to both patients with Gleason score 6 (P < 0.001) and 7 (3 + 4) (P = 0.004). There was no difference in the 5-year cumulative incidence of BCR between patients with pre-ISUP Gleason score 6 and post-ISUP Gleason score 7 (3 + 4) (P = 0.34). In a multiple Cox-proportional hazard regression model, ISUP 2005 grading was a strong prognostic factor for BCR within 5 years of RP (hazard ratio 0.34; 95% confidence interval 0.22–0.54; P < 0.001).

Conclusion

The revision of the Gleason grading system has reduced the risk of BCR after RP in patients with biopsy Gleason score 6 and 7 (3 + 4). This may have consequences when comparing outcomes across studies and historical periods and may affect future treatment recommendations.

Editorial: Current Gleason score 3 + 4 = 7: has it lost its significance compared with its historical counterpart?

Berg et al. [1] report that patients classified as Gleason score 7 (3 + 4) according to the revised grading system published in 2005 are to some extent similar to patients with pre-2005 Gleason score 6, at least in terms of risk of biochemical recurrence. The logical but not necessarily correct conclusion is that current patients with Gleason score 7 on biopsy are appropriate candidates for active surveillance.

What must be kept in mind is that, using the post-2005 revised grading system, approximately 25% of men with Gleason score 3 + 4 = 7 on biopsy have either 3 + 4 = 7 with tertiary pattern 5 or >4 + 3 = 7 in the corresponding radical prostatectomy [1]. With the exception of men with a limited life expectancy, these men need definitive therapy for their potentially life-threatening cancer. Numerous studies have shown that extended biopsies, whether they are >10- or 12-core, are associated with less upgrading than sextant biopsies [2]. In the report by Berg et al. [1], the median number of cores sampled before 2005 was 6 with an interquartile range (IQR) of 6–6 compared with a median (IQR) of 10 (10–12) cores after 2005. Consequently, in their cohorts, the pre-2005 group of men with Gleason score 3 + 3 = 6 were more likely to have unsampled higher grade cancer and a correspondingly worse prognosis more closely approximating post-2005 better-sampled Gleason score 3 + 4 = 7 cancers.

Berg et al. [1] further claim that the prognostic and clinical value of Gleason score 7 has been weakened since the 2005 modifications. In fact, the revised grading system more accurately reflects prostate cancer biology than the pre-2005 Gleason system. The major consequence of the modification, as Berg et al. [3] illustrate, has been the better prognosis associated with post-2005 Gleason score 6 cancer because patterns associated with more aggressive behaviour have been shifted to Gleason score 7. Historically, a diagnosis of Gleason score 6 cancer, even at radical prostatectomy, was not as predictive of ‘good’ behaviour, and had a higher rate of progression with some men even dying from prostate cancer [4]. Currently, Gleason score 6 cancer at radical prostatectomy has a 96% cure rate at 5 years, even including cases with extraprostatic extension and positive margins [3]. Several studies have shown that post-2005 pure Gleason score 6 cancers at radical prostatectomy are incapable of metastasizing to lymph nodes [4]. Berg et al. are correct, however, that men with a post-2005 grade of Gleason Score 3 + 4 = 7 have a better prognosis than those graded prior to 2005. As a consequence, it has been recommended that pathologists should record the percent pattern 4 in cases with Gleason score 7 on biopsy for men being considered for active surveillance [5]. For the appropriate patient, depending on age, comorbidity, extent of cancer, MRI findings, patient desire, etc., could be a candidate for active surveillance with Gleason score 3 + 4 = 7 if the pattern 4 is limited. Currently, this information is not transparent in most pathology reports.

A new grading system, first proposed in BJUI by this author, and verified in a large multi-institutional study, resulted in a simplified five-grade group system that more accurately reflects the biology of prostate cancer than the pre-2005 grading system [3, 6]. Men with Gleason score 6 cancers need to be reassured that their cancer is the lowest grade that is currently assigned, despite Gleason scores ranging from 2 to 10. In addition, I have talked to some patients with Gleason score 3 + 4 = 7 who think that they are going to die in the near future because their score of 7 was closer to highest grade of 10 than the lowest grade of 2. With the new grading system, patients can be reassured that they have a Grade group 1 (3 + 3 = 6) out of 5, which is the lowest grade, or a Grade group 2 (Gleason score 3 + 4 = 7) out of 5, which is still a relatively low grade.

Jonathan I. Epstein
Departments of Pathology, Urology and Oncology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA

 

References

 

 

 

3 Epstein JI, Zelefsky MJ, Sjoberg DD et al. A contemporary prostate cancer grading system: a validated alternative to Gleason score. Eur Urol 2016; 69: 42835

 

4 RossHM, Kryvenko ON, Cowan JE, Simko JP, Wheeler TM, Epstein JI. Dadenocarcinomas of the prostate with Gleason score (GS) 6have thpotential to metastasize to lymph nodes? Am J Surg Pathol 2012; 36: 134652

 

5 Kryvenko ON, Epstein JI. Prostate cancer grading: a decade after the 2005 modied Gleason grading system. Arch Pathol Lab Med 2016; [Epub ahead of print]

 

6 Pierorazio PM, Walsh PW, Partin AW, Epstein JI. Prognostic Gleason grade grouping: data based on the modied Gleason scoring system. BJU Int 2013; 111: 75360

 

Video: Gleason Grading in the Spotlight

The impact of the 2005 International Society of Urological Pathology consensus guidelines on Gleason grading – a matched pair analysis

Kasper D. Berg*, Frederik B. Thomsen*, Camilla Nerstrøm*, Martin A. Røder*, Peter Iversen*, Birgitte G. Toft, Ben Vainer† and Klaus Brasso*

 

*Department of Urology, Copenhagen Prostate Cancer Center and Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

 

Objectives

To investigate whether the International Society of Urological Pathology (ISUP) 2005 revision of the Gleason grading system has influenced the risk of biochemical recurrence (BCR) after radical prostatectomy (RP), as the new guideline implies that some prostate cancers previously graded as Gleason score 6 (3 + 3) are now considered as 7 (3 + 4).

Patients and methods

A matched-pair analysis was conducted. In all, 215 patients with Gleason score 6 or 7 (3 + 4) prostate cancer on biopsy who underwent RP before 31 December 2005 (pre-ISUP group), were matched 1:1 by biopsy Gleason score, clinical tumour category, PSA level, and margin status to patients undergoing RP between 1 January 2008 and 31 December 2011 (post-ISUP group). Patients were followed until BCR defined as a PSA level of ≥0.2 ng/mL. Risk of BCR was analysed in a competing-risk model.

JunAOTMResults

Results

The median follow-up was 9.5 years in the pre-ISUP group and 4.8 years in the post-ISUP group. The 5-year cumulative incidences of BCR were 34.0% and 13.9% in the pre-ISUP and post-ISUP groups, respectively (P < 0.001). The difference in cumulative incidence applied to both patients with Gleason score 6 (P < 0.001) and 7 (3 + 4) (P = 0.004). There was no difference in the 5-year cumulative incidence of BCR between patients with pre-ISUP Gleason score 6 and post-ISUP Gleason score 7 (3 + 4) (P = 0.34). In a multiple Cox-proportional hazard regression model, ISUP 2005 grading was a strong prognostic factor for BCR within 5 years of RP (hazard ratio 0.34; 95% confidence interval 0.22–0.54; P < 0.001).

Conclusion

The revision of the Gleason grading system has reduced the risk of BCR after RP in patients with biopsy Gleason score 6 and 7 (3 + 4). This may have consequences when comparing outcomes across studies and historical periods and may affect future treatment recommendations.

Reaching a consensus…robotic radical cystectomy

What is your impression of a “consensus statement”? We have these periodically in urology and they do tend to get widely read. One wonders, how difficult could it be for a bunch of urologists to reach a consensus on something?? Especially if, at the end of the day, we are all agreeing to cut something out?! It’s not like radiation or doing nothing are on the cards for this particular topic! How difficult could it be?

Well, let me give you a peak into the workings of the robotic-assisted radical cystectomy (RARC) Consensus Conference which took place at the City of Hope Hospital in California last weekend, the findings to be known as “The Pasadena Consensus Statement on RARC”. This two-day conference took place in the beautiful foothills of the San Gabriel Mountains in Southern California, and was hosted by Dr. Tim Wilson, Chief of Urology at City of Hope. The event was co-ordinated by the eminent New England Research Institute, led by Dr. Ray Rosen, and funded by a generous philanthropist affiliated with the hospital. The format of the meeting was familiar, as there has already been a Pasadena Consensus Statement on robotic-assisted radical prostatectomy, which was published in European Urology in 2012 along with four systematic reviews, all of which have been highly-cited. The conference invited a group of leaders in radical cystectomy, open as well as robotic, to participate and the resulting faculty features some highly-published figures in muscle-invasive bladder cancer, including some of the pioneers of RARC. These include:

  • Tim Wilson, City of Hope, California
  • Bernie Bochner, Memorial Sloan-Kettering, New York
  • Peter Wiklund, Karolinska, Sweden
  • Khurshid Guru, Roswell Park, New York
  • Eila Skinner, Stanford University, California
  • Joan Palou, Fundacio-Puigvert, Barcelona
  • Jim Catto, Editor-in-Chief, European Urology, Sheffield
  • Giacomo Novara, Padua, Italy
  • Bertrand Yuh, City of Hope, California
  • Declan Murphy, Peter MacCallum Cancer Centre, Melbourne
  • Magnus Annerstedt, Stockholm, Sweden
  • Arnulf Stenzl, Tuebingen, Germany
  • Kevin Chan, City of Hope, California
  • Jim Peabody, Vattikuti Urology Institute, Detroit 

Photo courtesy of Dr Jim Catto.

The goal was to review the current evidence for RARC (by way of systematic reviews and other detailed review), and to agree a “Best Practices” white paper. We had been split into working groups and had submitted slides overviewing our topics ahead of time. The two-day schedule then allowed presentation of these slides with (very) detailed critique and discussion. Systematic review maestro Giacomo Novara had worked with Bertrand Yuh to complete the systematic reviews prior to the conference and findings from these also informed much discussion. Bernie Bochner (the most knowledgeable person I have ever met on the topic of muscle-invasive bladder cancer!), kindly agreed to present the findings from the MSKCC randomised controlled trial which are key data in this area. This paper is about to be submitted so the Pasadena group will be able to include these findings in the final papers.

So was it a cosy chat in the Californian sunshine with much nodding of heads on key topics? Well, occasionally! The group were very sociable with very lively interaction, but there was certainly robust discussion on certain topics. Some of these leaked out on Twitter as one might expect with a few prominent uro-twitterati in the room (@jimcatto, @giacomonovara, @declangmurphy, @joanfundi, @AStenzl, @jamesopeabody), and with a lively response from social media enthusiasts from around the world getting involved in the #RARC conversation (@dytcmd, @@uretericbud, @daviesbj, @dmsomford, @matthayn, @kahmed198, @uroegg, @UROncdoc, @urogill, @urorao, @nickbrookMD, @joshmeeks, @wandering_gu, @urologymatch, @urology_verona, @chrisfilson, @mattbultitude, @clebacle, @chapinMD, @ggandaglia, @urogeek, and more) – every corner of the globe involved!

At certain times, the weight of data for open radical cystectomy was difficult to counter, and led to lively discussion between Bernie and Khurshid. For confidentiality reasons, we can’t reveal key findings until the final papers have been written and published, but Twitter does allow a sneak peak:

A general lament was the lack of high-quality data overall, as tweeted in this quote from Arnulf Stenzl:

However, some of the big publications from the pioneering centres, especially the data from the International Robotic Cystectomy Consortium (IRCC), and the RCT from Memorial have given us plenty to consider.

Having been involved in another large consensus statement recently (The Melbourne Consensus Statement on the Early Detection of Prostate Cancer), I can tell you that these statements feature very robust discussion before consensus is reached, and occasionally consensus is not reached leading to topics being omitted. The chosen faculty for such statements are highly-knowledgeable leaders in the field, but often have views which are highly discordant. The Chair has a great challenge to moderate so that the final statements are agreeable to all, and I am sure that the Pasadena Statement on RARC will prove of great interest to all working in this field.

[The Pasadena Consensus Statement Best Practices white paper will be published in European Urology in coming months, along with two systematic reviews and a Surgery in Motion technique paper]

Declan Murphy is a urologist at Peter MacCallum Cancer Centre in Melbourne, Australia, and Associate Editor at BJUI. Twitter @declangmurphy

Disclosure – Declan Murphy received support to cover travel and accommodation costs through the New England Research Institute. No industry support was received by any participants in this conference.

 

The NERI Nocturia Advisory Conference 2012: focus on outcomes of therapy

 

 

 

 

The New England Research Institutes, Inc. (NERI) Nocturia Advisory Conference 2012: focus on outcomes of therapy

Jeffrey P. Weiss1,2, Jerry G. Blaivas1,2, Marco H. Blanker9, Donald L. Bliwise3, Roger R. Dmochowski4, Marcus Drake11, Catherine E. DuBeau5, Adonis Hijaz7, Raymond C. Rosen6, Philip E.V. Van Kerrebroeck10 and Alan J. Wein8

1Department of Urology, SUNY Downstate College of Medicine, Brooklyn, 2Weill Medical College of Cornell University, New York, NY, 3Emory University School of Medicine, Atlanta, GA, 4Department of Urologic Surgery, Vanderbilt University, Nashville, TN, 5Division of Geriatric Medicine, UMass Memorial Medical Center and UMass Medical School, Worcester, MA, 6New England Research Institutes, Watertown, MA, 7Urology Institute, University Hospitals Case Medical Center, Cleveland, OH, 8Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 9Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, 10Department of Urology, Maastricht University Medical Center, Maastricht, The Netherlands, and 11University of Bristol, Bristol, UK

INTRODUCTION

Nocturia, awaking to void urine, is a common and sometimes bothersome symptom that may impose detrimental impacts on sleep-quality, mood, and overall health [1]. The multi-factorial aetiology of nocturia, coupled with the recent demonstration that this symptom is highly variable over time and often resolves spontaneously [2] , makes nocturia a challenging clinical entity. Although nocturia may have little health impact for some, for others it can be a highly bothersome, debilitating condition. Multiple studies have shown an association between nocturia and disturbed sleep, reduced well-being, and increased morbidity [3, 4, 5].

A consensus statement published in 2011 provided guidance to clinicians who are confronted with the wide range of clinical presentations of nocturia [1]. That paper focused primarily on a description of nocturia, its prevalence, its impact on health-related quality of life (QOL) and overall health, and an overview of available treatment options. The present paper extends and elaborates on the previous paper by examining the most recent research on diagnostic and treatment outcomes. Numerous papers have been published in the 2 years since the previous conference was organised, and the field, as a whole, has a large and dynamic research agenda. This paper summarises the findings resulting from a 2012 conference of key thought leaders in the field of nocturia who focused on updating outcome studies published since the previous conference was held.

 

© 2020 BJU International. All Rights Reserved.