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February #urojc summary: complications arising from radical treatment of prostate cancer

February 2014 twitter-based international urology journal club #urojc continued with the theme of prostate cancer. This time the discussion was based around the complications arising from radical treatment, and the paper was available open access courtesy of Lancet Oncology. Nam et al [1]
reported on a population based retrospective cohort study of men who underwent surgery or radiotherapy alone for prostate cancer in Ontario, Canada between 2002 to 2009. Instead of the traditional outcomes that usually include urinary incontinence and erectile dysfunction, they evaluated five other treatment related complications, hospital admissions; urological, rectal or anal procedures, open surgical procedures and secondary malignancies.

First author of the manuscript Rob Nam joined the discussion using the urojcguest twitter account. The journal club kicked off on Sunday 2nd February at 8pm GMT time, quick off the mark was the ‘Queen of uro-twitter’.

There was quick agreement.

Patients who underwent surgery were more likely to undergo minimally invasive urological procedures, most commonly diagnostic cystoscopy, was this due to easy access to it for urologists?

However, there was comment from Canada where the study was performed that this may not necessarily be the case.

One of the limitations of the study was noted,

Stacy Loeb commented

and the lead author Robert Nam explained

The question was posed how much emphasis was placed on non ED, non urinary incontinence adverse events when counseling patients regarding prostate cancer treatment.

Ben Davies (the self-proclaimed King of uro-twitter) commented that bladder neck contracture was rare in the robotic prostatectomy era, which was the experience of others.

It was noted that the risk of secondary malignancy is probably underplayed due to the relatively short follow up in the study,

and secondary malignancies may sway the decision-making balance towards surgery

Stacy Loeb changed her avatar and commented that the study may not be generalizable to patients treated in the active surveillance era

The timing and severity of complications post treatment was discussed

It was commented that this is likely ‘real world’ data.

The side effects and their likely effects on quality of life were commented on, (from a surgical perspective).

In the same way that surgeons get different results for the same procedure, do radiation oncologists results differ.

A radiation oncologist joined in the discussion.

There was discussion regarding the mode of radiotherapy and variability in outcomes.

We were reminded that not all prostate cancer requires radical treatment.

Final thoughts in the last few minutes of the journal club came from Stacy Loeb.

Thanks to all who participated, looking forward to next months #urojc. Best tweet prize was won by @VMisrai and is complimentary registration to #WCE14 courtesy of @EndourolSoc. His tweet provided a particularly useful link alerted us to an article published on line ahead of print in the ESTRO Green Journal within hours of his tweet. Special acknowledgement again to Rob Nam who contributed as an author and also to brave attendance by Matt Katz whose insightful tweets gave us urologists much to think about.

 

Kate. D. Linton is a consultant urological surgeon at Sheffield Teaching Hospitals/Barnsley Hospital, UKTwitter @linton_kate

 

Reference

  1. Nam RK, Cheung P, Herschorn S, et al. Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study. Lancet Oncol 2014; 15: 223-31

 

Out with the old; In with the new. Stats and metrics: The BJUI website 2013

Is it already over twelve months since the new Editor took over and the new BJUI web journal was launched? The old one had served its purpose well but the editorial board had decided the change of leadership dictated a clean new website would be launched in January 2013. Decisions were hard. Out went non-journal content such as case reports and in its place we created four main content areas with the aim of maintaining fresh, regularly changing content. These (article of the week; BJUI blogs; picture quiz of the week; BJUI poll) you will by now be familiar with, but how has the new web journal performed? Let’s look at the metrics over the last year.


The BJUI website prior to 2013

Firstly, most of the figures referred to in this article are for the www.bjui.org site only. They do not include direct access to the journal articles in the Wiley Online Library where the issues are stored. Thus analysing overall visitor numbers is not that valid and doesn’t allow for meaningful comparison. However, it appears there has been an increase in web visits of at least 10%. When we drill deeper, this is where we really notice a change. Readers now spend on average over 3 minutes on the site per visit. This is a dramatic change from previously – in 2012 the mean visit duration was just 87 seconds!

More and more people today decide to get involved with an online business, due to the fact that having a business operated through the internet offers a lot of advantages over doing it the traditional way. Online business means that you can do business right at the comforts of your own home. Thus, there is no need for you to get dress and step out of your house to earn a living. However, there are many important things that you need to learn more about in getting your online business off the ground. One of which is the creation of your own website, and the need to obtain hosting, in order to get it launched onto the World Wide Web. With so many employees working from home it’s understandable that so many businesses are now using software to monitor online activity as this means that staff can be easily managed.

Knownhost web hosting can be obtained through a company who have its own servers, where websites are hosted. In other words, a hosting service is one of the necessities in getting your own website visible through the internet. For sure, there are many ways that you can have your own web page today, such as creating a free blog or a free website. However, in most cases, these types of services are limited and having one of those pages does not mean that you entirely own them, since another website is actually hosting it.

In a nutshell, website hosting is very important because you simply could not launch your own website without having it. The hosting service provider is the one that will provide you with the space where you can upload your files that are related to your site, and they are also the ones who will ensure that your website is visible to people when they type your site’s address on their favorite web browsers.

Since there are a lot of web hosting service providers available in the market today, selection is very important in order to get associated with a reliable one. When you are able to obtain a hosting account from a reliable provider, you will be able to avoid loss of sales caused by downtimes. There are actually hosting service providers, which do not have reliable servers. In other words, they encounter a lot of downtimes, and because of that, your business would lose a lot of sales opportunities. This is because server downtimes mean that your website would not be visible on the net during those times. Thus, people who are suppose to make certain purchases, may decide to buy the items from your competitors.

In relation to that, aside from the importance of hosting for your online business, you should also become more aware of the importance of selecting a reliable web host; and one of the best ways to do that is by learning about the features of the hosting account that they can offer to you.

Geographically, the top country by visit is the United States with 22% of all visits, closely followed with the UK (21.6%) with Australia third. In total there were visits from 189 countries with both India and Japan making the top 10 (numbers of visitors) emphasising the journal’s global reach. This is truly an international journal.

 
Global subscriptions to BJUI represented as a “heat map”

Another major difference we have noticed is in bounce rate. This refers to the percentage of people who leave immediately after visiting the page they landed on i.e. if everyone only looks at the first page they come to then the bounce rate would be 100%. In 2012 the bounce rate was 66% – and this has improved significantly to 50% in 2013. This rate is never going to be very low – people come directly to a blog, quiz or just go straight onto the author guidelines or an article on Wiley Online Library. But to see such a reduction is encouraging and vindicates the approach we have taken with the web.

When we look at traffic sources, again we see another big change. This is how the visitor came to the site i.e. do they type in the web address, use a search engine or get driven to the site by social media. As you might expect, the largest single source of traffic (45%) is from Google – these visitors also spend over 3 minutes on the site with a bounce rate of 40% – so the site is not being found by accident and readers move onto other pages. 24% of traffic is direct but what is new behaviour is that 12% is from Twitter and 6% from Facebook – so social media is now driving nearly 20% of all website traffic. Facebook visitors also spend over 4 minutes on the site – they come for a reason! Of course there are the quirks – a men’s health magazine drove 1% of visits to a specific article on penis extenders! Those readers aren’t urologists as they only spend 16 seconds on the site with a bounce rate of 99.4% – this, however, does give credibility to the use of these statistics.

Apart from the homepage, the majority of social media-driven traffic is to the blogs. This has been highly successful with regular topical blogs and comments. Blog traffic has been high with the most popular (Melbourne Consensus Statement) receiving over 6500 views and 58 comments. Whilst this is clearly the highest, the top 8 blogs all have over 1000 views. Time spent on these blogs is high with several being read for an average of over 6 minutes. In January 2014 we added widgets to our blogs that allow you to see the number of reads each blog has received, and also  to allow tweeting and Facebook liking directly from the blog. Blogs posted prior to this time also have these features but the number of reads prior to January 2014 are not displayed. With this section being so popular are Letters to the Editor dead?

In a recent poll, we asked you what single feature you had liked best. Exactly equal with 34% were the blogs and the free Articles of the Week (which have also been popular in the web metrics with over 13,000 views). Picture quizzes have been successful with over 10,000 views. These demonstrate a shorter time on the page as one would expect (100 secs) but also a lower bounce rate (48%) – these readers often go elsewhere on the site. The video section has also been popular with over 2000 views although obtaining good quality videos is challenging and we encourage authors to submit video with their articles to further drive this section.

 

How does this translate to actual journal article downloads? Interestingly our approach has led to an increase of over 35% in full text downloads from Wiley Online Library compared with 2012. This is exciting and shows the web journal has been very successful not only in driving website activity as described above but also in promoting core journal content.

So for 2014 we have a new App to view the journal. Currently only on the Apple platform (80% of mobile devices used in 2013 to view the website were Apple), this is free to download although requires a log-in to view full content (available via your institutional subscription, from Wiley or from your society). It works really well on the iPhone as well as the iPad and allows access to not only the monthly journal but ‘Early View’ articles as well. This is already my preferred method for reading the journal and I highly recommend trying it.

With high-quality web and mobile interfaces, the question has to be are we ready to go paperless? As the Web Editor I should of course say yes. We discussed this at length at our first board meeting in November 2012. Due to our diverse international readership it was felt to be too early for such innovation. This will inevitably happen and another major urology journal has taken this step in 2014 (€60 supplement for the print version of European Urology). It is surely only a matter of time until digital is the standard platform. Hopefully you, the readers, will tell us when the time is right.

Matthew Bultitude
Associate Editor, Web

Another new year, but evidently no new overall survivability for patients presenting with metastatic prostate cancer

The first International Journal Club of 2014 pulled momentum from December’s discussion on treatment of metastatic prostate cancer. The study reported retrospective review of the California Cancer Registry (CCR) from 1988 to 2009 and found no significant improvement in overall or disease-specific survival in men presenting with metastatic prostate cancer. [1] Senior author Marc Dall’Era (@mdallera) led the Twitter #urojc chat.

 

 

 

 

Fresh into a new year, the crowd was giddy.

… and turned toward more important current events, like the U.S. Preventative Services Task Force’s prostate cancer screening recommendations from 2012.

Ultimately, Dall’Era reigned in the masses. His study sought to investigate whether improvement in patients with metastatic prostate cancer have contributed to the overall decline in prostate cancer mortality since the introduction prostate-specific antigen (PSA). The authors identified 19,336 men through the CCR who presented with de novo metastatic prostate cancer between 1988 and 2009. Over the entire study time period, median age of diagnosis decreased significantly from 73 years to 71 years.

The authors separated the men into chronologic cohorts:  1988-1992, 1993-1997, 1998-2003, and 2004-2009. Men in the recent era showed no significant overall survival (OS) or disease-specific survival (DSS) improvements versus earlier cohorts after 1988. Interestingly, on multivariate analysis controlling for baseline patient characteristics, OS was better for men in the 1988, 1993, and 1998 cohorts versus the 2004 cohort. DSS did improve with time when comparing the 2004 cohort with patients presenting in all earlier years.

If there have been no changes in overall survival in patients with de novo metastatic prostate cancer, might this support the effect of PSA screening?

Tweeters discussed prostate cancer screening selecting out a more biologically aggressive metastatic disease. Dall’Era explained the theory.

The overwhelming question chat participants asked is whether the lack of survival benefit over time is truly accurate, a false reflection of treatment advancements made in recent years, or an artifact created from limitations of the study.

Future studies should attempt to control for the different metastatic disease profiles, namely those patients diagnosed after clinical symptom workup versus those who are asymptomatic on presentation. Examining and comparing tumor biology is another future step.

Ultimately, it’s important not to lose sight of the two dramatic trends over the past decade: the decline in prostate cancer-specific mortality and incidence of metastatic disease. The next steps are solidifying which low-risk patients to treat and developing advanced methods to treat the most aggressive diseases.

The Best Tweet prize for January goes to Parth Modi from New Brunswick, NJ, which goes to show that even Urology residents are in with a chance to win.  The January prize has been kindly been donated by European Urology.

Thank you, Marc Dall’Era, for joining the chat. Your interaction made the January chat particularly lively and insightful. Thank you, European Urology for generously providing the Best Tweet prize.

Finally, here are the Symplur.com analytics for the chat.

[1] Wu JN, Fish KM, Evans CP, deVere White RW, Dall’Era MA. No improvement noted in overall or cause-specific survival for men presenting with metastatic prostate cancer over a 20-year period. Cancer 2013. In Press. doi: 10.1002/cncr.28485

Christopher Bayne is a PGY-3 urology resident at The George Washington University Hospital in Washington, DC and tweets @cbaynemd.

 

The bashful bladder: can we ever truly define?

Commemorating the #urojc one year mark, Brian Stork reflected on the year that was, with a fun visual diagram on the most common words used during this period.

A fitting paper for moving into Season 2 of the #urojc, with the November International Journal Club discussion on Twitter was based on the paper “Detrusor Underactivity and the Underactive Bladder: A New Clinical Entity? A Review of Current Terminology, Definitions, Epidemiology, Aetiology, and Diagnosis” by Osman et al from European Urology, 26 October 2013.

Osman et al, attempted to provide clarity around the nonobstructive impairment of voiding function, referred to as detrusor underactivity and the underactive bladder, as a clinical entity, and provide consensus on the standardising of current concepts. In their attempt to achieve this aim, a wide ranging literature review was conducted on varying terms commonly pertaining to detrusor underactivity.

So, does definition matter when discussing bashful bladders?

Early discussion centred on how frustrating detrusor underactivity was as an entity in part due to lengthy and complex mathematical equations, 

difficult in defining, with Amrith Rao, adding another term into the mix,

and often concomitant disease processes.

Surgical intervention for a bashful bladder is not a new concept, with Amrith Rao noting a partial cystectomy for hypotonic bladder was offered in the 1970’s.

This lead to a clinical discussion with participants asked who would perform a TURP on a man with an underactive bladder as suggested by urodynamics? Nadir Osman brought to our attention a study published in The Journal of Urology by Djavan et al in 1997, which concluded patient age was the key factor in treatment failure. However, with no solid evidence, participants agreed it often came down to patient choice.

Although a smaller group of participants for this month’s discussion, conclusions included:

The main messages I took from this discussion were:

  1. This is an often forgotten and overlooked aspect of Urology practice
  2. To succeed in overcoming these obstacles, a standardised definition for DU / UD is needed

This month had a strong showing from Sheffield urologists and alumni including Nadir Osman, Kate Linton, Jake Patterson, Jim Catto, Henry Woo and Chris Chapple who was listening in from his newly created Twitter account. The winner of the best tweet prize for the November #urojc is Jake Patterson.  BMC Urology have kindly donated a complimentary manuscript submission to this open access journal (of course pending peer review process).

Whilst these non-oncology topics see smaller participation, these topics will continue to be supported to provide variety and to maintain interest to the general #urojc audience.

Helen Freeborn is an Australian Urology Trainee, currently completing a General Surgical year at Cairns Base Hospital, QLD. She is interested in surgical leadership and the power of social media in connecting health professionals. Twitter @DrHelenF

One year on and “The International Urology Journal Club on Twitter” still going strong

November marked the first anniversary of the International Urology Journal Club on Twitter. As far as we are aware, our #urojc was the first journal club on Twitter using the asynchronous format. Prior to our commencement and unknown to us, a very successful real time journal club had been established with great success. Our major challenge was to enable engagement from our global community and clearly the way forward was to use the asynchronous chat format. This has since proved to be the innovation that has enabled true global participation. Other specialties have since followed our model.

When we started, we were fortunate to be in a specialty group where there were already significant numbers on Twitter and we were able to rally up the troops for the first #urojc discussion in November 2012. In the first month of our existence, we had around 50 followers and since then there has been a steady growth in those following the #urojc account and as we reached our one year anniversary, we had hit the magic 1000 follower mark.

Before all is relegated to faint memory, it is important to acknowledge the supporters and Best Tweet (Hall of Fame) winners over the past 12 months.

A couple of the novel prizes, were not sur‘prize’ingly from Urology Match.

Thanks to all of you who have supported this project as participants and followers of the #urojc discussions. A shout out to BJUI for allowing us to have the audience of the BJUI Blogs to communicate and publicize our activities. Thank you to the supporters of the Best Tweet Prizes and the journals who have kindly allowed open access of articles discussed. A special thanks to authors who have been kind enough to make themselves available for the discussion – having author insights adds a special touch that is simply not possible with any other journal club format.

We have been off to a strong start for our second year and look forward to the continued success of this novel form of CME by social media.

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

The Surgical Spectacle: Blurred Lines

October’s #urojc discussion marks a number of important milestones– not only the 1st anniversary of the online, international Twitter-based Journal Club, but this month we reached 1000 followers on Twitter – an achievement indeed! We also saw a record number of participants in demonstration of the #urojc concept going from strength to strength.

Fittingly, this month’s paper “The Surgical Spectacle: A Survey of Urologists Viewing Live Case Demonstrations” by Elsamra et al, with free online access provided by BJUI for the duration of the discussion, looks not so much at advances in our theoretical knowledge but rather at the way technological advances are changing our ability to obtain surgical ‘know-how’.

 

Elsamra et al undertook a survey of all those who attended the live surgery sessions at the Atlanta AUA Meeting in 2012 and the 2013 Paris 3rd International Challenges in Endourology Meeting, to gauge the perceived educational benefits of live case demonstrations (LCD) particularly when compared with taped case demonstrations (TCD). There were a number of problems highlighted in the paper itself:

David Chen won the best Tweet Prize, free registration at EAU 2014, kindly donated by @EUPlatinum, with the following:

Interestingly, while 78% of survey respondents felt that LCDs were ethical and only 26% that interactive discussion may lead to distraction of the surgeon and potential morbidity, only 58% would allow themselves or a family member to undertake their own surgical management as an LCD.

Live case demonstrations are by no means a new concept – they have been undertaken since the advent of surgery for the purpose of education and learning.

Recent innovations have seen a blowout in the size of the viewing audience, with live streaming to conference audiences and potentially worldwide viewers, live tweeting and more recently, as pointed out by Dr Brian Stork, the use of Google Glass for both live surgery and the purpose of remote assistance. LCDs have become the drawcard of many surgical conferences, are often the most packed sessions, arguably for the educational benefit and more importantly for the buzz and thrill of seeing ‘the masters’ deal with difficult situations in real time… while answering questions from the audience simultaneously… “so that bleeding sir, where is it coming from exactly?!?!”

It seems that there is no argument that case demonstrations are of great educational benefit and there are some perceived advantages of live vs taped sessions, as summarized by Amrith Rao in a recent BJUI blog.

The vast majority of those involved in this #urojc discussion, however, seemed to suggest that it was hard to argue that the benefits of LCD outweighed those of TCD. Are we simply promoting a surgical circus? Does the perceived stress of operating to a live large audience have a potential negative impact on patient outcomes? Declan Murphy has already blogged about his own personal experience with LCD.

As for the ethical conundrum regarding the patient?

As suggested by Henry Woo:

In 2012 the EAU released guidelines with respect to the use of live case demonstrations within its own jurisdiction. Importantly, this has highlighted the need for regulation by means of submitting outcomes to a data registry, so as to provide a means of analyzing complications and patient safety outcomes.

Position statements or guidelines have also been released by the Royal College Surgeons (UK), American Urological Association and the Royal Australasian College of Surgeons, to name a few.

Where to from here? Will we continue the trend for ‘reality TV’?

There is certainly evidence out there to suggest that recording of basic operations and comparing with peers is potentially a useful means of assessing surgeon proficiency.

I think it very much remains a case of watch this space!

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

Bladder Cancer: a stagnant foe?

This month’s topic for the Twitter-based International Urology Journal Club #urojc was bladder cancer, with a paper titled Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades’ by Zehnder et al, published online in July 2013. Open access to the paper was kindly provided by the BJUI.

 Zehnder and colleagues undertook a retrospective analysis of the University of Southern California cohort and identified 1488 patients with muscle invasive bladder cancer who underwent radical cystectomy and extended pelvic lymph node dissection between 1998 and 2005. They also included 190 patients from the University of Bern cohort to determine outcomes in patients with clinical N0 disease who were upstaged on pathology to node positive disease. Analysis, performed based on decade of intervention, showed no significant difference in overall survival (OS) or recurrence free survival (RFS) over the three decades. 10-year RFS was 78-80% for organ confined, lymph node negative, 53-60% in locally advanced, LN –ve and 30% in LN positive patients.

 

 

Firstly, it has certainly been suggested that the overall survival and cancer free survival outcomes are not as good in broader population based studies (Ontario Cancer Registry). Why?

 

 

 

 

Analysis of the SEER database has shown that cancer specific survival and overall mortality has not improved for any clinical stage of bladder cancer and in fact suggests that the incidence is increasing in the United States.

 

 

And of course, we must always look at the study design and determine whether the outcomes are reflective of the patient populations that we see in practice.

 


 

The roles of neo- and adjuvant chemotherapy were discussed at length. Only 6% of patients received neoadjuvant chemotherapy, with worse OS and RFS in multivariate analysis. The use of adjuvant chemotherapy actually almost doubled from the 80’s to 90’s, stable in the 00’s at 29%.

 

  

 

 

 

 

 

If neoadjuvant chemotherapy is so widely recommended, why has its use failed to take off?

 

 

 

 

 

 

 

Jim Catto suggested an excellent clinical pathway for the implementation of neoadjuvant chemotherapy.

If indeed bladder cancer is the poor cousin of prostate cancer, why has progress stagnated and what can we change?

 

 

 

 

 

 

 

 

 

 

So what are my humble take home messages from the discussion surrounding this month’s #urojc paper?

  1. Current data suggests that we have made no significant progress in bladder cancer outcomes over the past 30 years
  2. Early referral and diagnosis coupled with timely intervention key; be wary of progression in context of high grade NMIBC
  3. Both surgeon volume and hospital volume are thought to be independent predictors of overall survival. Patie nts do best at a high volume facility under the care of a high-volume Uro-oncologist in a multidisciplinary context
  4. Neoadjuvant chemotherapy, despite randomized controlled trial evidence in favour of its use, has poor uptake in a real world setting. Advances in dense dose regimens (MVAC and Phase III GC underway) with resultant improvement in progression free survival, lower toxicity profile and fewer dose delays make for an attractive partner to radical cystectomy and extended pelvic lymph node dissection.

To finish with the words of the self-proclaimed Urology King of Twitter, Dr Ben Davies:

 

 

 

Winner of the best tweet prize for July’s #urojc was Mike Leveridge from Queens University, Canada – he was certainly a little frustrated with the apparent lack of progress we have made. The July #urojc Best Tweet Prize was kindly supported by the Nature Journal “Prostate Cancer Prostatic Diseases” which is edited by Dr Stephen Freedland and will be a complimentary 12 month online access to the journal.

 

 

 

 

 

 

Do join us for the August #urojc which commences on Sunday 4th/Monday 5th depending on your time zone.

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

Comments on this blog are now closed.

 

 

Canadian Urological Association annual meeting at Niagara Falls

The Canadian Urological Association held its annual meeting in the city of Niagara Falls, Ontario from June 22-25, 2013. Traditionally this meeting signals the start of summer in Canada and after a prolonged cool and wet spring the hot weather arrived as everyone convened. The central location in our vast country assured that the meeting was well attended with attendance far exceeding expectations. Even though I probably have seen this place two dozen times since childhood the physical spectacle of this natural wonder of the world never fails to awe.

Even renewing acquaintances with the venerable old Maid of the Mist after many years provided a memorable experience.

The meeting started on Saturday and as with other international societies, many specialty sections held their meeting on this day. These included the Canadian Urological Oncology Group (CUOG) as well as the Canadian Endourological Group (CEG). A Multi-Disciplinary Collaborative meeting for Genitourinary Cancers also took place. Canadian urology has long enjoyed a fruitful and respectful relationship with our radiation and medical oncology colleagues. The featured speaker of CEG was Dr. Brian Matlaga from @brady_urology who spoke about the role of technology assessment and health economics and how they will intersect to alter care in the treatment of urolithiasis over the next decade. I suspect the same debate will occur in many other domains of our specialty. The first of many Educational Forums also began on Saturday with a review of the management of castrate-resistant prostate cancer.

Sunday served as the formal start to the meeting with the first plenary sessions and a number of abstracts presented. Dr. Patrick Walsh from Hopkins was the keynote speaker to start things off and gave an outstanding evidence-based review as well as personal account of where we are in prostate cancer care and how we can work to improve things.

Day 1 ended with the annual CUA fun night. The CUA annual meeting has always enjoyed a reputation for being a very social meeting. Our country is relatively small and the urological community is well connected. While everyone took advantage of walking behind the falls in tunnels within the Niagara Escarpment the highlight of the night was the debut of the band “The Void”. Six talented urologists from across the country held court and provided a very high-calibre performance to the delight of everyone. They have been hired back for #cua14 in St Johns Newfoundland and I suspect will offer a member’s discount.

Monday June 24 brought more great abstracts and vigorous discussion. A major highlight for me was an outstanding talk given by @Robert_Uzzo of @FCCCUroOncology on the management of renal cell carcinoma in the elderly. It was a tour-de-force that was in large part philosophical discussion on managing risk and probability in clinical decision-making supported with good evidence. It was a talk that could easily be applied to most of what we do as urologists.

Dr. Andrew Macneilly the long-time program director at the University of British Columbia gave the CUA Scholars Fund address that surveyed training of residents and implications in a future environment where job prospects may be tight and where concerns about whether we have adequate volumes to teach operative skills will continue to grow.

As with the AUA and EAU the Canadian Urological Association has a well-established set of guidelines. New guidelines approved at this meeting include:

1. Management of Castrate Resistant Prostate Cancer
2. Postoperative Surveillance of Upper Urinary Tract Urothelial Carcinoma
3. Management of the Small Renal Mass

The President’s dinner on Monday night was very well attended. Dr. Klotz teamed up with half of the other member of The Void as well as Dr. Andrew Hussy from Stratford, Ontario to form a proficient jazz quartet. Four CUA Scholars Awards were given that night. Congratulations to Dr. Robert Hamilton of University of Toronto, Dr. Geoff Gotto from the University of Calgary, Dr. Lysanne Campeau from McGill University and Dr. Andrew Fiefer aka @urologymd1, also of the University of Toronto. The major disappointment of the night for me personally was the late collapse in the Stanley Cup Finals of my beloved Boston Bruins.

The final day brought with it more great educational forums and abstract presentations. A highlight for me was an address given by Dr. James Orbinski, the co-founder of Dignitas International and former president of Medicins Sans Frontieres. It was a brilliant overview on humanitarianism, global health and our role as urologists and citizens of the developed world. I think we have a strong obligation to promote these themes in our specialty.

Finally #cua13 was the year that the use of Social Media arrived in full force at the CUA.

A twitter board was set up in the main meeting hall to provide a real-time update of the conversation.

A good WIFI connection, which has been an issue at other recent meetings, served everyone very well. With a growing number of Canadian urologists now on twitter (joining early adopters including @_theurologist_, @urooncmd, @qdtrinh and myself). As these analytics show, 78 people participated via twitter during the actual meeting.

Many international colleagues joined in and @mattbultitude even made the top 10 from across the pond.

This form of communication has greatly enhanced our ability to connect and exchange ideas with colleagues from around the world. All urologists would be well advised to explore this technology. A nice primer with a Canadian perspective by @cmaer on the use of social media and twitter for physicians can be found here. At the recent #USANZ13 meeting use of Social Media for Urology was part of the scientific agenda as this presentation by @declangmurphy illustrates. I would like to see the number of participants at #cua14 surpass 200!

Of course living in Toronto made leaving on Tuesday from Niagara Falls about as easy an escape as one can make from any meeting. As we approach summer (at least in the Northern Hemisphere) I wish everyone a safe and restful time and look forward to continuing to engage with colleagues over the next year.

Dr Rajiv K Singal is a Urologist at Toronto East General Hospital and Assistant Professor in the Department of Surgery at the University of Toronto.
Follow him on Twitter @DrRKSingal

 

Comments on this blog are now closed.

 

 

 

Uro-oncology Highlights from #BAUS13

The BAUS annual meeting in Manchester proved hugely enjoyable and notable for the high level of educational content and the quality of the speakers involved. There was a clear emphasis on the increasing role of the web and social media in urological education in the UK, and it was exciting to hear @prokarurol lay out his vision for the BJUI in this regard.

All subspecialties were well represented at BAUS, but I would like to focus particularly on urologic oncology, which was the subject of a number of excellent sessions.

Before that, I would like to show you some the Symplur data on social media traffic at #baus13:

This figure shows that 88 people people engaged with the #baus13 hashtag, many of many of whom were not in Manchester or even in the UK. Using the complex algoritim on their website, they calculate that the 556 tweets sent led to over 340,000 impressions in social media and other digital spaces. 

The traffic each day was impressive and the largest spike happened during the BJUI Social Media Course. Well done to all who tweeted from the meeting.

Professor Ben Lee from Tulane University, New Orleans gave two fascinating talks on Tuesday and Thursday morning regarding novel imaging techniques to facilitate uro-oncologic diagnosis and treatment. He quoted work from Dr. Peter Pinto from @theNCI demonstrating the utility of MRI-TRUS fusion targeted biopsies which detected cancer in 37% of patients with a negative initial TRUS, 11% of whom had high-grade disease. He also discussed novel imaging techniques that may enter uro-oncology practice in the future, including diffuse reflectance imaging and confocal microscopy with fluorescein staining. These techniques may allow intraoperative assessment of oncologic margins at the histological level, and there has been some success with this in the field of breast lumpectomy. One final innovation is the development of a patient-specific simulator for minimally invasive renal surgery. This allows a patient’s CT imaging to be reconstructed into a virtual 3d model, allowing the surgeon to practice that individual patient’s procedure prior to putting knife to skin for real.

Wednesday morning’s session, chaired by Tim O’Brien, aimed to address a variety of contemporary issues across urological oncology. Mr. Ed Rowe and Dr. Stephen Tolchard from Bristol presented their experience of CPEX testing prior to radical cystectomy. Their series demonstrated that CPEX testing was highly predictive of the risk of post-op complications, whereas ASA grade performed poorly. The ability to assess risk pre-operatively is clearly going to be vital to the publication of properly risk-adjusted individual surgeon outcomes, and CPEX testing may be a useful way to do this.

Professor Tom Treasure from UCL was asked to make sense of pulmonary metastasectomy. He pointed to the difficulty of selection bias towards fitter patients with low volume disease who are likely to survive for longer regardless of the effect of the surgery. Prospective randomised trials are needed, but lacking.

Professor Markus Graefen won widespread acclaim for his presentation of the merits of the very high volume radical prostatectomy practice at the Martini clinic in Hamburg. Particularly impressive was the use of continuous statistical monitoring of results, so that incremental technical improvements could be identified and disseminated between surgeons.

The morning session concluded with Dr. Arthur Grollman giving an intriguing account of how Aristolochia herb ingestion was finally established as the underlying cause for Balkan endemic nephropathy.

Wednesday saw another session organised by the Section of Oncology, this time chaired by Mr. Simon Brewster and focussing on active surveillance (AS) for prostate cancer. The session format made use of short, punchy presentations from a variety of speakers addressing controversies in patient selection and protocols for active surveillance.

Professor Graefen returned to discuss surgical and pathological outcomes following delayed RP after active surveillance. He quoted work led by Ruth Etzioni that used a simulation model derived from large active surveillance and radical prostatectomy cohorts to predict comparative outcomes for immediate and deferred treatment. Only very modest reductions in cancer-specific survival with deferred treatment were predicted, with treatment able to be deferred for a median of 6.4 years.

Those data relate to men with low-risk prostate cancer, but what about active surveillance for intermediate-risk disease? Dr. Parker argued the case for, pointing to only 2 of 88 men in the Royal Marsden series developing PSA failure, and one death. @declangmurphy argued for caution however, pointing to the fact that 12 of 92 men in this category from the Göteborg screening study had progressed to require androgen deprivation therapy at a median follow-up of 6 years, which has to be regarded as a poor outcome from surveillance. There was general agreement however that intermediate-risk cancers are a heterogeneous group and that more sophisticated risk stratification is required. Biomarkers may be part of the answer, and Professor Martin Gleave gave an eloquent update including the new multiple gene expression panels that are becoming commercially available in the US.

Further presentations addressed the topic of how to evaluate men entering active surveillance. Mr. Brewster stressed the pitfalls in relying on PSA kinetics alone, given that they perform poorly as a predictor of adverse pathology or recurrence following radical prostatectomy for progression on biopsy-based criteria. Mr. Declan Cahill strongly advocated transperineal template biopsies as routine prior to enrolment and for repeat biopsies, pointing to an upgrading rate of 1/3 at Guy’s where all patients entering AS are offered transperineal biopsies. Professor Freddy Hamdy made the case for avoiding routine repeat transrectal biopsies, given that changes in grade/volume may be an artefact of inadequate sampling, and therefore unhelpful. Finally, Professor Mark Emberton discussed the current role of imaging, making the case for pre-biopsy multiparametric MRI which can exclude tumour foci down to a size of 0.2cc with 95% accuracy and allows targeted biopsies as mentioned earlier. Whether a man with a raised PSA and a negative MRI can safely avoid a biopsy however, remains an open question. MRI may also prove to be a safe, non-invasive way to monitor tumours for progression on AS, reducing the need for repeat biopsy.

Professor Gleave then switched the focus to castrate-resistant disease in the Prostate Cancer UK Guest lecture. Along with a masterful overview of androgen receptor pathways and novel endocrine therapies, he urged us as urologists to get involved in the administration of these agents. Whilst presently utilised post-chemotherapy, they are likely to move into the pre-chemo setting and possibly even replace LHRH analogues for hormone-naïve patients.

Thursday saw an oncologically-orientated @BJUI sub-plenary session chaired by @prokarurol. @jdhdavis provided some great insights into the utility and technique of robotic extended pelvic lymph node dissection in prostate cancer. @qdtrinh gave a fascinating insight into the complexities of health services research, as well as outlining some recent data regarding complications of robotic vs. open radical prostatectomy. Finally, Professor Rob Pickard discussed the recent health technology assessment addressing the relative cost-effectiveness of robotic and laparoscopic radical prostatectomy. Whilst the model requires a number of assumptions, it seems clear that centralisation of robotic surgery into high-volume centres is much more likely to result in acceptable cost-effectiveness, not to mention improved outcomes for patients.

In summary this has been a fantastic BAUS meeting for uro-oncological topics in particular and one I have thoroughly enjoyed attending. It seems the future uro-oncologist will need to be able to interpret and integrate advanced imaging techniques into their practice, make sophisticated decisions about when and how to defer treatment for prostate cancer, utilise a broad range of non-surgical treatments, and provide the very best surgical outcomes in a new era of transparency. I’m looking forward to the challenges ahead.

Ben Jackson
ST7 in Urological Surgery, Royal Derby Hospital
@Ben_L_jackson

 

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BAUS 2013 Conference Report – Day 1-2

This year’s BAUS Annual Meeting was held in Manchester’s International Convention Centre and attended by almost 1200 delegates from all over the world. There has been a lot of anticipation this year following great attendance and atmosphere at the USANZ13, EAU13 and AUA13; much of the success and excitement coming from those conferences was echoed by the delegates on Twitter.

This was my first BAUS conference and I was particularly excited about my place on a urology skills course using fresh frozen cadavers, along with teaching sessions on Paediatric Urology and Urogenital emergencies and a “Walk with Experts” session around the academic posters.

The conference started with 3 parallel sessions on Monday morning:

  • Andrology and Genito-Urethral surgery key updates were discussed with a joint academic session in the afternoon to include the latest basic science research into Peyronie’s pathophysiology, artificial sperm, post-prostatectomy ED and genital tissue Bioengineering.
  • The BAUS Female, neurological and Urodynamic Urology Section focused mainly on the latest updates for urological fistulae, with other Keynote addresses over the following day covering mesh erosions and recurrent stress incontinence.
  • The Academic Session consisted of presentations from the six best abstracts submitted to BAUS this year. As our chairman Professor Dasgupta pointed out, all these presentations were based on clinical research rather than basic science. Is this a bias towards the clinical or is the standard of clinical work higher? The session finished with the awarding of the prestigious BJUI John Blandy Prize, received by the best and most cited BJUI article over the last two years. This year Dr Jérémie Haffner from France won the prize and £5000, for his work titled [the] “Role of MRI for Prostate Cancer Screening”, which he presented in fluent English.

In the afternoon the Exhibition arena provides the opportunity to see some of the latest innovations from the pharmaceutical and equipment industry representatives, and even have a play with 3D laparoscopy. However most trainees are understandably drawn to the Da Vinci stand where a robotic console is the main attraction. Delegates got the chance to use the robot to test their basic skills. 

My walk with the experts was really informative; each group consisted of approximately six trainees and two consultants. It was comfortable to ask questions and really maximised how much you can learn from the posters.

Day two started with a great update on laparoscopy, followed by the BAUS President, Mr Adrian Joyce, who gave his official address and awards as follows;

  • St. Peter’s Medal was awarded to Mr Malcolm Lucas, Swansea, UK.
  • St. Paul’s Medal was awarded to Professor Glenn Preminger, Durham, USA.
  • The BAUS Gold Medal was awarded to Mr Justin Vale, London, UK.

Social media is increasingly present in professional conferences allowing worldwide coverage and dissemination of all the conference content. Recent success was publicised from other Urology conferences, see other BJUI blogs.

BAUS has embraced this emerging technology and the “uro-twitterati” by establishing a twitter hashtag #BAUS13 and having updates throughout the conference. Furthermore a sold-out teaching course on Social Media run by Associate Professor Declan Murphy (@declangmurphy) and Professor Dasgupta (@prokarurol), was held at BAUS this year, which must surely be one of the first at any surgical conference? The session aimed to raise awareness of social media and advise delegates on the safe and best uses of social media in light of the recently drawn GMC guidance on the issue. Members were also helped by the unveiling of a set of BJUI guidelines on social media.

A range of experience was shown by the group, with about 50% using Twitter and other social media professionally at the present time.

Teaching new things in new ways

The BJUI supports BAUS regarding social media and demonstrated their rapid uptake of social media by posting the highest “influence” of any urology journal with a Klout score of 56.
 

During the conference BAUS president Mr Adrian Joyce, blogged his response to a newspaper article demonstrating that BAUS are developing an interest in social media and are using the expertise of their friends at BJUI to help them get their message out. It is an exciting time for all and I think we will see much more activity in social media in urology.

Other changes for the future were raised at the BURST session, where simulation in Urology training was discussed. Simulation will be used more in training and may not just include surgical skills but extend to non-technical skills including leadership, and working with distraction and disruptions.  

The conference has a great educational element, produced by Miss Tamsin Greenwell, with numerous small skills and teaching sessions running on every day of the conference. This allows every delegate to tailor their experience to their interests and needs. In particular the skills session gave us the rare chance for realistic surgical simulation using fresh frozen cadavers, with significant sponsorship at a fraction of the cost. These courses ranged from PCNL access and TURP to basic cystoscopy, ureteric stenting and supra-pubic insertion.

The BAUS social programme is rightly famous, with great events planned every night. The main event from Day 1 was the regional football competition, which was again competitive and well attended with congratulations to the Newcastle Trainees for winning the Cup.

With so much to do and see I am sure that many had a completely different experience to me and I am already looking forward to next year.

Dr Nishant Bedi is a Core Surgical (Urology) Trainee in the West Midlands Deanery, UK.
@nishbedi

 

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