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Article of the month: Guideline of guidelines: social media in urology

Every month, the Editor-in-Chief selects an Article of the Month 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 a visual abstract prepared by members of the urological community, and a video recorded by the authors; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, we recommend this one. 

Guideline of guidelines: social media in urology

Jacob Taylor*, Stacy Loeb*†‡

*Department of Urology, Population Health, NYU School of Medicine, and Manhattan Veterans Affairs Medical Center, New York, NY, USA

Abstract

The use of social media is rapidly expanding. This technology revolution is changing the way healthcare providers share information with colleagues, patients, and other stakeholders. As social media use increases in urology, maintaining a professional online identity and interacting appropriately with one’s network are vital to engaging positively and protecting patient health information. There are many opportunities for collaboration and exchange of ideas, but pitfalls exist without adherence to proper online etiquette. The purpose of this article is to review professional guidelines on the use of social media in urology, and outline best practice principles that urologists and other healthcare providers can reference when engaging in online networks.

Fig. 1. Summary of professional guidelines on social media use in urology. PHI, protected health information.

Video: Guideline of guidelines: social media in urology

Guideline of guidelines: social media in urology

Abstract

The use of social media is rapidly expanding. This technology revolution is changing the way healthcare providers share information with colleagues, patients, and other stakeholders. As social media use increases in urology, maintaining a professional online identity and interacting appropriately with one’s network are vital to engaging positively and protecting patient health information. There are many opportunities for collaboration and exchange of ideas, but pitfalls exist without adherence to proper online etiquette. The purpose of this article is to review professional guidelines on the use of social media in urology, and outline best practice principles that urologists and other healthcare providers can reference when engaging in online networks.

“Is radiotherapy the work of the Devil?” – why we chose this title.

With the recent electronic publication of our editorial written for the BJUI USANZ supplement, we have been somewhat surprised with the Twitter response our title has generated with some very strong opinions expressed. Why would a radiation oncologist, who happens to be the Chair of their National Genito-Urinary group (“FROGG”) propose such a provocative title? The BJUI editorial board wisely suggested that we explain the origin of this title which would be lost on many outside Australia.

In mid-2014, a leading Australian urologist quipped that adjuvant post-prostatectomy radiotherapy was “the work of the Devil” when referring to some of the severe complications that can occur following post-prostatectomy radiation. This comment has become “infamous” in Australian Radiation Oncology circles leading to extensive discussions and interactions between our specialties with urologists stating that radiotherapy complications can occur late and be very challenging to treat and radiation oncologists stating that these complications are relatively uncommon and that overall quality of life is as good if not better when going down the radiotherapy pathway. This is the climate that the article by Ma et al was submitted to the BJUI describing the impact of radiotherapy complications on a tertiary urology service in Melbourne Australia over a 6 month period.

 

 

I was impressed that the BJUI approached a radiation oncologist to provide balance on such a paper. We provocatively titled the editorial “Is Radiotherapy the work of the Devil?” and were hoping the response to anyone reading the editorial would be a resounding “No”.  However, many have only seen “the headline” and not read the editorial itself which appears to have created offence especially from some of our international Radiation Oncology colleagues. The aim of such a title is that it will encourage people to read both the original article and the editorial which we feel provides a balanced view on the impact of radiotherapy complications in contemporary practice. We hope that in future, the response to our title: “Is Radiotherapy the work of the Devil” is “No – the Devil is in the detail”.

 

A/Prof Andrew Kneebone

Department of Radiation Oncology, Royal North Shore Hospital and Chair of the Faculty Of Radiation Oncology Genito-Urinary Group (FROGG)

 

 

 

The 6th BJUI Social Media Awards (2018)

It’s hard to believe that we have been doing the BJUI Social Media Awards for six years now! I recall vividly our inaugural BJUi Social Media Awards in 2013, as the burgeoning social media community in urology gathered in the back of an Irish Bar in San Diego to celebrate all things social. At that time, many of us had only got to know each other through Twitter, and it was certainly fun going around the room putting faces with twitter handles for the first time. That spirit continues today as the “uro-twitterati” continues to grow, and the BJUi Awards, remain a fun annual focus for the social-active urology community to meet up in person.

We continue to alternate the Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Last year we descended on Boston, MA, to join the 15,000 or so other delegates attending the AUA Annual Meeting and to enjoy beautiful Boston. This year, we set sail for the #EAU18 Annual Meeting in the wonderful (but very cold) city of Copenhagen, along with over 13,000 delegates from 100 different countries.

On therefore to the Awards. These took place on Sunday 18th March 2018 in the Crowne Plaza Hotel, Copenhagen. Over 50 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2018 BJUI Social Media Awards. Individuals and organisations were recognised across 12 categories including the top gong, The BJUI Social Media Award 2018, awarded to an individual, organization, innovation or initiative who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her outstanding individual contributions, and in 2015 by the #UroJC twitter-based journal club. In 2017 we recognised the #ilooklikeaurologist social media campaign which we continue to promote. This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, John Davis, as well as BJUI Managing Editor Scott Millar whose team in London drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions.

The full list of winners is as follows:

  • Most Read [email protected] – “Changing the LATITUDE of Treatment for High-Risk Hormone-Naïve Prostate Cancer: STAMPEDE-ing Towards Androgen Biosynthesis Inhibition”. Dr Zach Klaassen, Toronto, Canada

 

 

  • Most Social Paper – “Unprofessional content on Facebook accounts of US urology residency graduates”. Accepted by Dr Matt Bultitude on behalf of Dr Ann Gormley and colleagues

  • Best BJUI Tube Video – “The value of In-111 PSMA radioguided surgery for salvage lymphadenectomy in recurrent prostate cancer”. Dr Tobias Maurer, Munich, Germany.

  • Best Urology Conference for Social Media – awarded to the EAU for #EAU17 and #EAU18. Accepted by Prof Jim Catto on behalf of the EAU Communications Department.

  • Innovation Award EAU Communications Department, for their excellent Twitter strategy. Accepted by Prof Jim Catto onbehalf of Marc van Gurp and EAU colleagues

  • #UroJC AwardDr David Penson, Vanderbilt, USA. Accepted by Matt Bultitude

  • Best Social Media Campaign – awarded to The Urology Foundation, London, UK. In recognition of their use of social media to promote their advocacy, awareness and fundraising efforts in urology. Also an acknowledgement of twitter super-user Stephen Fry as a supporter of TUF, and his use of twitter to share his recent personal prostate cancer journey.

  • Most Social Trainee – Awarded to the “Bellclapper Podcasts”, featuring Jesse Ory, Kyle Lehman, Jeff Himmelman, from Dalhousie University, Canada.

  • The BJUI Social Media Award 2018 – awarded to @BURSTurology, in recognition of their use of social media to engage with other urology trainee and research groups around the world to drive collaborative research, including the #identify project. Collected by BURST Chair Veeru Kasi.

 

A number of the BJUI senior editorial team were also present to join the fun!

 

A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar, Max Cobb and team, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Chicago for #AUA19 where we will present the 7th BJUI Social Media Awards ceremony!

 

Declan Murphy

Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor, BJUI

@declangmurphy

 

USANZ 2018: Melbourne

G’day! The 71st  annual USANZ Congress, was held in Melbourne and had the biggest attendance on record for the past 6 years. The Urological Nurse’s congress: ANZUNS ran concurrently, encouraging multi disciplinary learning. An excellent and varied educational programme was masterminded by Declan Murphy, Nathan Lawrentschuk and their organising committee. Melbourne provided a great backdrop and soon felt like home with a rich and busy central business district, cultural and sporting venues, the Yarra river flowing past the conference centre, edgy graffiti and hipster coffee shops, plus too many shops, bars and restaurants to visit.

The programme included a day of masterclasses on a range of subjects, including: urological imaging, advanced robotic surgery with a live case from USC, metastatic prostate cancer and penile prosthetics. These were well attended by trainees and consultants alike. The PCNL session (pictured) with Professor Webb was popular and he generously gave his expertise.  The session was supported by industry and provided an opportunity to use the latest nephroscopes on porcine models and innovative aids to realistically practice different puncture techniques.

Two plenary sessions were held each morning covering the breadth and depth of urology and were well attended. Dr Sotelo is always a highlight; he presented, to an auditorium of collective gasps, a unique selection of ‘nightmare’ cases  His cases gave insight in how intraoperative complications occur and how they can be avoided.  Tips, such as zooming out to reassess in times of anatomical uncertainty during laparoscopy or robotic surgery have great impact when you witness the possible consequences. Tim O’Brien shared his priceless insights on performing IVC thrombectomy highlighting the need for preoperative planning, early control of the renal artery and consideration of pre-embolisation.  His second plenary on retroperitoneal fibrosis provided clarity on the management of this rare condition highlighting the role of PET imaging and, as with complex upper tract surgery, the importance of a dedicated team.

Tony Costello’s captivating presentation covered several myths in robotic prostate surgery, plus the importance of knowing your own outcome figures and a future where robotics will be cost equivalent to laparoscopy. Future technology, progress in cancer genomics and biomarkers were also discussed in various sessions.  One example of new technology was Aquablation of the prostate; Peter Gilling presented the WATER trial results suggesting non-inferiority to TURP.  A welcome addition to the programme was Victoria Cullen (pictured), a psychologist and Intimacy Specialist who provides education, support and strategies for sexual  rehabilitation. She described her typical consultation with men with sexual dysfunction and how to change worries about being ‘normal’ to focusing on what is important to the individual.

Joint plenary sessions with the AUA and EAU were a particular highlight. Prof Chris Chapple confirmed the need for robust, evidence guidelines which support clinical decision making; and in many cases can be used internationally. He suggested collaboration is crucial between us as colleagues and scientists working in the field of urology. Stone prevention and analysis of available evidence was described by Michael Lipkin; unfortunately stone formers are usually under-estimaters of their fluid intake so encouragement is always needed! Amy Krambeck presented evidence for concurrent use of anticoagulants and antiplatelets during BOO surgery and suggested there can be a false sense of security when stopping these medications as it isn’t always safe. She championed HoLEP as her method of BOO surgery and continues medications, although the evidence does show blood transfusion rate may be higher. She also uses a fluid warming device which has less bleeding and therefore improved surgical vision; importantly it is preferred by her theatres nurses! MRI of the prostate was covered  by many different speakers, however Jochen Walz expertly discussed the limitations of MRI in particular relating negative predictive value (pictured). He eloquently explained the properties of cribiform Gleason 4 prostate cancer and how this variant contributed to the incidence of false negatives.

Moderated poster and presentation sessions showcased research and audit projects from the UK, Australia, New Zealand and beyond, mainly led by junior urologists. The best abstracts submitted by USANZ trainees were invited to present for consideration of Villis Marshall and Keith Kirkland prizes. These prestigious prizes were valiantly fought for and reflected high quality research completed by the trainees. Projects included urethral length and continence, no need for lead glasses, obesity and prostate cancer, multi-centre management of ureteric calculi, mental health of surgical trainees and seminal fluid biomarkers in prostate cancer. This enthusiasm for academia will undoubtedly stand urology in good stead for the future; this line up (pictured) is one to watch!

The Trade hall provided a great networking space to be able to meet with friends and colleagues and engage with industry. It also hosted poster presentation sessions, with a one minute allocation for each presenter – which really ensures a succinct summary of the important findings (pictured)! It was nice to meet with Australian trainees and we discussed the highs and lows of training and ideas for fellowships. Issues such as clinical burden and operative time, selection into the specialty, cost of training, burn out and exam fears were discussed and shared universally; however there is such enthusiasm, a passion for urology and inspirational trainers which help balance burdens that trainees face. Furthermore, USANZ ‘SET’ Trainees were invited to meet with the international faculty in a ‘hot seat’ style session which was an enviable opportunity to discuss careers and aspirations.

In addition to the Congress I was fortunate to be invited for a tour and roof-top ‘barbie’ at the Peter Mac Cancer centre; plus a visit to Adelaide with Rick (Catterwell, co-author) seeing his new hospital and tucking into an inaugural Aussie Brunch. Peter Mac and Royal Adelaide Hospital facilities indicated an extraordinary level of investment made by Federal and State providers; the Peter Mac in particular had impressive patient areas, radiotherapy suites and ethos of linking clinical and research. However beyond glossy exteriors Australian public sector clinicians voiced concerns regarding some issues similar to those we face in the NHS.

Despite the distance of travelling to Melbourne and the inevitable jet lag the world does feels an increasingly smaller place and the Urological world even more so. There is a neighbourly relationship between the UK, Australia and New Zealand as evidenced by many familiar faces at USANZ who have worked between these countries; better for the new experiences and teaching afforded to them by completing fellowships overseas. The Gala Dinner was a great chance to unwind, catch up with friends and celebrate successes in the impressive surrounding of Melbourne Town Hall (pictured); the infamous organ played particularly rousing rendition of Phantom of the Opera on arrival.

The enthusiasm to strive for improvement is similar both home and away and therefore collaboration both nationally and internationally is integral for the progress of urology. The opening address by USANZ President included the phrase ‘together we can do so much more’ and this theme of collaboration was apparent throughout the conference. The future is bright with initiatives led by enthusiastic trainee groups BURST and YURO to collect large volume, high quality data from multiple centres, such as MIMIC which was presented by Dr Todd Manning. Social media, telecommunications and innovative technology should be used to further the specialty, especially with research and in cases of rare diseases – such as RPF.  Twitter is a tool that can be harnessed and was certainly used freely with the hashtag #USANZ18. Furthermore, utilisation of educational learning platforms such as BJUI knowledge and evidence based guidelines help to facilitate high quality Urological practice regardless of state or country.

So we’d like to extend a huge thank you to Declan, Nathan and the whole team, and congratulate them for a successful, educational and friendly conference; all connections made will I’m sure last a lifetime and enable us to do more together.

Sophie Rintoul-Hoad and Rick Catterwell

 

Have the days of ADT Monotherapy for Hormone Sensitive Prostate Cancer Come to an End? STAMPEDE in the June #urojc

The much awaited results of the STAMPEDE study of abiraterone for hormone naive prostate cancer was simultataneously presented at #ASCO17 and published ‘on line ahead of print’ in the NEJM. The formal title of the study was “Abiraterone for Prostate Cancer Not Previously Treated with Hormone Therapy”.

Briefly, the study randomised 1917 men with locally advanced or metastatic hormone naive prostate cancer  to receive either ADT alone or ADT in combination with abiraterone and prednisolone.  significantly higher rates of overall and failure-free survival than ADT alone.We were privileged to have the lead author Professor Nick James join us for the June #urojc.  He posted the following video which is a lovely summary about STAMPEDE.  All of us could benefit from watching this and it is a useful link for our patients.

The data from the study is clear and it was not surprising that the majority of the discussion surrounding this paper was not going to be a dissection of the methodology or dataset and its analysis but rather how these results might impact upon urological practice.

There was a somewhat provocative start to the discussion with:-

To turn the question around, we saw the following tweet:-

But @urogeek came out swinging

But he was not alone in these thoughts.

But lets be fair, these responses are from urologists immersed in clinical trials experience and highly academic centers.  The following tweet perhaps brought out what many were thinking.

But perhaps the onus is upon us to make that extra effort to learn. As has been mentioned, we manage one of the most toxic agents competently in the form of intravesical BCG for bladder cancer.

Naturally, there was bound to be some discussion about cost of treatment.

For a bit of light hearted banter, there was the following exchange which we hope nobody took too seriously.

The twitter account of the journal Prostate Cancer and Prostatic Diseases posted a poll which was responded to by 117 participants with only 10% choosing the ADT alone option.  Whilst far from scientific, does this represent a significant change in thinking?  It was not long ago where we could have predicted that almost all respondents would have chosen the ADT alone option.

And to finish up, a question answered by Nick James as follows:-

A big thanks to all who participated in the June #urojc discussion. A special thanks to lead author Nick James for his insightful comments that really added to the discussion.  We will be back for another installment of the #urojc in July.  See you then.

Henry Woo (@drhwoo) is the Director of Uro-Oncology and Professor of Robotic Cancer Surgery at the Chris O’Brien Lifehouse in Sydney, Australia. He is also Professor Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney.

 

Changing the LATITUDE of Treatment for High-Risk Hormone-Naïve Prostate Cancer: STAMPEDE-ing Towards Androgen Biosynthesis Inhibition

zach-klaassenEarlier this month at the annual American Society of Clinical Oncology (ASCO) meeting in Chicago, IL, Dr. Karim Fizazi and Dr. Nicholas James (@Prof_Nick_James) presented results from the LATITUDE and STAMPEDE trials, respectively. These randomized controlled trials (RCTs) assessed the utility of adding abiraterone acetate (AA) + prednisone to conventional androgen deprivation therapy (ADT) among men with high-risk, hormone-naïve prostate cancer. Since Dr. Charles Huggins’ 1941 Nobel prize winning finding that ADT is highly effective in controlling metastatic prostate cancer, nearly 70 years passed before CHAARTED and STAMPEDE demonstrated in 2015 that the addition of docetaxel to ADT prolongs survival in men with high volume metastatic prostate cancer. The de novo metastatic prostate cancer global incidence is striking: 3% in the US and rising, 6% across Europe, 4-10% in Latin America, and nearly 60% in Asia-Pacific. Historically, ADT has been standard of care, however most men with metastases progress to metastatic castration-resistant prostate cancer (mCRPC) driven by the reactivation of androgen receptor (AR) signaling. The rationale for adding AA + prednisone to ADT for metastatic hormone-naïve prostate cancer patients is threefold: (i) the mechanism of resistance to ADT may develop early, (ii) ADT alone does not inhibit androgen synthesis by the adrenal glands or prostate cancer cells, and (iii) AA + prednisone improves overall survival (OS) in mCRPC patients and reduces tumor burden in high-risk, localized prostate cancer.

LATITUDE

LATITUDE was conducted at 235 sites in 34 countries in Europe, Asia-Pacific, Latin America, and Canada. The objectives of the study were to evaluate the addition of AA + prednisone to ADT on clinical benefit in men with newly diagnosed, high-risk, metastatic hormone-naïve prostate cancer. Patients were stratified by the presence of visceral disease (yes/no) and ECOG performance status (0, 1 vs 2) and then randomized 1:1 to either ADT + AA (1000 mg daily) + prednisone (5 mg) (n=597) or ADT + placebo (n=602). The co-primary endpoints were OS and radiographic progression-free survival (rPFS). Secondary endpoints included time to: (i) pain progression, (ii) PSA progression, (iii) next symptomatic skeletal event, (iv) chemotherapy, and (v) subsequent prostate cancer therapy. The study was powered to detect an HR of 0.67 and 0.81 in favor of AA for rPFS and OS, respectively.
Over a median follow-up of 30.4 months, patients treated with ADT + AA + prednisone had a 38% risk reduction of death (HR 0.62, 95%CI 0.51-0.76) compared to ADT + placebo.

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Median OS was not yet reached in the ADT + AA + prednisone arm compared to 34.7 months in the ADT + placebo arm. OS rates at 3 years for the ADT + AA + prednisone arm was 66%, compared to 49% in the ADT + placebo arm. This OS benefit was consistently favorable across all subgroups including ECOG 0 and 1-2, visceral metastases, Gleason ≥8 disease, and bone lesions >10.

There was also 53% risk of reduction of radiographic progression or death for patients treated with ADT + AA + prednisone (median 33.0 months; HR 0.47, 95%CI 0.39-0.55) compared to ADT + placebo (14.8 months).

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Secondary endpoints showed statistically significant improvement for ADT + AA + prednisone, including time to PSA progression (HR 0.30, 95%CI 0.26-0.35), time to pain progression (HR 0.70, 95%CI 0.58-0.83), time to next symptomatic skeletal event (HR 0.70, 95%CI 0.54-0.92), time to chemotherapy (HR 0.44, 95%CI 0.35-0.56), and time to subsequent prostate cancer therapy (HR 0.42, 95%CI 0.35-0.50).

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Secondary to the results presented at ASCO, the study was discontinued after the first interim analysis. Adverse events were comparable in the two groups. Hypertension only rarely required treatment discontinuation, and only two patients discontinued treatment due to hypokalemia (no hypokalemia-related deaths). Two patients in each arm died of cerebrovascular events, and 10 patients treated with ADT + AA + prednisone compared to 6 patients treated with ADT + placebo died of cardiac disorders.

STAMPEDE

STAMPEDE is a large multi-stage, multi-arm, RCT being conducted in the United Kingdom to assess the utility of novel therapeutic agents in conjunction with ADT. Currently being tested are AA, enzalutamide, zoledronic acid, docetaxol, celecoxib and radiotherapy (RT). The AA arm of the study was presented at ASCO as a late-breaking abstract. Inclusion criteria included men with locally advanced or metastatic prostate cancer, including newly diagnosed with N1 or M1 disease, or any two of the following: stage T3/4, PSA ≥ 40 ng/mL, or Gleason score 8-10. Patients undergoing prior radical prostatectomy or RT were eligible if they had more than one of the following: PSA ≥ 4 ng/mL and PSADT < 6 months, PSA ≥ 20 ng/mL, N1, or M1 disease. Patients were then randomized 1:1 to standard of care (SOC; ADT for ≥2 years, n=957) vs SOC + AA (1000 mg) + prednisone 5 mg daily (n=960). Treatment with RT was mandated in patients with N0M0 disease, while strongly encouraged for N1M0 patients. Primary outcomes were OS and failure-free survival (FFS), where failure was defined as PSA failure, local failure, lymph node failure, distant metastases or prostate cancer death. Secondary outcome included toxicity and skeletal-related events (SREs). The study was powered to detect a 25% improvement in OS for the treatment group (requiring 267 control arm mortalities).
Both groups were balanced and patients were predominantly metastatic (52% M1, 20% N+M0, 28% N0M0), median was PSA 53 ng/mL, and 99% were treated with LHRH analogues. Over a median follow-up of 40 months, there were 262 control arm deaths, of which 82% were prostate cancer-related; there were 184 deaths in the SOC + AA + prednisone arm. There was a 37% relative improvement in overall survival (HR 0.63, 95%CI 0.52-0.76) favoring SOC + AA + prednisone.

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A Forrest plot split on stratification factors demonstrated no evidence of heterogeneity based on any of the factors, including M0/M1 status (p=0.37). Second, SOC+AA + prednisone demonstrated a 71% improvement in FFS (HR 0.29, 95%CI 0.25-0.34), with an early split in the KM curves.

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SOC + AA + prednisone also significantly decreased SREs among the entire cohort (HR 0.46, 95%CI 0.37-0.58), as well as specifically in the M1 cohort (HR 0.45, 95%CI 0.37-0.58). This resulted in a 55% reduction in SREs in the M1 subset analysis.

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When looking at treatment progression, 89% of the SOC arm went on to next line of therapy, whereas 79% of the SOC + AA + prednisone arm received additional therapy, most commonly docetaxel. As expected, the rate of Grade 3-5 adverse events was higher in the SOC + AA prednisone arm (47% vs. 33%), and were primarily cardiovascular (HTN, MI, cardiac dysrhythmias) or hepatic (transaminitis) in nature.

REACTION, INTERPRETATION & FUTURE DIRECTIONS

As has become the norm during academic conferences, there was significant buzz on Twitter over the course of the two days these results were presented:

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This also included the New England Journal of Medicine immediately tweeting after the presentations that LATITUDE and STAMPEDE were published instantaneously:

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Furthermore, immediately following Dr. Fizazi’s presentation of LATITUDE, Dr. Eric Small from @UCSF presented a discussion of LATITUDE. A number of important points were raised. First, although this was a well-designed, placebo controlled, randomized phase III study, early unblinding (although appropriate) resulting in an HR of 0.62 for OS is based on only 50% of the targeted total deaths. Making conclusions based on interim analyses must be made with caution. However, with every endpoint reaching statistical significance and conditional probability modeling, if the study had remained blinded, the probability of reaching the same conclusions is high. Second, since twice as many patients in the ADT + placebo arm received life-prolonging therapy than compared to the ADT + AA + placebo arm, the benefit of AA is not explained by more secondary life-prolonging therapy, strengthening the cause for AA + ADT.

Perhaps the most interesting and pertinent clinical comparison is assessing outcomes of the LATITUDE and CHAARTED (high-volume disease) treatment arms (AA vs docetaxel). With similar median OS outcomes between the ADT control arms of the two trials (suggesting similar populations), the HRs for OS based on treatment are nearly identical:

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Similarly, the rPFS outcomes were comparable between the two trials:

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With nearly identical OS and rPFS outcomes for men receiving ADT + AA or ADT + docetaxel, the question becomes whether the impact of adding AA to ADT is volume or risk dependent. Results from the STAMPEDE trial would suggest remarkably similar outcomes support the use of AA + ADT in patients with less burden of disease. Arguably the most important slide of the meeting was captured and tweeting by Dr. Agarwal (@neerajaiims):

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Dr. Small eloquently summarized future directions into two groups. Unanswered questions regarding efficacy include: (i) Can a genomic classifier be used to select patients more likely to benefit from AA or docetaxel? (ii) Can AA be added in even earlier settings (with radiation? Increasing PSAs?) (iii) Should AA and docetaxel be combined or used sequentially? Additionally, there are also unanswered questions regarding AA resistance, including (i) Will the mechanisms of resistance to AA be the same when used in the non-mCRPC setting? (ii) Will androgen receptor amplification still be observed? (iii) Will there be an increased risk of treatment-associated small cell/neuroendocrine prostate cancer? (iv) Does adding chemotherapy or AA to ADT result in more aggressive disease at the time of resistance? (v) What is the optimal therapy for a patient who progresses on ADT + AA, compared to a patient who progresses on ADT + docetaxel? Given the avoidance of potential chemotherapy related side effects (ie. neutropenic complications) for an oral, long-term treatment, AA + ADT should be considered standard of care for untreated, high-risk metastatic prostate cancer.

But what is the long-term economic landscape like when practice changing trials such as LATITUE and STAMPEDE suddenly thrust an expensive medication such as AA + prednisone directly to the forefront of hormone-naïve disease? Following these presentations, urologic oncologist, Twitter veteran, and Forbes correspondent Dr. Ben Davies (@daviesbj) wrote a provocative piece highlighting the potential ‘financial toxicity’ (particularly in the United States) that may result downstream of these trials:

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A conservative estimate is a wholesale cost of $115,000 per year per patient for AA + prednisone, resulting in a crude estimate of a $2.8 billion annual expenditure for the drug in the United States alone if used in the hormone-naïve setting, according to Dr. Davies. As Dr. Davies also points outs, although the patent for AA expired in 2016 and there are currently 13 applications to make generic AA, the patent for prednisone lasts until 2027, with $30 billion riding on the lawsuit. Dr. David Penson (@urogeek) succinctly summarized via Twitter:

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Strictly academically speaking, LATITUDE and STAMPEDE, in addition to the docetaxel benefits of CHAARTED, have provided clinicians with exciting Level 1 evidence for improving patient care in the high-risk/metastatic setting. The investigators and more importantly the thousands of patients and families are to be thanked and congratulated for their perseverance, hard-work, and willingness to participate in these practice-changing clinical trials. It is our job as clinicians to continue advocating the best treatment for our patients, whether this be through economic barriers in the United States, or access to appropriate care on a global scale.

 

Zach Klaassen, MD

Urologic Oncology Fellow

University of Toronto/Princess Margaret Cancer Centre

Toronto, Ontario, Canada

@zklaassen_md

 

The Surgical Safety Check List – May #urojc

Ever since the World Health Organisation launched the Safe Surgery Saves Lives campaign in 2007, surgical safety has been drawn to the forefront of the daily surgical routine. The introduction of the 19-point Surgical Safety Checklist, aimed at reducing preventable complications, has become key, with shouts of ‘time-out’ or ‘checklist’ becoming the norm at the start of each case. Equally whether known as the ‘huddle’ or ‘team brief’, the meeting of all team members at the beginning of the list not only helps plan for any changes from the normal routine, but gives a good chance to get to know any new members of staff and helps to promote the team-based atmosphere that encompasses a productive operating list. In the 2009 study evaluating the benefits of the Surgical Safety Checklist, a reduction in both the mortality rate and rate of inpatient complications were found to be significantly reduced1. Implementation of these safety protocols however requires effort and engagement from all members of the theatre team.

In the May, the International Urology Journal Club (@iurojc) #urojc debated a study by Haynes et al in which the reduction of 30-day mortality following the implementation of a voluntary, checklist-based surgical quality improvement program2. The study identified that hospitals completing the program had a significantly lower rate of 30-day mortality following inpatient surgery.

One of the first topics brought up in the debate is the variability in the implementation of safety checklists.

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@StorkBrian raised the possibility that due to the addition of more items at the surgical time out, effectiveness decreases. Whether there is a lack of ability to concentrate on too much paper work was discussed

Conflicting evidence regarding the effect surgical checklists have on mortality was identified, with @WallisCJD bringing up the paper by Urbach et al as an example3.

The different outcomes from the two studies may however be attributed to the difference in follow up period and study design.

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Another aspect of study design discussed was the inclusion criteria – which excluded day case procedures. Whether the outcome in 30-day mortality would be different if these are included, as they are more likely to be lower-risk surgery, is unclear.

Equally whether 30-day mortality is the most appropriate endpoint for the study was questioned – although clearly very important, it would be interesting to know if other factors, such as significant morbidity, altered following the quality improvement program.

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Although the surgical checklist has become part of our daily life, the question as to why they are important was raised by @CanesDavid, with a variety of responses.

For many, it seemed that alongside the safety promotion, it helps to promote cohesive teamwork and communication, which may give all team members the confidence to voice any concerns.

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Giving all team members the ability to speak up with confidence if they identify any concerns will only benefit patients and staff.

Equally, the culture of safety promoted in teams who engage with the surgical checklist process may not be limited to the checklist itself, but to the surgical environment in general

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One clear concern some have with the mandating of the surgical checklist is ensuring it does not just become a ‘tick-box’ exercise

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Regardless of whether you find the checklist another form to fill, or a key part of your operating list, the goal of the process is clear: to protect our patients from preventable mistakes.

This study, confirming the original findings from the 2009 study that surgical safety checklists improve operative mortality, adds to the argument that this must become an inherent part of our practice. Key in this study however was the entire program promoting engagement in the concept of surgical safety, and supporting the team as a unit in this. The debate around this paper has highlighted that although the process of completing the mandatory checklists is important, perhaps the more important aspect is creating a culture of safety, openness and honest communication in which all team members can work together to promote safe surgery.

 

Sophia Cashman is a urology trainee working in the East of England region, UK. Her main areas of interest are female and functional urology. @soph_cash

 

References

1. Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 2009;360(5):491-9
2. Haynes AB, Edmondson LBA, Lipsitz SR, et al. Mortality Trends After a Voluntary Checklist-based Surgical Safety Collaborative. Annals of Surgery 2017. Published Ahead-of-Print
3. Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada. New England Journal of Medicine 2014;370(11):1029-1038

 

The 5th BJUI Social Media Awards

It’s hard to believe that we have been doing the BJUI Social Media Awards for five years now! I recall vividly our inaugural BJUI Social Media Awards in 2013, as the burgeoning social media community in urology gathered in the back of an Irish Bar in San Diego to celebrate all things social. At that time, many of us had only got to know each other through Twitter, and it was certainly fun going around the room putting faces with twitter handles for the first time. That spirit continues today as the “uro-twitterati” continues to grow, and the BJUI Awards, (or the “Cult” Awards as our Editor-in-Chief likes to call them), remains a fun annual focus for the social-active urology community to meet up in person.

As you may know, we alternate the Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Last year, we descended on Munich, Germany to join the 13,000 or so other delegates attending the EAU Annual Meeting and to enjoy all the wonderful Bavarian hospitality on offer. This year, we set sail for the #AUA17 Annual Congress in Boston, MA, along with over 16,000 delegates from 100 different countries. What a great few days in beautiful Boston and a most welcome return for the AUA to this historic city. Hopefully it will have a regular spot on the calendar, especially with the welcome dumping of Anaheim and Orlando as venues for the Annual Meeting.

Awards

On therefore to the Awards. These took place on Saturday 13th May 2017 in the City Bar of the Westin Waterfront Boston. Over 80 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2017 BJUI Social Media Awards. We actually had to shut the doors when we reached capacity so apologies to those who couldn’t get in! Individuals and organisations were recognised across 12 categories including the top gong, The BJUI Social Media Award 2017, awarded to an individual, organization, innovation or initiative who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her outstanding individual contributions, and in 2015 by the #UroJC twitter-based journal club. Last year’s award went to the #ilooklikeaurologist social media campaign which we continue to promote.

This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, John Davis, as well as BJUI Managing Editor Scott Millar whose team in London (Max and Clare) drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions.

The full list of winners is as follows:

Most Read [email protected] – “The optimal treatment of patients with localized prostate cancer: the debate rages on”. Dr Chris Wallis, Toronto, Canada

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Most Commented [email protected] – “It’s not about the machine, stupid”. Dr Declan Murphy, Melbourne, Australia

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Most Social Paper – “Novel use of Twitter to disseminate and evaluate adherence to clinical guidelines by the European Association of Urology”. Accepted by Stacy Loeb on behalf of herself and her colleagues.

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Best BJUI Tube Video – “Combined mpMRI Fusion and Systematic Biopsies Predict the Final Tumour Grading after Radical Prostatectomy”. Dr Angela Borkowetz, Dresden, Germany

AUA

Best Urology Conference for Social Media – #USANZ17 – The Annual Scientific Meeting of the Urological Association of Australia & New Zealand (USANZ) 2017. Accepted by Dr Peter Heathcote, Brisbane, Australia. President of USANZ.

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Best Urology App – The EAU Guidelines App. Accepted by Dr Maria Ribal, Barcelona, Spain, on behalf of the EAU.

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Innovation Award – BJUI Urology Ontology Hashtags keywords. Accepted by Dr Matthew Bultitude, London, UK, on behalf of the BJUI.

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#UroJC Award – Dr Brian Stork, Michigan, USA. Accepted by Dr Henry Woo of Brian’s behalf.

UroJC
Most Social Trainee – Dr Chris Wallis, Toronto, Canada

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Best Urology Journal for Social Media –Journal of Urology/Urology Practice. Accepted by Dr Angie Smith, Chapel Hill, USA, on behalf of the AUA Publications Committee.

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Best Urology Organisation – Canadian Urological Association. Accepted by Dr Mike Leveridge, Vice-President of Communications for CUA.

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The BJUI Social Media Award 2017 – The Urology Green List, accepted by Dr Henry Woo, Sydney, Australia.

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All the Award winners (except Dr Brian Stork who had to get home to work), were present to collect their awards themselves. A wonderful spread of socially-active urology folk from all over the world, pictured here with BJUI Editor-in-Chief, Prokar Dasgupta.

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A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar, Max Cobb and Clare Dunne, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Copenhagen for #EUA18 where we will present the 6th BJUI Social Media Awards ceremony!

 

Declan Murphy

Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor, BJUI

@declangmurphy

EAU 2017 Congress Days 3&4

London calling! On Sunday morning London called one hour earlier than I had planned – damn daylight saving time! Last nights’ celebrations with urology friends from around the world at the ESRU (European Society of Residents in Urology) dinner party made me pay. Yet this was going to be a great meeting day.

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Sunday morning sessions served as a wake-up call after a short night due to daylight saving time.

Dr. Rajesh Nair has already reported on a great kick-off and continuation of the EAU17 congress in his blog on congress days 1 & 2.

The Sunday programme started with a plenary session in eURO auditorium on redefining and optimising contemporary bladder cancer care. The EAU chose a great concept for the plenary session by presenting an easily digestible mix of different lectures: Experts in the field used case discussions to illustrate real-life clinical scenarios and everyday issues for urologist. Speakers delivered their best arguments in the debates on pros and cons on urgent clinical questions. Finally, State-of-the-art lectures summarized the most important aspects in the field.

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EAU17 Delegates joining the congress action.

Sunday’s State-of-the art lectures on bladder cancer were held by James Catto and Walter Artibani. Catto reported on “Enhanced Recovery After Surgery (ERAS) for bladder cancer: Non-surgical options to improve outcomes of cystectomy”. Catto systematically covered 22 ERAS items on preoperative, intraoperative and postoperative measures. Appliance of ERAS for radical cystectomy yielded better outcomes for length-of-stay as well as readmission and transfusion rates when compared to traditional recovery concepts.

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State-of-the-art lecture: Three principles of the Enhanced Recovery after Surgery (ERAS) Philosophy.

The second State-of-the-art lecture by Walter Artibani gave perspectives on “What determines Quality-of-Life after urinary diversion and how do we measure it?” Artibani pointed out that we have to do a better job in defining and researching health-related quality of life in order to compare outcomes of urinary diversions. Multidisciplinarity is a must and there is room and need for enhanced long-term personalized information and support programs.

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Quality of Life after urinary diversion – Walter Artibani’s twist of Albert Einstein’s wisdom.

Besides scientific meetings, the Annual Meeting of course is the place for board meetings of the EAU bodies. The EAU Section Office Members took the opportunity to step out of the congress and enjoy London’s incredibly good weather.

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EAU Section Office Members enjoying London’s sun for a group photo.

At high noon it was time for me to join the Advanced Course on Social Media – take it to the next level! An expert panel of Social media users in urology gave insights on the wide variety of Social media use in our field. Twitter queen Stacy Loeb (@LoebStacy) gave examples on the use of social media for scientific research and for dissemination of content. Matthew Cooperberg (@dr_coops) showed in his talk “reputation management” why and how urologists should take care of their digital self. Finally, Inge van Oort (@onco_uroloog) presented do’s and don’ts of Twitter use emphasizing the importance of Social Media guidelines.

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Great conclusion of the advanced Social Media Course by @LoebStacy.

Yet, ESU Courses weren’t limited to lectures and discussions. HOT – Hands on Training was offered to delegates with 1-on-1-supervision. I was amazed by the variety of simulators and technical equipment for course participants. But why would they use red irrigation fluid? – Making the TURP simulation a more realistic experience? 😉

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Simulation and tutoring during European School of Urology Hands-on-training courses.

On Monday morning the EAU launched a new initiative: the Young Urologist Office provided a new course format: the EAU Leadership Course. Ambitious urologists from all over the world gathered to expand on their leadership skills: What are my leadership styles? Can I flex my style? Am I effective? These were only some of the aspects covered by a team of specialized leadership coaches.

 

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One key skill for leadership: great rhetorical skills!

Another thing I liked about the EAU congress was the professional media coverage – EAU TV offered short interviews covering highlights from abstract sessions, plenary sessions and insights from the EAU bodies. It was EAU TV that attracted my attention to Amanda Chung’s study “Is your career hurting you? – The ergonomic consequences of surgery in 701 urologists worldwide”.  Against common presumption, Chung et al. didn’t find a dose-response relationship between volume of surgeries performed and back pain. A protective effect against back pain was found for exercise, instead increasing weight and BMI were associated with higher pain – thanks for these insights! I definitely aim for a lifestyle change after hearing these findings!

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EAU TV enriches the conference experience.

There were a lot of things to learn during the congress. During the congress first-ever e-Poster Abstract Session on New technologies: Urology and multimedia, I learned from session chair and BJUI’s editor-in-chief Prokar Dasgupta that the highest cited paper on Altmetrics in 2015 was on a new antibiotic that kills pathogens without detectable resistance. Maybe this is why the EAU heavily announced it’s thematic session on infections in urology: “Killer bacteria and viruses in urology”. One must-read I got from this session was an update on the management of sepsis and septic shock.

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Highlights from the EAU Infectious diseases session “Killer bacteria and viruses in urology”.

As usual the EAU congress featured lots of live and semi-live surgeries. For some of them the Copenhagen Room wasn’t quite enough to accommodate all delegates interested.

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Live and semi live surgery as usual attracting lots of EAU delegates.

The EAU congress truly offered a cocktail of everything: the latest science presented in plenary & poster sessions, education, updates on guideline knowledge and of course lots of networking in form of meeting, greeting and tweeting.

Finally, my EAU17 journey ended on Monday night after lots of congress input, short nights and a great time meeting urology friends from around the world. Thanks a lot to all organisers and contributors for your hard work and great performance! See you in Copenhagen!

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Hendrik Borgmann, Urologist, University Hospital Mainz

@HendrikBorgmann

 

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