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Highlights from BAUS 2016

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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).

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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.

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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.

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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.

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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.

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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.

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

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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.

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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.

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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.

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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%.

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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…

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Social media review shows good contribution daily.

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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

 

Quality matters most where the BJUI and stone disease are concerned

Size (and shape) is important and sometimes strings should be attached, but quality matters most where the BJUI and stone disease are concerned …

The Editor-in-chief of the BJUI has consolidated the journal’s commitment to accepting only the highest quality papers, and this is certainly evident in the upper urinary tract section of this edition, where two studies demonstrate what it takes to be published in the journal nowadays.

In the first article, Kerri Barnes and colleagues from University of Iowa Department of Urology [1] have followed their own department’s earlier retrospective analysis of the benefit of “tethered stents” [2], by analysing the safety and effectiveness of this approach in a prospective, randomised controlled trial. It is often stated that randomised controlled trials are difficult in surgical disciplines, but this study affirms the proverb that “where there’s a will, there’s a way”. Although there was a substantial drop out in the number of patients that could have been included (three quarters of the patients approached for the study declined to be involved as they wished to determine the nature of the stent left in situ), statistical significance was not approached for any of the key concerns that leaving a stent on a string might cause for either the patient or their surgeon.

Furthermore, they have shown that that leaving the strings in place allowed patients to remove their stents significantly earlier (and in the convenience of their own home), than if they had to return to hospital for cystoscopic removal a week or so post-operatively. Despite the established knowledge that stents contribute to postoperative morbidity and can adversely affect quality of life, and the increasing evidence that stents are not required in “uncomplicated” ureteroscopy, it is clear that most urologists continue to leave a stent for a sense of security after performing ureteroscopic stone surgery. Shorter stent dwell times may help reduce the overall burden of stent related symptoms, and it is worth emphasising that none of the patients whose stent was removed at 7 days post operatively had any adverse consequences; neither did the 15% of this group whose stents fell out even earlier. As Fernando and Bultitude [3] comment in the associated editorial, the next question is: “If you are going to place a stent, how long does the stent need to stay for?” Perhaps, in order to emphasise that, where stent bother is concerned, shorter is better, this should be re-phrased as “how little time is enough time for a stent to stay in”…

In the second, Will Finch, from Norfolk and Norwich University Hospital, and his colleagues from Addenbrooke’s Hospital, Cambridge [4], have shown that stone size assessments from CT are most reliably calculated by a 3D-reconstructed stone volume. They have demonstrated that the maximum diameter of a stone tends to predict its overall shape such that a rugby ball-shaped stone (a “prolate ellipsoid”) has the polar diameter as the major axis, whereas a disc-shaped stone (an “oblate ellipsoid”) has the equatorial diameter as its major axis. Stones less than 9mm in diameter tended to be prolate, whilst those of 9–15 mm in diameter tended to be oblate; stones larger than 15 mm in diameter approach the more “random” shape of a scalene ellipsoid, for which the formula used to calculate stone volume (length (l) × width (w) × depth (d) × π × 0.167, which is often simplified to (l × w × d) / 2 in clinical practice) can be used.

However, if this is used for all stones regardless of their size and shape, rugby-ball and disc-like stones of less than 15mm in size are likely to have their volume over-estimated. Accordingly, the authors challenge the guidance of the EAU regarding stone volume calculations [5] to recommend that formulae based on the shape of the stone (π/6*a*a*c* for an oblate and π/6*a*b*b* for a prolate stone – see the paper itself to make sense of this) offer a more accurate assessment of stone volume.

Whilst these formulae are recommended for day-to-day calculations to guide treatment choices, they emphasise that 3D-reconstructed stone volumes should be used to report stone volume in research papers. In an age of stone surgery where CTKUB is so widely used in patients’ imaging assessment, and accepting that stone volume is the key determinant of achieving a stone free patient, this would allow the most accurate comparisons between the effectiveness of different surgical treatments.

Both articles are simple, straightforward, and well conducted studies that apply to the every-day practice of stone surgery. High quality papers are, of course, only really of benefit if they change practice for the better. So why not speak to your radiologist today about adding stone volume assessments to CTKUB reports (and point them to Finch et al. for the evidence) or even do it yourself! And the next time you put in a stent, reassure yourself, and the patient,

that there is no harm, and many benefits, in having some strings attached …

Daron Smith
University College Hospital, London, United Kingdom

Read the April issue

References

  1. Barnes KT, Bing MT, Tracy CR. Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trialBJU Int 2014; 113: 605–609
  2. Bockholt N, Wild T, Gupta A, Tracy CR. Ureteric stent placement with extraction strings: no strings attached? BJU Int 2012; 110 (11 Pt C): E1069–1073
  3. Fernando A, Bultitude M. Tether your stents! BJU Int 2014; 113: 517–518
  4. Finch W, Johnston R, Shaida N, Winderbottom A, Wiseman O. Measuring stone volume – three-dimensional software reconstruction or an ellipsoid algebra formula? BJU Int 2014; 113: 610–614
  5. Tiselius HG, Alken P, Buck C et al. European Association of Urology 2008 Guidelines on Urolithiasis. Available at: https://www.uroweb.org/fileadmin/user_upload/Guidelines/Urolithiasis.pdf. Accessed 17 June 2012
 

Article of the Week: Pain relief after ureteric stent removal: think NSAIDs

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying blog written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. QC Kinetix’s charleston pain management relief center has decades of collective experience treating patients with all kinds of conditions. We make a concerted effort to treat each patient with professionalism and dignity as they work their way back to a pain-free life. We do everything in our power to earn the trust of each person that walks through our doors for treatment. Regenerative medicine is the future of medical care. QC Kinetix is offering non-invasive treatments that allow people to avoid going under the knife, while accelerating their recovery times and minimizing side effects. Discover why people across the state of South Carolina trust QC Kinetix when it comes to pain relief. At our clinic for pain management in Mt. Pleasant, SC, our specialists take the time to understand each patient’s needs and symptoms. We go out of our way to understand each person’s unique situation and how we can best treat their condition. Then, we very carefully formulate a plan to get them back to an active and healthy lifestyle. One of our most common treatments is laser therapy. We use non-invasive laser energy to target the affected area and reduce inflammation and pain. This triggers a photochemical response that initiates tissue repair and quickly improves a patient’s range of motion and functionality. Laser therapy is often the first step in our pain management plan before moving onto stem cell-based treatments.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of  Michael Conlin discussing his paper.

If you only have time to read one article this week, it should be this one.

A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial

Nicholas N. Tadros, Lisa Bland, Edith Legg, Ali Olyaei and Michael J. Conlin

Read the full article
OBJECTIVES

• To determine the incidence of severe pain after ureteric stent removal.

• To evaluate the efficacy of a single dose of a non-steroidal anti-inflammatory drug (NSAID) in preventing this complication.

 PATIENTS AND METHODS

• A prospective, randomised, double-blind, placebo-controlled trial was performed at our institution.

• Adults with an indwelling ureteric stent after ureteroscopy were randomised to receive either a single dose of placebo or an NSAID (rofecoxib 50 mg) before ureteric stent removal.

• Pain was measured using a visual analogue scale (VAS) just before and 24 h after stent removal.

• Pain medication use after ureteric stent removal was measured using morphine equivalents.

RESULTS

• In all, 22 patients were enrolled and randomised into the study before ending the study after interim analysis showed significant decrease in pain level in the NSAID group.

• The most common indication for ureteroscopy was urolithiasis (14 patients).

• The proportion of patients with severe pain (VAS score of [1]7) during the 24 h after ureteric stent removal was six of 11 (55%) in the placebo group and it was zero of 10 in the NSAID group (P < 0.01).

• There were no complications related to the use of rofecoxib.

 CONCLUSIONS

• We found a 55% incidence of severe pain after ureteric stent removal.

• A single dose of a NSAID before stent removal prevents severe pain after ureteric stent removal.

Read Previous Articles of the Week

Editorial: Stent removal need not be painful

Matthew Bultitude

Matthew Bultitude
Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Ureteric stents are undoubtedly a significant cause of morbidity while in situ [1].Whilst there are different options for removal, they are usually removed under local anaesthetic with the aid of a flexible cystoscope. This is an uncomfortable procedure and a proportion of patients seem to get fairly severe pain afterwards, which may be attributable to ureteric spasm. The pain after stent removal has not been well reported in the literature. In this issue of the BJUI we present a randomised controlled trial of a non-steroidal anti-inflammatory (NSAID) to dramatically reduce pain after stent removal.

This beautifully simple study by Tadros et al. [2] had simple aims: to determine the incidence of pain after stent removal and whether this could be reduced using a single oral dose of a NSAID given before the procedure. In a prospective randomised double-blind placebo controlled trial, the authors have shown a clear advantage to the use of active medication over placebo, such that the trial was stopped after an interim analysis. Using a visual analogue scale (VAS) the mean pain after stent removal was 2.7 in the NSAID group compared with 5.5 with placebo.More impressively the proportion of patients with severe pain (as defined as aVAS >=7) within 24 hours of stent removal was 0% vs. 55%. A corresponding reduction in narcotic use was seen (1.67 mg vs. 4.77 mg).

With increasing healthcare pressures on emergency departments and beds, and in the UK with financial penalties for re-admissions, this simple intervention has the potential to improve our own patients pain ratings and satisfaction and also reduce emergency consultations and even re-admissions. It should be noted that in this trial, there were two visits to the emergency department and one re-admission, all in the placebo group.

NSAIDs are thought to work through a number of mechanisms such as direct effect on pain pathways, reduced ureteric contractility and renal blood flow. This is thought to be a class effect for all NSAIDs. The drug used in this trial (rofecoxib) has subsequently been withdrawn from the market, although one would expect similar outcomes with other NSAID medications.

References
1 Joshi HB, Stainthorpe A, MacDonagh RP et al. Indwelling ureteral stents: evaluation of symptoms, quality of life and utility. J Urol 2003; 169: 1065–9
2 Tadros NN, Bland L, Legg E et al. A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial. BJU Int 2013; 111: 116–20

Read the full article

Michael Conlin’s commentary on NSAIDs

Pain relief after ureteric stent removal: think NSAIDs

Nicholas N. Tadros, Lisa Bland, Edith Legg, Ali Olyaei and Michael J. Conlin*
Oregon Health & Science University and *Portland Veterans Administration Medical Center, Portland, OR, USA

OBJECTIVES

• To determine the incidence of severe pain after ureteric stent removal.

• To evaluate the efficacy of a single dose of a non-steroidal anti-inflammatory drug (NSAID) in preventing this complication.

PATIENTS AND METHODS

• A prospective, randomised, double-blind, placebo-controlled trial was performed at our institution.

• Adults with an indwelling ureteric stent after ureteroscopy were randomised to receive either a single dose of placebo or an NSAID (rofecoxib 50 mg) before ureteric stent removal.

• Pain was measured using a visual analogue scale (VAS) just before and 24 h after stent removal

• Pain medication use after ureteric stent removal was measured using morphine equivalents.

RESULTS

• In all, 22 patients were enrolled and randomised into the study before ending the study after interim analysis showed significant decrease in pain level in the NSAID group.

• The most common indication for ureteroscopy was urolithiasis (14 patients).

• The proportion of patients with severe pain (VAS score of ≥7) during the 24 h after ureteric stent removal was six of 11 (55%) in the placebo group and it was zero of 10 in the NSAID group (P < 0.01).

• There were no complications related to the use of rofecoxib.

CONCLUSIONS

• We found a 55% incidence of severe pain after ureteric stent removal.

• A single dose of a NSAID before stent removal prevents severe pain after ureteric stent removal.

Tadros NN, Bland L, Legg E, et al. A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial. BJU Int 2013, 111: 101–105.

Read the full article
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