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The 6th BJUI Social Media Awards (2018)

It’s hard to believe that we have been doing the BJUI Social Media Awards for six years now! I recall vividly our inaugural BJUi Social Media Awards in 2013, as the burgeoning social media community in urology gathered in the back of an Irish Bar in San Diego to celebrate all things social. At that time, many of us had only got to know each other through Twitter, and it was certainly fun going around the room putting faces with twitter handles for the first time. That spirit continues today as the “uro-twitterati” continues to grow, and the BJUi Awards, remain a fun annual focus for the social-active urology community to meet up in person.

We continue to alternate the Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Last year we descended on Boston, MA, to join the 15,000 or so other delegates attending the AUA Annual Meeting and to enjoy beautiful Boston. This year, we set sail for the #EAU18 Annual Meeting in the wonderful (but very cold) city of Copenhagen, along with over 13,000 delegates from 100 different countries.

On therefore to the Awards. These took place on Sunday 18th March 2018 in the Crowne Plaza Hotel, Copenhagen. Over 50 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2018 BJUI Social Media Awards. Individuals and organisations were recognised across 12 categories including the top gong, The BJUI Social Media Award 2018, awarded to an individual, organization, innovation or initiative who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her outstanding individual contributions, and in 2015 by the #UroJC twitter-based journal club. In 2017 we recognised the #ilooklikeaurologist social media campaign which we continue to promote. This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, John Davis, as well as BJUI Managing Editor Scott Millar whose team in London drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions.

The full list of winners is as follows:

  • Most Read B[email protected] – “Changing the LATITUDE of Treatment for High-Risk Hormone-Naïve Prostate Cancer: STAMPEDE-ing Towards Androgen Biosynthesis Inhibition”. Dr Zach Klaassen, Toronto, Canada

 

 

  • Most Social Paper – “Unprofessional content on Facebook accounts of US urology residency graduates”. Accepted by Dr Matt Bultitude on behalf of Dr Ann Gormley and colleagues

  • Best BJUI Tube Video – “The value of In-111 PSMA radioguided surgery for salvage lymphadenectomy in recurrent prostate cancer”. Dr Tobias Maurer, Munich, Germany.

  • Best Urology Conference for Social Media – awarded to the EAU for #EAU17 and #EAU18. Accepted by Prof Jim Catto on behalf of the EAU Communications Department.

  • Innovation Award EAU Communications Department, for their excellent Twitter strategy. Accepted by Prof Jim Catto onbehalf of Marc van Gurp and EAU colleagues

  • #UroJC AwardDr David Penson, Vanderbilt, USA. Accepted by Matt Bultitude

  • Best Social Media Campaign – awarded to The Urology Foundation, London, UK. In recognition of their use of social media to promote their advocacy, awareness and fundraising efforts in urology. Also an acknowledgement of twitter super-user Stephen Fry as a supporter of TUF, and his use of twitter to share his recent personal prostate cancer journey.

  • Most Social Trainee – Awarded to the “Bellclapper Podcasts”, featuring Jesse Ory, Kyle Lehman, Jeff Himmelman, from Dalhousie University, Canada.

  • The BJUI Social Media Award 2018 – awarded to @BURSTurology, in recognition of their use of social media to engage with other urology trainee and research groups around the world to drive collaborative research, including the #identify project. Collected by BURST Chair Veeru Kasi.

 

A number of the BJUI senior editorial team were also present to join the fun!

 

A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar, Max Cobb and team, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Chicago for #AUA19 where we will present the 7th BJUI Social Media Awards ceremony!

 

Declan Murphy

Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor, BJUI

@declangmurphy

 

Video: Highlights from USANZ 2018

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.

Sophie Rintoul-Hoad & Declan Murphy

 

PRECISION delivers on the PROMIS of mpMRI in early detection of prostate cancer

Today, Dr Veeru Kasi of University College London, presented the results of the PRECISION (PRostate Evaluation for Clinically Important disease: Sampling using Image-guidance Or Not?) study in the “Game Changing” Plenary session at the #EAU18 Annual Meeting in Copenhagen. The accompanying paper was simultaneously published in the New England Journal of Medicine. And it is stunning! Everyone in the packed eURO auditorium knew they were witness to a practice-changing presentation, and the swift reaction on social media around the world confirms this.

 

Congratulations to Veeru (a second year urology resident in London), senior author Dr Caroline Moore, Prof Mark Emberton, and all the collaborators on this multicenter international trial. I had the great privilege to be the Discussant in the Plenary session so have been digesting this study in detail for the past few weeks.

Let me summarise the PRECISION study in brief. In this multicenter international study, 500 men with a suspicion of prostate cancer (mean age 64, median PSA 6.7), were randomised to receive a standard of care (SOC) diagnostic pathway (12 core TRUS biopsy), or an MRI directed pathway. In the MRI pathway, all patients had an MRI, and if the MRI was abnormal (72% of men), they had a targeted biopsy of the lesion(s) (with no systematic biopsy; ie only the abnormal lesion was biopsied). If the MRI was normal (28% of men), they did not have a biopsy, and continued on routine PSA surveillance. The primary outcome was detection rate of clinically significant cancer; and secondary outcomes included the detection rate of clinically insignificant cancer. In the standard of care arm, the detection rate of clinically significant cancer was 26%, and the detection rate of clinically insignificant cancer was 22%. In the MRI pathway, the detection rate of clinically significant cancer was 38%, and the detection rate of taking insignificant cancer was 9%. This is depicted below in one of my summary slides from the plenary discussion.

 

Therefore, despite the fact that over one quarter of men in the MRI pathway actually avoided a biopsy, the detection rate of clinically significant cancer was much greater in this arm (ie UNDER-diagnosis was reduced). Furthermore, the detection rate of the clinically insignificant cancer was much less (ie OVER-diagnosis was reduced). And all this with a median number of biopsy cores of only four, compared with 12 in the SOC arm. The reduction in core numbers along that too much less complications for these patients.

This looks like WIN-WIN all round!

 

And I truly believe that these findings should provoke an immediate change in our diagnostic pathway for early prostate cancer in two ways:

  1. All patients with a clinical suspicion of prostate cancer should be offered an MRI as part of their informed/shared decision making pathway
  2. All patients with an abnormality on their MRI scan should be offered be targeted biopsy alone.

The obvious concern of course, is the fate of those patients with a normal MRI (28% of patients), who despite a clinical suspicion of prostate cancer, did not have a biopsy. How many clinically significant cancers might we miss by not offering biopsy to those patients? Of course, we already have an idea of what we would find, as the PROMIS study also included extensive biopsy (transperienal mapping) for patients with a normal MRI.

In PROMIS, the negative predictive value of MRI for detecting any pattern 4 cancer is 76% ie up to 1 in 4 men will have some pattern 4 cancer on transperineal biopsy. However, no primary pattern 4 cancers were missed on MRI. This is something we have to digest. I think that we can accept missing some pattern 4 cancers in some men, provided the “routine follow up” is adequate. But we must also continue to use the other tools we have in our multivariable approach to early detection, and if there are red flags due to family history, palpable nodules, adverse PSA parameters (including PSA density), BRCA mutations, then there will clearly be a role for systematic biopsy in some of these men with normal MRI scans.

In my opinion, we now have enough evidence to fully embrace mpMRI in our approach to early detection of prostate cancer. Following on from the PROMIS study, published in the Lancet 2017, the PRECISION study provides us with the imprimatur to fully embed MRI in the assessment of men with a suspicion of prostate cancer. The era of blind random prostate biopsy is surely over, except perhaps in those patients in whom MRI is contra-indicated. The next challenge will be to create enough capacity and expertise to make this paradigm available to all.

Resourcing will inevitably be an issue, but the PROMIS and PRECISION papers provide a compelling health economic argument for funders. Less men undergoing biopsy; less biopsy cores; less complications; less insignificant cancer – this surely makes economic sense. In Australia, where MRI has already been enthusiastically embraced, a high-quality mpMRI on a 3T machine costs $USD300, and costs are usually borne by patients. In the USA, we hear that a 1.5T MRI (with an endorectal coil) can cost USD$2-3000!! Why is this?! Australia is an expensive country – an iPhone or a da Vinci robot costs 1.5 times the cost in the USA; why therefore should an MRI cost so much in the USA? A symptom of a much broader issue with the bloated US health economy, and likely a barrier to adoption of the paradigm proposed by PRECISION.

So there you have it. A truly practice-changing study. While there will be much discussion about the nuances, I for one will immediately embrace this paradigm:

  • MRI for all (I already do this)
  • Targeted biopsy alone for those with MRI lesions (a new departure for me)
  • No biopsy for those with normal MRI scans (unless there are other red flags).

My concluding slide from the plenary discussion:

 

Congrats again Veeru, Caroline, Mark and colleagues for publishing this landmark study.

 

Declan G Murphy

Urologist & Director of Genitourinary Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia

Twitter: @declangmurphy

 

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

 

The 5th BJUI Social Media Awards

It’s hard to believe that we have been doing the BJUI Social Media Awards for five years now! I recall vividly our inaugural BJUI Social Media Awards in 2013, as the burgeoning social media community in urology gathered in the back of an Irish Bar in San Diego to celebrate all things social. At that time, many of us had only got to know each other through Twitter, and it was certainly fun going around the room putting faces with twitter handles for the first time. That spirit continues today as the “uro-twitterati” continues to grow, and the BJUI Awards, (or the “Cult” Awards as our Editor-in-Chief likes to call them), remains a fun annual focus for the social-active urology community to meet up in person.

As you may know, we alternate the Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Last year, we descended on Munich, Germany to join the 13,000 or so other delegates attending the EAU Annual Meeting and to enjoy all the wonderful Bavarian hospitality on offer. This year, we set sail for the #AUA17 Annual Congress in Boston, MA, along with over 16,000 delegates from 100 different countries. What a great few days in beautiful Boston and a most welcome return for the AUA to this historic city. Hopefully it will have a regular spot on the calendar, especially with the welcome dumping of Anaheim and Orlando as venues for the Annual Meeting.

Awards

On therefore to the Awards. These took place on Saturday 13th May 2017 in the City Bar of the Westin Waterfront Boston. Over 80 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2017 BJUI Social Media Awards. We actually had to shut the doors when we reached capacity so apologies to those who couldn’t get in! Individuals and organisations were recognised across 12 categories including the top gong, The BJUI Social Media Award 2017, awarded to an individual, organization, innovation or initiative who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her outstanding individual contributions, and in 2015 by the #UroJC twitter-based journal club. Last year’s award went to the #ilooklikeaurologist social media campaign which we continue to promote.

This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, John Davis, as well as BJUI Managing Editor Scott Millar whose team in London (Max and Clare) drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions.

The full list of winners is as follows:

Most Read [email protected] – “The optimal treatment of patients with localized prostate cancer: the debate rages on”. Dr Chris Wallis, Toronto, Canada

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Most Commented [email protected] – “It’s not about the machine, stupid”. Dr Declan Murphy, Melbourne, Australia

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Most Social Paper – “Novel use of Twitter to disseminate and evaluate adherence to clinical guidelines by the European Association of Urology”. Accepted by Stacy Loeb on behalf of herself and her colleagues.

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Best BJUI Tube Video – “Combined mpMRI Fusion and Systematic Biopsies Predict the Final Tumour Grading after Radical Prostatectomy”. Dr Angela Borkowetz, Dresden, Germany

AUA

Best Urology Conference for Social Media – #USANZ17 – The Annual Scientific Meeting of the Urological Association of Australia & New Zealand (USANZ) 2017. Accepted by Dr Peter Heathcote, Brisbane, Australia. President of USANZ.

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Best Urology App – The EAU Guidelines App. Accepted by Dr Maria Ribal, Barcelona, Spain, on behalf of the EAU.

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Innovation Award – BJUI Urology Ontology Hashtags keywords. Accepted by Dr Matthew Bultitude, London, UK, on behalf of the BJUI.

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#UroJC Award – Dr Brian Stork, Michigan, USA. Accepted by Dr Henry Woo of Brian’s behalf.

UroJC
Most Social Trainee – Dr Chris Wallis, Toronto, Canada

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Best Urology Journal for Social Media –Journal of Urology/Urology Practice. Accepted by Dr Angie Smith, Chapel Hill, USA, on behalf of the AUA Publications Committee.

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Best Urology Organisation – Canadian Urological Association. Accepted by Dr Mike Leveridge, Vice-President of Communications for CUA.

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The BJUI Social Media Award 2017 – The Urology Green List, accepted by Dr Henry Woo, Sydney, Australia.

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All the Award winners (except Dr Brian Stork who had to get home to work), were present to collect their awards themselves. A wonderful spread of socially-active urology folk from all over the world, pictured here with BJUI Editor-in-Chief, Prokar Dasgupta.

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A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar, Max Cobb and Clare Dunne, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Copenhagen for #EUA18 where we will present the 6th BJUI Social Media Awards ceremony!

 

Declan Murphy

Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor, BJUI

@declangmurphy

Capitalising On Our Strengths: The 70th USANZ ASM

Canberra, our nation’s capital and the host city for the 2017 USANZ ASM, is a gem in its own right, but one which was created to satiate two feuding states locked in a bitter rivalry. In 1908, Canberra embodied the very meaning of compromise and collaboration, a technique which has garnered much success for our Country over the ensuing 100 odd years. Arguably the first official Australian collaborative effort, this way of thinking has become an almost uniquely Australian attribute and a strength imbued in our national pride.

USANZ 2017 was held in CanberraCanberra from up high, a breathtaking backdrop for a fantastic USANZ ASM.

Given this year’s mantra of: “Capitalising on our strengths” It is perhaps fitting then, that the 70th anniversary of the Urological Society of Australia and New Zealand (USANZ) Annual Scientific Meeting (ASM) including the Australia and New Zealand Urological Nurses Society (ANZUNS) 22nd ASM, should be held in such a location. In addition to providing some wonderful tourist opportunities for guests including the War Memorial, the National Gallery and Parliament House.

Convenors A/Prof Nathan Lawrentschuk and Kath Schubach went to great efforts to successfully welcome both national and international guests and Scientific Program Directors A/Prof Shomik Sengupta and Carla D’Amico ensured a star-studded academic program addressing contemporary updates in Urological evidence based practice, which were aptly discussed both inside and outside the confines of the National Convention Centre.

1-2Senior YURO members standing outside Parliament House (from left to right): Dr. Daniel Christidis, Dr. Tatenda Nzenza, Dr. Todd Manning, Dr. Shannon McGrath

 

The representation by International faculty was exceptional, with countless urological household names from world leading centres across the globe both involved in the academic program and socially. Urological goliaths including Prof. Christopher Chapple, Prof. Prokar Dasgupta and Prof. Laurence Klotz weighed in on various topical issues providing an intercontinental perspective that complimented the equally impressive national line-up of speakers.

As with previous years, use of social media was rife, with those not able to attend kept in the loop via #Usanz17 and a steady stream from the ever focused twitterati. The ASM provided more than 5 million impressions and over 2800 individual tweets from more than 400 participants. The usual suspects were eminent as always, along with a few newcomers who provided impact in their own right. The official USANZ 2017 App also kept participants up to date via timely notifications and was user friendly.

Guests were spoilt for choice in the convention centre during well timed breaks, which was perpetually abuzz with attendees networking. In the background the ‘Talking Urology’ team headed by Mr Joseph Ischia and A/Prof Nathan Lawrentschuk provided a steady stream of captivating interviews with guests, regarding a myriad of urological topics. Simultaneously, numerous academics gave brief summaries of research posters during allocated presentation sessions. Exhibitors provided a captivating backdrop for these activities including many hands-on simulators and challenges for those keen to test their dextrous mettle. All the while guests relished a variety of delectable culinary options.

1-3Guests networking at the Gala Dinner, whilst being entertained by opera classics in the Great Hall foyer of Parliament House

 

The meeting’s common themes were strong and pertinent to contemporary urology. They centred around collaborative research efforts such as the ANZUP trials group and the Young Urology Researchers Organisation (YURO), technology especially PSMA PET and social media and social justice including women in urology and operating with respect. Discussions were directed by chairpersons during purposefully allocated Q&A times at the conclusion of each session, a new and well received addition to this years meeting. This was generously embraced by both senior and junior academics and led to intriguing symposiums and at times heated debate.

 

USANZ 2017 Friday Highlights

The first official day of proceedings provided a smorgasbord of morning and afternoon workshops ranging from technical skills courses to the medico-legal implications of E-Health and technology. This was followed by an allocated networking session for Urology trainees with International faculty.

Officially opening the conference in the Royal Theatre of the convention centre, A/Prof Lawrentschuk introduced this year’s Harry Harris orator; Elizabeth Cosson, AM CSC.  Her speech entitled “leading with grit and grace” eloquently detailed her journey in the armed forces and highlighted the difficulties of the unmistakably imbalanced workplace for women in the military. Her talk clearly underlined her role in not only forging a highly successful career for herself but also for those women following in her footsteps. Her inspiring dialogue was synchronous with contemporary issues surrounding Urological practice, especially concerning equality for women but more resolutely, appropriate equity both in training and established practice.

With the tone well established for an exceptional meeting, guests enjoyed a variety of canapés and drinks in the exhibition hall, unwinding with social discussion.

1-4YURO President, Dr Todd Manning talks to young researchers with help from Prof. Henry Woo and A/Prof. Lawrentschuk during the YURO annual meeting

 

Saturday Highlights

Plenary sessions aplenty began the second day of proceedings with International academic giants including Prof. Klotz, Prof. Chapple, Prof. Traxer and Prof Nitti mixed in with National heavy hitters such as Prof Frank Gardiner, Mr Daniel Moon and outgoing USANZ president Prof. Mark Frydenberg.

Afternoon sessions included subspecialty discussions and some stellar Podium Poster presentations, with an especially impressive mix of senior and junior researchers regarding countless and diverse urological topics.

 

Sunday Highlights

Heralding the beginning of another exceptional day, the ‘Women in Urology’ breakfast symposium chaired by Dr Anita Clark along side distinguished panellists including Dr Caroline Dowling and Dr Eva Fong was a conference stand out for many.

Following this, more plenary sessions filled the remainder of the pre-lunch program, leading into the highly anticipated Keith Kirkland and Villis Marshall presentations by Urology SET trainees. The presentations did not disappoint. As in previous years, research of unyielding professional and academic quality was offered by the group of future urologists, who as is tradition weathered the gauntlet of probing and tough questions from the floor. All presentations were captivating in their own right.  2017 Villis Marshall winner Dr Marlon Perera presented ground-breaking research regarding the reno-protective role of zinc in contrast nephropathy. Dr Amila Siriwardana was deservedly awarded the Keith Kirkland

award for his multicentre retrospective review on Robot assisted salvage node dissection to treat recurrences detected by PSMA PET.

Following these presentations, the YURO annual meeting once again heralded a complement of enthusiastic, innovative and clever minds from all Australian states, eager to pursue research opportunities through collaborative means. Joined this year by Prof. Henry Woo, the group was fortunate to receive his valuable insight and feedback regarding past success and future direction. The group solidified upcoming positions of leadership and highlighted new directions in educational, research and mentorship avenues for younger members.

The Gala Dinner is a stand out affair during each ASM and this year was no exception. Guests were provided with the unique opportunity to see Australia’s Parliament House from the inside. The night began with surprise operatic renditions of many well known classics in the spacious foyer of the Great Hall and culminated with a climactic performance of Nesson Dorma. Guests then enjoyed a delectable 3 course meal in identical fashion to a rare collection of political royalty including; Barack Obama, Prince William and the Duke and Duchess of Cambridge.

1-5Twitter metrics tabulated from the conference via the #Usanz17 (courtesy of Symplur LLC)

 

Monday Highlights

The final day of proceedings saw once again provided an array of interesting and thought provoking topics.  The clear highlight of the morning was the metaphorical prize fight between Mr Joseph Ischia and Dr Shankar Siva debating the roles of surgery and radiotherapy in Oligometastatic disease. Although these two went toe to toe over many rounds, the inevitable conclusion was understandably a draw. Although on PowerPoint slide pictures alone, Dr Siva’s extensive use of Star Wars based analogies won my vote.

Insight and introduction to the 71st USANZ ASM was then delivered and as a Melbournian my bias was admittedly hard to hide. Attendees received a taste of the excitement to come, with what is assured to be another blockbuster cast of national and international urologists led boldly by Convenor Mr Daniel Moon and Scientific Program Director Prof. Declan Murphy. I for one, eagerly anticipate the return of the ASM to out Nation’s culinary and cultural capitol and I’m sure guests in 2018 will be captivated by the world most liveable city!

It can be said with certainty that this years USANZ 70th ASM presented a scientific program as strong as ever within a fascinating and historical backdrop and complimented by a lively social atmosphere. This consensus of a highly successful meeting, I’m sure was shared by all.

I look forward to seeing you all next year and hope you are eagerly anticipating the ‘flat whites’.

 

Dr. Todd G Manning, Department of Surgery, Austin Health, Melbourne, and Young Urology Researchers Organisation (YURO), Australia. Twitter: @DocToddManning

 

Randomised Controlled Trials in Robotic Surgery

PDGSep16It has been nearly 15 years since one of the first ever randomised controlled trials (RCT) in robotic surgery was conducted in 2002. The STAR-TRAK compared telerobotic percutaneous nephrolithotomy (PCNL) to standard PCNL and showed that the robot was slower but more accurate than the human hand [1].

In the 24 h since the much anticipated RCT of open vs robot-assisted radical prostatectomy was published in The Lancet [2], our BJUI blog from @declangmurphy was viewed >2500 times, receiving >40 comments, making it one of our most read and interactive blogs ever. It is a negative trial showing no differences in early functional outcomes between the two approaches.

And it is not the only negative trial of its kind as a number of others have matured and reported recently. The RCT of open vs robot-assisted radical cystectomy and extracorporeal urinary diversion showed no differences in the two arms [3], and likewise a comparison of the two approaches to cystectomy as a prelude to the RAZOR (randomised open vs robotic cystectomy) trial showed no differences in quality of life at 3-monthly time points up to a year [4]. The only RCT comparing open, laparoscopic and robotic cystectomy, the CORAL, took a long time to recruit and yet again showed no differences in 90-day complication rates between the three techniques [5].

In all likelihood, despite the level 1 evidence provided in The Lancet paper showing no superiority of the robotic over the open approach, the Brisbane study may not change the current dominance of robotic prostatectomy in those countries who can afford this technology. Why is this? Apart from the inherent limitations that the BJUI blog identifies, there are other factors to consider. In particular, as observed previously in a memorable article ‘Why don’t Mercedes Benz publish randomised trials?’ [6], there may be reasons why surgical technique is not always suited to the RCT format.

A few additional reflections are perhaps appropriate at this time:

  1. Despite the best statistical input many of these and future studies are perhaps underpowered.
  2. Many have argued that the RCTs have shown robotics to be as good, although not better than open surgery, even in the hands of less experienced surgeons.
  3. Patient reported quality of life should perhaps become the primary outcome measure because that in the end that is what truly matters.
  4. Cost-effectiveness ratios should feature prominently, as otherwise there is much speculation by the lay press without any hard data.
  5. Industry has a role to play here in keeping costs manageable, so that these ratios can become more palatable to payers.
  6. Surgery is more of an art than a science. The best surgeons armed with the best technology that they are comfortable with will achieve the best outcomes for their patients.

While this debate will continue and influence national healthcare providers and decision makers, the message looks much clearer when it comes to training the next generation of robotic surgeons. A cognitive- and performance-based RCT using a device to simulate vesico-urethral anastomosis after robot-assisted radical prostatectomy (RARP) showed a clear advantage in favour of such structured training [7]. In this months’ issue of the BJUI, we present the first predictive validity of robotic simulation showing better clinical performance of RARP in patients [8]. This is a major step forward in patient safety and would reassure policy makers that investment in simulation of robotic technology rather than the traditional unstructured training is the way forward.

Most of our patients are knowledgeable, extensively research their options on ‘Dr Google’ and decide what is good for them. It is for this reason that many did not agree to randomisation in other robotic vs open surgery RCTs, like LopeRA (RCT of laparoscopic, open and robot assisted prostatectomy as treatment for organ-confined prostate cancer) and BOLERO (Bladder cancer: Open vs Lapararoscopic or RObotic cystectomy). Many of them continue to choose robotic surgery without necessarily paying heed to the best scientific evidence. Perhaps what patients will now do is select an experienced surgeon whom they can trust to use their best technology to deliver the best clinical outcomes.

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

@declangmurphy

Associate Editor BJUI

References

2 Yaxley JW, Coughlin GD, Chambe rs SK et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 2016 [Epub ahead of print]. doi: 10.1016/S0140-6736(16)30592-X
3 Bochner BH, Sjoberg DD, Laudone VP, Memorial Sloan Kettering Cancer Center Bladder Cancer Surgical Trials Group. A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med 2014; 371:38990

4

Messer JC, Punnen S , Fitzgerald J et al. Health-related quality of life from a

6 OBrien T, Viney R , Doherty A, Thomas K. Why dont Mercedes Benz publish
randomised trials? BJU Int 2010; 105 : 2935
8 Aghazadeh MA, Mercado MA, Pan MM , Miles BJ, Goh AC. Performance of

 

It’s not about the machine, stupid

Robotic surgery trial exposes limitations of randomised study design

 

Here it is, the highly anticipated randomised controlled trial of open versus robotic radical prostatectomy published today in The Lancet. Congratulations to the team at Royal Brisbane Hospital for completing this landmark study.


DM1


The early headlines around the world include everything from this one in the Australian Financial Review:

DM2b      –   to this from The Telegraph in London

DM3bAs ever, there will be intense and polarising discussion around this. One might expect that a randomised controlled trial, a true rarity in surgical practice, might settle the debate here; however, it is already clear that there will be anything BUT agreement on the findings of this study. Why is this so? Well let’s look first at what was reported today.

 

Study design and findings:

This is a prospective randomised trial of patients undergoing radical prostatectomy for localised prostate cancer. Patients were randomised to undergo either open radical prostatectomy (ORP, n=163) or robotic-assisted radical prostatectomy (RARP, n=163). All ORPs were done by one surgeon, Dr John Yaxley (JY), and all RARPs were done by Dr Geoff Coughlin (GC). The hypothesis was that patients undergoing RARP would have better functional outcomes at 12 weeks, as measured by validated patient-reported quality of life measures. Other endpoints included positive surgical margins and complications, as well as time to return to work.

So what did they find? In summary, the authors report no difference in urinary and sexual function at 12 weeks. There was also no statistical difference in positive surgical margins. RARP patients had a shorter hospital stay (1.5 vs 3.2days, p<0.0001) and less blood loss (443 vs 1338ml, P<0.001), and less pain post-operatively, yet, these benefits of minimally-invasive surgery did not translate into an earlier return to work. The average time to return to work in both arms was 6 weeks.

The authors therefore conclude by encouraging patients “to choose an experienced surgeon they trust and with whom they have a rapport, rather than choose a specific surgical approach”. Fair enough.

In summary therefore, this is a randomised controlled trial of ORP vs RARP showing no difference in the primary outcome. One might reasonably expect that we might start moth-balling these expensive machines and start picking up our old open surgery instruments. But that won’t happen, and my prediction is that this study will be severely criticized for elements of its design that explain why they failed to meet their primary endpoint.

 

Reasons why this study failed:

1.      Was this a realistic hypothesis? No it was not. For those of us who work full-time in prostate cancer, the notion that there would be a difference in sexual and urinary function at 12 weeks following ORP or RARP is fanciful. It is almost like it was set up to fail. There was no pilot study data to encourage such a hypothesis, and it remains a mystery to me why the authors thought this study might ever meet this endpoint. I hate to say “I told you so”, but this hypothesis could never have been proved with this study design.

2.      There is a gulf in surgical experience between the two arms. The lack of equipoise between the intervention arms is startling, and of itself, fully explains the failure of this study to meet its endpoints. I should state here that both surgeons in this study, JY (“Yax”) and GC (“Cogs”), are good mates of mine, and I hold them in the highest respect for undertaking this study. However, as I have discussed with them in detail, the study design which they signed up to here does not control for the massive difference in radical prostatectomy experience that exists between them.  Let’s look at this in more detail:

  1.        ORP arm: JY was more than 15 years post-Fellowship at the start of this study, and had completed over 1500 ORP before performing the first case in the trial.
  2.       RARP arm: GC was just two years post-Fellowship and had completed only 200 RARP at the start of the study.

The whole world knows that surgeon experience is the single most important determinant of outcomes following radical prostatectomy, and much data exists to support this fact. In the accompanying editorial, Lord Darzi reminds us that the learning curve for functional and oncological outcomes following RARP extends up to 700 cases. Yes 700 cases of RARP!! And GC had done 200 radical prostatectomies prior to operating on the first patient in this study. Meanwhile his vastly more experienced colleague JY, had done over 1500 cases. The authors believe that they controlled for surgeon heterogeneity based on the entry numbers detailed above, and state that it is “unlikely that a learning curve contributed substantially to the results”. This is bunkum. It just doesn’t stack up, and none of us who perform this type of surgery would accept that there is not a clinically meaningful difference in the experience of a surgeon who has performed 200 radical prostatectomies, compared with one who has performed 1500. Therein lies the fundamental weakness of this study, and the reason why it will be severely criticized. It would be the equivalent of comparing 66Gy with 78Gy of radiotherapy, or 160mg enzalutamide with 40mg – the study design is simply not comparing like with like, and the issue of surgeon heterogeneity as a confounder here is not accounted for.

3.      Trainee input is not controlled for – most surprisingly, the authors previously admitted that “various components of the operations are performed by trainee surgeons”. One would expect that with such concerns about surgeon heterogeneity, there should have been tighter control on this aspect of the interventions. It would have been reasonable within an RCT to reduce the heterogeneity as much as possible by sticking to the senior surgeons for all cases.

Having said all that, John and Geoff are to be congratulated for the excellent outcomes they have delivered to their patients in both arms of this study. These are excellent outcomes, highly credible, and represent, in my view, the best outcomes to be reported for patients undergoing RP in this country. We are all too familiar with completely unbelievable outcomes being reported for patients undergoing surgery/radiotherapy/HIFU etc around the world, and we have a responsibility to make sure patients have realistic expectations. John and Geoff have shown themselves to be at the top of the table reporting these credible outcomes today.

 

“It’s about the surgeon, stupid”

To paraphrase that classic phrase of the Clinton Presidential campaign of 1992, this study clearly demonstrates that outcomes following radical prostatectomy are about the surgeon, and not about the robot. Yet one of the co-authors, a psychologist, comments that, “at 12 weeks, these two surgical approaches yielded similar outcomes for prostate cancer patients”. Herein lies one of the classic failings of this study design, and also a failure of the investigators to fully understand the issue of surgeon heterogeneity in this study. It is not about the surgical approach, it is about the surgeon experience.

If the authors had designed a study that adequately controlled for surgeon experience, then it may have been possible for the surgical approach to be assessed with some equipoise. It is not impossible to do so, but is certainly challenging. For example a multi-centre study with multiple surgeons in each arm would have helped balance out the gulf in surgical experience in this two-surgeon study. Or at the very least, the authors should have ensured that they were comparing apples with apples by having a surgeon with in excess of 1500 RARP experience in that arm. Another approach would have been to get a surgeon with huge experience of both procedures (eg Dr Smith at Vanderbilt who has performed >3000 RARP and >3000 ORP), and to randomise patients to be operated on only by a single surgeon with such vast experience. That would have truly allowed the magnitude of the surgical approach effect to be measured, without the bias inherent in this study design.

 

Robotic surgery bridges the experience gap:

Having outlined these issues with surgeon heterogeneity and lack of equipoise, there is another angle which my colleague Dr Daniel Moon has identified in his comments in the Australian media today and which should be considered.

Although this is a negative study which failed to meet its primary endpoints, it does demonstrate that a much less experienced surgeon can actually deliver equivalent functional and oncological outcomes to a much more experienced surgeon, by adopting a robotic approach. Furthermore, his patients get the benefits of a minimally-invasive approach as detailed in the paper. This therefore demonstrates that patients can be spared the inferior outcomes that may be delivered by less experienced surgeons while on their learning curve, and the robotic approach may therefore reduce the learning curve effect.

On that note, a point to consider would be what would JY’s outcomes have been in this study if he had 13 years and 1300 cases less experience to what he had entering this study? Would the 200 case experience-Yax have been able to match the 1500 case experience-Yax?? Surely not.

And finally, just as a footnote for readers around the world about what is actually happening on the ground following this study. During the course of this study, the ORP surgeon JY transitioned to RARP, and this is what he now offers almost exclusively to his patients. Why is that? It is because he delivers better outcomes by bringing a robotic approach to the vast surgical experience that he also brings to his practice, and which is of course the most important determinant of better outcomes.

Sadly, “Yax” and “Cogs”, the two surgeons who operated in this study, have been prevented from speaking to the media or to being quoted in or commenting on this blog, but we are looking forward to hearing from them when they present this data at the Asia-Pacific Prostate Cancer Conference in Melbourne in a few weeks.

 

Declan G Murphy
Associate Editor BJUI; Urologist & Director of Genitourinary Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia

Twitter: @declangmurphy

 

 

 

The 4th BJUI Social Media Awards

As you may know, we alternate the occasion of the BJUI Social Media Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Our first awards ceremony took place at the AUA in San Diego in 2013, followed by the EAU in Stockholm, and a really fun evening at AUA in New Orleans last year. This year, we descended on Munich, Germany to join the 13,000 or so other delegates attending the EAU Annual Meeting and to enjoy all the wonderful Bavarian hospitality on offer. More about that in our blog posts from #eau16.

1.1On therefore to the Awards. These took place on Sunday 13th March 2016 in the roof garden bar of the beautiful Bayerischer Hof hotel. Over 70 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2016 BJUI Social Media Awards. Individuals and organisations were recognised across 46 categories including the top gong, The BJUI Social Media Award 2016; awarded to an individual, organization, innovation or initiative that has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her exceptional individual contributions, and in 2015 by the #UroJC twitter-based journal club. This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, Mike Leveridge, and Henry Woo, as well as BJUI Managing Editor Scott Millar whose team in London drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions. As befits the fast-moving nature of social media, we decided to omit a couple of previous categories and add two new ones.

One of these was the “Best #EAU16 Selfie” competition which we launched on the eve of this year’s EAU Annual Meeting to encourage some fun among congress attendees.

1.2

We had dozens of enthusiastic entries which betrayed the social side of urology conferences today – see examples on our Awards Prezi.

 

The full list of awardees, along with some examples of “best practice” in the urology social media sphere can be found in the Prezi. The winners are also listed here:

  • Most Read [email protected] – “The drugs don’t work”. Dr Matt Bultitude
  • Most Commented [email protected] – “The Urology Foundation Cycle India” – 87 comments. Accepted by Dr Ben Challacombe, on behalf of Prof Roger Kirby, London, UK
  • Most Social Paper (new category) – “Twitter response to the USPSTF recommendations against screening with PSA”. Published in BJUI 2015. Accepted by Stacy Loeb on behalf of Dan Makarov and other co-workers.
  • Best BJUI Tube Video – “Extended PLND – creating the spaces”. Accepted by Declan Murphy on behalf of John Davis, MD Anderson, USA.
  • Best Urology Conference for Social Media – #AUA15 – The American Urological Association Annual Meeting 2015. Accepted by Dr Stacy Loeb on behalf of the AUA.
  • Best Urology App – The “British Association of Urological Surgeons Emergency Urology App”. Accepted by BAUS President Mark Speakman on behalf of BAUS and Dr Nick Rukin
  • Innovation Award 2016 – “Urology Ontology Tag Project”. Accepted by Dr Jim Catto and Dr Henry Woo (Dr Alex Kutikov not present)
  • #UroJC Award – Dr Rustom Manecksha, Dublin, Ireland
  • Most Social Trainee (new category) – Kari Tikkinen
  • Best Selfie – Khurshid “Macgyver” Guru
  • Best Urology Journal for Social Media –Journal of Sexual Medicine. Accepted by Associate Editor for Social Media, Mikkel Fode
  • Best Urology Organisation – European Association of Urology. Accepted on behalf of EAU by European Urology Editor-in-Chief, Jim Catto.
  • Best #EAU16 Selfie (new category) – Maria Ribal with special mentions to Morgan Roupret and Inge van Oort
  • The BJUI Social Media Award 2016 – #ilookllikeaurologist. Accepted on behalf of female urologists all over the world by Dr Stacy Loeb, New York, USA

Most of the Award winners were present to collect their awards themselves, including Dr Stacy Loeb who received our top gong for her work in driving the #ilooklikeaurologist campaign. The Awards Committee had identified this wonderful social media campaign from early on as a stand-out example of how social media (Twitter in particular), can be deployed to drive a really important social message. The #ilooklikeasurgeon campaign had already caught the imagination of all of us who identified with the message that female surgeons were undervalued in our specialty, and the #ilooklikeaurologist campaign really brought a welcome focus on our female urology specialists and trainees. The tweet that first used the hashtag was sent by Stacy in August 2015 in reply to a tweet from Rustom Manecksha:

1.3

Since that time, over 1000 tweets have been sent using this hashtag, most featuring great pictures of our female urologists at work or at play. See plenty of examples on our Prezi or just search the hashtag #ilooklikeaurologist.

A special thanks to our outstanding BJUI team at the Editorial Office in London, Scott Millar and Max Cobb, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Boston for #AUA17 where we will present the 5th BJUI Social Media Awards ceremony!

Declan Murphy, Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor – Social Media, BJUI

@declangmurphy

 

 

 

 

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