How I Almost Did Not Become a Urological Surgeon.

If anybody had suggested that I would become a urologist when I was a medical student or even as an intern, I would have told them that they were dreaming. My exposure to the field was fairly minimal during my time as a medical student and the thought of operating amidst urine just did not spark the slightest interest.  If anything at all, I was interested in becoming a plastic surgeon or a general surgeon. 

At the commencement of internship, we were all allocated to do at least one surgical term out of the 5 terms for the year. I was allocated urology for my surgical rotation. It was known to be horrendously busy and quite ironically, the two interns allocated to that rotation were probably lucky to ever have time to empty their bladders. I was horrified at the thought of doing the surgical specialty that was of least interest to me.  I quickly got in touch with a friend whose career interest was in psychiatry and he was completely unfazed about which surgical term he would do.  The swap was made and I got out of urology and did a plastic surgery rotation instead.  I just loved my time doing Plastics and by the end of the term, I was virtually unmovable in my desire to be in that specialty.  

For the second post graduate year (or resident medical officer year), it was again a fairly general year and to my horror, I was again allocated urology. I thought ‘hang on a sec, isn’t urology meant to be an intern rotation?’  Given that the term was so stressful for two interns, it was thought that it would be better to replace one of the interns with an RMO. Having that extra year of experience was going to make a huge difference.  I again hit the phones and on this occasion could not find anybody who was willing to do a swap. Begrudgingly, I accepted the fact that I would have to do this rotation. In spite of the adversity, I threw myself into the job and to my great surprise found the specialty extraordinarily interesting.  Urologists were both physicians and surgeons of the genitourinary tract and were not beholden to masters in any other specialty group in order to have a practice livelihood. On top of this, the urologists to whom I was to be exposed to, took great interest in my work ethic and general interest in surgery.  Their kindness and support for me had a profound impact on me although I was still steadfastly obsessed with having a career in Plastic Surgery.  

My primary career focus during my RMO year was to pass my surgical primary examination which at that time has a pass rate of around 25%. It was at that time, a clear barrier to restrict entry into the surgical profession. Fortunately I passed the examination on my first attempt which was pretty good going since my undergraduate academic record at university was fairly ordinary (after I discovered the medical revue, I never saw another credit or distinction grade for the remainder of my medical degree).  I now had to think carefully about where my next career move would be.  Something that I had noticed about the plastic surgery trainees at the time was the fact that they were all relatively old compared to other trainees.  At that time, those entering into plastic surgery training would first complete their general surgical training and then spend a year or more in non-accredited plastic surgery positions before commencing core training.  I came to realisation that the majority of those who were undertaking plastic surgery training were going to nudging 40 years of age by the time they were ready to commence independent surgical practice.  I thought that this was crazy and that I did have a life to live and made the tough decision to abandon the idea of training in plastic surgery.  My mind kept me returning to my time in urology and I soon became convinced that this was where my future lay.  

As is so often the case, it can be the mentors that you meet in the field rather than the field itself that can initially draw you towards it. 

To this day, I have no regrets.

Robert H. Farnsworth - my hero in urology

At the Gala Dinner of the Urological Society of Australia and New Zealand (USANZ) Annual Scientific Meeting on 13 April 2015, a special man was the recipient of the Society Medal (USANZ Medal). 

Robert Farnsworth's achievements are well known within my profession.  

The next few tweets sum up my thoughts

I was in my final year of urology training when I worked for Bob. Just some of the things that I recalled from my time with him included

1. treating everybody with equal kindness and respect, whether a janitor or internationally acclaimed professor
2. never ever making me feel bad when there was something that I could have done better
3. always having time for me, even for what in hindsight were trivial matters (even if this meant him going home later than planned)

When I returned from additional training abroad, I entered independent practice and there were a number of occasions that I would call him for clinical advice. Even though I was now his competitor, he continued to be so willing to share his wisdom.

It was a proud moment for all of us who have had the privelege of training under him to see him awarded the USANZ medal.  He's the closest you get to a Mr Holland (as per the movie Mr Holland's Opus) that would be possible in the Sydney urology scence. 

Great Gigs at the AUA Annual Meeting

I thought that I would share the story of how a group of people attending an Annual Meeting of the American Urological Association managed to score an entry into a Prince concert.

We had been enjoying a wonderful meal at a San Diego restaurant and mention was made that Prince was in town. A couple of our group were from Minnesota which of course is the home town for Prince. As such we were cajoled into walking back to our hotel via the Hard Rock Cafe Hotel for the sake of a possible glimpse of fame.  As we reached the Hard Rock Cafe Hotel, there was a long line on the footpath.  When asked as to why they were lining up, we were told that they were waiting to get into the Prince concert which was starting at around 10pm.  One person in the line mentioned that there might still be tickets at the sales desk in the hotel lobby. 

Upon reaching the ticket sales desk in the hotel lobby, we were advised that no more tickets could be sold because just at that very moment, their printer had completely malfunctioned. A well dressed man with a much younger lady who was literally hanging off him, was not happy. He carried the attitude of “do you know who I am?” and it was suggested to him by one of the bouncers to try using the hotel’s business center to see if tickets could be purchased on line and printed out from there. We decided to follow this couple to the business center to check out whether tickets were available and how much they were going to cost. Once ‘on line,’ it quickly became evident that ticket sales for this show had been discontinued as it was too close to the time of the show’s commencement.  In any case, this was a small and fairly intimate gig with ticket prices being in the vicinity of $250 each.  The pricing pretty much turned us off from pursuing this any further.

The man I mentioned earlier was really unhappy and complained bitterly to bouncer.  The bouncer then suggested that he go to the head bouncer at the entrance door to the venue to try to resolve the situation. My thoughts were that we should tag along in case we could benefit from being in the slipstream and I signalled to the others with my hand to follow.  At the entrance, the story was explained to the head bouncer that an attempt was made to buy tickets in good faith but because of the printer malfunction, attendance to the gig was not going to be possible. The head bouncer went into a huddle with his colleagues and then announced that if $250 cash per person was paid, then entry would be permitted. The couple that we followed coughed up the cash and were granted entry.  We jokingly said how about $250 for the five of us but that was a no go. As we were walking away from the entrance, we bumped into the first bouncer who had been directing us in the hotel lobby.

He asked, ‘how did you go?’  I explained the story of how we had 5 Australians and 2 from loyal Prince fans from Minnesota who had tried in good faith to buy tickets but were not able to as a result of the printer malfunction and then with the closure of the on line ticketing website for sales to this gig.  I explained how as visitors to this town, we simply did not walk around with hundreds of dollars in our pockets and relied on our credit cards.  The bouncer then says. "F**k, I hate when this happens.  Look, come with me."

He leads us down the footpath and around the corner where it was dark.  He pulls our entry wristbands and says to us "just give me what you have in cash and I’ll make sure it goes to Prince’s favourite charity"  Most of us only had about $20 in our wallets and even though it was all that I had left in my wallet, I was happy to part with it. We put on our wristbands and he then lead us through a back way through the hotel into the venue. The next moment we were inside and the doors behind us closed and the bouncer was gone.  It was major high five and it is pretty obvious that it was a fantastic gig.

You never know what is going on in town when you attend an AUA meeting. In the previous year in Atlanta, we were treated to an outdoor concert featuring the Flaming Lips,  This year, the only performers of note were Modest Mouse.  Tickets were available although scarce but at over 5 times the original cost so decided to give it a miss.

Tips For Junior Surgical Registrars by Dr Kesley Pedler

This is the first ever guest blog piece on "Surgical Opinion."  It is written by Dr Kesley Pedler who has just completed the Surgical Education & Training (SET) in Urology.  We are on the brink of seeing her enter urological practice and in this piece she shares tips on the day to day work as a surgical trainee.  I think you will all quickly gather that Dr Pedler is going to be one of those individuals who will create their own luck. - Henry Woo

_______________________________________________________________________

Tips for junior registrars (SET 1 to 3): things I wish I knew when I started my training

This week I completed my SET Urology training! It has been quite a journey and I have learnt a great deal from my many mentors over the last six years.  I have decided to share a few tips which I have figured out over the last few years which I have found helpful in performing my day to day job as a urology registrar. 

These tips will help you become an organised, competent, efficient and mature registrar which means your consultants will be more likely to increase your level of responsibility both inside and outside theatre which will allow you to learn more!

Be organised! ( especially for operating lists)

·       Know the cases beforehand:

o   This includes the indication for the procedure and results of relevant investigations .

o   This will help you understand the decision making process that has lead to your consultant bringing the patient to theatre.

o   Make sure you review the relevant imaging beforehand and display in the theatre (e.g. for a radical nephrectomy- make sure the CT is displayed demonstrating the tumour and also the vascular anatomy)

·       Know what major cases are coming up a few weeks in advance

o    Your consultants will expect you to know

o   This also gives you time to prepare for the case and read-up in advance. If you demonstrate understanding and knowledge of the operative steps, your consultant will feel a lot more comfortable letting you perform a significant part of the operation.

o   Befriend the administration staff in the bookings office in order to preview lists ahead of time.

·       Be punctual

o   Ensure you allow enough time to arrive on time (or even early) to theatres

o   This means scheduling enough time beforehand to complete ward rounds

o   Unless there has been an unforseen emergency elsewhere, avoid arriving at your theatre list after your consultant (and they will take note especially if this is a recurring occurrence).

Keep a notebook of details of operations

·       I have found it useful to keep a record of the particulars of certain procedures. This includes pre-op preparation, patient positioning, intra-operative details of each step including details such as particular sutures used and post operative management.

·       This can either be in the form of a notebook or keeping copies of select operation reports

·       This is invaluable since it will be a good reference to read before doing the particular case next time

o   Your consultant will be impressed you recall the details of the procedure and will be more likely to let you do more the next time.

o   You will often find that different consultants will perform the same procedure slightly differently and you will be expected to perform the procedure in their specific fashion.

·       This is also a useful resource in preparation for the operative viva in the fellowship examination.

·       It may also be useful when starting consultant practice- you can pick and choose which way you will perform a particular procedure according to what you have seen work well during your training.

Be organised outside the operating theatre

·       Keep a list of your inpatients close at hand

o   It is impossible to remember all details

o   I use this to record important information such as drain outputs, salient blood results and pending investigations.

o   I then refer to it when speaking to consultants about their patients (and jot down instructions and changes to the plan)

Think before calling your consultant

·       Have a definite purpose to your phone call

·       Think about how you will present your case before dialling.

·       Articulate your plan of management (even if you are not sure, suggest what you think is appropriate, it will help your learning even if you are incorrect)

·       Have a list of all your consultants patients plus any other issues you need to discuss so that all issues are dealt with in one phone call

Think beyond the acute hospital admission

·       This can take a little time to develop since as junior doctors we are only exposed to the acute hospital setting which is predominantly focused upon discharging patients

·       Think about what long term follow-up, investigations and future procedures are required. This will help you learn to manage the patient completely- a skill necessary in consultant practice and this will be assessed in the exam.

Look after yourself

·       Try to get enough sleep, eat and exercise when you can (although this is not always possible)

·       Have a proper holiday (i.e. going away and not thinking about study or work) at least once a year.

Remember that there is more to life than just urology!

·       Don’t neglect the significant people in your life (family, partners, friends). This is what is really important in life and it can be difficult to keep this a priority when your work and training often clash with other life events. 

·       The last thing you want is for the significant people in your life to feel of lesser importance than your work.

     (This piece was originally published in the USANZ Training Newsletter called "Bridges" in  February 2014. Dr Pedler has been kind enough to allow this piece to be reproduced here)

Superbugs and Prostate Biopsy

I am deeply concerned about the rising incidence of so called ‘superbug’ infections associated with prostate biopsy.  These bacteria are resistant to the great majority of antibiotics we have available for use and the only ones that work generally have to be given through the veins.  These bacteria have become particularly prevalent in Asia where the indiscriminant use of antibiotics in agriculture has lead to the breeding of antibiotic resistant bacteria in the community.  When you are well, they are of no risk and they live harmoniously within your body.  Should you be placed in circumstances where your own bacteria turn against you and you happen to have the ‘superbug’, this can lead to serious infection as conventional antibiotics are not effective.  For those who wish to get technical, with the term ‘superbug’, I am referring to the so called extended spectrum beta lactamase producing bacteria (ESBL). With increasing travel to Asia, growing numbers of Australians will carry these bacteria within their intestines.  Any procedure that carries ANY risk of infection, which happens to include prostate biopsies, will carry a risk of serious infection.

The article published in the The Age today is entitled “Prostate biopsy blamed for preventable superbug deaths”.  This headline will understandably place fear in every man who is about to be scheduled to undergo a prostate biopsy should they read this piece.  However, there needs to be some perspective on the calls for urgent rectification of the problem of superbugs by having all public hospitals purchase the equipment that will enable the risk of any prostate biopsy related infection to be eliminated.  The typical cost of such equipment is $150,000 and multiply this by the number of public hospitals, it poses a massive infrastructure cost and represents monies that have to be taken from somewhere else in the health budget.

Transperineal prostate biopsy (TPB) creates significant burdens on resource utilization. TPB require a general anaesthetic and day surgery admission to hospital as well as utilization of precious operating theatre time.  Almost all Transrectal ultrasound prostate biopsies (TRUSPB) are performed in an outpatient setting and typically take 15 to 30 minutes including turnover time.  A TPB can typically utilize as much as 45 to 60 minutes of operating time including turnover time.   More than 20,000 prostate biopsies are performed in Australia each year and if every one of these were to be immediately pushed into the hospital system, urological surgical resources would be pressed to cope.  Waiting lists would likely significantly increase and it is highly unlikely that there would be increased allocations of operating theatre sessions for urological procedures.

Figure 1. Transperineal biopsies performed in the operating theatre setting 

Even if a reliable mechanism was found to perform the procedure under local anaesthetic, the procedure would still need to be performed in the hospital setting as appropriate infrastructure such as physical floor space and the operating table which enables coupling to the transperineal biopsy equipment is simply not readily available in the outpatient setting.  

The majority of men would need to take the day off for the procedure and often the following day given that they have had a general anaesthetic.  If the procedure is performed as a TRUSPB under local anaesthesia, most are able to return to normal activities either the same or following day.

There are certainly issues with infections associated with TRUSPB.  These men can become very sick and a small number of cases may require admission to Intensive Care Units.  Men should however, be reassured that their risk of dying from a prostate biopsy infection is extremely small.  The Victorian data demonstrates a reported incidence of 2 deaths over the past five years. With over 7000 biopsies being performed in Victoria each year, this equates to an incidence of 2 out of over 35,000 prostate biopsy procedures (<0.006%) and in the article published in the Age today, these are attributed to the ‘superbugs’.  When we look at the mortality rates associated with infections, a recent paper found that the incidence of community acquired ESBL sepsis was around 10%.  In a mix of patients with healthcare related and community acquired ESBL sepsis, the mortality rate was as high as 20%.   The patients most likely to die were elderly or had significant medical co-morbidity and exactly the type of patient who perhaps prostate biopsy ought not be undertaken.

There are relatively few invasive procedures that do not carry a risk of infection although transperineal prostate biopsy is one where the risk is negligible if not zero.   This data has been repeatedly confirmed and provide a compelling argument to switch completely from TRUSPB to TPB.  But are there any medical reasons why we should reflect on this assertion?  A recent Australian study published this year, the risk of acute urinary retention was 4.2% whereas following TRUSPB, it is a very rare event.

Rather than see panic stations with public outcry and a call for all hospitals to be immediately armed with the expensive equipment, other processes should be enter into practice with a greater level of urgency.  We have to be pragmatic and recognize that hospitals are not about to be funded for this equipment in the immediate future and other strategies need to be sought in the meantime. 

With the recognition that too many men diagnosed with prostate cancer die with the disease rather than from it, we need to better select the men in whom prostate biopsies are recommended.  We also need better risk assess which men are more likely to carry the ESBL ‘superbug’ and a history of recent travel to Asia should be explored.  We also need to get smarter about either using or searching for simple strategies to minimize the risk of ESBL infection such as performing rectal microbial swabs in advance of the prostate biopsy, use of antiseptics such as betadine suppositories in the rectum or dipping the biopsy needle in chemicals such as formaldehyde before each pass.  These strategies need more work but represent that the profession recognizes more needs to be done. With growth in the use of MRI scans prior to prostate biopsy, it is also possible that fewer biopsies will need to be taken and there is the potential that fewer numbers of biopsies taken may ultimately be proven to be associated with less risk of infection.  We can also potentially improve the recovery from infection by having men appropriately counseled to attend for assistance immediately with the onset of infection rather than ‘sitting on it overnight and attending in the morning’ – when bacteria are capable of double in numbers as fast as 20 minutes for some, early presentation can make a huge difference to recovery.

In conclusion, ‘superbug’ infections are a serious problem and we need to do more to minimize the risk to our patients on many fronts.  I believe that transperineal prostate biopsies are one way forward, but the practicalities and priority needs to be considered in the context of other health priorities. 

Disclosure - A/Prof Henry Woo has access to TPB equipment at his hospital and does perform this procedure in selected men. The vast majority of his patients undergo TRUSPB under a local anaesthetic prostate block in an ambulatory outpatient setting.

Urolift-off. The rewards associated with Doctors working together with Engineers.

Since 2005, I have in my spare time, been working on a project that I was invited to join by a start up company called Neotract Inc which is based in the Bay area of San Francisco.  The company was initially made up of a small group of engineers who had a great idea of how a minimally invasive device could be created to treat male lower urinary tract symptoms (LUTS).  Over the years, minimally invasive devices to treat LUTS as a consequence of benign prostatic hyperplasia involved destroying prostate tissue whether it be by freezing, cooking, steaming, lasering or even microwaving. Whilst less invasive than procedures that physically removed prostate tissue at the time of surgery, these still required a period of recovery and there was often a delay in deriving full benefit due to the need for tissues to recover after destructive energy or one sort or another had been applied to the prostate. The idea was to use a mechanical implant that would pull open the prostate urethra. 

(Screenshot taken from www.neotract.com)

Through my involvement with Neotract, I was able to provide clinical input as well as being part of the clinical trials. This has lead to a number of publications that can easily be found by searching under my name and the search term either prostate or urolift.  This month, we have seen this technology finally achieved US FDA approval. I wrote a piece about the benefits of clinicians and engineers working together for the BJUI Blogs.  I was deeply moved to receive the following letter from Josh Makower, Chair of the Board of Neotract, Inc.  I felt compelled to share this letter (with permission) which was addressed to myself and my co-investigator Dr Peter Chin.

Dear Henry and Peter –

This morning I opened my email and found this...  http://www.bjuinternational.com/bjui-blog/urolift-takes-off-from-down-under-the-potential-rewards-when-engineers-bring-you-into-their-inner-circle/

I must say, Henry’s words brought a small tear to my eye.   After 9 years of amazing struggle against many obstacles, our small team of passionate dedicated people have finally made it through a most significant hurdle towards bringing this technology to patients in the US.  It’s a milestone that for many years seemed almost un-attainable and there were many dark days,.. but perseverance, trust and a vision held us together. 

Henry and Peter – you were the first.  There are always those who go first and history thankfully will mark them as innovators and leaders. You went where no one had gone before and gave us your time, your ideas and your talent towards a dream.  That dream is one step closer to being realized and we would not be here if it were not for the two of you.  When procedures and technologies become mainstream medicine, people often forget what it took to get there.  They  forget, or do not even know, how much a toll such a process takes on our relationships as we invest our lives in bringing something like this to fruition.  But for those of us who were all in the trenches together; for those of us who hunkered down, re-grouped, re-engaged, re-energized and stood up again to regain ground when all appeared lost, we will never forget you and never forget the team that brought us here.

On behalf of all us, Henry and Peter, thank you for your leadership and your partnership.  Henry – you articulated something special that must be shared – the partnership between engineers, entrepreneurs and physicians needed to advance medical technology is an essential one that we must never lose.  Without it, medical innovation would not happen.  Thank you for sharing your thoughts and putting them to paper in such a special way.  I hope thoughts like these help preserve that special balance of talents, interests and shared goals that truly have the power to change the world and make it a better place.

From all of us at ExploraMed and NeoTract, and for all the patients who will benefit from all our collective efforts – thank you.

Sincerely -

Josh