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Should we abandon live surgery: reflections after Semi-Live 2017

Prokar_v2Ever since 2002, I have performed live surgery almost every year where it is transmitted to an audience eager to learn. This year I was invited by Markus Hohenfellner to the unique conference, Semi Live 2017 in Heidelberg. To say that it was an eye opener is perhaps stating the obvious. One look at the program will show you that the worlds most respected Urological surgeons had been invited to participate, but with a difference. There was no live surgery. Instead videos of operations – open, laparoscopic and robotic were shared with the attendees “warts and all” as a learning experience. These were not videos designed to show the best parts of an operation. There were plenty of difficult moments, do’s and don’ts and troubleshooting, but all this was achieved without causing harm or potential harm to a single patient.

My highlights were laparoscopic sacrocolpopexy (Gaston), robotic IVC thrombectomy up to the right atrium (Zhang) and reconstructive surgery for the buried penis (Santucci). The event takes place every 2 years and the videos are all available on the meeting app which can be downloaded here and is an outstanding educational resource.

We were treated to a heritage session which included the superstars Walsh, Hautmann, Clayman, Mundy, Schroder and Ghoneim. This was followed by our host Markus Hohenfellner comparing and contrasting the art of Cystectomy and reconstruction by Ghoneim, Stenzl and Studer.

 

Open surgery is certainly not dead yet. The session ended with Seven Pillars of Wisdom from Egypt which turned out to be a big hit on Twitter.

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The editor’s choice session, a new innovation for 2017, allowed me to showcase the Best of BJUI Step by Step, a section that has now replaced Surgery Illustrated with fully indexed and citable HD videos and short papers.

Has live surgery had its day?

Many on Twitter seemed to agree that in 20 years time we might look back and say that it was not the right thing to do.

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Surgeons do not operate “live” every day. Most doctors in a survey, would not subject themselves or their families to be patients during live surgery. Talk about hypocrisy!! Why should it be any different for our patients? Live surgery is NOT a blood sport practised in Roman times….

The counterpoint is that patients often have the services of the best surgeons during live surgery, recorded, edited videos are not quite the same and that the whole affair has become safer thanks to patient advocates and strict guidelines from some organisations like the EAU. Others have banned the practice for good reason. While the debate continues, I for one came away feeling that Semi-Live was as educational, less stressful and much safer for our patients.

 

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

 

Highlights from #BAUS15

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#BAUS15 started to gain momentum from as early as the 26th June 2014 and by the time we entered the Manchester Central Convention Complex well over 100 tweets had been made. Of course it wasn’t just Twitter that started early with a group of keen urologists cycling 210 miles to conference in order to raise money for The Urology Foundation.

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Monday 15th June 2015

By the time the cyclists arrived conference was well under way with the andrology, FNUU and academic section meetings taking place on Monday morning:

  • The BJU International Prize for the Best Academic Paper was awarded to Richard Bryant from the University of Oxford for his work on epithelial-to-mesenchymal transition changes found within the extraprostatic extension component of locally invasive prostate cancers.
  • Donna Daly from the University of Sheffield received the BJUI John Blandy prize for her work on Botox, demonstrating reductions in afferent bladder signaling and urothelial ATP release.

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  • Professor Reisman’s talk on ‘Porn, Paint and Piercing’ as expected drew in the crowds and due to a staggering 44% complication rate with genital piercings it is important for us to try to manage these without necessarily removing the offending article as this will only serve to prevent those in need from seeking medical attention.
  • With the worsening worldwide catastrophe of antibiotic resistance, the cycling of antibiotics for prevention of recurrent UTIs is no longer recommended. Instead, Tharani Nitkunan provided convincing evidence for the use of probiotics and D-Mannose.

The afternoon was dominated by the joint oncology and academic session with Professor Noel Clarke presenting the current data from the STAMPEDE trial. Zolendronic acid conferred no survival benefit over hormones alone and consequently has been removed from the trial (stampede 1). However, Docetaxal plus hormones has shown benefit, demonstrated significantly in M1 patients with disease-free survival of 65 months vs. 43 months on hormones alone (Hazard ratio 0.73) (stampede 2). This means that the control arm of M1 patients who are fit for chemotherapy will now need to be started on this treatment as the trial continues to recruit in enzalutamide, abiraterone and metformin arms.

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The evening was rounded off with the annual BAUS football tournament won this year by team Manchester (obviously a rigged competition!), whilst some donned the

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lycra and set out for a competition at the National Cycle Centre. For those of us not quite so energetic, it was fantastic to catch up with old friends at the welcome drinks reception.

 

Tuesday 16th June 2015

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Tuesday kicked off bright and early with Professor John Kelly presenting results from the BOXIT clinical trial, which has shown some benefit over standard treatment of non-muscle invasive bladder cancer, but with significant cardiovascular toxicity.

The new NICE bladder cancer guidelines were presented with concerns voiced by Professor Marek Babjuk over discharging low-risk bladder cancer at 12 months given a quoted 30-50% five-year recurrence risk. Accurate risk stratification, it would seem, is going to be key.

The President’s address followed along with the presentation of the St. Peter’s medal for notable contribution to the advancement of urology, which was presented to Pat Malone from Southampton General Hospital. Other medal winners included Adrian Joyce who received the BAUS Gold Medal, and the St. Paul’s medal went to Mark Soloway.

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A plethora of other sessions ensued but with the help of the new ‘native’ BAUS app my programme was already conveniently arranged in advance:

  •     ‘Heartsink Conditions’ included pelvic and testicular pain and a fascinating talk by Dr Gareth Greenslade highlighted the importance of early and motivational referral to pain management services once no cause has been established and our treatments have been exhausted. The patient’s recovery will only start once we have said no to further tests: ‘Fix the thinking’
  • Poster sessions are now presented as ‘e-posters’, abolishing the need to fiddle with those little pieces of Velcro and allowing for an interactive review of the posters.

 

Photo 22-06-2015 22 36 07Pravisha Ravindra from Nottingham demonstrated that compliance with periodic imaging of patients with asymptomatic small renal calculi (n=147) in primary care is poor, and indeed, these patients may be better managed with symptomatic imaging and re-referral as no patients required intervention based on radiograph changes alone.

Archana Fernando from Guy’s presented a prospective study demonstrating the value of CTPET in the diagnosis of malignancy in  patients with retroperitoneal fibrosis (n=35), as well as demonstrating that those with positive PET are twice as likely to respond to steroids.

 

Wednesday 17th June 2015

Another new addition to the programme this year was the Section of Endourology ‘as live surgery’ sessions. This was extremely well received and allowed delegates to benefit from observing operating sessions from experts in the field whilst removing the stressful environment and potential for risk to patient associated with live surgery. This also meant that the surgeon was present in the room to answer questions and talk through various steps of the operation allowing for a truly interactive session.
Wednesday saw multiple international speakers dominating the Exchange Auditorium:

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  • The BJU International guest lecture was given by Professor Hendrik Van Poppel: a heartfelt presentation describing what he believes to be the superiority of surgery over radiotherapy for high-risk localised prostate cancer.
  • The Urology Foundation presented the Research Scholar Medal to Ashwin Sachdeva from Freeman Hospital, Newcastle for his work on the ‘Role of mitochondrial DNA mutations in prostate carcinogenesis’. This was followed by an inspiring guest lecture by Inderbir Gill on ‘Robotic Urologic Oncology: the best is yet to come’ with the tag line ‘the only thing that should be open in 2015 is our minds’
  • Robotic Surgery in UK Urology: Clinical & Commissioning Priorities was a real highlight in the programme with talks from Jim Adshead and Professor Jens-Uwe Stolzenburg focussing on the fact that only 40% of T1a tumours in the UK were treated with partial (as opposed to radical) nephrectomy, and that the robot really is the ‘game-changer’ for this procedure. Inderbir Gill again took to the stage to stress that all current randomised trials into open vs. robotic cystectomy have used extracorporeal reconstruction and so do not reflect the true benefits of the robotic procedure as the dominant driver of complications is in the open reconstruction.

These lectures were heard by James Palmer, Clinical Director of Specialised Commissioning for NHS England who then discussed difficulties in making decisions to provide new technologies, controlling roll out and removing them if they show no benefit. Clinical commissioning policies are currently being drafted for robotic surgery in kidney and bladder cancer. This led to a lively debate with Professor Alan McNeill having the last word as he pointed out that what urologists spend on the robot to potentially cure cancer is a drop in the ocean compared with what the oncologists spend to palliate!

 

Thursday 18th June 2015

The BJU International session on evidence-based urology highlighted the need for high-quality evidence, especially in convincing commissioners to spend in a cash-strapped NHS. Professor Philipp Dahm presented a recent review in the Journal of Urology indicated that the quality of systematic reviews in four major urological journals was sub-standard. Assistant Professor Alessandro Volpe then reviewed the current evidence behind partial nephrectomy and different approaches to this procedure.

Another fantastic technology, which BAUS adopted this year, was the BOD-POD which allowed delegates to catch-up on sessions in the two main auditoria that they may have missed due to perhaps being in one of the 21 well designed teaching courses that were available this year. Many of these will soon be live on the BAUS website for members to view.

The IBUS and BAUS joint session included a lecture from Manoj Monga from The Cleveland Clinic, which led to the question being posed on Twitter: ‘Are you a duster or a basketer?’The audience was also advised to always stent a patient after using an access sheath unless the patient was pre-stented.

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The updates session is always valuable especially for those studying for the FRCS (Urol) exam with far too many headlines to completely cover:

  • Endourology: The SUSPEND trial published earlier this year was a large multi-centre RCT that showed no difference in terms of rates of spontaneous passage of ureteric stone, time to stone passage or analgesic use between placebo, tamsulosin and nifedipine. There was a hot debate on this: should we be waiting for the meta-analysis or should a trial of this size and design be enough to change practice?
  • Oncology-Prostate: The Klotz et al., paper showed active surveillance can avoid over treatment, with 98% prostate cancer survival at 10 years.
  • Oncology-Kidney: Ellimah Mensah’s team from Imperial College London (presented at BAUS earlier in the week) demonstrated that over a 14-year period there were a higher number of cardiovascular-related admissions to hospital in patients who have had T1 renal tumours resected than the general population, but no difference between those who have had partial or radical nephrectomy.
  • Oncology-Bladder: Arends’s team presented at EAU in March on the favourable results of hyperthermic mitomycin C vs. BCG in the treatment of intermediate- and high-risk bladder cancer.
  • Female and BPH: The BESIDE study has demonstrated increased efficacy with combination solifenacin and mirabegron.
  • Andrology: Currently recruiting in the UK is the MASTER RCT to evaluate synthetic sling vs. artificial sphincter in men with post-prostatectomy urinary incontinence.

 

Overall BAUS yet again put on a varied and enjoyable meeting. The atmosphere was fantastic and the organisers should be proud of the new additions in terms of allowing delegates to engage with new technologies, making for a memorable week. See you all in Liverpool!

 

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Rebecca Tregunna, Urological Trainee, West Midlands Deanery @rebeccatregunna

 

Dominic Hodgson, Consultant Urologist, Portsmouth @hodgson_dominic

 

The Surgical Spectacle: Blurred Lines

October’s #urojc discussion marks a number of important milestones– not only the 1st anniversary of the online, international Twitter-based Journal Club, but this month we reached 1000 followers on Twitter – an achievement indeed! We also saw a record number of participants in demonstration of the #urojc concept going from strength to strength.

Fittingly, this month’s paper “The Surgical Spectacle: A Survey of Urologists Viewing Live Case Demonstrations” by Elsamra et al, with free online access provided by BJUI for the duration of the discussion, looks not so much at advances in our theoretical knowledge but rather at the way technological advances are changing our ability to obtain surgical ‘know-how’.

 

Elsamra et al undertook a survey of all those who attended the live surgery sessions at the Atlanta AUA Meeting in 2012 and the 2013 Paris 3rd International Challenges in Endourology Meeting, to gauge the perceived educational benefits of live case demonstrations (LCD) particularly when compared with taped case demonstrations (TCD). There were a number of problems highlighted in the paper itself:

David Chen won the best Tweet Prize, free registration at EAU 2014, kindly donated by @EUPlatinum, with the following:

Interestingly, while 78% of survey respondents felt that LCDs were ethical and only 26% that interactive discussion may lead to distraction of the surgeon and potential morbidity, only 58% would allow themselves or a family member to undertake their own surgical management as an LCD.

Live case demonstrations are by no means a new concept – they have been undertaken since the advent of surgery for the purpose of education and learning.

Recent innovations have seen a blowout in the size of the viewing audience, with live streaming to conference audiences and potentially worldwide viewers, live tweeting and more recently, as pointed out by Dr Brian Stork, the use of Google Glass for both live surgery and the purpose of remote assistance. LCDs have become the drawcard of many surgical conferences, are often the most packed sessions, arguably for the educational benefit and more importantly for the buzz and thrill of seeing ‘the masters’ deal with difficult situations in real time… while answering questions from the audience simultaneously… “so that bleeding sir, where is it coming from exactly?!?!”

It seems that there is no argument that case demonstrations are of great educational benefit and there are some perceived advantages of live vs taped sessions, as summarized by Amrith Rao in a recent BJUI blog.

The vast majority of those involved in this #urojc discussion, however, seemed to suggest that it was hard to argue that the benefits of LCD outweighed those of TCD. Are we simply promoting a surgical circus? Does the perceived stress of operating to a live large audience have a potential negative impact on patient outcomes? Declan Murphy has already blogged about his own personal experience with LCD.

As for the ethical conundrum regarding the patient?

As suggested by Henry Woo:

In 2012 the EAU released guidelines with respect to the use of live case demonstrations within its own jurisdiction. Importantly, this has highlighted the need for regulation by means of submitting outcomes to a data registry, so as to provide a means of analyzing complications and patient safety outcomes.

Position statements or guidelines have also been released by the Royal College Surgeons (UK), American Urological Association and the Royal Australasian College of Surgeons, to name a few.

Where to from here? Will we continue the trend for ‘reality TV’?

There is certainly evidence out there to suggest that recording of basic operations and comparing with peers is potentially a useful means of assessing surgeon proficiency.

I think it very much remains a case of watch this space!

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

A benedictory ode to urological live surgery

This blog was originally published as a comment article in BJU International, 112: 11–12. doi: 10.1111/j.1464-410X.2012.11780.x

 

With the explosion and expansion of information technology, instantaneous dissemination of medical knowledge across the globe is a reality and here to stay. Performing live surgery to an audience, whether to the medical community or to the general public, has raised much controversy and continues to be hotly debated even today. While a recent article by a very senior urologist concentrated on the drawbacks of live surgery, little was written about the benefits [1]. We begin our debate with this ‘Benedictory Ode’ to live surgery:

Came the news about cancer of the prostate
Surgery, radiation or I had to be castrate
I was won over by the argument of the daVinci Robot
Surgical smile assured me protection of the lover’s knot
I was asked to be a patient for live surgery
I thought to myself, is it a circus or butchery?
Should I be scared, Should I be excited?
But was convinced many will be benefitted
My choice was voluntary and informed
Consent on the dotted line was performed
The day came and the day went
Surgery was smooth without a dent
Some might argue that I was a damn fool
But I am proud to have been an educational tool

Anonymous Patient

When did ‘live surgery’ really begin? Probably the answer would be as early as the birth of medicine itself. Medicine and surgery as we know them today have been based upon the ‘teacher–apprentice’ model for centuries. Whenever the ‘teacher’ became famous, apprentices from surrounding towns, and subsequently from surrounding countries, would flock to watch the way a diagnosis was made or indeed how the surgery was performed. In historical documents from the Middle Ages through to the Renaissance, we are reminded of the amphitheatre that was built especially to demonstrate anatomical dissections and surgeries. Indeed the very origin of the term ‘operating theatre’ probably stems from the fact that operations were carried out to an audience in a theatrical manner, as beautifully portrayed in many medical paintings across the world.

The birth of the first transmission of surgical procedures can be traced back to the famous British Broadcasting Corporation (BBC) series Your Life in Their Hands. This was first aired in 1958 and eight episodes were then broadcast over the next two months. This innovative series was conceived with three goals: to investigate new medical techniques; to applaud the medical profession; and to provide ‘reassurance’ for citizens at home. At the end of that period, the BBC had received 909 letters from viewers praising the programme and only 37 letters from viewers who were against it [2].

Professor Arthur Smith rightly points out the death of a patient that occurred in 2006 during live surgery organised by The Japanese Society of Thoracic Surgeons [1]; however, we should highlight that the very next year, the Japanese Society for Cardiovascular Surgery, the Japanese Association for Thoracic Surgery and the Japanese Society for Vascular Surgery collaborated in the development of guidelines for performing live surgeries [3]. In their guidelines, they rightly emphasize the need for feedback on the outcome of a patient who has undergone live surgery:

‘When a fixed interval has elapsed after live surgery, the surgeon must report on the postoperative course followed by the patient at an organized Society or research meeting. By this means, the body organizing such a meeting can investigate each of the cases in which live surgery has been conducted, and assesses the appropriateness of the use of live surgery in each.’

Recognizing the need for guidance for physicians and institutions with regard to live surgery, organisations such as the General Medical Council, AUA and the Royal College of Surgeons have published relevant guidelines. In their paper, Challacombe et al. [4] elegantly discuss the various aspects of the ethics of live surgery and highlight the important issues of patient consent and disclosures. We have followed the above guidelines for live robotic surgery to an audience and also to conduct the first live webcast in the UK of a robotic prostatectomy. Contrary to the norm, extra care is taken during live surgeries. Indeed, this may be an advantage for the patient as shown in Table 1. The operating surgeon is always an expert and, in our case, the surgeon was well trained to listen, respond to questions and operate without any hesitation. It is safe to assume that not all surgeons will achieve this high standard in their career. It is also vital to have a moderator who can manage the questions appropriately and convey them to the operating surgeon at the appropriate time.

In the era of evidence-based medicine, no debate can be complete without presenting supporting data from the literature. Several studies across different specialties have looked at the outcomes of patients who have undergone live surgeries. None of the studies showed any adverse outcome in the cohort of patients who subjected themselves to live surgery. Recently, a study analysed the outcomes of patients undergoing robotic partial nephrectomy as a live broadcast as compared with a cohort treated without observers [5]. The authors concluded that live robotic surgery is associated with excellent patient outcomes that compare favourably with cases performed under normal operating procedures. There is further evidence that live surgery as part of a course has a powerful impact on the practice patterns of a urologist [6]. Surprisingly, there is no published evidence in the literature that these patients come to any harm. There are several surveys of surgeons across specialties in the literature with contradictory views on live surgery, but there is no denying that transmission of live surgeries is becoming more and more popular, as evidenced by the packed rooms at all major urological meetings.

Conclusion

Performing live surgery on a patient is here to stay and will be an integral part of the dissemination of medical knowledge. The obligation that the medical society has towards the field of live surgery is to ensure that the operation is performed by the ‘right surgeon on the right patient in a right environment and with the right intentions’.

 

Amrith R. Rao and Omer Karim
Department of Urology, Wexham Park Hospital, Wexham, Berkshire, UK

References

1    Smith A. Urological live surgery – an anathema. BJU Int 2012; 110: 299–300 Full Article (HTML)

2    van Lingen A. Your life in their hands. Published online 27 November 2006. Accessed at https://www.birth-of-tv.org/birth/assetView.do?asset=1413260435_1164637516. Accessed 28 August 2012

3    Misaki T, Takamoto S, Matsuda H, Shigematsu H. Joint Committee for the Establishment of Guidelines for the Live Session of Thoracic and Cardiovascular Surgery. Published August 2007. Available at https://jscvs.umin.ac.jp/eng/live.html. Accessed 28 August 2012

4    Challacombe B, Weston R, Coughlin G, Murphy D, Dasgupta P. Live surgical demonstrations in urology: valuable educational tool or putting patients at risk? BJU Int 2010; 106: 1571–1574 Full Article (HTML)

5    Mullins JK, Borofsky MS, Allaf ME et al. Live Robotic Surgery: are outcomes compromised? Urology 2012; 80: 602–607 Web of Science®

6    Altunrende F, Autorino R, Haber GP et al. Immediate impact of a robotic kidney surgery course on attendees practice patterns. Int J Med Robot. 2011; 7: 165–169. doi: 10.1002/rcs.384 Full Article (HTML)

 

 

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