Podcast: Survival following cytoreductive nephrectomy: a comparison of existing prognostic models
Part of the BURST/BJUI Podcast Series
Mr Kenneth MacKenzie MBChB, FRCS (Urol) is a ST7 in Urology in North East England and BURST committee member.
Posts
Residents’ podcast: Exercise-induced attenuation of treatment side effects in newly diagnosed PCa patients beginning androgen-deprivation therapy
Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses a recent Article of the month:
Exercise‐induced attenuation of treatment side‐effects in patients with newly diagnosed prostate cancer beginning androgen‐deprivation therapy: a randomised controlled trial
Abstract
Objectives
(i) To assess whether exercise training attenuates the adverse effects of treatment in patients with newly diagnosed prostate cancer beginning androgen‐deprivation therapy (ADT), and (ii) to examine whether exercise‐induced improvements are sustained after the withdrawal of supervised exercise.
Patients and Methods
In all, 50 patients with prostate cancer scheduled for ADT were randomised to an exercise group (n = 24) or a control group (n = 26). The exercise group completed 3 months of supervised aerobic and resistance exercise training (twice a week for 60 min), followed by 3 months of self‐directed exercise. Outcomes were assessed at baseline, 3‐ and 6‐months. The primary outcome was difference in fat mass at 3‐months. Secondary outcomes included: fat‐free mass, cardiopulmonary exercise testing variables, QRISK®2 (ClinRisk Ltd, Leeds, UK) score, anthropometry, blood‐borne biomarkers, fatigue, and quality of life (QoL). HealthEd Academy can provide an extensive guides about bodybuilding, the best SARMs, Anadrole reviews and much more, take a look!
Results
At 3‐months, exercise training prevented adverse changes in peak O2 uptake (1.9 mL/kg/min, P = 0.038), ventilatory threshold (1.7 mL/kg/min, P = 0.013), O2 uptake efficiency slope (0.21, P = 0.005), and fatigue (between‐group difference in Functional Assessment of Chronic Illness Therapy‐Fatigue score of 4.5 points, P = 0.024) compared with controls. After the supervised exercise was withdrawn, the differences in cardiopulmonary fitness and fatigue were not sustained, but the exercise group showed significantly better QoL (Functional Assessment of Cancer Therapy‐Prostate difference of 8.5 points, P = 0.034) and a reduced QRISK2 score (−2.9%, P = 0.041) compared to controls.
Conclusion
A short‐term programme of supervised exercise in patients with prostate cancer beginning ADT results in sustained improvements in QoL and cardiovascular events risk profile.
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Residents’ podcast: Health‐related quality of life among non‐muscle‐invasive bladder cancer survivors: a population‐based study
Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses a recent Article of the week:
Health‐related quality of life among non‐muscle‐invasive bladder cancer survivors: a population‐based study
Abstract
Objective
To examine the effect of non‐muscle‐invasive bladder cancer (NMIBC) diagnosis and treatment on survivors’ quality of life (QoL).
Patients and Methods
Of the 5979 patients with NMIBC diagnosed between 2010 and 2014 in North Carolina, 2000 patients were randomly selected to be invited to enroll in this cross‐sectional study. Data were collected by postal mail survey. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire‐Core (QLQ‐C30) and the NMIBC‐specific module were included in the survey to measure QoL. Descriptive statistics, t‐tests, anova, and Pearson’s correlation were used to describe demographics and to assess how QoL varied by sex, cancer stage, time since diagnosis, and treatment.
Results
A total of 398 survivors returned questionnaires (response rate: 23.6%). The mean QoL score for QLQ‐C30 (range 0–100, higher = better QoL in all domains but symptoms) for global health status was 73.6, function domain scores ranged from 83.9 to 86.5, and scores for the top five symptoms (insomnia, fatigue, dyspnoea, pain, and financial difficulties) ranged from 14.1 to 24.3. The lowest NMIBC‐specific QoL domain was sexual issues including sexual function, enjoyment, problems, and intimacy. Women had worse bowel problems, sexual function, and sexual enjoyment than men but better sexual intimacy and fewer concerns about contaminating their partner. Stage Ta had the highest global health status, followed by T1 and Tis. QoL did not vary by time since diagnosis except for sexual function. The cystectomy group (n = 21) had worse QoL in sexual function, discomfort with sexual intimacy, sexual enjoyment, and male sexual problems than the non‐cystectomy group (n = 336).
Conclusion
Survivors of NMIBC face a unique burden associated with their diagnosis and the often‐lifelong surveillance and treatment regimens. The finding has important implications for the design of tailored supportive care interventions to improve QoL for NMIBC survivors.
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Residents’ podcast: NICE Guidance – Transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia
Nikita Bhatt is a Specialist Trainee in Urology in the East of England Deanery and a BURST Committee member @BURSTUrology
NICE Guidance – Transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia
Recommendations
- 1.1 The evidence on transurethral water jet ablation for lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) raises no major safety concerns. The evidence on efficacy is limited in quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.
- 1.2 Clinicians wishing to do transurethral water jet ablation for LUTS caused by BPH should:
- Inform the clinical governance leads in their NHS trusts.
- Ensure that patients understand the uncertainty about the procedure’s efficacy and provide them with clear written information to support shared decision‐making. In addition, the use of the National Institute for Health and Care Excellence (NICE) information for the public is recommended.
- Audit and review clinical outcomes of all patients having transurethral water jet ablation for LUTS caused by BPH. NICE has identified relevant audit criteria and has developed an audit tool (which is for use at local discretion).
- 1.3 The procedure should only be done by clinicians who have been trained in the technique.
- 1.4 NICE encourages further research into transurethral water jet ablation for LUTS caused by BPH and may update the guidance on publication of further evidence. Further research should report long‐term follow‐up and include re‐intervention rates.
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Residents’ podcast: NICE guidelines: Urinary tract infection
Nikita Bhatt is a Specialist Trainee in Urology in the East of England Deanery and a BURST Committee member @BURSTUrology
NICE guideline: Urinary tract infection (lower): antimicrobial prescribing
This guideline sets out an antimicrobial prescribing strategy for lower urinary tract infection (also called cystitis) in children, young people and adults who do not have a catheter. It aims to optimise antibiotic use and reduce antibiotic resistance.
See also the following related NICE guidelines: Complicated UTIS; and Sepsis
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Residents’ podcast: Artificial intelligence applications in urology
Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she is joined by Dr Christopher Weight, an Associate Professor in the Department of Urology at the University of Minnesota. They are discussing a recent BJUI Article of the month:
Current status of artificial intelligence applications in urology and their potential to influence clinical practice
Abstract
Objective
To investigate the applications of artificial intelligence (AI) in diagnosis, treatment and outcome prediction in urologic diseases and evaluate its advantages over traditional models and methods.
Materials and methods
A literature search was performed after PROSPERO registration (CRD42018103701) and in compliance with Preferred Reported Items for Systematic Reviews and Meta‐Analyses (PRISMA) methods. Articles between 1994 and 2018 using the search terms “urology”, “artificial intelligence”, “machine learning” were included and categorized by the application of AI in urology. Review articles, editorial comments, articles with no full‐text access, and nonurologic studies were excluded.
Results
Initial search yielded 231 articles, but after excluding duplicates and following full‐text review and examination of article references, only 111 articles were included in the final analysis. AI applications in urology include: utilizing radiomic imaging or ultrasonic echo data to improve or automate cancer detection or outcome prediction, utilizing digitized tissue specimen images to automate detection of cancer on pathology slides, and combining patient clinical data, biomarkers, or gene expression to assist disease diagnosis or outcome prediction. Some studies employed AI to plan brachytherapy and radiation treatments while others used video-based or robotic automated performance metrics to objectively evaluate surgical skill. Compared to conventional statistical analysis, 71.8% of studies concluded that AI is superior in diagnosis and outcome prediction.
Conclusion
AI has been widely adopted in urology. Compared to conventional statistics AI approaches are more accurate in prediction and more explorative for analyzing large data cohorts. With an increasing library of patient data accessible to clinicians, AI may help facilitate evidence‐based and individualized patient care.
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Dr Weight specializes in the surgical treatment of urologic cancers including prostate, bladder, kidney, adrenal, testis and penile cancer. He performs open, endoscopic, laparoscopic, robotic (da Vinci) and retroperineoscopic surgery.
Dr Weight completed his residency training at Cleveland Clinic where he received several awards including the George and Grace Crile Traveling Fellowship Award, the Society of Laparoendoscopic Surgeons Resident Achievement Award and the ASCO Genitourinary Cancer Symposium Merit Award. Dr. Weight then completed a fellowship in Urologic Oncology at Mayo Clinic, where he also completed a Masters degree in Clinical and Translational Research from Mayo Graduate School and was awarded the Mayo Fellows Association Humanitarian Award.
Dr Weight believes that medical research is a key component to offering excellent patient care. His research is focused on improving patient outcomes and the use of artificial intelligence in different urologic applications. He is an author of more than 45 peer-reviewed publications and book chapters and has been invited to speak at regional, national and international conferences.
Residents’ podcast: NICE guidelines – renal and ureteric stones
Nikita Bhatt is a Specialist Trainee in Urology in the East of England Deanery and a BURST Committee member @BURSTUrology
NICE Guideline – Renal and ureteric stones: assessment and management
Context
Renal and ureteric stones usually present as an acute episode with severe pain, although some stones are picked up incidentally during imaging or may present as a history of infection. The initial diagnosis is made by taking a clinical history and examination and carrying out imaging; initial management is with painkillers and treatment of any infection.
Ongoing treatment of renal and ureteric stones depends on the site of the stone and size of the stone (less than 10 mm, 10 to 20 mm, greater than 20 mm; staghorn stones). Options for treatment range from observation with pain relief to surgical intervention. Open surgery is performed very infrequently; most surgical stone management is minimally invasive and the interventions include shockwave lithotripsy (SWL), ureteroscopy (URS) and percutaneous stone removal (surgery). As well as the site and size of the stone, treatment also depends on local facilities and expertise. Most centres have access to SWL, but many use a mobile machine on a sessional basis rather than a fixed‐site machine, which has easier access during the working week. The use of a mobile machine may affect options for emergency treatment, but may also add to waiting times for non‐emergency treatment.
Although URS for renal and ureteric stones is increasing (there has been a 49% increase from 12,062 treatments in 2009/10, to 18,066 in 2014/15 [Hospital Episode Statistics data]), there is a trend towards day‐case/ambulatory care, with this increasing by 10% to 31,000 cases a year between 2010 and 2015. The total number of bed‐days used for renal stone disease has fallen by 15% since 2009/10. However, waiting times for treatment are increasing and this means that patient satisfaction is likely to be lower.
Because the incidence of renal and ureteric stones and the rate of intervention are increasing, there is a need to reduce recurrences through patient education and lifestyle changes. Assessing dietary factors and changing lifestyle have been shown to reduce the number of episodes in people with renal stone disease.
Adults, children and young people using services, their families and carers, and the public will be able to use the guideline to find out more about what NICE recommends, and help them make decisions. These recommendations apply to all settings in which NHS‐commissioned care is provided.
Table 2.Surgical treatment (including SWL) of ureteric stones in adults, children and young people Abbreviations: PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy.
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Residents’ podcast: Resident burnout
Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the month:
Resident burnout in USA and European urology residents: an international concern
Abstract
Objective
To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood.
Subjects and methods
An anonymous 32‐question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts.
Results
Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work–life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non‐medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on‐call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047).
Conclusion
In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.
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Resident’s podcast: Palliative care use amongst patients with bladder cancer
Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:
Palliative care use amongst patients with bladder cancer
Abstract
Objectives
To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.
Patients and methods
Using Surveillance, Epidemiology, and End Results‐Medicare data, we identified patients diagnosed with muscle‐invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.
Results
Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+, or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder‐sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.
Conclusions
Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease‐specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician‐, patient‐, and system‐level barriers to this care.
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Residents’ podcast: Vaccines for preventing recurrent UTIs
Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:
Vaccines for the prevention of recurrent urinary tract infections: a systematic review
Abstract
Objectives
To systematically review the evidence regarding the efficacy of vaccines or immunostimulants in reducing the recurrence rate of urinary tract infections (UTIs).
Materials and Methods
The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), PubMed, Cochrane Library, World Health Organization (WHO) International Clinical Trials Registry Platform Search Portal, and conference abstracts were searched up to January 2018 for English‐titled citations. Randomised placebo‐controlled trials evaluating UTI recurrence rates in adult patients with recurrent UTIs treated with a vaccine were selected by two independent reviewers according to the Population, Interventions, Comparators, and Outcomes (PICO) criteria. Differences in recurrence rates in study populations for individual trials were calculated and pooled, and risk ratios (RRs) using random effects models were calculated. Risk of bias was assessed using the Cochrane Collaboration’s tool and heterogeneity was assessed using chi‐squared and I2 testing. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence (QOE) and summarise findings.
Results
In all, 599 records were identified, of which 10 studies were included. A total of 1537 patients were recruited and analysed, on whom data were presented. Three candidate vaccines were studied: Uro‐Vaxom® (OM Pharma, Myerlin, Switzerland), Urovac® (Solco Basel Ltd, Basel, Switzerland), and ExPEC4V (GlycoVaxyn AG, Schlieren, Switzerland). At trial endpoint, the use of vaccines appeared to reduce UTI recurrence compared to placebo (RR 0.74, 95% confidence interval [CI] 0.67–0.81; low QOE). Uro‐Vaxom showed the greatest reduction in UTI recurrence rate; the maximal effect was seen at 3 months compared with 6 months after initial treatment (RR 0.67, 95% CI 0.57–0.78; and RR 0.78, 95% CI 0.69–0.88, respectively; low QOE). Urovac may also reduce risk of UTI recurrence (RR 0.75, 95% CI 0.63–0.89; low QOE). ExPEC4V does not appear to reduce UTI recurrence compared to placebo at study endpoint (RR 0.82, 95% CI 0.62–1.10; low QOE). Substantial heterogeneity was observed across the included studies (chi‐squared = 54.58; P < 0.001, I2 = 84%).
Conclusions
While there is evidence for the efficacy of vaccines in patients with recurrent UTIs, significant heterogeneity amongst these studies renders interpretation and recommendation for routine clinical use difficult at present. Further randomised trials using consistent definitions and endpoints are needed to study the long‐term efficacy and safety of vaccines for infection prevention in patients with recurrent UTIs.
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