Tag Archive for: RCT

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The challenge with systematic reviews of non-randomised studies in urology

In this issue, BJU International has made the conscious decision to publish a systematic review (SR) and meta-analysis (MA) by Guo et al. [1]to inform the question of whether patients undergoing nephrouretectomy for upper tract urothelial carcinoma are at increased risk of worse oncological outcomes. This question was also the topic of a similar review by Marchioni et al. [2] published earlier this year in this journal. Both studies were submitted around the same time and underwent independent, parallel peer review that resulted in different editorial decisions. Given their similarity in methodological quality they both deserved similar consideration for publication, which the journal is hereby honouring.

At the same time, this provides the unique opportunity to reflect on methodological developments in the field and BJU International‘s efforts to raise the bar of the methodological quality of SRs, which include the provision of an Assessment of Multiple Systematic Reviews (AMSTAR) rating [3]. AMSTAR is a validated tool to assess the components of a SR on an 11-point scale (0–11), with higher scores reflecting higher methodological rigor. An updated version of this tool has recently been provided, which offers greater clarity in interpretation [4]. Another related instrument that has become available is the Risk of Bias in Systematic Reviews (ROBIS), which assesses the study limitations in SRs (i.e., the relevance of the review, concerns with the review process, and potential bias introduced during the review) [5]. Meanwhile, while it would be premature to claim success, it is our impression that BJU International’s initiative to provide AMSTAR ratings is making a valuable contribution in raising awareness for such methodological issues and improving the transparency of published reviews.

As BJU International takes a lead in promoting high-quality SRs in urology, the journal has seen a considerable increase in the number of submissions, including SRs of non-randomised studies (NRS). Whilst much of what we practice on a day-to-day basis is based on evidence from NRS, studies of those designs have infrequently been included in the Cochrane Library, which has pioneered much of the underlying methodology. This is for a few reasons: First, the ‘garbage in–garbage out’ phenomenon; if the underlying individual studies only provide very low-quality evidence, combining these studies will rarely enhance the confidence we place in their results. Second, the need for methodological advances in the assessment and analyses of NRS. Third, when high-quality evidence from randomised controlled trials (RCTs) is available, it may be inefficient to review the NRS literature.

However, progress is being made on the methodology front. Members of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group are credited with having developed an approach for rating the quality or certainty of evidence from randomised and NRS to inform decision making [6]. While a body of evidence from RCTs, which starts as high-quality evidence, may be downgraded for study limitations, a body of evidence from NRS, which starts as low-quality evidence, may be upgraded for one of three reasons, most commonly for large magnitude of effect [7]. The underlying assumption is that, whilst we have to assume that bias is likely to be present in these studies, it is unlikely to explain the entire observed effect.

It nevertheless remains critical to assess the risk of bias of NRS. While the Newcastle-Ottawa scale (as used in both of these SRs) is a widely used instrument to evaluate risk of bias in NRS, it has critical limitations that the recently developed Risk Of Bias In Non-randomised Studies – of Interventions (ROBINS-I) seeks to overcome [8]. ROBINS-I evaluates NRS by using a standardised comparison to an RCT (i.e. target trial) [9]. In this way, ROBINS-I captures the bias inherent to studies without proper randomisation or allocation concealment, namely the lack of a balance of known and unknown confounders and selection of participants. ROBINS-I allows users to fundamentally start all studies at the same quality level, providing the transparency requested by some SR authors conducting SRs of NRS.

While ureterorenoscopy before nephroureterectomy may indeed increase the risk of intravesical recurrence as the authors suggest, additional exploration would be needed to make a statement about the causality of the relationship. Guo et al. [1] conducted sensitivity analyses to describe the potential for bias introduced by confounders of previous bladder tumour history and bladder-cuff management, thereby increasing our confidence that the observed effect may be closer to the truth. It seems equally important to note that Guo et al. found no increased risk in cancer-specific, recurrence-free or overall survival, which are other outcomes of potentially greater patient importance.

Understanding the inherent limitations of NRS, and placing their findings into appropriate clinical context are critical to the conduct of SRs. Moving forward, BJU International will continue to seek out the highest quality reviews that make use of the best, up-to-date methodology. We hope that these efforts will both serve as a beacon for the research community, but more importantly, result in improved evidence-based care for our patients.

Philipp Dahm*, Jae Hung Jung† and Rebecca L. Morgan
*Department of Urology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN, USADepartment of Urology, Yonsei University Wonju College of Medicine,
Wonju, Korea and Department of Health Research MethodsEvidence, and Impact, McMaster University, Hamilton, ON, Canada

 

References

 

 

 

3 Dahm P. Raising the bar for systematic reviews with Assessment of Multiple Systematic Reviews (AMSTAR). BJU Int 2017; 119: 193

 

 

5 Whiting P, Savovic J, Higgins JP et al. ROBIS: a new tool to assess risk of bias in systematic reviews was developed. J Clin Epidemiol 2016; 69: 22534

 

6 Guyatt GH, Oxman AD, Vist GE et al. GRADE: what is quality of evidence and why is it important to clinicians? BMJ 2008; 336: 9958

 

7 Guyatt GH, Oxman AD, Sultan S et al. GRADE guidelines: 9. Rating up the quality of evidence. J Clin Epidemiol 2011; 64: 13116

 

8 Deeks JJ, Dinnes J, DAmico R et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003; 7: iiix, 1173

 

9 Sterne JA, Hernan MA, Reeves BC et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919

 

Urolithiasis around the world

Stone disease is a highly prevalent condition that unites all countries around the world, although surgical management will depend on many factors including availability of different technologies. However, percutaneous nephrolithotomy (PCNL) remains the cornerstone for the management of larger renal stones in all parts of the world, and Rizvi et al. [1] report on a huge cohort of PCNL procedures – 3 402 to be precise from Karachi. This is a single-centre series, over an 18-year period, reporting real-life data and showing a stone clearance rate of ~80%, as assessed by plain abdominal radiograph of the kidneys, ureters and bladder, and ultrasonography (US). Whilst the definition of stone-free and imaging modality used to judge it remains a contentious issue, this paper reflects the excellence of high-volume surgery in specialist centres.

Recently, the BJUI became the affiliated journal for the International Alliance of Urolithiasis (IAU), whose annual meeting takes place in Shaoxing this month. To celebrate this, we are proud to publish a ‘Best of Urolithiasis’ issue, which features some of the top stone papers published in the BJUI over the last few years [2]. Choosing articles for this was quite a task given the quality and whilst we have attempted to recognise submissions that potentially change practice, the geographical diversity of the work shows not only the global nature of stone disease but also the excellent research that is being done worldwide and in different healthcare systems to improve care and outcomes. Of particular importance are randomised trials that are often lacking in surgical areas. One such paper from China addressed the question of US vs fluoroscopy for PCNL access during mini-PCNL [3]. Whilst the truth is that surgeons should use whatever gives the best outcomes, the authors in a very high-volume centre were able to demonstrate the effectiveness of US-only punctures, although a combination may be better in complex stone burdens. Another randomised controlled trial (RCT) of clinical importance was from the USA, where the authors conducted a good quality double-blind RCT of NSAID use before ureteric stent removal under local anaesthesia [4]. Whilst a small study, the incidence of severe pain in the 24 h after stent removal was 55% in the placebo group vs 0% in the NSAID group – as such this simple study should have changed practice for all who perform this procedure.

Other papers worthy of inclusion include a single-centre experience of the conservative management of staghorn calculi, which challenges the dogma that all staghorn stones should be treated [5]. This single-centre series showed a conservative policy could be adopted in highly selected patients. Is this practice changing? Maybe … but it certainly gives an evidence base for stone surgeons in making decisions in very high-risk patients. Manoj Monga and his group recently reported on the accuracy of US for the detection of renal stones [6]. This again is a very important topic and a question that commonly arises. In a series of >500 patients with US-detected stones who subsequently underwent CT scanning, 22% of patients would have been inappropriately counselled about their stone based on US alone. Again, the message is clear … US is a good screening tool but do not rely on it for treatment decisions.

I hope you take the time to check out the virtual issue on urolithiasis and read the other papers I could not mention here. Please continue to send your high-quality stone papers to the BJUI and maybe your submission will feature in our next ‘Best of Urolithiasis’ issue.

Matthew Bultitude, BJUI Associate Editor

 

Guys and St Thomas NHS Foundation Trust, London, UK

 

References

 

1 Rizvi SA, Hussain M, Askari SH, Hashmi A, Lal M, Zafar MN. Surgical outcomes of percutaneous nephrolithotomy in 3402 patients and results of stone analysis in 1559 patients. BJU Int 2017; 120: 7029

 

2 BJU International. Virtual Issues Page. Available at: https://bit.ly/BJUI-VIs. Accessed September 2017

 

 

4 Tadros NN, Bland L, Legg E, Olyaei A, Conlin MJ. A single dose of non-steroidal anti-inammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-  controlled trial. BJU Int 2013; 111: 1015

 

5 Deutsch PG, Subramonian K. Conservative management of staghorn calculi: a single-centre experience. BJU Int 2016; 118: 44450

 

6 Ganesan V, De S, Greene D, Torricelli FC, Monga M. Accuracy of ultrasonography for renal stone detection and size determination: is it good enough for management decisions? BJU Int 2017; 119: 4649

 

April Editorial: The BJUI’s clinical trials initiative

The BJUI supports clinical trials. Plain, simple, and with some new strategies.

Randomised clinical trials (RCTs) are the highest level of evidence-based medicine. We know this to be true, but we also know that RCTs are a challenge to fund, accrue patients, execute, and follow to endpoints. From a statistician’s point of view, RCTs provide unbiased estimates of the effects of different treatments. From a clinician’s point of view, RCTs provide the grandest of experiments in nature – a true test of option A vs option B. We are thrilled when one option beats the other. We can be satisfied if the options are equivalent, at least knowing the matter is settled and move on to the next question. Either way, the story lines can be rich with ongoing debate, drama, and analysis: were the cohorts truly equivalent? Was the study population generalisable? Were the treatments contemporary? Were there unintended harms/toxicities?

Allow us to illustrate some examples of what we propose to our readers. In 2003, Thompson et al. [1] published the famous Prostate Cancer Prevention Trial in the New England Journal of Medicine: ‘The influence of finasteride on the development of prostate cancer’. This landmark study has been cited 2541 times, according to Google Scholar. Looking further at impact, one can go to the www.swog.org site and query the protocol ‘SWOG-9217’ and see that over 150 publications have been produced using this dataset (16 in 2016!). Several publications pre-dated the primary endpoint paper and discussed trial design, the dilemma of chemoprevention, and updates to trial progress. Post primary endpoint, publications have looked at multiple strategies – costs, the high-grade findings, longer-term follow-up, biopsy findings from the placebo arm, etc. Just last year, the UK made its mark on the prostate cancer world with the landmark Prostate Testing for Cancer and Treatment (ProtecT) study [2]. Again, we see the primary endpoint paper in the New England Journal of Medicine, but secondary endpoint papers, such as the quality-of-life outcomes are in the BJUI [3], and a mortality outcome analysis for trial screen failures in European Urology [4].

The BJUI can support clinical trial efforts through multiple pathways. Certainly, we would love to receive a primary endpoint paper from an important RCT in urology. We can also have impact by featuring important secondary endpoint papers, trial design papers (preferably ones that read like a good review article, with the trial proposed as the ‘answer’ to the dilemma), as well as smaller/early phase I–II trials that are stand-alone pieces of key knowledge. Figure 1 shows a possible flow chart of a RCT with each box representing possible publication points. In addition to content in the BJUI, our webpage Blogs section has a ‘rapid response team’ to start immediate dialogue on important RCTs published in other journals. For example with the recent Yaxley et al. [5] trial in the Lancet, our blogs section, led by Declan Murphy, had over 10 000 views and over 50 follow-up comments. So clearly, our readers care about RCTs.

apr-ed

Figure 1. A possible flow chart of a randomised clinical trial (RCT) with each box representing possible publication points. QOL, quality of life; f/u, follow-up.

Finally, the BJUI can help with RCTs in two more ways. For the reader, we will highlight RCT-related papers in their native sections (i.e. oncology, functional, education) with a special ‘Trials’ headline, and will invite experts to comment on the significance of the study. For reviewers and authors, we will be critical on RCT design, such that flaws are identified, and papers not given inflated significance. It is frustrating to receive papers that lack adequate reporting on what researchers did, RCT-related papers submitted to the BJUI frequently fail to adhere to the 2010 Consolidated Standards of Reporting Trials (CONSORT) guidance for reporting RCTs, which potentially leads to major revisions, if not outright rejection. The CONSORT requirements are on our author submission guidelines, but ideally these are read and adhered to in advance, as many are not possible to correct after the fact. Recently, we have also added that all RCTs must be registered (i.e. clinicaltrials.gov or similar) before the first patient is enrolled.

John W. Davis, Associate Editor, Urological Oncology* and
Graeme MacLennan, Consulting Editor, Statistics and Trials

*MD Anderson Cancer Center, Houston, TX, USA and University of Aberdeen, Aberdeen, UK


References

How to Cite this article

Davis, J. W. and MacLennan, G. (2017), The BJUI‘s clinical trials initiative. BJU International, 119: 503. doi: 10.1111/bju.13837

 

Editorial: The Jury on Posterior Muscolofascial Reconstruction is still out

In their systematic review and meta-analysis, Grasso et al. [1] address the question of whether posterior muscolofascial reconstruction (PMR), the so-called Rocco stitch, positively affects urinary continence after radical prostatectomy. The relevance of the question to this structured form of inquiry is that individual studies to date have been inconclusive. We recognize Sir Archie Cochrane, who gave his name to the Cochrane Collaboration that pioneered the methods for conducting systematic reviews, for emphasizing the critical importance of looking at the entire body of evidence in a structured manner when seeking to answer a clinical question [2]. In the present study, which included both randomized controlled trials (RCTs) and observational studies of variable methodological quality, a favourable impact of PMR across all postoperative time points (3–7 days, 30 days, 3 and 6 months) was observed. The effect was most pronounced early on at the time of catheter removal, when the patients undergoing PMR were nearly twice as likely as the control group (risk ratio 1.9; 95% CI 1.3–2.9) to be continent, thereby suggesting a major benefit of this approach. It should be noted, however, that this analysis was dominated by the observational studies, particularly retrospective observational studies, which offer the least degree of methodological rigor.

Even more important, therefore, than the act of pooling across studies is the rating of the quality of evidence for the body of evidence on an outcome-specific basis. Based on the GRADE approach, which has become the most widely endorsed framework for rating the quality of evidence, we would initially place a high and low level of confidence in a body of evidence drawn from RCTs and observational studies, respectively [3]. As a result, one might plan a separate analysis of those two groups of studies first, and only move to pool them if their results were similar. In this case, the results from the RCTs and observational studies were different, with prospective and retrospective studies reporting larger, probably exaggerated effect sizes; however, it is also understood that other aspects such as study limitation (risk of bias), inconsistency, impression, indirectness and risk publication bias may lower our confidence in the effect estimates from RCTs [4]. Focusing on the body of evidence from RCTs alone (Table 1) we have ‘moderate’ confidence that PMR may not improve early continence at the time of catheter removal. Similarly, the few RCTs that contributed to the assessment of continence at later timepoints do not provide evidence that continence is affected favourably, although our confidence for those outcomes is only ‘low’ or ‘very low’, suggesting that future trials may change these estimates of effect. Meanwhile, it should be noted that none of the RCTs appeared to provide information on the potential downsides of PMR, such as rates of urinary retention or bladder neck contracture. As a result, enough uncertainty remains to state that the jury on PMR is still out; this is consistent with the authors’ call for a future high-quality trial, which is reportedly ongoing. While PMR is already widely used by open and robot-assisted prostatectomy surgeons around the globe, this example sheds light on current evidentiary standards of surgical innovation. Following the IDEAL recommendations, it would be much preferred if the urological community committed to well designed trials for novel surgical approaches and device-dependent interventions up front, before moving to widespread dissemination [5].

JulEOTW2

Philipp Dahm
Department of Urology, Minneapolis VA Health Care System, Urology Section 112D and University of Minnesota, Minneapolis, MN, USA

 

References

 

 

2 Hajebrahimi S, Dahm P, Buckingham J. Evidence-based urology in practice: the cochrane library. BJU Int 2009; 104: 10489

 

3 Caneld SE, Dahm P. Rating the quality of evidence and the strength of recommendations using GRADE. World J Urol 2011; 29: 3117

 

4 Guyatt GH, Oxman AD, Vist GE et al. GRADE: what is quality of evidence and why is it important to clinicians? BMJ 2008; 336: 9958

 

5 McCulloch P. The IDEAL recommendations and urological innovation. World J Urol 2011; 29: 3316

 

Highlights from BAUS 2016

1.1

In the week following Britain’s exit from Europe after the BREXIT referendum, BAUS 2016 got underway in Liverpool’s BT convention Centre. This was the 72nd meeting of the British Association of Urological Surgeons and it was well attended with 1120 delegates (50% Consultant Member Urologists, 30% Trainees, 10% Non member Urologists/Other, 10% Nurses, HCP’S, Scientists).

1.2

Monday saw a cautionary session on medicolegal aspects in Andrology, focusing on lawsuits over the last year. Mr Mark Speakman presented on the management issue of testicular torsion. This sparked further discussion on emergency cover for paediatrics with particular uncertainty noted at 4 and 5 year olds and great variation in approach dependent on local trust policy. Mr Julian Shah noted the most litigious areas of andrology, with focus on cosmesis following circumcisions. Therefore serving a reminder on the importance of good consent to manage patients’ expectations.

1.3

In the Dragons’ Den, like the TV show, junior urologists pitched their ideas for collaborative research projects, to an expert panel. This year’s panel was made up of – Mark Emberton, Ian Pearce, and Graeme MacLennan. The session was chaired by Veeru Kasivisvanathan, Chair of the BURST Research Collaborative.

1.4

Eventual winner Ben Lamb, a trainee from London, presented “Just add water”. The pitch was for an RCT to investigate the efficacy of water irrigation following TURBT against MMC in reducing tumour recurrence. Ben proposed that water, with its experimental tumouricidal properties, might provide a low risk, low cost alternative as an adjuvant agent following TURBT. Judges liked the scientific basis for this study and the initial planning for an RCT. The panel discussed the merits of non-inferiority vs. superiority methodology, and whether the team might compare MMC to MMC with the addition of water, or water instead of MMC. They Dragons’ suggested that an initial focus group to investigate patients’ views on chemotherapy might help to focus the investigation and give credence to the final research question, important when making the next pitch- to a funding body, or ethics committee.

Other proposals were from Ryad Chebbout, working with Marcus Cumberbatch, an academic trainee from Sheffield. Proposing to address the current controversy over the optimal surgical technique for orchidopexy following testicular torsion. His idea involved conducting a systematic review, a national survey of current practice followed by a Delphi consensus meeting to produce evidence based statement of best practice. The final presentation was from Sophia Cashman, East of England Trainee for an RCT to assess the optimal timing for a TWOC after urinary retention. The panel liked the idea of finally nailing down an answer to this age-old question.

1.5

Waking up on Tuesday with England out of the European football cup as well as Europe the conference got underway with an update from the PROMIS trial (use of MRI to detect prostate cancer). Early data shows that multi-parametric MRI may be accurate enough to help avoid some prostate biopsies.

1.6

The SURG meeting provided useful information for trainees, with advice on progressing through training and Consultant interviews. A debate was held over run through training, which may well be returning in the future. The Silver cystoscope was awarded to Professor Rob Pickard voted for by the trainees in his deanery, for his devotion to their training.
Wednesday continued the debate on medical expulsion therapy (MET) for ureteric stones following the SUSPEND trial. Most UK Urologists seem to follow the results of the trial and have stopped prescribing alpha blockers to try and aid stone passage and symptoms. However the AUA are yet to adopt this stance and feel that a sub analysis shows some benefit for stones >5mm, although this is not significant and pragmatic outcomes. Assistant Professor John Hollingsworth (USA) argued for MET, with Professor Sam McClinton (UK) against. A live poll at the end of the session showed 62.9% of the audience persuaded to follow the SUSPEND trial evidence and stop prescribing MET.

1.7

In the debate of digital versus fibreoptic scopes for flexible ureteroscopy digital triumphed, but with a narrow margin.

1.8

In other updates and breaking news it appears that BCG is back! However during the shortage EMDA has shown itself to be a promising alternative in the treatment of high grade superficial bladder cancer.
The latest BAUS nephrectomy data shows that 90% are performed by consultant, with 16 on average per consultant per year. This raises some issues for registrar training, however with BAUS guidelines likely to suggest 20 as indicative numbers this is looking to be an achievable target for most consultants. Robotic advocates will be encouraged, as robotic partial nephrectomy numbers have overtaken open this year. The data shows 36% of kidney tumours in the under 40 years old are benign. Will we have to consider biopsying more often? However data suggests we should be offering more cytoreductive nephrectomies, with only roughly 1/10 in the UK performed compared to 3/10 in the USA.

1.91.10

The andrology section called for more recruitment to The MASTER trial (Male slings vs artificial urinary sphincters), whereas the OPEN trial has recruited(open urethroplasty vs optical urethotomy). In the treatment of Peyronie’s disease collagenase has been approved by NICE but not yet within the NHS.

Endoluminal endourology presentation showed big increases in operative numbers with ureteroscopy up by 50% and flexible ureteroscopy up by 100%. Stents on strings were advocated to avoid troubling stent symptoms experienced by most patients. New evidence may help provide a consensus on defining “stone free” post operation. Any residual stones post-operatively less than 2mm were shown to pass spontaneously and therefore perhaps may be classed as “stone free”.

Big changes seem likely in the treatment of benign prostatic hyperplasia, with a race to replace the old favorite TURP. Trials have of TURP (mono and bipolar) vs greenlight laser are already showing similar 2 year outcomes with the added benefit of shorter hospital stays and less blood loss. UROLIFT is an ever more popular alternative with data showing superiority to TURP in lifestyle measures, likely because it preserves sexual function, and we are told it can be performed as a 15 minute day case operation. The latest new therapy is apparently “Aquabeam Aquablation”, using high pressured water to remove the prostate. Non surgical treatments are also advancing with ever more accurate super selective embolisation of the prostatic blood supply.

1.11

This year all accepted abstracts were presented in moderated EPoster sessions. The format was extremely successful removing the need for paper at future conferences? A total of 538 abstracts were submitted and 168 EPosters displayed. The winner of best EPoster was P5-5 Altaf Mangera: Bladder Cancer in the Neuropathic Bladder.

1.12

The best Academic Paper winner was Mark Salji of the CRUK Beatson institute, titled “A Urinary Peptide Biomarker Panel to Identify Significant Prostate Cancer”. Using capillary electrophoresis coupled to mass spectrometry (CE-MS) they analysed 313 urine samples from significant prostate cancer patients (Gleason 8-10 or T3/4 disease) and low grade control disease. They identified 94 peptide urine biomarkers which may provide a useful adjunct in identifying significant prostate cancer from insignificant disease.

The Office of Education offered 20 courses. Popular off-site courses were ultrasound for the Urologist, at Broadgreen Hospital, a slightly painful 30 min drive from the conference centre. However well worth the trip, delivered by Radiology consultants this included the chance to scan patients volunteers under guidance, with separate stations for kidneys, bladder and testicles and learning the “knobology” of the machines.

Organised by Tamsin Greenwell with other consultant experts in female, andrology and retroperitoneal cancer, a human cadaveric anatomy course was held at Liverpool university. The anatomy teaching was delivered by both Urology consultants and anatomists allowing for an excellent combination of theory and functional anatomy.

BAUS social events are renowned and with multiple events planned most evenings were pretty lively. The official drinks reception was held at the beautiful Royal Liver Building. The venue was stunning with great views over the waterfront and the sun finally shining. Several awards were presented including the Gold cystoscope to Mr John McGrath for significant contribution to Urology within 10 years appointment as consultant. The Keith Yeates medal was awarded to Mr Raj Pal, the most outstanding candidate in the first sitting of the intercollegiate specilaity examination, with a score of over 80%.

1.13

During the conference other BAUS awards presented include the St Peter’s medal was awarded to Margeret Knowles, Head of section of molecular oncology, Leeds Institute of Cancer and Pathology, St James University hospital Leeds. The St Paul’s medal awarded to Professor Joseph A. Smith, Vanderbilt University, Nashville, USA. The Gold medal went to Mr. Tim Terry, Leicester General Hospital.

An excellent industry exhibition was on display, with 75 Exhibiting Companies present. My personal fun highlight was a flexible cystoscope with integrated stent remover, which sparked Top Gear style competiveness when the manufacturer set up a time-trial leaderboard. Obviously this best demonstrated the speed of stent removal with some interesting results…

1.14

Social media review shows good contribution daily.

1.15

1.16
Thanks BAUS a great conference, very well organised and delivered with a great educational and social content, looking forward to Glasgow 2017! #BAUS2017 #Glasgow #BAUSurology

Nishant Bedi

Specialist Training Registrar North West London 

Twitter: @nishbedi

 

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