USANZ 2019 Conference Summary

Joseph Ischia: Hello, I’m Joseph and I’m talking urology. We’ve put together a podcast of conference highlights from the recent USANZ 2019 Annual Scientific Meeting held from April 13th to 16th in Brisbane at the Brisbane Convention and Exhibition Centre. The conveners brought forth a stellar cast a good number of whom we were able to catch up with and we asked them for their top two or three take home messages from their talks. Unfortunately, we couldn’t chat to everyone and I apologize to those that were clever enough to avoid the crazy bloke with the microphone Talking Urology guest or not, the speakers were all outstanding so sit back and enjoy the conference highlights from USANZ 2019.

Let’s get this party started with Peter Burke who was the USANZ 2019 convenor and he lets us in on what was the driving philosophy of the conference this year.

Dr Peter Burke: We wanted to focus this year similar to what’s happening for Queensland meetings in the past and the northern section generally likes to run an ASM that is educational, but also fun and really social. Feedback that I’ve had from delegates across the board is that there’s been great science, but also the opportunity to meet with friends, colleagues, sometimes people that I don’t see that often in a relaxed fashion both during the course of the daytime, but also at some great social events and we’ve really enjoyed hosting all of urological and nursing delegates and happy that they’ve had a great time.

Joseph: Ian Vela was the scientific committee chair and responsible for bringing the amazing scientific program to life with a great variety of local and international speakers.

Dr Ian Vela: This year has been an outstanding success from my perspective. The international faculty have been absolutely remarkable in the quality of their presentations, but not just that, they’re also wonderful people and we’ve absolutely enjoyed making lifelong friends from the faculty. The feedback from the delegates is that there hasn’t been a bad session, and so from a scientific chair’s perspective, that’s all I can ask. So, I really do need to thank them for working very very hard during the meeting. They all had multiple presentations and I’m very acutely aware of how much work that is for people to prepare, but all that hard work definitely paid off. Hopefully the delegates were educated about topics that they may not have heard about before and what’s coming on the future of urology which I think is critical to make this meeting relevant and what the aim of it is, is an educational meeting so it’s been a great success. We’ve had a lot of fun doing it, but we’re all glad it’s over. With that in mind, we now like to share with you the highlights of our meeting and we’ll see you all next year in Sydney.

Joseph: Thank you Ian and I will second Ian’s point that this year has been a fantastic meeting. So, let’s hear from our guests. Axel Heidenreich is professor and chairman of urology at University Hospital in Cologne, Germany. Axel swapped Cologne for the sweet perfume in Brisbane and gave several fantastic talks. There were two in particular that had podcast-worth key messages. Firstly, on the back of STAMPEDE and COMET extolling the virtues of radiating the prostate in metastatic prostate cancer, Axel eloquently outlined what role site a reductive prostatectomy may play in this space.

Dr Axel Heidenreich: You need to consider local treatment in patients who have newly-diagnosed metastatic prostate cancer. It could be radiation therapy. It could be side a reductive radical prostatectomy. Especially in patients who have low-volume disease, we know that we can improve overall survival. We know that we can prevent local complications and this is basically what we have to think about in those patients.

Joseph: I asked Axel if he had any concerns extrapolating the radiation efficacy data to surgery.

Dr Heidenreich: No, I wouldn’t have any concerns to extrapolate the data of radiation therapy. The only concern I would have that you really have to select patients very well. So, you need to know about the extraprostatic extensions. Every single patient needs an MRI and you also need to know about your surgical skills. So, you really have to do an internal quality control not to harm the patient, but in terms of overall survival, in terms of on ecological outcome, I would not have any harms to extrapolate the data from radiation therapy to surgery.

Joseph: And what gems did Axel have for us on the burgeoning field of biomarkers in prostate cancer.

Dr Heidenreich: A key message would be that the diagnosis and the stratification of patients with regard to specific treatment options will become more and more complicated over the years. We will have biomarkers to have an idea who needs a biopsy to start with. We will have biomarkers to identify those patients who will benefit from active surveillance or active treatment. And when it comes to metastatic disease, we already have biomarkers which can tell you who is responding to AR targeted therapies, to cytotoxic treatments or who needs an individual approach initially.

Joseph: Be prepared. Better biomarkers mean more complexity in the prostate cancer journey. So, just when you thought urology could not get any more fun, it’s going to keep getting better.

Next, Dr Guido Barbagli, the Director of the Center for Reconstructive Urethral Surgery at Centro Chirurgico Toscano Hospital in Arezzo, Italy was at USANZ to tell us what he has learned from 40 years in and around the urethra. Hoping for some tips and tricks on how to do the perfect primary anastomotic urethroplasty? What gems will he have for us?

Dr Guido Barbagli: The first message for the audience for all people that like to start urethral surgery is don’t render complex what is a simplex please. Use a simple technique that provide the best success rate in your end, not in their literature reports. In your end, do the surgery what you are more confident that provide the best result in your end. The second message I like is take care not only over the disease – urethral stricture disease, but also of the patient. Patient is different. Patient with hyposadia repair is different than patient with bulbar urethral stricture. So, take care of the psychological aspect of the patient and the complaints of the patient. Third message is that the surgery, as said by friend George Webster, is time and brain consuming. Don’t do surgery when you are tired and the stress. Delay the surgery. Thank you.

Joseph: I was not expecting that, but such sage words from one of the true doyens of urology. Peter Gilling from New Zealand is the PI in the water study comparing aquablation to TURP for the surgical management of BPH. At the conference, he updated us with the one-year data.

Professor Peter Gilling: Essentially, TURP and aquablation were equivalent for both urodynamic parameters and symptom scores, and they would know the re treatment rate was similar at one year and the low morbidity continued for both the treatments. I think the conclusion is that perioperative factors the important differences between the two techniques because the long-term clinical data seems to be equivalent.

Joseph: I can hear you screaming out your questions from your cars. So, what is the advantage of aquablation over TURP?

Professor Gilling: The main advantage for aquablation is that there is no learning curve. Essentially doctors were able to enroll patients into this trial with one or two roll-in cases and most didn’t even need that to be able to tackle 50 to 80 g prostates and achieve the same results as TURP. The automation and the robotic assistance, of course, give you a glimpse of how treatments for BPA might proceed in the future, but essentially the average operating time was size independent at around 4 minutes. By adding back in the setup time and just the organizational aspects, it was equivalent to TURP in terms of the total operating time, but really, it only takes four minutes to actually perform the ablation. It’s size independent, its learning curve independent, and if they can get the cost right it can actually probably help us particularly with jurisdictions where waiting lists are a problem for smaller prostates at this stage though there are trials of course looking at the 80 to 150 g group as well showing similar findings though albeit with a higher transfusion rate.

Joseph: No learning curve. This is the future of robotics and artificial intelligence and it has already arrived in New Zealand. Rajeev Kumar is the professor of urology in the All India Institute Of Medical Sciences in New Delhi, India. I was looking forward to his talk on the growing scourge of the pseudo-journals and their predatory practices. I had two questions. Firstly, what are pseudo journals?

Dr Rajeev Kumar: Thank you for asking me to speak here. So, predatory journals are pseudo-journals are a bunch of journals which mimic real journals, and try and get you to give them manuscripts, which they can then put on a website and then you need to pay to publish them. The problem with these journals is that they avoid the basic hallmark of a scientific publication which is peer review, so you can give them anything and as long as you pay them, they will publish it. There is no peer review. There is no scientific appraisal of what’s happening and the manuscripts that you give to them once they’re with them are dead.

Joseph: And secondly, how can we avoid the minefield?

Dr Kumar: The basic way of working around these problems is to look for the credibility of the journal if it’s listed on standard indices or Standard Indexing Services. So, for example, if the journal is listed on PubMed, it’s listed on Science Citation Index, it’s listed on the Directory of Open Access Journals, it’s likely to be genuine. If it isn’t listed on any of these standard indices, you need to run it through a few checks and a few websites could guide you on these checks. So, the websites include the thinkchecksubmit.org website. You could go to the World Association of Medical Editors or wami.org. You could the Urology Green Initiative which is originally from Australia and see if the journal is listed there. And if it is and if it passes the checks that these websites tell you, it’s likely to be genuine.

Jo Semins is assistant professor at the University of Pittsburgh and made the quick hop across the Pacific to give us some fantastic practical tips on the red-hot topic right now of minimizing radiation exposure to patients while they undergo treatment for their stone disease.

Dr Jo Semins: So, I’ll start with just saying that radiation exposure in patients of ours is quite high, specifically in the kidney stone patient, which is my population that I deal with the most often. And I will say that these radiation exposure levels are concerning for potential future cancer development and that’s really the reason why we care. So, when we’re talking about reducing radiation exposure in our kidney stone patients, we’re talking about throughout their entire care meaning from diagnosis, to intervention, to postoperative follow up. So, in diagnosis, you’re thinking about non radiation based imaging such as ultrasounds and KUB potentially which is less radiation than the standard CT. If you are going to get CT for preoperative planning, you’re thinking about low-dose or ultra-low dose which significantly lowers the effective dose.

In the operating room, you with (a) radiation protocols and we’ll talk about that in a second. But in addition, you need a curriculum for your physician and your trainees to teach them and that can reduce radiation exposure by almost 50%. You can also provide feedback to the surgeon about their personal times that’s been shown to decrease fluoroscopy times. And in terms of the radiation protocols, if you have a formal radiation protocol, it can decrease exposure by 80% with similar outcomes and that’s knowing your machine. So, collimation, using techniques where you don’t have to duplicate images, like save and swap. You can use low-dose settings. My biggest thing is the low dose button and pulse fluoroscopy and I routinely use one pulse per second even for the most morbidly obese patient.

And lastly, in follow up periods, there are three main strategies. Number one, following the patient with non-radiation-based imaging such as ultrasound or low-dose radiation such as KUB. Number two, actually reducing kidney stones, so metabolic management. It’s s not a direct way to reduce radiation exposure, but reducing kidney stone events and recurrence is going to translate to less diagnostic imaging and image-based intervention being carried out.

And lastly, patient-specific care pathways. So, having an electronic health record, have an automatic trigger to physicians in the emergency room for patients who are recurrent stone formers to order an ultrasound instead of a CT scan and lastly teaching and educating the patient to advocate for themselves. So, telling them when they show up in an emergency room to please ask for an ultrasound instead of a CT scan.

Joseph: So, how is your local hospital radiation minimization education program coming along?

I think we should just move along quietly.

Scott Eggener is the professor of surgery and radiology at the University of Chicago. He’s not afraid of the hard conversations and started with a topic close to my heart which is the controversial but possible role of active surveillance in Gleason 3+4 =7 prostate cancer.

Dr Scott Eggener: I think most people that spend a lot of time prostate cancer are convinced based on the overwhelming evidence that low-risk cancers or Gleason 6 cancers should very routinely go on active surveillance. The next frontier, selecting the patients that have some pattern for which equates to Gleason 3+3, Gleason grade group two to go on surveillance and putting together the talk was an opportunity to dive into the literature and become a lot smarter about what’s out there and what I learned myself was there’s just a load of data suggesting that the majority of men with Gleason 7 will never have meaningful events even with pretty loose follow up. And so, there’s all sorts of ways of selecting the men with small amounts of Gleason 7 and some other factors we talked about with no cribriform, relatively low PSA density and there’s a lot of really long term follow up suggesting these guys can do great on active surveillance with a relatively low risk of meaningful problems.

I don’t think there’s any magical cut off, but as you start seeing more pattern for, certainly if they become palpable, my level of concern would go way up and I would absolutely recommend treatment but often if there’s low volume Gleason 7, I just think it needs to be thoughtfully discussed with the patient as an option. I would never say with Gleason 7 here’s what you absolutely need to do if you’re perfectly healthy, but just to have a well-rounded discussion and I’d like to put numbers and percentages to patients to help them out.

Joseph: I’ve looked at these data myself and the percentages he is alluding to is an absolute survival benefit of around 1 to 2% of surgery over watchful waiting out to more than 15 years. Would a good active surveillance protocol reduce that even further? Scott also discussed his take on focal therapy for prostate cancer.

Dr Eggener: Focal therapy conceptually to me makes a lot of sense and there’s a lot of other paradigms within urology and other surgical oncology. The most convenient paradigm that it’s similar to is lumpectomy for breast cancer. Like I said in the talk, we’re probably 30 to 50 years behind it and I don’t know if focal therapy will ever become widespread nor am I sure that it should. But what I hammered home in the message is I think absolutely positively it warrants investigation and thoughtful clinical trials and more data to figure out if there are men that can qualify for it and do well. We’re in that exciting era where that data is starting to come in and we’ll see where it takes us. There’s a lot of energy sources out there. I think they’re more similar than different and there’s different mechanisms, but in essence, destroying part of the prostate is relatively easy. The more challenging part is figuring out who, where, how much to follow, and getting all the details.

Joseph: Challenge accepted and the need for good registries with these new techniques for partially zapping parts of the prostate.

Tim Donahue made the long trek from Memorial Sloan Kettering in New York from the airport with his passport to end support and put a cork in the rumors that using upfront mesh around ileal conduit stomas is a bad thing.

Dr Timothy Donahue: Despite about 60 to 70 years of experience putting in ileal conduits, we still have major complications that occur with this. One of the most common is parastomal hernia and this happens in up to a third to half of patients. They’re symptomatic. They can sometimes have power strangulation and fixing the hernia once it’s occurred is fraught with complications as well and they often, despite our best efforts of fixing it, will recur within a year or two. So, the idea was could we put in a piece of mesh or so do some maneuver at the time of forming the conduit to reduce that risk? And so, we looked at risk factors and they generally tend to be females and higher body weight or higher BMI. So, these are the people that are at the highest risk of developing a hernia. So, we started a trial in a randomized fashion to see if this was going to be effective. But before we could do that, we had to convince ourselves and others that it would be safe because this is really the worry that people have. I think the one take away point that I would use or give to a urologist is when we look at about 400 people in the colorectal literature that had prophylactic mesh placed, the complication rates were no different. The mesh-related complications did not occur in a way that caused people to need to take down the diversion. And so, we looked at it in our own series of 65 people at Memorial and the same thing was found. We had no complications in that. We’ve done it now in well over 130 patients and we’ve had two complications. One was a mesh infection that was managed with antibiotics alone and the other was a patient who unfortunately flew away and didn’t return for about a month after a surgery, and he had a wound infection that probably could have been salvaged if addressed earlier. So, we’re not yet ready to say whether this has improved the hernia rates. We believe it will but that’s the point of the randomized study. But from a safety standpoint and that’s really what folks have been most concerned about when you address this topic safety we’ve not found that to be a problem. People have looked at biologic meshes. People have looked at permanent meshes and then what we found and what others have found in the successful randomized trial is a combination of a semi-permeable mesh. These are usually a component of monochrome which can absorb and then a component of Prolene which will stick around and so it’s is a wide pore mesh. It’s the one that we use as called UltraPro and it’s made by Ethicon. It’s called Vypro in Europe, but it’s the same type of material.

Joseph: I think that report puts a fork in the talk of avoiding mesh.

Alex Mottrie is professor at OLV hospital in Aalst, Belgium with a special interest in robotic surgery. One of his talks covered the role of robotic salvage prostatectomy in pelvic lymph node dissection. What was his take home message?

Professor Alex Mottrie: I plea that as we have more and more experience in robotic surgery, we are also setting the boundaries and just doing more and more difficult stuff. We should bear in mind that this is less invasive and probably with at least as good an oncological outcome as the classical open resection. So, I do believe that in tertiary referral centers, tis would be a good alternative to the patients provided the surgeon has experience with it.

Joseph: Next, I asked him what new innovations are coming in medicine robotics and very interestingly, education.

Professor Mottrie: Well, to be frank, I’m convinced that medicine in a whole and surgery specifically will change more dramatically in the coming decade than it did the last century. So, when I look at my kitchen, I see robotization all around, so why wouldn’t this happen in the OR? So, I believe that we will see a lot of innovative robotic devices. We will have automation. We will have image overlay. We’ll have tissue recognition. We’ll have a big data coming in, so that will be smart surgery, intelligent surgery, automation of robots. So, this is all coming along. This is technical innovation, but we should not forget that we should also think to renovate education.

I believe that education nowadays is too much the old fashioned Halstedian way, “See one, do one, teach one.” And we have to move away from that and do basic science on how to improve education, which I call quality-assured training. With this, we should be able to lower complication rates with 50% which is unbelievable. We have started to do this work with ERUS, but this is a plea also to the rest of the world and to USANZ, why don’t we join together into this very important work which is good for the patients which could make surgery much more cheaper when we have less complications and to work together, we’ll make work lighter for everybody of us.

Joseph: So USANZ, we’ve heard the call. The times they are changing.

Peter Chin is a urologist in Sydney who has been stapling prostates for over 10 years now. Now, he explains why they had to specifically look at and investigate applying the UroLift to the median low and discusses the hazards of off-label recommendations.

Dr Peter Chin: The technique for trying to pull that prostate away from the actual prosthetic fossa, we could figure out we could do lateral lobes, but nobody could quite figure out how to do the median lobe because you can’t fire backwards because there’s a rectum sitting there. That’s why the original studies were only done on lateral lobe enlargement because we haven’t figured out a way of doing middle lobe enlargement. Subsequent to commercialization in 2013, the FDA specifically said, you’re not allowed to do middle lobes because you haven’t studied it which was quite reasonable in America, but fortunately in Australia we didn’t quite get that from the TGA because TGA and CE mark are very different to the FDA approval. So, CE mark and TGA is really an approval that you can manufacture this device to a certain standard. That’s manufacturing and you do need some studies to say that it works, but it’s not as, I guess, definitive as the FDA.

So, once we got TGA approval, I could then figure out how to actually deal with the middle lobe and I discovered that you can actually pin the middle lobe from one side through to the lateral lobe and basically hold it open. And if you can hold it open, then you actually get almost a better result than if you just pin the lateral lobes from that original, I guess, technique the MedLift study was born and the MedLift study was actually necessary because they could not deal with the middle lobe in America and if you did it, it was off-label and there was several cases where CEOs of big companies who recommended ways of treating things off-label were actually indicted and sentenced to 20 years in jail. So, nobody in the UroLift company wanted to suggest that you could do something off-label, which is where the MedLift study came.

So, the MedLift study was looking at purely middle low management with the UroLift and they recruited 45 men. They found that the results of the MedLift study were better than just doing the lateral lobes. So, what it actually indicated was that if you deal with the middle lobe, you can get a really good result and a lot of times better than just dealing with the lateral lobe. When you combine them, you actually get a better result than just pure lateral lobe or dealing with the lateral lobe. So, any study that deals with both the lateral lobe and the middle lobe is likely to have a better result than if you just dealt with the lateral lobe.

Joseph: Median lobes, I’m not afraid of you anymore, but let me check with my lawyers.

David Nicol, Australian, and now Chief of Surgery at the Royal Marsden Hospital in the UK gave a fascinating talk on the role of surgery in metastatic renal cancer and discusses what the trials of the future in this space should look like.

Professor David Nicol: Dealing with the topic of cytoreductive nephrectomy that has been tossed around for quite some time. Historically, it was seen to assist the effect of Interferon with doubling the survival time, the problem was even then it was still quite modest and we did question whether it was just stealing from the patients remaining quality of life time. The issue is the drug treatments we are now using have moved on, not once but twice, and we’ve really been unable to adequately assess the utility of cytoreductive nephrectomy. It’s attractive conceptually and given that it’s been verified in a modest way with the randomized study, I mentioned I think it needs continuing evaluation.

We have attempted several trials with cytoreductive refractory in the TKI drugs both of which were confounded by I think flawed study design, as well as the fact they’re extremely difficult to recruit and in fact, probably the most useful study was terminated when it only recruited 99 of a planned 400+ recruitment to meet the study endpoints. That particular study did actually support the concept of initial drug treatment and then the use of side cytoreductive nephrectomy on a selected basis to those responded. Those studies obviously may rapidly become irrelevant because we’ll have new treatments with a completely different mode of action, this time immunological thus revisiting the first concepts of cytoreductive nephrectomy. I think what we need to do is to actually look at trials and how they should be structured to not only answer the question of whether the drug is effective, but also how it may be most effectively delivered. And in practical terms, that is whether a drug does or does not need a combination with cytoreductive nephrectomy to produce the best outcome for the patient.

Unfortunately, pharma can hijack this because they control and fund the big studies and I think we, as urologists, need to impress upon them this potentially important role the surgery that needs to be explored. But it should be undertaken at the time the drug is initially evaluated rather than waiting for trials that may or may not succeed subsequently being undertaken.

Joseph: Fascinating insight. So, currently in metastatic RCC pharma companies fund a trial of old drug A versus new drug B, not a mention of surgery anywhere. Then surgeons ask, is there a role for cytoreductive nephrectomy? Well, no one wants to fund that trial. Pharma already knows that drug B is better and whether cytoreductive adds anything is not going to affect them and they won’t fund the trial. So, that is a fantastic suggestion by David that in fact, as surgeons, we should be insisting that any future trials of super new drug C should have three arms, drugs C with cytoreductive nephrectomy versus drug C without surgery versus the current standard drug B. A siren’s call to action for all our budding clinical trialists.

James N’Dow is a urologist from the UK and chairman of the EAU Guidelines Office Board. He gave a fantastic talk highlighting the issues of making guidelines when most of the literature is just not good enough.

Professor James N’Dow: The presentation today really for me focused on the challenges we have in terms of lack of evidence that underpins guideline recommendations. Currently, 90% of the evidence that is published is not fit for purpose to change practice. So, we’re ending up having to use innovative ways of filling the gaps. One is consensus finding using a global approach to that, but the second is now investing in big data, using big data to try and answer questions for the next generation. And that means bringing data sets from not only across Europe, but globally to a neutral platform where we encourage datasets owners to share data and be part of research – the research consortium, to answer these questions and we’ve just secured now funding from the European Commission, IMI, 12M to look at big data outcomes for prostate cancer covering from genetic profiling all the way to survivorship. And we hope that by bringing such data to a neutral platform, we can start using analytical techniques that are very novel to answer questions that are thorny, but current research has failed to address so far.

Joseph: So, the future is big data and bright minds. If he could just let me know which is the 10 percent I should be reading.

Andrea Tubaro is a urologist from Sapienza University in Italy. While he gave many wonderful talks, there was one right on the last day that I thoroughly enjoyed where he discussed this incredibly important issue of bias and conflicts of interest in speakers and those that make the guidelines. Listen to his cracking insight on the personal conflicts of interest that we may all suffer as surgeons.

Professor Andrea Tubaro: I think there is no unbiased opinion. We are bias anyway. The pharma industry is making a lot of noise about making transparent any contribution to the medical world and in the guideline office. We try to be transparent about any financial conflict of interest we have. But the most difficult issue is how to deal with a personal conflict of interest that in the academic world are very common and I don’t think that anybody is unbiased. The problem is how to declare it, how to manage, and how to judge the personal conflicts of interests that are very difficult to measure. Some of us, like me, consult from different pharma companies, but at the same time, when studied, for example, robotic surgery 10 years ago and we were the few ones who could use a robot, wasn’t that a big conflict of interest? If you think about prostate cancer management, I think it was much more than being involved in consultancy boards with the industry.

Joseph: Very nice, real food for thought there.

I hope you enjoyed the cream of the comments [30:37] from this year’s guests, but I feel like I did not do their amazing expertise justice in the time we had available. But as one chapter draws to a close, a new one is just beginning.

So, let’s hear a big welcome from next year’s convenor Jerard Ghossein, a urologist from Perth, who I assume must have a beach house on Sydney Harbor. He also has an interesting tip on the possible physical requirements of future aspiring convenors.

Dr Jerard Ghossein: I got the call about few weeks ago from Michael Negara and he asked me whether I would convene it in Sydney and I thought Michael either probably likes me a lot or absolutely hates me. I thought it probably only logical that a person from Perth will host the next meeting in Sydney. So, I guess, I’ll have to get to know Sydney very well next year. The other thing that Michael has specified that he needed two bald guys wearing glasses from Perth to do it. So, I think that was only down to two, myself and Shane, and so Shane was a lucky person to get the scientific section.

Joseph: So, what has Shane got lined up for us next year and what clever play on words can he make of the theme for 2020?

Shane: So, next year’s meeting in Sydney has been set for the 7th to the 10th of March which is a fantastic time to be in Sydney. The weather’s great. The heat of the summer’s cooling off and it’s a really nice time to be there. It’s going to be held at the Sydney Convention Center which is a brand-new building that’s purpose-built and it’s going to be an exciting return to Sydney because the conference hasn’t actually been in Sydney city for many, many years and we’re really looking forward to it. We’ve already got a great faculty lined up. We’ve had some confirmations from several European and British speakers as well as a couple of really exciting speakers from the United States and it’s going to be a broad conference with the theme entitled “2020 Vision for Urology” looking at where we’re going and trying to perhaps show the right way forward in terms of the future of urology in Australia and New Zealand.

So, we’re really looking forward to seeing you there and we hope that you make your plans early and arrange to spend time both at the meeting and in Sydney because there’s so much to see in and around the beautiful harbor city which is a beautiful place admittedly. Perth is. you know. my hometown and we’re proud of Australia and we’re proud to showcase Sydney for the rest of the world.

Joseph: So, don’t let this admittedly amazing podcast be all you take away from Sydney next year. Get along and enjoy good urology, good friends and good views.

Thanks to all our international and local guests who made the mistake of making eye contact with me and I hope you enjoyed the podcast at home, at work, and in your car. I look forward to chatting to you again soon. Remember there are lots of great podcasts at talkingurology.com.au or follow us on Twitter for the latest podcast releases at talking_urology.

This podcast was produced by Joseph Ischia and Cara Webb and made possible by the generous support of Ipsen.