USANZ 2017 Conference Summary Part 2

Joseph Ischia: Hello, I’m Joseph Ischia. Welcome back to part 2 of the Talking Urology 2017 USANZ conference highlights from Canberra. In this podcast we will hear from international speakers Kevin McVary discussing the new minimally invasive surgery techniques for BPH, Chris Chapple discussing the underactive bladder and James Eastham discussing the role of neoadjuvant and adjuvant therapies in high-risk prostate cancer. Unfortunately, I missed a chance to chat to a couple of the big names before they skipped town. Couldn’t wait to get away of Canberra apparently. Olivier Trexer had some fantastic tips and tricks on using the laser during stone surgery. And I also missed the always entertaining Professor Prokar Dasgupta discussing what he has learned from 15 years with the robot. He began by asking us to clear our minds of all biases and misconceptions. However, I was lucky enough to catch up with Declan Murphy and Frank Gardiner to give us their perspectives on the robot. First, let’s hear from Declan.

Dr Declan Murphy: I think Prokar, as an academic and an editor-in-chief of the BJUI, of course, has a perspective on how we conduct these trials. But, of course, personally himself, he has conducted a number of randomized trials in robotic surgery, cystectomy, in particular; and what he covered here at the USANZ meeting was some of the challenges in conducting these studies and how we interpret the results. And referring to the Yaxley study in Brisbane, which of course, has been one of the most landmark studies we’ve had in robotic surgery, he reflected on some of the achievements, first of all, in just completing this study and I think that’s very, very important, Joseph. He was very complimentary to Frank Gardiner and John Yaxley, and Geoff Coughlin and team for completing this study. It’s a huge achievement to fully accrue this study and read it out.

But, second, he reflected on why there’s been some differing views, I suppose, on the results of this study; and we all have our own way and we’re going to interpret results depending on our perspectives, but he did circle around and talk about the whole premise for randomized trials in surgery and why we have some challenges in reading these out. And I think it’s very important that we understand that it’s very different conducting a randomized trial in surgery versus randomized control in a medical intervention, because medical interventions are highly controlled. We understand that these medications we use are very standardized in the way in which they’re dosed in various centers, whereas surgical studies we find it very difficult to standardize as surgeon heterogeneity, by its very nature, means that surgeons will be a little bit different, and may influence the results of studies. So, I think that’s what he was reflecting on wondering whether a randomized study is the correct way to evaluate surgical technique.

Joseph: And he made a really good point 15 years ago. He said he was an ardent supporter of robot and now it was vastly superior, and he talked about his humbling experience over the next 15 years of realizing that maybe we could have jumped the gun a bit regarding its superiority.

Dr Declan Murphy: Yes, and Frank Gardiner, also from the floor, who was at that session, of course, talked about the truth, and he reflected on this. He said sometimes we have to move away from our own preconceived opinions, which I think is what Prokar was reflecting on himself, and try and use a correct study design to find the truth. Is this really better? Is it worse? You know, what are the impacts on the patient, etc., etc.? And I think Prokar is self-deprecating or self-effacing really in reflecting himself on his own enthusiasm for an intervention and then actually how everything is panning out for him, and I think it does remind us we do need to conduct very good studies here. But he did make a point, didn’t he, about alternate study designs and he quoted a very nice comment written by Tim O’Brien, one of his colleagues in London in the BJUI a few years ago, and Tim wondered why Mercedes Benz don’t do randomized controlled trials, and why don’t Mercedes Benz do a randomized trial of the old E class up against the new E class? They’re telling us it’s lighter, it’s more fuel efficient, it’s more spacious on the inside, and we all go out and buy one of those or you do Joe. I drive a Toyota Yaris, as you know.

Joseph: I’m Tesla, Tesla.

Dr Declan Murphy: Yes, you’re a Tesla guy, okay. And so, where’s the evidence to show the new one is better than the old one? And the point being in that piece that Tim O’Brien wrote, he said that industry uses different methods to show that something new is better than something old and they don’t use a randomized design. They use a thing called statistical process control (SPC) and it’s just a way of which we can measure incremental improvements and show it’s better than the old thing. And I think that there might be lessons in that. Why if we use them a new energy device, our ligature is that better than the old energy device? We don’t have randomized evidence there either. But we all know some things are just better than the old thing. And I think that’s what Prokar was saying in his state-of-the-art piece that yes, of course, a randomized control trial is a very pure thing, but it may well be that because of limitations and surgeon heterogeneity and all these sorts of studies, we should be looking at other ways of measuring quality and measuring incremental improvement to see if things we introduce in surgery are truly better.

Joseph: All right. So, I don’t own a Tesla. I thought it just sounded more environmentally friendly. The fact that it’s still more expensive than a Mercedes was lost on me at the time. Declan was as eloquent and convincing as ever and a known robot advocate. So, I thought I would try to find someone to provide some balance and who better than senior author of Australia’s landmark open versus robotic prostatectomy trial Frank Gardiner. Frank makes a great point that he is not anti-robot but he is anti-hype. Frank has a long and distinguished research career and he always says “Show me the evidence” but robotic trials are hard to do. Maybe we should just abandon them Frank.

Dr. Frank Gardiner: Joseph, they are hard to do and they often take a long time to complete. But we should identify the things that really are important and we should address them. And we should address them as rigorously as we can and that means randomized controlled trials because that is the way we will obtain the truth about things and it’s a truth that matters.

Joseph: So, I asked Frank what does he think of the robot.

Dr Frank Gardiner: The robot is wonderful technology, it’s undeniable. Certainly, our 12 weeks results did not show an advantage in terms of the primary outcomes although there were some differences in secondary outcomes. But these were not as pronounced that people might like to say.

Joseph: So, what are the broader implications of the robot debate though?

Dr Frank Gardiner: The broader implications relate to whether it’s something that we should embrace instead of open surgery. My concern is that it’s silly to try to replace open surgery. I think that based on that 12-week data, and indeed our longer term data may be different because we have an open mind, but based on their 12-week data, we could see excellence of the surgeon that matters.

Joseph: And Frank makes one more very pertinent point for the broader implications.

Dr Frank Gardiner: The other thing is if we endorse, unilaterally, robotic surgery and we find that the evidence is equivocal, what we are saying to third world countries is that they must follow us and that has a devastating effect for health budgets worldwide. And I think this is something we have to bear in mind in terms of getting overawed with one technology or another, it doesn’t just apply to robotic surgery.

Joseph: Thanks very much to Declan and Frank fulfilling the very big shoes of Prokar. Next. I caught up with Kevin McVary from Southern Illinois University School of Medicine who gives us the highlights of his talk on the new minimally invasive treatments for BPH.

Dr. Kevin McVary: Well, one of the focuses of my practice and Urology itself is where does the minimally invasive surgical treatment fit to what we already do, what’s called a MIST therapy, and I think it’s a controversial point because these are in some ways newer technology kind of busting their way in to our more traditional algorithm. One of the things I mentioned this morning was about why are patients and physicians attracted to these new technologies and my feeling is that they’re attractive because of the reduced risk of changes in sexual function. There is a cost when you have less risk and that’s that you probably have less impact. So, the things that a urologist may care about improving the symptoms, improving the flow with some low level but definite risk of change in sexual function is a bit of a tradeoff for a patient where he may accept not such robust outcomes if he can reduce his risk. So, balance, impact versus risk, and when patients do that they tend to choose less risk. So, one of the things I think that drives this again is not what they do, it’s what they don’t do, and they don’t impact sexual function.

Joseph: Your thoughts on the UroLift?

Dr. Kevin McVary: Well, it’s a very innovative technique and for a NISH prostate, it’s got some distinct advantages. It improves symptoms and does not impact sexual function at least by every measure that we make.

Joseph: What are some of the newer techniques or agents coming through?

Dr Kevin McVary: So, one in America that is catching on is convective vapor therapy, water vapor called Rezum, where you inject into the transition zone a small amount of steam, water converted steam, and it stays within the transition zone.

Joseph: So, Rezum has durable results out to two years but as is always the way, there is something newer and fancier on the horizon.

Dr Kevin McVary: There is a very innovative idea about— it’s called Protox and it’s a fusion protein that is activated into apoptosis creating impact on the prostate and it’s activated by PSA. It’s really a cool idea. It takes about literally two minutes to do in the office. It is absolutely simple.

Joseph: So, the prostate can be steamed, microwaved, baked, burnt, fried and now seasoned with Protox. It’s a veritable cooking class of flow improvement. But what about strangling it? What does Kevin think of prostate artery embolization?

Dr Kevin McVary: There’s a problem with that technique. I should say those studies, they’re poorly designed studies and there really aren’t good control groups so you’d really don’t know how are you really changing it for the man. I mean, you always have to say, “Oh, this is an improvement compared to what?”

Joseph: Well, I like what I hear. But what are the real issues with prostatic artery embolization?

Dr Kevin McVary: It’s that they’re not urologists doing the procedures. They really have not demonstrated an understanding of what drives lower urinary tract symptoms. In many of those studies, it’s like if you have a prostate, we’re going to infarct it. Well we know that prostate is not the whole story on LUTS. In fact, it’s a fraction of it. LUTS is a much more complex problem. So, what are you really treating when you’re embolizing, and guess what the PSA drops and then it comes back right back to where it used to be. To me, that says problem with durability.

Joseph: Kevin was very generous with his time. So, this is an edited version of his highlights. Please do to the website talkingurology.com.au for the full version. So, let’s get an Australian perspective with Henry Woo. Let’s start with the UroLift. It has some very definite advantages in some men. But how does he interpret the 23% retreatment rate?

Dr. Henry Woo: It’s very easy to criticize what is seemingly high retreatment rate, but it all comes down to a tradeoff with the benefits associated with that technology. Now, a particular feature of the UroLift technology is the fact that there is no diminution of sexual function. So, therefore, if you have a man for whom sexual function is material concern then they may well be very prepared to accept a 23% or even greater risk of failure at say four or five years.

Joseph: And what does Henry think of Rezum and its water vapor?

Dr Henry Woo: The data so far has primarily been in glands less than 80 cc and in a similar way to the UroLift it has actually demonstrated preservation of sexual function. The magnitude of improvement in symptom scores is not dissimilar. However, there does seem to be perhaps a slightly improved flow rate improvement compared to what we see with UroLift.

Joseph: Do we have it in Australia?

Dr Henry Woo: It’s not yet available in Australia but we’re on the brink of having it reach our shores.

Joseph: I just could not help myself. I asked Henry what he thought of prostatic artery embolization and he was very diplomatic about the readouts of the trials.

Dr Henry Woo: When you see results that are too good to be true then quite often that turns out to be exactly the case, but one of the big problems about PAE is the way in which they define technical success as well as clinical success and they use parameters which are not commonly used in the urological literature. So, what interventional radiologists may consider to be a clinically successful outcome does not sort of match what we would necessarily call a clinically successful outcome.

Joseph: Are you seeing many patients around Sydney getting PAE?

Dr Henry Woo: It’s certainly available in Sydney but it’s not being conducted in quite an organized fashion as it is at the Wesley Hospital where there is good cooperation with the urologists.

Joseph: Anything new you’d want to see or think we will see in the near future? What’s on the horizon? What excites you most?

Dr Henry Woo: Well, I have to say the Rezum technology does excite me, but we need more clinical data. I’m especially interested in seeing how well Rezum benefits men in larger glands in particular glands greater than 80 cc. We know with the UroLift it’s challenging with the very large glands. To be fair, it hasn’t been tested in that group and we haven’t seen published outcomes in that but just from my own personal experience, I think that that particular group is going to be a challenge to treat. Now, with Rezum because you’re relying upon the dissipation of water vapor through the gland, intuitively you would think that prostate size is going to be less of a barrier to successful treatment.

Joseph: Thanks Henry who is here to tell us that size does not matter.

Joseph: Excellent. You also spoke about prostatic artery embolization, what are your thoughts on this, Henry?

Henry: When you see results that are too good to be true then quite often that turns out to be exactly the case, but one of the big problems about PAE is the way in which they define technical success as well as clinical success and they use parameters which are not commonly used in the urological literature. So, what interventional radiologists may consider to be a clinically successful outcome does not sort of match what we would necessarily call a clinically successful outcome.

Henry: Yeah, Rezum is a very interesting technology which involves the injection of water vapor and this is then transported through the prostate tissue through a convective heat transfer rather than conductive heat transfer, which is a feature of older versions of heat-based ablative therapies. The data so far has primarily been in glands less than 80 cc and in a similar way to the UroLift it has actually demonstrated preservation of sexual function. The magnitude of improvement in symptom scores is not dissimilar. However, there does seem to be perhaps a slightly improved flow rate improvement compared to what we see with UroLift.

Joseph: So, do we have it in Australia? Next, I grabbed Chris Chapple from Middlesex in the UK who is one of the world’s doyens of the misbehaving bladder. Here are his highlights on the underactive bladder and some of our misconceptions about the target organ or mechanism of action of the usual medications for the overactive bladder.

Dr Chris Chapple: Certainly, detrusor underactivity is a very important condition which increases with age affecting around 30% to 50% of people over the age of 65 to 70, and it’s one of those sort of conditions, unless you actually consider its presence, you won’t necessarily recognize it. And it’s clearly important because if the bladder is not working properly then it can lead on to both storage and voiding symptoms and be misconstrued as being either overactive bladder or in fact bladder outlet obstruction. Conventional concept about the detrusor not so being the most important target for therapy is, in fact, rather a simplification. In fact, we now understand in 2017 that the major target for many therapies is the sensory mechanisms which involves not only the peripheral innovation, sensory innovation at the level of the urothelium and suburothelial plexus but also, of course, the spinal cord and the central mechanisms. And, in fact, all of our existing therapies work predominately on those levels although most people think that they’re working on the detrusor muscle. But clearly, you can have a completely clapped out detrusor and obviously that will be important if it’s underactivity, but in many cases it’s in fact a more subtle problem which is related to aging affecting innovation.

Joseph: Okay, so it’s common, it can be hard to diagnose. Can we do anything about it if we do diagnose it?

Dr Chris Chapple: Well, I think the first thing is to be aware of it as a possibility because obviously you won’t diagnose this unless you think about it. And so, if somebody has got a large residual always bear in mind it may not just be outlet obstruction but in fact may be impaired contractility and that could be related to the detrusor muscle or more commonly due to the sensory innovations and neuroanatomical factors. So, what can you do about it? Well, clearly if a patient has got an increased residual, think in terms of the voiding efficiency. The voiding efficiency is where you relate the residual to the functional capacity which is a voided volume plus the residual, which first of all you cannot diagnose unless you use a bladder diary and that’s in all the guidelines although many people don’t tend to use these or think about them. Having done that, if you’ve got a voiding efficiency of 40% which is a threshold, in other words that’s a residual of 200 with a functional capacity of 500 for instance, then you can see if the patient is symptomatic or not. If they’re not symptomatic, then it’s reasonable just to observe the situation probably with yearly ultrasound, check the upper tracts, and so on. If, however, they’ve got a larger residual and symptomatic, then intermittent self-catheterization is the easiest thing to do. The gut reaction people have with residuals is to start catheterization. Often it’s not necessary, it’s just a matter of careful observation on the patient.

Joseph: And has Chris enjoyed his trip to Australia?

Dr Chris Chapple: Yes, I always do. It’s great. I’ve got so many friends here in Australia and it’s always great to make so many new friends and I must say that we’re very proud of the strong link we have is USANZ at the European Association Urology and we’ve certainly increased our strong collaboration together in recent years not only in terms of many members of USANZ becoming joint members of the EAU, but the adoption of the EAU Guidelines by USANZ and our collaborative work together on that along with our collaborative work on patient information.

Joseph: Fantastic and it’s a great point you make. Our USANZ membership does now get us an EAU membership with all the associated benefits. And a technical point for the USANZ members. You have to go into your online account tick the box confirming that you are happy to have your details shared with the EAU. It’s not automatic. And where did Chris get that number of 23% prevalence? Could it be from an Australian study? Could it be our very own Johan Gani? The intrigue is killing me. Here’s Johan.

Dr Johan Gani: My paper was we looked at the incidence of detrusor underactivity in patients who have had urodynamic studies and we found that in 23% percent of consecutive patients actually were diagnosed with detrusor underactivity. So, it’s actually a very prevalent condition and we know that other papers have also suggested that especially in those over the age of 70 years up to 45% of patients may have detrusor underactivity. So, it’s a very common condition that’s probably under recognized.

Joseph: What’s your treatment approach to these patients, just in broad strokes, what the big broad categories

Dr Johan Gani: So the broad categories are some patients can just be observed, some patients may need to do self-catheterization. We know sacral neuromodulation has a role. Other surgical treatments like TURP may also have a limited role. So, if a patient has had chronic retention for a long time, has minimal symptoms, hasn’t had ever any complications then you can practically just observe these patients. Those that you’re more concerned about, the younger ones, who already have symptoms or some symptoms, intermittent self-categorization is very useful in them. We also note TURP may have a limited role in some men. There have been very interesting papers by a Japanese group, it shows good short-term results in terms of IPSS improvement at three months on the initial paper but they followed it up to 12 years and they actually found that the IPSS improved after seven years but beyond that it reverts back the original score. So, for some reason, the postulated reason is that these patients as they get older, they probably cannot effectively stream as good as what they used to. So, TURP can reduce the outflow resistance, but as the men get older, they cannot sustain the same amount of efficient streaming.

Joseph: As a functional urologist, what’s the one bit of advice or what’s the one key mistake that non-functional urologists make when the patients eventually come to see you?

Dr Johan Gani: So, the diagnosis is the key thing. It can be very difficult to diagnose underactive bladder or detrusor underactivity. The only reliable method is to do urodynamic study but it’s impractical to do urodynamic study on everybody. So, you have to have a high degree of suspicion. So, patients who have both voiding symptoms and also storage symptoms, they may not just have the overactive bladder especially if they’re old, they have risk factors like lower back surgery, pelvic surgery, neurogenic history. So, all of that, if you’re suspicious that they have underactive bladder then they may have it. For example, some patients who do not improve after overactive bladder medications, you have to wonder, “Did I get the diagnosis right?”

Joseph: Thanks Johan. For more information, go to his website www.futileturping.com Next, I spoke to James Eastham, Chief of Urology at Memorial Sloan Kettering in New York who spoke about neoadjuvant and adjuvant treatments for high-risk prostate cancer. He starts by discussing the treatment options.

Dr. James Eastham: From the standpoint of clinically localized high-risk prostate cancer, the standards of care are either radiation plus hormones or surgery. Those are both accepted treatment strategies and should be in the conversation of any man that’s discussing his options for care in that setting.

Joseph: And do we have any proven adjuvant treatments in high risk prostate cancer?

Dr James Eastham: Certainly, in the radiotherapy world, standard of care is a combination of radiation plus hormones. There are some issues with what’s the appropriate dose of radiation therapy, what’s the duration of hormonal therapy but fairly standard in the radiation oncology world that combination therapy is beneficial compared to either strategy alone, either radiation alone or hormones alone.

Joseph: And what about in surgery?

Dr James Eastham: So far, no. We’ve primarily looked at relatively short courses, three to eight months, of neoadjuvant standard hormonal therapy and LHRH agonists typically before radical prostatectomy. While there were some histologic benefits, there were no longer term benefits in terms of meaningful outcomes like biochemical recurrence or clinical progression. So, radical prostatectomy, as a standalone procedure, is considered standard of care for clinically localized high-risk disease.

Joseph: And what study have we got running at the moment that you you hope might show a difference?

Dr James Eastham: So, there’s a couple of studies that are ongoing. So, there is a completely accrued neoadjuvant chemotherapy trial looking at Docetaxel plus radical prostatectomy versus radical prostatectomy alone. That study hopefully will report out at least a biochemical endpoint in the next year or so, and there are also what I think are very important studies comparing adjuvant to salvage radiation therapy in patients with higher risk pathologic features really to determine whether adjuvant truly is better than waiting until the patient shows at least signs of biochemical recurrence and then instituting radiation therapy at that time. In the localized but high risk, it’s going to be less than 10% likely. But for that small subset of patients, they’re likely to show a benefit as well and perhaps neoadjuvant strategies in that population of selected patients will aid in precision medicine as you mentioned.

Joseph: Thanks James and that’s exciting news that we’re going to hear soon about the effectiveness of neoadjuvant chemo in high-risk prostate cancer patients. Maybe the robot could give chemo intraoperatively. And now, let’s heart from Ian Vela from Brisbane who had some fantastic insights on how the landscape may be a little different in Australia for men with high-risk prostate cancer.

Dr Ian Vela: We’ve got a slightly different wrinkle, if you will, in the current environment in potentially high-risk prostate cancer and that we have a new novel imaging technology that’s really taken off in Australia in the form of PSMA PET/CT and PET/MRI which North America hasn’t really embraced at this point in time. So, I think we are potentially using that as a routine staging of men with this sort of high-risk disease and we can potentially identify with greater accuracy men who have potentially metastatic disease, the lymph nodes, which obviously changes their risks profile compared to standard-of-care imaging which is really used for a lot of the trials in the US and even Europe at this point in time. The question is what do we do with those men who have potentially positive nodes on our advanced imaging compared to the standard of care, and can we then potentially use those imaging technologies to then enroll men in trials such as neoadjuvant chemotherapy or for further trials?

Joseph: So, we can enrich outpatient populations to those that are more likely to respond?

Dr Ian Vela: Correct, and one of the issues obviously with even the CALGB trial that Dr. Eastham was talking about is that those men essentially have known metastatic disease by definition to be enrolled, but they’re higher risk so there’s a proportion of men who probably won’t benefit from having neoadjuvant chemotherapy. If you can potentially use either a genomic risk profile or like Decipher, that is a test in the US, it’s not available in Australia, but that indicate a high likelihood of recurrence after definitive therapy or marker of metastatic disease picked up on advanced imaging, if we enrich for those men maybe we will show that there’s a signal for neoadjuvant chemotherapy in the right patients and improve survival in our men.

Joseph: Food for thought. In PSMA, we have this amazing imaging modality and we are not making the most of it with regards to preop staging or the role of its increased sensitivity in oligometastatic disease. I was recently at the ANZUP Prostate Cancer Concept Development Workshop and this oligometastatic disease state has been identified as a major potential space for us to do world-class research. If you have an idea for a trial, get in touch with me, ANZUP, Scott Williams or Ian Davis and let us know how we can change the world. I am prepared to share the Nobel prize.

Next, I wanted to check to Olivier Traxer about his talk on tips and tricks for using the holmium laser during endoscopic stone surgery. Now, I thought already knew everything, just ask my wife. But Olivier had some great tips. Unfortunately, Olivier was out of Canberra like a politician at 5 PM but Damien Bolton was able to outline his keypoints.

Dr Damien Bolton: Yes, this struck me as a really good presentation that he gave, Joseph, and something so central to our practice that we often overlook. To me, turning on the lasers often just like turning on the light switch, but I think that was his main point, that there are subtleties to it which we will all learn to use the laser, to optimize its settings for us, to optimize management of each individual stone. I think probably these key points where the importance of setting the frequency and the energy and pulse duration to optimize the treatment of a stone in its setting to avoid retropulsion of the stone, where that’s important. We can do that, as he mentioned, by increasing the pulse width and by using a smaller fiber.

Joseph: Olivier also spoke about how often we should trim the fiber.

Dr Damien Bolton: He did mention that the fiber tip should be trimmed with metal scissors every 10 to 15 minutes in order to optimize the clarity of the pulse from the end of the fiber, and that also the fiber should be positioned about 3 to 4 mm beyond the tip of the scope. It makes sense that there’s retrograde progression of energy from the fiber as well as antegrade progression, and positioning the fiber that place will help minimize any damage to the lens at the end of the telescope.

Joseph: So, does the size of the laser fiber matter?

Dr Damien Bolton: We all know size matters with everything doesn’t it? The key aspect of that is that with a smaller fiber, you’ve got increased density of energy, which will provide greater fragmentation of the calculus per pulse that’s delivered. The key thing about the smaller fiber as well is that it increases the amount of fluid that can flow beside the fiber through the working channel and was retropulsion.

Joseph: Size matters indeed. The day we stop making size matters jokes is the day that saw palmetto actually works better than a tic-tac. Now, let’s check to the antithesis or crackery and snake oils, how illustrious and immediate past president of USANZ, Mark Frydenberg who discusses his thoughts on the direction of USANZ and some of the immediate and looming issues for Australia and New Zealand urologists.

Dr. Mark Frydenberg: Thanks, Joseph. The two-year term has actually really been very, it’s very enjoyable, but also very challenging at the same time. I think from just an organizational and personal viewpoint, I mean, it’s been a terrific personal growth thing for me. You know, it certainly does allow you to meet a lot of both national and international people, incredibly talented, smart and intelligent and you know they do become your friends but you learn a lot from them as well and also the process of actually just running the organization, actually you learn a whole lot of skills that you don’t have previously. As an organization, we’ve really developed a lot. I think this meeting clearly highlights that. But our stature, I think, in the international urologic community has actually increased enormously and I think a lot of that has been due to a lot of the work that the society has done in building bridges with a lot of the international organizations. I think at home the challenges the urologists are to really adept to the current working environment in 2017. I think in the past, if you go back you know 5-10 years ago, we largely self-regulated. You know, we would be sort of doing any procedure that we thought that we were able to do. We would perhaps, as a group, examine our own outcomes, complications, morbidity, mortalities. Costs really weren’t looked at and so on, but all of it was pretty much done as sort of an internal process by ourselves as a group of responsible professional specialists. But the world has changed and that has probably changed because of the fact that medicine is expensive. Health funds and private health insurance, at least in Australia, is I think viewed as a fairly poor product by a lot of people currently because of a lot of the excessive costs that they have to pay on top of their fees and most other insurances, the insurance covers for whatever it is they go through, that’s not the case in health insurance.

Joseph: So, the good old days of self-appraisal are over which is a shame because I think I am very good surgeon and comedian. They say laughter is the best medicine, but it tends not to work to impotence.

Dr Mark Frydenberg: So, governments now are beginning to sort of get involved in that space and saying, “Well, we need to have a very transparent way of knowing which people can do what safely.” And that’s why, for example, in New South Wales there’s a scope of practice commission that are doing a project to try and work out what is core urology procedures that any urologist can do but what are some procedures that can’t be done.

Joseph: The government is aware about different competencies and outcomes between surgeons and monitoring or regulating our scope of practice is on their agenda. Mark Continues.

Dr Mark Frydenberg: Fees are another issue. So, you’ve got private health funds like Medibank Private, Bupa that are now publishing patient outcomes not only with regard to outcomes of surgery and complications but also out-of-pocket costs. So, they’re very transparently being looked at by all of the health funds and then at the end of the day, you’ve also got surgical complications and outcomes which again are being looked at by various organizations. There’s a group called the Health Roundtable that are looking at this data. You’ve got the health funds that are looking at this data as well.

Joseph: So, you know that paranoid feeling you have that someone is watching over your shoulder? Well, they are. So, how should we react?

Dr Mark Frydenberg: The initial reaction of, even myself as a practicing urologist but really all urologists, is that of discomfort because of the fact we’re not used to having people looking over our shoulder at what we’re doing. We’re used to regulating things ourselves and it’s a bit of an affront on our own professionalism because we’ve always viewed that we handle ourselves ethically and appropriately and do make good decisions for patients and do good surgery and we do. The problem is that we have to unfortunately have to get over the discomfort. We have to adapt to this. This is not going away. All this stuff is going to remain because for the community it’s expensive and it’s important. We need to be very proactive in this area and actually have a seat at the table, otherwise, data is actually going to be misinterpreted. But the reality is that if like most urologists, we are practicing good quality urology, we’re making good decisions for our patients, we’re charging them fairly, and we’re getting good outcomes for them with minimal complications, there’s actually nothing to fear about this process because they will actually see how good we are as a profession.

Joseph: Thank you, Mark, and we really do need to be prepared for further oversight and government regulation and it sounds like the leadership at USANZ is well placed to represent us so we could continue to offer the best care for our patients. Please go to the website talkingurology.com.au for the unabridged version of Mark’s talk.

So, that ends the second part of the USANZ conference highlights. Please tune in to the third and final part where we will hear from myself and Shankar Siva discussing the role of metastasis directed therapy or focal therapy in oligometastatic disease, Laurie Klotz arguing why surgery is better than radiation for localized prostate cancer and we will also hear from the award winners from the conference. I will also chat to Kath Schubach about the highlights from the nursing conference.