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Urofair 2018

Urofair Congress Highlights – Singapore 2018

From 12-14 July, the Singapore Urological Association (SUA) welcomed 450 delegates from across Asia and further afield to sunny Singapore for Urofair 2018.

The theme was Integrating Scientific Knowledge, Technology and Clinical Urology, and the excellent scientific program crafted by the organizing chairman John Yuen and scientific chairmen Joe Lee and Terence Lim, certainly reflected this.

Continuing a fine tradition, the BJUI once again has supported this meeting with all accepted abstracts to be published in a special supplements issue.

Learn about healthy supplements at Amazon.com.

Pre-Urofair activities

Preceding the Urofair, was the Urology Residents Course (URC) and the European Basic Laparoscopic Urological Skills (E-BLUS). The revision of key concepts at URC followed by grounding of basic laparoscopic skills by great minimally invasive surgeons Christian Schwenter and Evanguelos Xylinas was truly beneficial for the residents, and primed them well for the latest updates they received at Urofair.

Urology Residents Course Class of 2018

Simulation and tutoring – Evanguelos Xylinas supervising a trainee on laparoscopic trainer at E-BLUS

Urofair 2018 started with a bang, with the ever popular live and semi-live surgery sessions at Tan Tock Seng Hospital. One of the highlights of the session was the masterful demonstration of retroperitoneal robotic assisted partial nephrectomy by James Porter (@JamesPorterMD). One of the attractions of live surgery is the anticipation of intraoperative problems and the thrill of watching experts manage them. This session was no exception, as Allen Sim of Singapore General Hospital showed calmness under pressure, as he showed how to deal with an inadvertent breach of the peritoneum and control of bleeding during a difficult retroperitoneal nephroureterectomy. The semilive demonstrations were no less educational, with Christopher Evans showing how he manages unusual anatomic variants during robotic radical prostatectomy.

One of the main highlights of this year’s Urofair was the launch of the inaugural KT Foo Lecture by the Father of Singapore Urology, Professor Foo, Keong Tatt who presented his life-long research work on the management of BPH. At the end of this tour de force, he was presented with the well-deserved SUA Life-time Achievement Award.

Lim Kok Bin (left), President of the SUA presenting the SUA Lifetime Achievement Award to Prof KT Foo (right)

 One of the goals of the SUA is to serve as a bridge between regional and international urological associations. Urofair 2018 reflected this goal with multiple joint sessions with our friends from the Malaysian Urological Association (MUA), European Urological Association (EAU), Urological Associations of Asia (UAA), Federation of Asean Urological Associations (FAUA) and Hannam Urological Association. Dr Tan Hui Meng delivered the MUA lecture on testosterone replacement therapy (TRT). He refuted some of the controversies regarding TRT, and cited the supporting data to defend its use. On a practical note, he shared his checklist for counselling and consent-taking before starting TRT in clinical practice. We were deeply honoured that the Secretary General of the EAU Professor Christopher Chapple(@ProfCRChapple) himself, delivered the EAU plenary on Substitution Urethroplasty. The management of urethral strictures is challenging due to the vast variability between patients, stricture aetiology, location and available tissue reconstruction. One key tip was that urethroscopy was useful to identify early stricture recurrence, which otherwise can be missed on uroflowmetry.

Hong Seok Shin from the Hannam Urological Association presented his unique presentation on Plastic surgery in collaboration with phẫu thuật gọt hàm, highlighting the importance of patient selection and counselling. The FAUA session was held concurrently with attendance of key office-holders of the various ASEAN urological associations. The theme of the session was on the development of MIS in Urology in the ASEAN countries discussion on “Cross-boundary Disease Management” with interesting clinical cases presented from different countries was lively. Koon Ho Rha delivered the UAA lecture on “The Role of Cytoreductive Prostatectomy in Advanced Prostate Cancer”, and showed in his series, that well selected patients with locally advanced disease, benefited from prostatectomy, which can be safely done robotically.

Multiple masterclasses ran concurrently on a range of subjects, including MRI-TRUS Fusion biopsies, Renal Transplantion, Andrology and Reconstructive Urology. The Robotic Surgery Masterclass chaired by Png Keng Siang was attended by a full house! The five expert robotic surgeons (Chris Evans, Koon Ho Rha, James Porter, Declan Murphy and Steve Chang) spoke on a range of topics from retroperitoneoscopic RAPN, to nerve-sparing techniques and complications of RARP to the use of different versions of robots (Si vs Xi) in robotic nephroureterectomy. The session ended with lively discussions between the panel and the audience in an interactive video session on trouble shooting challenging surgical aspects of RAPN and RARP.

The closing plenary was a “Glimpse into the Future”, covering topics from Precision Oncology and the role of Clinical Genetics for Urologic cancers, to the “The New Robots on the Block”.

Koon Ho Rha gave us a tour of the development of the ubiquitous Da Vinci, followed by the up and coming competitors, including one which has licensed and commercially available in Korea. Competition in this field can only make robotics in urology better and hopefully more cost effective.

Declan Murphy(@declanmurphy), Social Media Director of the BJUI shared his insights on the role of Social Media in Urology Practice. He highlighted the shift in the publishing paradigm, with videos and blogs of new findings peer reviewed on social media, before “traditional publication” by a journal, followed by amplification of the publication on social media.

Nurses are an integral part of the urological care, and they were certainly active at Urofair. The 180 strong audience at the Nursing Symposium were rapt with attention as Ms Helen Crowe shared her vast experience as Australia’s first Urology Nurse Practitioner on Prostate Cancer Nursing as well as expanding the role of Urology Nurses.

The Nursing Masterclass on the management of urinary incontinence was fully subscribed, and the practical hands on nature of the class was a big hit with the participants.

Physiotherapists conducting pelvic floor exercises with the Urology Nurses

 Our GP partners were not forgotten, and the 120 GPs who attended were treated to a great program. In this era of fake news, the standout lecture must have been “Google is not your friend”, where Lee Fang Jern shared the perils of medical fake news, and how medical practitioners can guide our patients to navigate the internet in search of reliable medical information.

The Gala Dinner was a fitting end to a fruitful Urofair, where everyone had a chance to strengthen and renew friendships over good food and wine.

Organising Chairman John Yuen is all smiles after the successful conclusion of Urofair

 The highlight of the Gala, was the rarely seen Bian Lian (变脸) performance. Bian Lian is an ancient Chinese dramatic art, where performers wear brightly colored costumes and vividly colored masks, typically depicting well known characters from the opera, which they change from one face to another almost instantaneously with the swipe of a fan, a movement of the head, or wave of the hand.

Bian Lian (变脸) performer

On a personal note, Urofair was a great opportunity to reconnect with Declan Murphy, who was my supervisor during my fellowship at the Royal Melbourne Hospital. I was honoured to have him and his son @cianblakemurphy (who is probably the youngest person to drive the Da Vinci) visit the National University Hospital where I work. Declan shared to a multispecialty group of robotic surgeons, his journey of expanding the adoption of robotics across multiple surgical disciplines at the Peter MacCallum Cancer Centre, and that the Da Vinci’s role in education, research and talent retention was key in surmounting concerns regarding cost.

On behalf of the SUA, we would like to thank all our international and local faculty for their efforts, and the delegates from near and far, for making Urofair 2018 a resounding success.

Finally, we are excited to announce Urofair 2019 will be held on 4-6 April 2019. Please save the date, and we look forward to welcoming you to Singapore.

Lincoln Tan

Consultant Urologist and Director of Urologic Oncology, National University Hospital, Singapore

Twitter: @LincolnRoboDoc

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.

1-7

#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

Article of the Week: Patterns of prescription and adherence to EAU guidelines on ADT in PCa

Every Week the Editor-in-Chief selects an Article of the Week 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 Giuseppe Morgia and Giorgio Ivan Russo, discussing their paper.

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

Patterns of prescription and adherence to European Association of Urology guidelines on androgen deprivation therapy in prostate cancer: an Italian multicentre cross-sectional analysis from the Choosing Treatment for Prostate Cancer (CHOICE) study

Giuseppe Morgia1, Giorgio Ivan Russo1, Andrea Tubaro2, Roberto Bortolus3, Donato Randone4, Pietro Gabriele5, Fabio Trippa6, Filiberto Zattoni7, Massimo Porena8Vincenzo Mirone9, Sergio Serni10, Alberto Del Nero11, Giancarlo Lay12 , Umberto Ricardi13, Francesco Rocco14, Carlo Terrone15, Arcangelo Pagliarulo16, Giuseppe Ludovico17, Giuseppe Vespasiani18, Maurizio Brausi19, Claudio Simeone20, Giovanni Novella21, Giorgio Carmignani22, Rosario Leonardi23, Paola Pinnaro5, Ugo De Paula24Renzo Corvo25, Raffaele Tenaglia26, Salvatore Siracusano27, Giovanna Mantini28, Paolo Gontero29, Gianfranco Savoca30 and Vincenzo Ficarra31 (Members of the LUNA Foundation, Societa Italiana dUrologia)

 

Department of Urology, University of Catania, Catania, Department of Urology, Sant Andrea Hospital, La Sapienza’ University of Roma, Roma, S.O. Oncologia Radioterapica, Pordenone, Urology, Presidio Ospedaliero Gradenigo, Torino, Radiotherapy, IRCC Candiolo, Torino, Radiotherapy, A.O. Santa Maria, Terni, Department of Urology, University of Padova, Padova, Department of Urology, University of Perugia, Perugia, Department of Urology, Universita Federico II of Napoli, Napoli,
10 Department of Urology, University of Firenze, Firenze, 11 Urologia I, Azienda Ospedaliera San Paolo, Milano, 12 Radiotherapy, ASL of Cagliari, Cagliari, 1Radiotherapy, AOU University S. Giovanni Battista Molinette, Torino, 14 Department of Urology, University of Milano, Milano, 15Urology, University Hospital Maggioredella Carita, Novara,16 Urology, University of Bari, Bari, 17 Urology, Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti, 18 Department of Urology, University Tor Vergata, Roma, 19 Urology, Ospedale Civile Ramazzini, Carpi, 20 Department of Urology, University of Brescia, Brescia, 21 Department of Surgery, Urology Clinic, AOUI Verona, Verona, 22 Department of Urology, University of Genova, Genova, 23 Urology, Centro Uro-Andrologico La CURA, Acireale, 24 Radiotherapy, AO S. Giovanni Addolorata, Roma, 25 Radiotherapy, Istituto Nazionale per la Ricerca, Genova, 26 Department of Urology, University of Chieti, Chieti, 27 Department of Urology, University of Trieste, Trieste, 28 Radiotherapy, Policlinico Universitario Agostino Gemelli, Roma, 29 Department of Surgical Sciences, Città della Salutee della Scienza, University of Torino, Torino, 30 Urology, Fondazione Istituto San Raffaele G. Giglio di Cefalù, Cefalù, and 31 Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy

 

Objective

To evaluate both the patterns of prescription of androgen deprivation therapy (ADT) in patients with prostate cancer (PCa) and the adherence to European Association of Urology (EAU) guidelines for ADT prescription.

Methods

The Choosing Treatment for Prostate Cancer (CHOICE) study was an Italian multicentre cross-sectional study conducted between December 2010 and January 2012. A total of 1 386 patients, treated with ADT for PCa (first prescription or renewal of ADT), were selected. With regard to the EAU guidelines on ADT, the cohort was categorized into discordant ADT (Group A) and concordant ADT (Group B).

AOTWJun5Results

Results

The final cohort included 1 075 patients with a geographical distribution including North Italy (n = 627, 58.3%), Central Italy (n = 233, 21.7%) and South Italy (n = 215, 20.0%). In the category of patients treated with primary ADT, a total of 125 patients (56.3%) were classified as low risk according to D’Amico classification. With regard to the EAU guidelines, 285 (26.51%) and 790 patients (73.49%) were classified as discordant (Group A) and concordant (Group B), respectively. In Group A, patients were more likely to receive primary ADT (57.5%, 164/285 patients) than radical prostatectomy (RP; 30.9%, 88/285 patients), radiation therapy (RT; 6.7%, 19/285 patients) or RP + RT (17.7%, 14/285 patients; P < 0.01). Multivariate logistic regression analysis, adjusted for clinical and pathological variables, showed that patients from Central Italy (odds ratio [OR] 2.86; P < 0.05) and South Italy (OR 2.65; P < 0.05) were more likely to receive discordant ADT.

Conclusion

EAU guideline adherence for ADT was low in Italy and was influenced by geographic area. Healthcare providers and urologists should consider these results in order to quantify the inadequate use of ADT and to set policy strategies to overcome this risk.

Editorial: EAU guidelines – do we care? Reflections from the EAU Impact Assessment of Guidelines Implementation and Education group

There is increasing evidence in the literature that androgen deprivation therapy (ADT) is overused among practising urologists in the setting of localized, and even locally advanced, prostate cancer (PCa) [1, 2]. Morgia et al. [1] report a misuse of ADT prescriptions among Italian urologists in roughly a quarter of cases, mainly in the setting of low-risk/localized disease where ADT may harm patients without proven benefit with regard to disease-specific outcomes [3]. Such clinical practice behaviours are even more unjustifiable given the high level of evidence upon which the current European Association of Urology (EAU) guidelines recommendations on ADT use are based [4].

Morgia et al. [1] should be congratulated for highlighting the magnitude of the problems the urological community currently face in terms of the gap between evidence and practice. Unfortunately, while the authors report significant geographical differences in ADT prescriptions within the same country (Italy), the methods they used in their study do not allow an understanding of the reasons for the discrepancy. It is currently unknown whether the gap between evidence and practice is attributable to physician or patient attitude or to the national health system structure. The inclusion of qualitative methods, such as semi-structured interviews, would have been ideal to probe clinician reasoning for discordant adherence. This is crucial because knowledge of possible barriers to the application of guidelines represents a key step in their implementation process. Indeed, once the issue is raised, the next logical questions to pose would be: how can we reduce such variation in urological practice especially where there is a real risk of causing harm to patients and how can we improve and implement the use of guideline recommendations when clearly underpinned by high-quality evidence?

It is indeed intuitive that any huge evidence–practice gap may have profound implications not only in the process of patient care optimization but also in the context of national healthcare efficiency.

Certainly the issue of ADT overuse raised by Morgia et al. [1] can be considered the perfect setting to scale up and prioritize efforts aimed at improving current urological practice for three main reasons: (i) the high prevalence of the disease studied (namely, PCa); (ii) the availability of an up-to-date evidence-based guideline showing the impact of ADT in terms of patient side effects and costs; and (iii) the now known gap between evidence and practice patterns.

Given this setting, it should then be mandatory to promote ways not only to assess the use of guideline recommendations but also to increase dissemination among users (not only healthcare professionals, but also patients and policy makers) and to evaluate their impact. The aim of this highly articulated process of knowledge translation is eventually to move research findings into clinical practice. Ideally, this approach should be based on the following five crucial questions: (i) What should be transferred? (ii) To whom should research knowledge be transferred? (iii) By whom should research knowledge be transferred? (iv) How should research knowledge be transferred? and (v) To what effect should research knowledge be transferred? [5]. Each of these questions represents a crucial step in any knowledge translation process. To optimize this approach, it is critical to identify barriers to knowledge implementation and to choose the optimum interventions to limit or to overcome them. This ‘global process’ is much more complicated than commonly thought, given the significant cultural, social, economic and health system differences not only between countries but also within the same country, as shown by Morgia et al. [1]. It is likely, therefore, that any knowledge implementation approach should be tailored according to each country and should be based on key steps, such as: selection of a credible ‘messenger’; development of the appropriate technological and organizational instruments to facilitate access to disseminate and use existing high-quality evidence; and the setting up of education programmes to improve clinical research literacy skills.

Finally, we believe that the paper by Morgia et al. [1] strongly supports the notion that ‘evidence-based medicine should be complemented by evidence-based implementation’ [6]. It is indeed likely that creating a knowledge translation setting where the gap between evidence and practice is eventually bridged is as important as producing accurate, scientifically sound and meticulous guidelines that can be trusted by all stakeholders.

Tackling the crucially important problem of discordant guideline adherence is the remit of the recently established EAU Guidelines Office ‘IMAGINE’ project (IMpact Assessment of Guidelines Implementation and Education) which aims to: ascertain adherence to prioritized guideline recommendations; elucidate the barriers and facilitators to change; design bespoke knowledge transfer interventions; and evaluate the impact of the EAU guidelines, thereby optimizing adherence, with the ultimate goal of improving patient care.

Alberto Briganti*, Steven MacLennan, Lorenzo MarconiKarin Plass§ and James NDow on behalf of EAU Guidelines Ofce IMAGINE project
*Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy, Academic Urology Unit, University of Aberdeen, Aberdeen, UK, Department of Urology, Coimbra University Hospital, Coimbra, Portugal and §EAU Central Ofce, Guidelines Ofce, Arnhem, The Netherlands

 

References

 

 

Video: Patterns of prescription and adherence to EAU guidelines on ADT in PCa

Patterns of prescription and adherence to European Association of Urology guidelines on androgen deprivation therapy in prostate cancer: an Italian multicentre cross-sectional analysis from the Choosing Treatment for Prostate Cancer (CHOICE) study

Giuseppe Morgia1, Giorgio Ivan Russo1, Andrea Tubaro2, Roberto Bortolus3, Donato Randone4, Pietro Gabriele5, Fabio Trippa6, Filiberto Zattoni7, Massimo Porena8Vincenzo Mirone9, Sergio Serni10, Alberto Del Nero11, Giancarlo Lay12 , Umberto Ricardi13, Francesco Rocco14, Carlo Terrone15, Arcangelo Pagliarulo16, Giuseppe Ludovico17, Giuseppe Vespasiani18, Maurizio Brausi19, Claudio Simeone20, Giovanni Novella21, Giorgio Carmignani22, Rosario Leonardi23, Paola Pinnaro5, Ugo De Paula24Renzo Corvo25, Raffaele Tenaglia26, Salvatore Siracusano27, Giovanna Mantini28, Paolo Gontero29, Gianfranco Savoca30 and Vincenzo Ficarra31 (Members of the LUNA Foundation, Societa Italiana dUrologia)

 

Department of Urology, University of Catania, Catania, Department of Urology, Sant Andrea Hospital, La Sapienza’ University of Roma, Roma, S.O. Oncologia Radioterapica, Pordenone, Urology, Presidio Ospedaliero Gradenigo, Torino, Radiotherapy, IRCC Candiolo, Torino, Radiotherapy, A.O. Santa Maria, Terni, Department of Urology, University of Padova, Padova, Department of Urology, University of Perugia, Perugia, Department of Urology, Universita Federico II of Napoli, Napoli,
10 Department of Urology, University of Firenze, Firenze, 11 Urologia I, Azienda Ospedaliera San Paolo, Milano, 12 Radiotherapy, ASL of Cagliari, Cagliari, 1Radiotherapy, AOU University S. Giovanni Battista Molinette, Torino, 14 Department of Urology, University of Milano, Milano, 15Urology, University Hospital Maggioredella Carita, Novara,16 Urology, University of Bari, Bari, 17 Urology, Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti, 18 Department of Urology, University Tor Vergata, Roma, 19 Urology, Ospedale Civile Ramazzini, Carpi, 20 Department of Urology, University of Brescia, Brescia, 21 Department of Surgery, Urology Clinic, AOUI Verona, Verona, 22 Department of Urology, University of Genova, Genova, 23 Urology, Centro Uro-Andrologico La CURA, Acireale, 24 Radiotherapy, AO S. Giovanni Addolorata, Roma, 25 Radiotherapy, Istituto Nazionale per la Ricerca, Genova, 26 Department of Urology, University of Chieti, Chieti, 27 Department of Urology, University of Trieste, Trieste, 28 Radiotherapy, Policlinico Universitario Agostino Gemelli, Roma, 29 Department of Surgical Sciences, Città della Salutee della Scienza, University of Torino, Torino, 30 Urology, Fondazione Istituto San Raffaele G. Giglio di Cefalù, Cefalù, and 31 Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy

 

Objective

To evaluate both the patterns of prescription of androgen deprivation therapy (ADT) in patients with prostate cancer (PCa) and the adherence to European Association of Urology (EAU) guidelines for ADT prescription.

Methods

The Choosing Treatment for Prostate Cancer (CHOICE) study was an Italian multicentre cross-sectional study conducted between December 2010 and January 2012. A total of 1 386 patients, treated with ADT for PCa (first prescription or renewal of ADT), were selected. With regard to the EAU guidelines on ADT, the cohort was categorized into discordant ADT (Group A) and concordant ADT (Group B).

AOTWJun5Results

Results

The final cohort included 1 075 patients with a geographical distribution including North Italy (n = 627, 58.3%), Central Italy (n = 233, 21.7%) and South Italy (n = 215, 20.0%). In the category of patients treated with primary ADT, a total of 125 patients (56.3%) were classified as low risk according to D’Amico classification. With regard to the EAU guidelines, 285 (26.51%) and 790 patients (73.49%) were classified as discordant (Group A) and concordant (Group B), respectively. In Group A, patients were more likely to receive primary ADT (57.5%, 164/285 patients) than radical prostatectomy (RP; 30.9%, 88/285 patients), radiation therapy (RT; 6.7%, 19/285 patients) or RP + RT (17.7%, 14/285 patients; P < 0.01). Multivariate logistic regression analysis, adjusted for clinical and pathological variables, showed that patients from Central Italy (odds ratio [OR] 2.86; P < 0.05) and South Italy (OR 2.65; P < 0.05) were more likely to receive discordant ADT.

Conclusion

EAU guideline adherence for ADT was low in Italy and was influenced by geographic area. Healthcare providers and urologists should consider these results in order to quantify the inadequate use of ADT and to set policy strategies to overcome this risk.

Editorial: Cost-effectiveness of robotic surgery; what do we know?

The introduction of the daVinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) has led to a continuous discussion about the cost-effectiveness of its use. The capital costs and extra costs per procedure for robot-assisted procedures are well known, but there are limited data on healthcare consumption in the longer term. In this issue of BJUI, a retrospective study investigated the NHS-registered, relevant care activities up to three years after surgery comparing robot-assisted, conventional laparoscopic, and open surgical approaches to radical prostatectomy and partial nephrectomy [1].

The robotic system is particularly useful in difficult to perform laparoscopic surgeries, which are easier to perform with the daVinci system due to improved three-dimensional vision, ergonomics, and additional dexterity of the instruments. Because the use of the robotic system is more costly, to justify its use the outcomes for patients should be improved. Therefore, more detailed information about the clinical and oncological outcomes, as well as the incidence of complications after surgery with the daVinci system, is needed.

Lower rates of positive surgical margins for robot-assisted radical prostatectomy (RARP) vs open and laparoscopic RP have been reported [2]. There also is evidence of an earlier recovery of functional outcomes, such as continence. RARP is associated with improved surgical margin status compared with open RP and reduced use of androgen-deprivation therapy and radiotherapy after RP, which has important implications for quality of life and costs. Ramsay et al. [3] reported that RARP could be cost-effective in the UK with a minimum volume of 100–150 cases per year per robotic system.

Centralisation of complex procedures will not only result in better outcomes, but also facilitate optimal economical usage of expensive medical devices. Furthermore, the skills learned to perform the RARP procedure can be used during other procedures, such as robot-assisted partial nephrectomy (RAPN) and radical cystectomy (RARC). The recent report by Buse et al. [4] confirms that RAPN is cost-effective in preventing perioperative complications in a high-volume centre, when compared with the open procedure. Minimally invasive techniques for complex procedures, such as a RC, take more time to perform, but result in less blood loss. A systematic review by Novara et al. [5] showed a longer operation time for RARC, but fewer transfusions and fewer complications compared with open surgery. However, there is no solid evidence about the cost-effectiveness of this technique to date. The RAZOR trial (randomised trial of open versus robot assisted radical cystectomy, DOI: 10.1111/bju.12699) is likely to provide some answers about differences in cost, complications, and quality of life when the results of the study become available later this year.

Additionally, the robotic system has been shown to shorten the learning curve of complex laparoscopic procedures in simulation models [6]. Recently, a newly structured curriculum to teach RARP has been validated by the European Association of Urology-Robotic Urology Section [7]. The effect of the shorter learning curve on the cost of the procedures has not yet been well studied for cost-effectiveness. However, due to the shorter learning curves, patients have lower risks of complications, which from the patients’ perspective is more important than any increased costs.

The study reported in this issue [1]; however, does not include the ‘out of pocket’ expenses of patients, it does not report on the differences in patient and tumour characteristics, and outcomes such as complications and oncological safety. These issues are all challenges to be addressed in a thorough prospective (randomised) trial on the cost-effectiveness of the use of robot-assisted surgery, including quality-of-life measurements and complications of the surgical procedures. In the Netherlands the RACE trial (comparative effectiveness study open RC vs RARC, www.racestudie.nl) started in 2015 and the results are expected in 2018–2019.

Carl J. Wijburg
Department of Urology, Robotic Surgery , Rijnstate HospitalArnhem, The Netherlands

 

References

 

 

2 HuJC, Gandaglia G, Karakiewicz PI et al. Comparative effectiveness of robot-assisted versus open radical prostatectomy. Eur Urol 2014; 66: 66672

 

 

4 Buse S, Hach CE, Klumpen P et al. Cost-effectiveness of robot-assisted partial nephrectomy for the prevention of perioperative complications. World J Urol 2015; [Epub ahead of print]. DOI:10.1007/s00345-015-1742-x

 

 

6 Moore LJ, Wilson MR, Waine E, Masters RS, McGrath JS, Vine SJRobotic technology results in faster and more robust surgical skill acquisition than traditional laparoscopy. J Robot Surg 2015; 9: 6773

 

 

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