Tag Archive for: International Urology Journal Club


The Surgical Safety Check List – May #urojc

Ever since the World Health Organisation launched the Safe Surgery Saves Lives campaign in 2007, surgical safety has been drawn to the forefront of the daily surgical routine. The introduction of the 19-point Surgical Safety Checklist, aimed at reducing preventable complications, has become key, with shouts of ‘time-out’ or ‘checklist’ becoming the norm at the start of each case. Equally whether known as the ‘huddle’ or ‘team brief’, the meeting of all team members at the beginning of the list not only helps plan for any changes from the normal routine, but gives a good chance to get to know any new members of staff and helps to promote the team-based atmosphere that encompasses a productive operating list. In the 2009 study evaluating the benefits of the Surgical Safety Checklist, a reduction in both the mortality rate and rate of inpatient complications were found to be significantly reduced1. Implementation of these safety protocols however requires effort and engagement from all members of the theatre team.

In the May, the International Urology Journal Club (@iurojc) #urojc debated a study by Haynes et al in which the reduction of 30-day mortality following the implementation of a voluntary, checklist-based surgical quality improvement program2. The study identified that hospitals completing the program had a significantly lower rate of 30-day mortality following inpatient surgery.

One of the first topics brought up in the debate is the variability in the implementation of safety checklists.


@StorkBrian raised the possibility that due to the addition of more items at the surgical time out, effectiveness decreases. Whether there is a lack of ability to concentrate on too much paper work was discussed

Conflicting evidence regarding the effect surgical checklists have on mortality was identified, with @WallisCJD bringing up the paper by Urbach et al as an example3.

The different outcomes from the two studies may however be attributed to the difference in follow up period and study design.


Another aspect of study design discussed was the inclusion criteria – which excluded day case procedures. Whether the outcome in 30-day mortality would be different if these are included, as they are more likely to be lower-risk surgery, is unclear.

Equally whether 30-day mortality is the most appropriate endpoint for the study was questioned – although clearly very important, it would be interesting to know if other factors, such as significant morbidity, altered following the quality improvement program.


Although the surgical checklist has become part of our daily life, the question as to why they are important was raised by @CanesDavid, with a variety of responses.

For many, it seemed that alongside the safety promotion, it helps to promote cohesive teamwork and communication, which may give all team members the confidence to voice any concerns.


Giving all team members the ability to speak up with confidence if they identify any concerns will only benefit patients and staff.

Equally, the culture of safety promoted in teams who engage with the surgical checklist process may not be limited to the checklist itself, but to the surgical environment in general


One clear concern some have with the mandating of the surgical checklist is ensuring it does not just become a ‘tick-box’ exercise


Regardless of whether you find the checklist another form to fill, or a key part of your operating list, the goal of the process is clear: to protect our patients from preventable mistakes.

This study, confirming the original findings from the 2009 study that surgical safety checklists improve operative mortality, adds to the argument that this must become an inherent part of our practice. Key in this study however was the entire program promoting engagement in the concept of surgical safety, and supporting the team as a unit in this. The debate around this paper has highlighted that although the process of completing the mandatory checklists is important, perhaps the more important aspect is creating a culture of safety, openness and honest communication in which all team members can work together to promote safe surgery.


Sophia Cashman is a urology trainee working in the East of England region, UK. Her main areas of interest are female and functional urology. @soph_cash



1. Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 2009;360(5):491-9
2. Haynes AB, Edmondson LBA, Lipsitz SR, et al. Mortality Trends After a Voluntary Checklist-based Surgical Safety Collaborative. Annals of Surgery 2017. Published Ahead-of-Print
3. Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada. New England Journal of Medicine 2014;370(11):1029-1038


Does presentation with metastatic prostate cancer matter?

CaptureNovember saw the return of the International Urology Journal Club #urojc on Twitter. The annual meetings of the World Congress for Endourology (#WCE2015) and Société Internationale D’Urologie (#SIU15) led to an October break for #urojc. This month’s discussion was based around a recent editorial in the New England Journal of Medicine by Welch et al on the effects of screening on the incidences of metastatic-at-diagnosis prostate and breast cancers. In the three days prior to the start of the discussion the editorial and it’s now well-known graph had been trending amongst medical Twitter users.


The issue of PSA screening for prostate cancer has been a topic of debate amongst urologists for a number of years. PSA and DRE are first line for early detection of prostate cancer. Supporters of PSA screening argue that it leads to a significant fall in prostate cancer specific mortality. Many others believe there is insufficient evidence to support universal PSA screening given the risks of prostate biopsy and potential overtreatment of low risk prostate cancer.

The editorial presented data showing a significant fall in the number of patients first presenting with metastatic prostate cancer (advanced stage incidence) following the introduction of universal screening. However no effect was shown on similar data for breast cancer. Variations in disease dynamics were suggested to play a role.

The conversation started on Sunday 1st November at 20:00 (GMT), marking the beginning of the fourth year of #urojc. The first questions centred around the reasons behind the trends seen in the graph. Being a urology journal club the conversation was based almost exclusively on the prostate cancer aspect of the editorial.


One suggestion for the discrepancy between the two cancers is that PSA is a better detector of metastatic disease, whilst mammography can only detect localised disease.


Based on incidence of metastatic prostate cancer, the article makes a convincing statement in support of universal PSA screening. However, a successful screening programme should result in a reduction in the incidence of advanced cancers, decreased advanced-stage incidence and reduced mortality. Leading to the question of whether looking solely at advanced-stage incidence is useful.


The importance of responsible treatment and active surveillance was mentioned early on.

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One of the most important questions of the discussion: What impact and relevance does the image have? Views were polarised. Some contributors were cautious about drawing conclusions from the graph whilst others were satisfied that it justified PSA screening.

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The article drew comparison between Halsted’s and Fisher’s descriptions of cancer progression. Halsted suggested cancer originates from a single site and spreads, whereas Fisher’s paradigm proposed that breast cancer is a systemic disease by the time it is detectable.

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The United States Preventive Services Task Force (USPSTF) has recommended against universal screening of prostate cancer, suggesting the risks of testing outweighed the benefits. However, many believe this to be based on outdated evidence.


The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial results showed a 12% higher incidence of prostate in the screening arm versus control, with no difference in mortality. Yet, the European Randomized Study of Screening for Prostate Cancer (ERSPC) has shown screening to result in a 1.6 fold increase in prostate cancer with a 21% reduction in mortality.


The debate briefly discussed the morbidity and cost of metastatic disease.

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The editorial certainly raised a number of interesting points. It seems the topic of universal PSA screening will continue to be debated. There is a significant benefit to screening in the prevention of metastatic prostate cancer. Whether this is due to differing disease dynamics or PSA being a better screening tool than mammography is as yet unclear.

One point we can all agree on is that increasing utilisation of active surveillance with timely biopsies is important in preventing overtreatment of low risk disease and identifying those at risk of disease progression for curative treatment.


Anthony Noah Urology Speciality Trainee, West Midlands, UK
Twitter: @antnoah


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