In November 2016, I had the pleasure of attending the 34th World Congress of Endourology in the culturally rich city of Cape Town, South Africa. Many of your urologic colleagues were also in attendance with a strong representation from the United Kingdom and Europe.
We were blessed with day after day of blue skies, making the pre and post session views of Table Mountain and Victoria and Alfred Harbour quite spectacular. The South African hosts were friendly and welcoming, and the entire experience was a real pleasure.
The congress programme was varied with the main plenary and poster sessions allowing me plenty to pick and choose from to suit my advanced nursing practice interests. The timetable also included topics specifically relevant to the African continent, but of importance to all of us, like the ‘save the rhino’ presentation given by Karen Trendler. Trendler is a passionate speaker, personally involved in rehabilitating young rhinos orphaned by poaching. She explained how the highly-skilled staff at the rhino calf orphanage aims to achieve healthy, viable, self-sustaining rhinos that can be successfully released back into the wild.
This process starts with the initial rescue and recovery of the rhino calves from the wild, a very challenging procedure. They have often been alone for days before they are located and have developed blood sugar abnormalities, temperature control issues, dehydration, starvation, and immune compromise. She stated that the rhino calves also commonly exhibit symptoms of post-traumatic stress disorder.
Urologically they have a high incidence of UTI and cystitis, and can also develop a burst bladder as they are often too weak to stand and they are anatomically unable to urinate if lying down. It was a most interesting presentation and food for thought on how the world’s population needs to strongly support antipoaching activities and the work organisations such as hers are doing to preserve a species on the verge of extinction.
Another interesting African-based presentation was by Prof. André Van Der Merwe, Head of Stellenbosch University’s division of urology in South Africa. He informed the audience of how traditional circumcision practices often result in disfigurement and complications leading to organ loss. Young men are naturally deeply traumatised by these events with psychological illness and even suicide not uncommon in this group. In response, and as part of a pilot study, Van Der Merwe’s team performed the world’s first penis transplant in December 2014. It was for a 21-year-old man whose penis had to be amputated after he developed severe complications from a circumcision.
Prof. Van Der Merwe explained how the surgical team had spent many months researching the techniques used by face transplant surgeons before attempting the penis transplant. They used the same type of microscopic surgery to connect the blood vessels and nerves in the nine-hour operation. After nearly two years, the young man has regained all urinary, reproductive and sexual functions with his transplanted organ, and he considered the successful surgery as having changed his life, significantly improving his psychological well-being and self-esteem.
“..those patients with stents with strings had less sexual intercourse while the stent was in place, than those with traditional stents.”
One of many thought-provoking plenary sessions was a panel presentation where urologists from a variety of settings presented their views on the optimal management of different small renal masses. The panellists presented rationales for active surveillance, renal mass biopsy, partial nephrectomy and ablative techniques. The factors that influenced their decision-making included: size and characteristics of the mass on imaging; renal biopsy findings if performed; and patient’s age and co-morbidities. The merits (or otherwise) of treating CT-diagnosed Bosniak 3 cysts were also discussed. The general consensus was to closely follow these patients although the tendency in young, fit patients was to treat Bosniak 3 lesions as there is a 50-60% chance that they will in fact be renal cell carcinomas.
This session followed on well from the previous presentation expounding the value of ‘more diagnosis and less treatment’ of small renal masses. American urologist Ralph Clayman noted the increase in the number of incidentalomas being detected due to the large number of CT scans now performed annually. He reported that more than 30% of diagnosed renal masses are smaller than 3 cm, presenting urologists with (in his view) a strong indication to biopsy these lesions so that they know exactly what they are dealing with.
He commented that there are many reasons as to why fewer biopsies are performed than perhaps one would expect. These include a perception that the results won’t change the management plan, the risk of tumour seeding, the risk of false positive and false negative results, the risk of complications from the procedure, and the lack of infrastructure in medical centres to enable the procedure to be conducted safely. Clayman then went on to use literature and personal experience to dispute these reasons, urging the audience in his closing statement to get a tissue diagnosis with biopsy then decide whether or not to treat. Other speakers were less convinced that biopsy was always necessary. The general consensus appeared to lean towards the first issue Clayman raised- whether tissue diagnosis would change the treatment plan.
A session on novel imaging of renal masses added to the discussion with a report on the potential merits of performing a Sestamibi SPECT/CT scan to determine the histology of renal tumours. This scan can differentiate benign oncocytomas from other renal tumour histologies with excellent specificity and
sensitivity. This raises the possibility of its use for pre-treatment stratification of patients presenting with an indeterminate renal mass in the future, pending confirmatory studies. Another imaging modality presented as having promise is PSMA scans, for the imaging of metastatic clear cell renal cell carcinoma. Large prospective studies were called for in the novel imaging arena.
The same panel format was used to explore the potential risks and benefits of the various renal and ureteric calculi treatment modalities. It was an excellent presentation using case discussions to illustrate varied clinical scenarios. The points made during the discussions clarified my thinking in this He reported that more than 30% of diagnosed renal area of practice, leading me to increased confidence in my ability to educate and support calculi patients back in my hospital.
Another useful session discussed strategies to reduce ureteric stent discomfort. Stent omission after ureteric stone treatments is associated with an increased risk of unplanned medical visits due to complications, including pain. Speakers reported that alpha-blockers prescribed with anticholinergics are more effective for stent discomfort than a single agent. Tadalafil has also been shown to help. Study results disappointedly indicated that patient education regarding stent-related symptoms did not reduce patients overall discomfort. Patients were reported to have a strong preference for stents with removal strings over those requiring cystoscopic removal. The data indicated however those patients with stents with strings had less sexual intercourse while the stent was in place, than those with traditional stents. In our unit we use both types of stents; it seems it might be timely to explore our patient’s preferences prior to their placement!
Sue Osborne, Urology Nurse, Auckland (NZ), firstname.lastname@example.org