Recently, I attended the BAUS conference held at the BT Convention Centre in Liverpool, England last June 25 to 27.
I was joined by a few urological colleagues from New Zealand and Australia, but accents were predominantly British and European. There were around 950 names on the published delegates list but I was unable to ascertain the breakdown of medical staff, nursing and allied health workers.
I was very much looking forward to this, my first British conference given the similarities between the New Zealand healthcare system and the National Health Service. I was not disappointed, finding the conference sessions stimulating and relevant to our healthcare environment. I particularly enjoyed the thought provoking session hosted by BURST Research Collaborative. This is a trainee-led research group comprised primarily of urological registrars, supported by consultants, junior trainees and medical students. The aim of the collaborative is to produce high impact multi-centre audit and research that can improve patient care. They also offer on-line education series aimed at honing the research skills of health care practitioners.
At the conference, the group updated us on their project called ‘MIMIC.’ This is a multi-centre cohort study designed primarily to establish the relationship between White Blood Cell (WBC) on admission and spontaneous stone passage (SSP) in patients discharged from emergency department after initial conservative management. The hypothesis of the study is that a raised WBC is associated with decreased odds of SSP and it is hoped that the evidence from this study will guide clinicians on the management of patients who present with acute renal colic.
MIMIC has closed for recruitment and its primary data analysis is underway. A BURST poster was presented at the conference on the secondary aim of the MIMIC study, evaluating the role of Medically Expulsive Therapy (MET) in SSP in patients with acute ureteric colic. The protocol included all patients admitted with acute renal colic with CT-KUB confirmed obstructing ureteric stone. Statistical analysis was used to explore the effect of age, gender, stone size and position, (upper, middle or lower ureter) on whether MET use had an effect on SSP.
Data was collected from 4181 patients. 75% (3127) were discharged with conservative management. 80% of these (2516) later spontaneously passed their calculus and were included in the multivariate analysis. Results indicated that 44% (952) were prescribed MET in the form of Tamsulosin and 56% were not (1234). The rate of SSP in the two groups was 78% and 72%, respectively. Although this is a 6% difference in favour of MET use, this effect disappeared when confounders such as stone size and position were adjusted for in the multivariate analysis. The study therefore concluded that MET has no benefit in SSP regardless of stone size or position.
IDENTIFY’s interim findings
The BURST Research Collaborative also presented interim findings from IDENTIFY, a protocol that is recruiting until the end of this year. IDENTIFY is the acronym for study: Investigation and Detection of urological neoplasia in patients referred with suspected urinary tract cancer: a multicentre analysis. IDENTIFY is a study dear to my heart as the centre where I practice collects a very similar data set on individuals that are seen at our one-stop haematuria clinic, modelled on clinic protocols in the UK. I felt disappointed not to have been aware of the study earlier, especially when I noted that around six Australian sites were participating in the data collection.
To date, 7,500 patients have been recruited in just six months, a testament to the power and organisation of BURSTS international trainee network. This study is designed to inform the creation of haematuria risk stratification pathways, beyond patient age and type of haematuria (visible/ non visible). These pathways can be incorporated into urology guidelines utilised to determine the need for and type of haematuria screening investigations.
The session presenters informed us that of the 73 United Kingdom Hospitals participating in the study 82% have a one-stop haematuria clinic and 52% did routine PSA screening as part of their work-up. 52% utilise renal tract ultrasound scan as their first-line imaging for visible haematuria, with 45% using CT scan. Preliminary findings (may change after final data analysis) reveal a renal cancer diagnosis rate of 1% (78) and upper tract Urothelial Carcinoma of 1% (79). Bladder cancer was diagnosed in 14.6% of patients (970) and prostate cancer in 0.8% (51). This is from referrals for both visible and non-visible haematuria and other referral symptoms, the data not yet stratified.
One interesting interim finding is that there was a 5% cancer detection rate in under 45-year-olds, a group which the NICE guidelines excluded from the recommendation to refer to secondary care for renal or bladder cancer investigations. If this statistic is confirmed it will be interesting to see if it is incorporated into an updated NICE guideline going forwards.
The BURST team outlined the ‘next big idea’- an RCT of a personalised investigative pathway for haematuria vs standard of care. The hypothesis is that personalised investigation will result in no worse cancer detection rate with lower investigative burden than standard of care. This concept was greeted with much enthusiasm from BURST Twitter followers, leaving me feeling inspired by the idea of how these large, speedy recruitment multicentre studies really have the potential to inform practice in a timely manner.
The session wrapped up with a ‘Dragons Den’ where three finalists presented excellent research study proposals. The study designs were critiqued by the ‘dragons’ with questions from the audience. Twitter and in-house voting picked the winning proposal. The author said his study would challenge the “there’s no harm in exploring” mentality that often leads to scrotal exploration in acute scrotal pain. The runners-up aimed to investigate the outcomes resulting from the different practices of ‘ureteric stenting with delayed definitive stone treatment’ versus ‘immediate acute ureteroscopy’ for obstructing calculi, with the third finalist’s protocol designed to try and ascertain optimal stent duration postureteroscopy.
I found all proposals thought-provoking along with the constructive critique they received from the dragons. I left the session feeling the future of urology continues to be in good hands. In my next column I will share some other conference highlights that confirm this view. Until then, be well.
Sue Osborne, Urology Nurse Practitioner, Auckland (NZ), firstname.lastname@example.org