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Urology in Zomba, Malawi. Reflecting on surgical care in a Resource-Limited country

Rajiv SingalAt the recent AUA meeting in San Diego as at all of our major meetings, a tremendous amount of data was presented and technology displayed to advance our specialty.   Walking through exhibit hall one sees an expensive bauble at every turn. The advancement of urology over the last 50 years has been remarkable.   We have a lot to be proud of.  I think we have the most interesting, exciting specially in all of medicine.  Urologist are generally technophiles and have always loved to push surgical procedures to new heights.   From robotics, lasers and endourology to advancing the molecular understanding of disease, urologists have always aimed to drive the bus.

As many of you know, I am on a short trip to Malawi Africa. I have written about this elsewhere. I am here on one hand as a board member for Dignitas International.  On the surgical side it is not a mission under the guise of anyone but rather my own personal attempt to understand what urology and surgery in a resource poor country might look like. I have been here in Zomba, Malawi and working at Zomba Central Hospital, which is one of four central hospitals in the country.

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A goal has been to try and assess what the basic urological needs might be in this part of the world and see how I could help bridge the gap, whether it would be with equipment, external manpower or ultimately by improving training and leaving something sustainable. I optimistically set out, confident in my abilities to eventually network and bring colleagues together and establish over time a reasonable urology program that at least resembles something familiar. I have the COSECSA guidelines on what it takes to establish a training program at my side. Perhaps nothing illustrates what a daunting task this will be like my days in surgery this week.

To start with, a typical OR at ZCH requires some refocusing compared to what I am used to. My DaVinci robot is nowhere to be seen

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I made ward rounds with my clinical officer yesterday and lined up several TUR type cases to try and do, with men bleeding from bladder tumours (all invariably Bilharzial disease) as well as men in retention. Some have had catheters for months, even years.

First there is the set up. No discussion about lasers and lifts or any other such fun. We don’t even have the 3L irrigation bags. For my irrigation set up, with a little water and some chlorine pucks we are ready to go.

 

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My first patient was a TURBT.  A very large, incompletely resected lesion, actively bleeding.  I clearly left disease behind but perhaps he won’t bleed for a while.  The tissue will not be sent to pathology.  Patients need to pay 16,000 MWK for it. The typical pay for many is 20,000-30000/month and 1$USD=700 MWK.  Managing him from any even rudimentary oncological perspective is a non-starter.

The second patient also had a bladder tumour.  It was palpable as a mass to just under the skin.  Again, the goal was to stop some bleeding, at least for a few weeks.    He almost certainly has metastatic disease but I have no way to image and know for sure. I did order a chest xray to look for obvious pulmonary nodules.  He will eventually just quietly die.

Before I could start a third case I found myself in the gynecology OR 2 weeks after a hysterectomy post-delivery for bleeding.  Following an injury, the left ureter was leaking.  I attempted the repair as best as I could with no proper light, no electrocautery no retractors and no ability to stent my freshly re-implanted ureter.   All of this on an HIV+ve new mother.   I hope it heals open.  I am not sure if it will.   I have come to understand that ureteral injuries are a not uncommon consequence of obstetrical care in Malawi.

My third patient had a TURP which was fairly straightforward.   He should hopefully void assuming reasonable residual bladder function.  He has had a catheter in place for months.

At least we did do some work Thursday.  On Tuesday my four patient list turned into one as my anesthetist did not attend.  Before surgical care can be improved, the critical shortage of anesthesia care has to also be addressed. I also wrote about that earlier.

I did bring a surgery checklist to ZCH on Tuesday.

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And Thursday in follow up, I gave a talk to the surgical team about checklists and so that is certainly good.

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They keep asking me to see men in the clinic with catheters.  With the inefficiencies of late start times, anesthesia shortages and only a week to go, most will get left behind.  It is really a depressing thought.

My OR team though is there to help and keen to learn.

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Daniel, Rex (T Rex) and Maryeuster

As I reflect on my experience in the operating room during week one I am struck by how discordant what I saw in San Diego was from the realities still faced in much of the world.  Basic endoscopic equipment does not exist. Serendipitously, a retired colleague of mine did bring some basic equipment a few months ago and this one set, washed and then resterilized (in a pail of chlorinated water) is all that we have.   I am still not clear what happens when the loops wear out.

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I do question when we pull millions of dollars and much intellectual capital into improving technology and chasing robots as to what are we really doing to benefit the care of our urological patients on a global scale. Do we have some obligation as champions of mens’ health and urologic care more broadly, to play a part?  I do wonder whether some of our intellectual energy and financial resources could be better spent simply bringing parts of this world even into the 1970s. If this was valued as worthy of academic support and promotion the way oncology, endourology and everything else is in our specialty is, then some of the bright young minds in our field might move this along further.  Whether we do a robot prostatectomy retroperitoneally or intraperitoneally, debate about a Rocco stitch or tweak this or do that, these changes are often incremental at best. Supine versus prone PCNL?  Who cares.  Other parts of the world I think deserve some of our high-level expertise to meet their complex challenges. I would invite the urological community to try and collectively address this problem. Should we keep pouring all of our massive resources only to steady, incremental benefit?  Clearly we always must advance the body of knowledge and the state of the art.  However, is there a role for reserving some resource and energy to advocate for simpler things that could affect a change on the order of several magnitudes?  Some of the easier things we might do is to at least act as advocates and lead some process change whether it be a surgical checklist, counting instruments and sutures pre and post operatively and ensure better preoperative screening and post-operative care.   Updating equipment and building surgical expertise necessarily follows.

Laser TURP?  Plasma button?  Urolift?   The men in Malawi and much of Africa would be happy just to get rid of their catheters.

We often joke about our ‘first world problems’.  It’s time to get serious.

Let’s do better.

Dr Rajiv Singal is a Urologist at Michael Garron Hospital and an Assistant Professor in the Department of Surgery at the University of Toronto

Follow him on Twitter at @DrRKSingal

To read more about Dr Singal’s experience in Malawi follow this link https://www.rajivsingal.com/blogCategories/view/malawi-june-2016/

 

 

 

West Coast Urology: Highlights from the AUA 2016 in San Diego… Part 2

By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

 

The AUA meeting was starting to hot up with the anticipation of the Crossfire sessions, PSA screening and the MET debate that appeared to rumble on.  We attended the MUSIC (Michigan Urological Surgery Improvement Collaborative) session. It is a fantastic physician led program including >200 urologists, which aims to improve the quality of care for men with urological diseases. It is a forum for urologists across Michigan, USA to come together to collect clinical data, share best practices and implement evidence based quality improvement activities. One of their projects is crowd reviewing of RALP by international experts for quality of the nerve spare in order to improve surgical outcomes.

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The MET debate continues to cause controversy. In the UK there has been almost uniform abandonment of the use of tamsulosin for ureteric stones following The Lancet SUSPEND RCT.

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The MET crossfire debate was eagerly awaited. The debate was led by James N’Dow (@NDowJames) arguing against and Philipp Dahm (@EBMUrology) in favour of MET. Many have criticised the SUSPEND paper for lack of CT confirmation of stone passage. Dr Matlaga (@BrianMatlaga) stated that comparing previous studies of MET to SUSPEND is like comparing apples to oranges due to different outcome measures. He recommended urologists continue MET until more data is published. More conflicting statements were made suggesting that MET is effective in all patients especially for large stones in the ureter. The AUA guidelines update was released and stated that MET can be offered for distal ureteric stones less than 10mm.

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In a packed Endourology video session there were many high quality video presentations. One such video was a demonstration of the robotic management for a missed JJ ureteric stent. Khurshid Ghani (@peepeeDoctor) presented a video demonstrating the pop-corning and pop-dusting technique with a 100w laser machine.

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One of the highlights of the Sunday was the panel discussion plenary session, Screening for Prostate Cancer: Past, Present and Future. In a packed auditorium Stacy Loeb (@LoebStacy), gave an excellent overview of PSA screening with present techniques including phi, 4K and targeted biopsies. Freddie Hamdy looked into the crystal ball and gave a talk on future directions of PSA testing and three important research questions that still needed to be answered. Dr. Catalona presented the data on PSA screening and the impact of the PLCO trial. He argued that due to inaccurate reporting, national organisations should restore PSA screening as he felt it saved lives.

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There was a twitter competition for residents and fellows requiring participants to  tweet an answer to a previously tweeted question including the hashtag #scopesmart and #aua16. The prize was Apple Watch. Some of the questions asked included; who performed the 1st fURS? And what is the depth of penetration of the Holmium laser?

UK trainees picked up the prizes on the first two days.

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The British Association of Urological Surgeons (BAUS) / BJU International (BJUI) / Urological Society of Australia and New Zealand (USANZ) session was a real highlight of day three of the AUA meeting. There were high quality talks from opinion leaders in their sub specialities. Freddie Hamdy from Oxford University outlined early thoughts from the protecT study and the likely direction of travel for management of clinically localised prostate cancer. Prof Emberton (@EmbertonMark) summarised the current evidence for the role of MRI in prostate cancer diagnosis including his thoughts on the on going PROMIS trial. Hashim Ahmed was asked if HIFU was ready for the primetime and bought us up to speed with the latest evidence.

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The eagerly awaited RCT comparing open prostatectomy vs RALP by the Brisbane group was summarised with regards to study design and inclusion criteria. It is due for publication on the 18th May 2016 so there was a restriction of presenting results.  Dr Coughlin left the audience wanting more despite Prof. Dasgupta’s best effort to get a sneak preview of the results!  We learnt from BAUS president Mark Speakman (@Parabolics) about the UK effort to improve the quality of national outcomes database for a number of index urological procedures.

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Oliver Wiseman (@OJWiseman) gave us a flavour of outcomes from the BAUS national PCNL database and how they are trying drive up standards to improve patient care. A paediatric surgery update was given by Dr Gundeti. The outcomes of another trial comparing open vs laparoscopic vs RALP was presented. There was no difference in outcomes between the treatment modalities but Prof. Fydenburg summarised by saying that the surgeon was more important determinant of outcome than the tool. Stacy Loeb closed the meeting with an excellent overview of the use of twitter in Urology, followed by a drinks reception.

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It was not all about stones and robots. The results of the Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment (ROSETTA) trial results were presented. Botox came out on top against neuromodulation in urgency urinary incontinence episodes over 6 months, as well as other lower urinary tract symptoms.

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The late breaking abstract session presented by Stacy Loeb highlighted a paper suggesting a 56% reduction in high-grade prostate cancer for men on long term testosterone. This was a controversial abstract and generated a lot of discussion on social media.

 

 

 

 

 

 

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It has been an excellent meeting in San Diego and we caught up with old and met new friends. It was nice to meet urologists from across the globe with differing priorities and pressures. There was a good British, Irish and Australian contingent flying the flag for their respective countries. It was another record-breaking year for the #AUA16 on twitter. It surpassed the stats for #AUA15 with over 30M impressions, 16,659 tweets 2,377 participants. See you all in Boston for AUA 2017.

 

West Coast Urology : Highlights from the AUA 2016 in San Diego… Part 1

By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

 

The 2016 AUA returned to the beautiful city of San Diego set on the shores of the Pacific in an excellent conference centre located in the centre of the town adjacent to the Gaslamp district. For a change the wifi was excellent and allowed enhanced levels of social media interaction and urological discussion. Opening these interactions were 2 key sessions which provoked much debate. Firstly the announcement that after over 10 years of trying the FDA has approved HIFU treatment although it seemed to get there through a slightly “de novo” pathway. Apparently the FDA approved it as an ablation tools but not for prostate cancer.

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Although not directly approved for use in prostate cancer, that is exactly what it is going to be used for. A packed house saw a debate with evidence from both sides. Dr Nathan Lawrentschuk promoted the 4 Ds of HIFU. His key point was that 56/101 had a post treatment biopsy of which 51 where biopsy positive!

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The second big session focussed on the AUA/SAR consensus statement  document on prostate cancer diagnostics. This recommended a “High Quality” MRI should be strongly considered if patient has a rising PSA with a previous negative biopsy, has persistent clinical suspicion for prostate cancer or is undergoing a repeat biopsy. There was no mention of MRI for all at the pre-biopsy stage which many had hoped for and only 2 lines on trans-perineal biopsy as an option. This is of course related to health resources and the outpatient office-based nature of most USA urologists.

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A welcome innovation was the Crossfire Sessions which pitted 2 well known advocates of one treatment against 2 with the opposite views. It was hardly debating of the Oxbridge variety but none the less did provoke some useful discussions. Topics included radical prostatectomy vs radiotherapy, endoscopic vs nephro-ureterectomy management of upper tract TCC, and enucleation at partial nephrectomy vs formal resection. Standing room only at the back of the halls but no real audience interaction or voting which was a shame. 

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The session which really woke everyone up was Rene Sotalo’s wonderful complication horror show. Bleeding, bleeding and more bleeding in a variety of ways. How would you handle this he asked? Pray I thought! But this and similar sessions clearly show the benefits of recording all cases and reviewing these DVDs if something goes wrong. The cause of some complications were only identified by review of the intra-operative tapes. Some clinical titbits learn’t included  using only a horizontal incision for the camera port at RARP to reduce hernias and turning off pneumocompression stockings if there is a major venous injury to prevent excessive venous bleeding.

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From a SoME perspective there was both good and bad. One poster showed that 40% of graduating US residents had publicly accessible unprofessional content on social media. Food for thought at the consultant interview no doubt, but on the other side SoMe ranks third in the acquisition of urological knowledge (and climbing…). One hack produced this tweeting guideline for all to reflect on.

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Prof Prokar Dasgupta had the honour of presenting the widely anticipated session on emerging robotic technology . At last there appears to be some real competition to Intuitive’s dominance on the way. There are at least 3 credible robotic systems on the way. He finished with an intriguing slide on Dr Google being the most powerful doctor in the world!

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Despite Europe and Asia moving towards the use of PMSA PET , the USA is not moving in this direction due to reimbursement issues if the PMSA molecule.

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There was a lot of interest in a packed auditorium to see live surgery for a single use disposable fURS “Lithovue” with some reporting superior vision , optics and deflection.

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There were some sceptics amongst the stone community with the environmental impact and cost effectiveness a concern.

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With the popular Gaslamp district a stones throw away many delegates went after the conference for a meal and drinks. The local baseball team San Diego Padres was a popular destination with may watching baseball for the 1st time whist others had gone for a run along the harbour and even caught a sighting of some seals!

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