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Radical cystectomy for bladder cancer – is there a changing trend?

The first #urojc instalment of 2015 discussed the recent European Urology paper ‘Trends in operative caseload and mortality rates after radical cystectomy (RC) for bladder cancer in England for 1998-2010. Hounsome et al., examined a total of 16,033 patients who underwent RC – over the study period 30-day and 90-day mortality rates decreased and 30-day, 90-day, 1-year and 5-year survival rates significantly improved.

Henry Woo (@DrHWoo) suggests this paper is breaking the mould in comparison to other series.

Analysis of the SEER database would suggest otherwise – there has been little or no change in the incidence, survival or mortality rates with respect to bladder cancer over an even longer study period (1973-2009). Likewise, Zehnder noticed no survival improvement in patients undergoing RC over the last three decades (1980-2005).

However, Jim Catto (@JimCatto) and Alexander Kutikov (@uretericbud) were quick to point out the differences between survival rates and mortality rates, although Hounsome et al., reported beneficial outcomes in both parameters.

 

 

 

 

 

 

 

 

In the UK, the Improving Outcomes in Urological Cancers guidance (IOG) recommends patients be considered for RC for muscle invasive bladder cancer (MIBC) and high risk recurrent non-muscle invasive bladder cancer (NMIBC). Key aspects of this guidance include – a minimum caseload requirement for performing RC, an MDT approach and specific 30day mortality rates of 50% despite no change in the incidence of bladder cancer. The reasoning for this is multifactorial but in part due to designated cancer centres are offering surgery to more candidates as a result of service improvements that include service reconfiguration, improved surgical training, neoadjuvant chemotherapy, enhanced recovery principles, and continued improvements in peri-operative care.

The on-line debate moved towards discussing the effect of centralisation of cancer services as a causative factor behind these positive results.

Rather intuitively, in a systematic review in 2011, Goossens-Laan et al., postoperative mortality after cystectomy is significantly inversely associated with high-volume providers.

Although the benefits of being treated in a cancer centre of excellence are undoubted- high volume fellowship trained surgeons, a multidisciplinary approach and improved peri-operative conditions; the impact of distance from central services was broached. O’Kelly et al., postulated a higher stage of prostate cancer based on distance from a tertiary care centre, other studies have shown for a variety of cancers (lung, colon)that distance from a central provider can impact outcomes. Outside of the impact on oncological outcomes, the impact on the patient’s lifestyle as well as the economic consequences were not discussed.

While contrary to this, Jim Catto (@JimCatto) highlighted the deskilling associated with centralisation.

 

 

 

 

 

A further significant implicating factor in the positive results seen in this study is due to the use of neo-adjuvant chemotherapy, a question often posed by the patient.

Rather contentiously, David Chan (@dytcmd) remarked that optimal surgical results have already been achieved, a statement challenged by Jim Catto (@JimCatto).

This study although examining a vast number of patients over a lengthy time period is not without its limitations. Specifically the lack of tumour stage, smoking status and the use of chemotherapy as well as issues surrounding a retrospective study looking at data collected by individual hospital coding systems.

This month’s #urojc attracted substantial coverage on Twitter – keep it up.

Many thanks to those you participated in the debate. We look forward to next month’s #urojc discussion.

Greg Nason (@nason_greg) is a Specialist Registrar in Urology, Beaumont Hospital, Dublin, Ireland

 

Highlights from the Irish Society of Urology 2014

 

Failte go Cill Airne (Welcome to Killarney, Co Kerry).
The urology community of Ireland descended on the picturesque town of Killarney in the south west of Ireland for its annual scientific meeting.

Mr David Quinlan (@daithiquinlan), President of the ISU, commenced proceedings with a tribute to the late Professor John Fitzpatrick and Mr Dermot O’Flynn. It is the first ISU following the sad passing of Professor Fitzpatrick in May of this year. Professor Fitzpatrick led a distinguished career and was a respected figure in world urology. The recent BJUI blog following his death demonstrated how highly regarded he was across the globe, with many sharing personal memories of him. Outside of his undoubted ability in the operating room, he was entertaining, had a special way with words and was a great story teller. He will be missed both here and afar.

 

Dermot O’Flynn, past President of the RCSI, also passed away this year aged 93. Mr O’Flynn was an established urologist in the Meath Hospital. He played a significant role in the formalisation of urological training in Great Britain and Ireland not only to the training programme but also the specialist exit examination.

 

 

 

Academic Program

The academic program commenced on Thursday morning with front line basic science presentations. Kieran Breen (@kjkibbles – who won the ISU Registrar’s Prize winner) from the Conway Institute (scientific laboratory set up by Professor Fitzpatrick) reported tissue microarrays following radical prostatectomy regarding immunohistochemistry staining for insulin receptors, IGF-1 receptor and PTEN as markers of predicting biochemical recurrence. Early data suggest these markers could identify potential patients at risk of biochemical recurrence. Tuzova et al. presented a multi-centre study led by the St James’ group that suggested urinary profiling of DNA hypermethylation can selectively detect high-risk prostate cancers with improved specificity over the traditional PSA test.
The afternoon podium session focused on prostate cancer and resulted in an expected heated debate – Daniel Good (@willbgood1) from Edinburgh, reported the use of a novel device in prostate cancer detection. The E-finger, is a probe that fits on the tip of a finger and attempts to differentiate significant from insignificant findings based upon prostate elasticity. The debate continued regarding the use of pre biopsy MRI as well as the role of transperineal biopsies as a standard. Rick Popert advocated the use of systematic transperineal biopsy based on an anatomical map of the prostate as opposed to the traditional ‘lucky dip’ that is the transrectal ultrasound biopsy.
Friday morning focused on urological training in Ireland – Elaine Redmond outlined the lack of urological exposure among primary care physicians and suggested a urological or men’s health module be incorporated in their curriculum. Matthew Burke, highlighted the need for dedicated paediatric urological training to meet the needs of the health service going forward – this echoed the thoughts of BAUS President Mark Speakman who highlighted the impending void in paediatric urology.
Other highlights included the suggestion of a national network for the management of penile cancer in Ireland, similar to this week’s BJUI article of the week. In a country with such low volumes, a supra-regional network may improve long-term morbidity and survival.
Finally, O’Kelly et al. (@fardodokelly), demonstrated the merits and quality of national urological meetings from the smaller European countries with a favourable final publication rate of 46%. The quality of presentations, in particular basic science demonstrated this will continue.

Guest Speakers

The ISU has continued to attract significant guest speakers from the world of urology and this year we were joined by Craig Peters (‘THE’ American Paediatric Urologist), Mike Leonard (Vice-President of the Canadian Urological Association), Mark Speakman (President of BAUS) and Prokar Dasgupta (@prokarurol – Editor of the BJUI).

Guest Speakers – Mr John Thornhill (incoming ISU President), Mr Roger Plail (President of the Section on Urology, Royal Society of Medicine), Mr David Quinlan (outgoing ISU President), Professor Prokar Dasgupta (BJUI Editor), Professor Craig Peters (University of Virginia), Mr Mark Speakman (President of BAUS), Professor Mike Leonard (Vice-President Canadian Urological Association)

Professor Peters lecture on Robotic Surgery in Paediatric Urology ‘Reflections on emerging technologies’ was an eye opener in to what can be achieved if we push the boundaries. His strive for excellence and improved patient outcomes in the face of ‘robot-scepticism’ have led to advances in paediatric robotics. Outside of the robotic pyeloplasty – they have pioneered and tested the use of robotics in hypospadiology due to the undoubted improved optics as well the management of congenital abnormalities.
In one of the highlights of the meeting, Professor Peters was pitted against Professor Mike Leonard (Vice-President of the Canadian Urological Association) in a debate ‘Robotics are alien in paediatric urology’ panelled by Professor Dasgupta and Mark Speakman. ‘Robocop’ versus the sensible Canadian approach duelled in a fascinating debate – detailing clinical efficacy, cost effectiveness, quality control. Professor Peters offered Professor Leonard his card for redo pyeloplasty ‘in which the robot works quite well’.
Professor Dasgupta, (the man who still carries a diary) engaged the audience in a tour de force regarding immunotherapy in prostate cancer as well as detailing his future vision for the BJUI. This was the first year the abstracts were published in the BJUI, the Official Journal of the ISU. This is a most welcome addition and adds to the standing of our annual meeting.

Professor Prokar Dasgupta – the Editor of the ‘journal that never sleeps’ – with his pocket diary.

Mark Speakman, gave an impressive demonstration in the art of oratory at the gala dinner regarding delivering a service and the impending need to publish surgeon-specific outcomes. He continued to speak to trainees and the need to add a ‘second string to your bow’ highlighting the areas which will require urologists in the future – paediatrics, andrology and female urology – warning that we cannot all be robotic pelvic oncological urologists.

Social Media Presence

The #ISU14 hashtag gathered momentum in the past few days. Again an inaugural addition to our meeting and something we will endeavour to promote in years to come. Any attendee at the EAU, AUA, BAUS will attest to the quality of social media presence and this is something we can learn from. By the end of the meeting we had followers across the globe, in the United States and Australia.

ISU Social Media Team ( Mr Rustom Manecksha – @dr_rpm, Mr David Bouchier-Hayes – @dbh44, Mr Garrett Durkan – @gcd67, Professor Prokar Dasgupta – @prokarurol, Mr Greg Nason – @nason_greg, Mr David Quinlan – @daithiquinlan,
Mr Fardod O’Kelly – @fardodokelly)

The now standard selfie – Mr John Thornhill, Mr Roger Plail, Mr David Quinlan, Professor Prokar Dasgupta, Professor Craig Peters, Mr Mark Speakman, Professor Mike Leonard)

Symplur #ISU14 analytics

 

Moving forward

The annual meeting also ended Mr David Quinlan’s tenure as the President of the Irish Society of Urology. The ISU has moved from strength to strength under his watchful eye, incoming President John Thornhill applauded Mr Quinlan as ‘a rock who sailed a steady ship’. We look forward to welcoming all to next year in Limerick for hopefully a bigger annual conference with a wider global audience.

Mr David Quinlan (outgoing President of ISU), Professor Prokar Dasgupta (BJUI Editor), Mr John Thornhill (incoming ISU President)

 

Greg Nason is a Specialist Registrar in Urology in Ireland.
ISU Social Media Team (David Quinlan, Rustom Manecksha, David Bouchier-Hayes, Fardod O’Kelly, Greg Nason)

 

 

Fellowships – a key ingredient or the ‘icing on the cake’?

What is the ultimate endpoint of a residency or speciality training program? Is it to complete 5 or 6 years of training in core urological procedures? Is it to produce safe, competent independent urologists? Is it to achieve FRSC (Urol) certification? In an ideal world it would be a marriage of all three; a safe, competent, independent, certified, practising urologist ready and eager to tackle any urological referral. In reality, we know that not to be the case.

Urology is a broad and advancing speciality encompassing patients of all ages and both sexes involving a complexity of benign and malignant pathologies. It is unrealistic to be an expert in all the sub-specialties and be able to offer the best and least invasive treatments to our patients. Furthermore, with a necessary emphasis on patient safety, transparency and proficiency, surgical training programs face significant barriers in affording trainees the opportunity to operate, specifically in the working time directive era.

Fellowships are usually undertaken at the completion of higher surgical training scheme often in a centre of excellence overseas. Fellowships offer trainees intensive experience in their niche area. On completion of a coveted fellowship, trainees hope to have acquired and polished the required skills to practice independently in their chosen field.

A recent pan European survey of 219 urological residents demonstrated laparoscopy and robotics were available in 74% and 17% of centres respectively [1]. Only 23% of trainees report their exposure as ‘satisfactory’. 68% have not completed a laparoscopic radical nephrectomy as first operator. Despite this 81% are considering fellowships in laparoscopy.

Buffi et al., have called for a validated and structured training curriculum in robotic surgery [2]. Trainees acknowledge the challenges in the acquisition of such skills but the modularisation of training is the best way to learn a procedure. Step by step trainees can piece together the operations. Hours spent on simulators and in dry and wet laboratories enhances these techniques. Furthermore, the dual consoles offer invaluable experience in robotics, however, are scarcely available.

The governing bodies have a responsibility to maintain standards of training as well as a duty towards patients. Proficiency in modern techniques such as laparoscopy and robotics are deficient in most training programs. Training programs need to encompass these techniques in a modular fashion from an early stage to develop the skills of tomorrows’ urologists [3]. Fellowships will undoubtedly foster and enhance these skills but a core knowledge and technical proficiency even in a simulator setting should be encouraged.

In truth, our learning and development never should never stop.

‘Live as if you were to die tomorrow. Learn as if you were to live forever’ Mahatma Gandhi

Mr Gregory Nason is a Specialist Registrar in Urology at the University Hospital Limerick, Ireland

References

  1. Furriel FTG, Laguna MP, Figueiredo AJ, Nunes PT, Rassweiler JJ. Training of European urology residents in laparoscopy: results of a pan-European survey. BJU Int 2013; 112: 1223–28.
  2. Buffi N, Van Der Poel H, Guazzoni G,  Mottrie A, on behalf of the Junior European Association of Urology (EAU) Robotic Urology Section with the collaboration of the EAU Young Academic Urologists Robotic Section. Methods and Priorities of Robotic Surgery Training Program. Eur Urol 2013; epub ahead of print.
  3. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialing. J Urol 2011; 185: 1191-7.

EWTD: Quantity or Quality?

The European Working Time Directive (EWTD) was due to be in full implementation from August 2009 limiting junior doctors to a 48-hour week averaged over a 6-month period. The reality of this is somewhat different from the legislation. In truth, the questions needed to be asked were – was it ever feasible? What was the training impact in a craft-based speciality going to be? Where are we now?

The detrimental effects to training in a reduced working environment has been documented in both hemispheres. Canter, in a review of the EWTD in the United Kingdom and Ireland reported ~90% non-compliance of the restricted working week. Time for Training reviewed the implications of the EWTD and Professor Temple felt ‘high quality training can be delivered in 48 hours’; however, this is precluded where trainees have a ‘major role in out of hours services’. As most trainees, in all health systems, will attest to junior doctors do play a ‘major role’ in on-call services.

As a current urological trainee, the pressures to develop skills to operate in an ever-changing and exciting field are evident. A limited working week, twinned with health service cut backs and limited hospitals beds is without doubt a concern when filling in our logbooks. Could a passage to India be the way to get more surgical experience?, a feature in the BMJ in 2012, Elliot sends trainees abroad to gain the invaluable exposure to numbers we are limited by here.

There are two sides to the impact that a limited working week will have to an aspiring surgeon’s experience, the quantity and quality of time spent in the hospital. The debate remains regarding the length of surgical training the current structures are changing in Ireland, led by the RCSI, in an effort to shorten the length of surgical training in line with other jurisdictions. We need to strive to efficiently and effectively train surgeons within an appropriate timeframe within the restraints of legislation without a drop in the standard of skills required.

As time has passed, it remains to be seen if the EWTD will ever be implementable in keeping with the continuity of patient care to the highest standard they deserve and that we aspire to offer them. The EWTD is currently being debated at a European Commission level in order to negotiate a revised directive more in line with the challenges of healthcare professionals in a 21st century health service. Revisions to the directive may allow for longer hours in certain disciplines such as the skill based surgical specialities.

Gregory J. Nason, MRCSI, is currently Registrar in Urology, St Vincent’s University Hospital, Dublin.

 

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