Section of Endourology - Chairman's Newsletter (Mar 2021)

BAUS has recently agreed a partnership with NCIP (National Consultant Information Programme) to ensure that urology is the vanguard surgical speciality for this programme. Implementation and development has started and it is expected that all urologists in England will have access to the web-based portal by December 2021. This will give you access to your surgical outcome data and provide supporting material for your whole practice appraisal.

Access to the portal means that you will not need to enter routinely collected data again, as was the case with the registries. Development of NCIP along with the focussed BAUS  “snapshot “ audits (see below) promises to make a real difference to urological practice.

As was explained in the BAUS update to all members last week, from Tim O’Brien and Andrew Dickinson, your data will not be published and will only be accessible to you and your Trust Medical Director and/or Responsible Officer. 

For further information, BAUS have produced a podcast about the NCIP portal and its rollout which you can listen to by clicking here.

Quality improvement is the key focus of audit for the Endourology Section, and the BAUS 2021 Renal Colic Audit should have seen your unit inputting data in March 2021 for all patients who presented to your hospital with ureteric colic in November 2020.

The audit focuses on many aspects of the patient journey that affect patient more than a small comparative difference in stone clearance related to a procedure (although we should also get some data on procedure outcomes and complications).  Are patients getting optimal analgesia and early access to CT? How quickly are patients with ureteric stones getting treated? Are they having definitive treatment or being temporised with stents? How many patients can access early lithotripsy and how well does it work in real life scenarios?

The answers will provide a national snapshot audit of how units manage acute colic currently, measuring NICE 2019 standards and complementing pathway work by the GIRFT Academy (see below) and will give individual units valuable data and highlight areas of the renal colic pathway for which resources need to be put into place in your unit and around the country to improve patient care.

We passed 1000 patients in the system over the weekend 0f 27-28 March 2021, but many units have still not entered data, and we are extremely keen that this snapshot represents as much of the UK as possible. 

THE CLOSING DATE FOR DATA ENTRY HAS BEEN EXTENDED BY TWO WEEKS UNTIL WEDNESDAY 14 APRIL 2021

• If you have not yet collected your data / submitted it, we hope this will give ample time to join in – see the website for more details; 
• If your data is ready to submit, but you need the link to the “Jotform” platform, please e-mail Louisa Hermans to enter the data for your unit; and
• If you have already submitted your data, many thanks, and please drop an email to your surrounding hospitals to make sure they have too, and therefore any insights for your region will be more valuable for your local practice. 

The preliminary results of the BAUS 2021 Renal Colic Audit will be presented at Virtual BAUS 2021 with a more detailed in-depth analysis at BAUS Endourology 2021 (see ”dates for your diary” below).

The National BOO audit was the first of the new-style BAUS "snapshot" audits. Urologists in the UK had previously been very good at submitting the initial procedure data for the registries but follow up data input was generally available in less <30% of cases. We managed to get returns for about 80% of the BOO procedures performed nationally during the audit period, with follow up data: this is a credit to urologists but also gives some validation to the new approach.

So what did we find?

There has been a quite a change to practice since the last National Prostatectomy Audit in the 1990s. A wide range of new minimally-invasive surgical techniques are used around the country in place of TURP and, while the cases were not randomised, the safety data is very good and the short term outcome data is very encouraging based on this real-life national snap-shot sample. Furthermore, it is difficult to argue that mono-polar TURP is still the “gold-standard” BOO procedure based on this evidence. So what has replaced it? Bipolar TURPs, HoLEP or a MIST? Perhaps each have their role for different patients and different clinical scenarios, and the gold standard is now to be able to guide the patient through a selection of options.

What can we do better?

Each unit has been sent its own outcomes with national comparisons and you should analyse this data to see what is necessary locally. Nationally, overall complications were few, but it was clear that urologists can do better at formally assessing fluid management before the decision to operate, as the use of frequency-volume charts - recommended by EAU and NICE - was poor.

The PCNL registry closed at the end of December 2020. As a result of the efforts of everyone who contributed data over the years, we now have a robust data set of >7000 patients over a 4-year period to benchmark against individual practice aainst. This includes outcome data relating to transfusion, sepsis, complications, length of stay and stone clearance to enable clinicians to compare their practice with their NCIP data as mentioned above.

Will Finch and the PCNL audit team are also developing a risk model to demonstrate how an individual patient's BMI, stone complexity, stone dimensions and co-morbidities affect these outcomes, enabling more individualised discussions about risks for a patient as part of the consent process.

The HSIB (Healthcare Safety Investigation Branch) published a report in October 2020 relating to the delayed removal of JJ stents, and the problems that follow when they become encrusted ... you can find the whole report here.

A number of recommendations were made, leading to an initial meeting with the GIRFT Joint National Clinical Leads (Simon Harrison, Kieran O’Flynn & John McGrath), the NHSE National Clinical Lead for Innovation (Tony Young) and me, and a subsequent one with NHS England, specifically its “Medical Devices Safety Programme”, which is linked closely to GIRFT.

Updates will follow, but please keep an eye out for a BAUS Endourology survey soon that will include questions regarding your unit’s management of its stent database. This information will be useful in trying to define the scale of the problem and, therefore, will help deliver a workable solution.

In addition to our link with GIRFT for overdue stent removal, the Section is also working with the GIRFT Academy to develop an Acute Stone Pathway to implement high quality research and NICE Quality Standards in everyday practice. A team of consultants from across the BAUS regions, with the support of the Academy and the Section, are developing a best practice pathway, decision-making tool and patient information.

Hopefully, this will be a great example of British Endourology implementing high quality and novel research including the MIMIC study from BURST, and established NIHR trials such as TISU alongside BAUS section audits, including the current renal colic audit. It will include innovative examples of best practice to offer patients the highest-quality, efficient and effective care. The outputs will help departments and regions assess their services, and provide a voice for patients and endourologists to achieve best outcomes and a consistent approach across the UK.

Anyone interested in highlighting or contributing their own examples of innovative practice that may also include the wider team of urologists, radiologists, A&E, primary care, radiographers, sonographers, nurses, information technology, management and admin staff should email Stephen Gordon, Chair of the working group.

The BAUS patient information leaflets remain an extremely valuable resource, which for many urologists form an essential part of the informed consent process. 

Co-ordinated by Hari Ratan, the executive committee members have conducted a thorough review of the existing leaflets relating to endourological conditions and procedures, to ensure that the information remains relevant and up to date. The leafets cover important topics such as ureteroscopy, ureteric stents and dietary advice for recurrent stone formers. 

With the increasingly widespread adoption of novel techniques for treating BPH, we have produced new leaflets on HOLEP and Rezum to complement the existing leaflets regarding TURP, BNI and Urolift.  We are also working on a specific “I have had a stent inserted” leaflet as part of the BAUS response to the HSIB report above.

As a legacy of the World Congress of Endourology meeting organised in London in 2015, we have a travelling scholarship that has been previously open to senior trainees / early year Consultants, which we are going to extend to include two additional scholarships of £2500 to attend the USICON (Urological Society of India) congress combined with a week or two in one of four world renowned endourology centres in India. Look out for details later in the year ...

You will have heard Tim O’Brien’s initiation lecture outlining his vision for his presidency last June, and at other times since, explaining the link between BAUS, TUF and the CHaRT research unit in Aberdeen to help promote the best opportunity for all UK Urologists to devise, design and deliver important research ideas that will change practice.

Undertaking large-scale, multicentre, randomised clinical trials is a complex process that requires professional support to design the study, comply with regulations, manage data collection, analyse results and understand the health impacts. Clinical Trials Units (CTUs) provide the necessary infrastructure to support such studies.

TUF has agreed to provide funding to CHaRT (Centre for Healthcare Randomised Trials), based in Aberdeen, to act as the CTU for Urological trials. CHaRT was the clinical trials unit that supported some of the world-leading randomised trials in stone disease management (SUSPEND, TISU and PuRE) led by Prof Sam McClinton.

This initiative will democratise access to trial support services for all urologists. NICE stone guidelines (2019) have highlighted some key unanswered questions that might be addressed. Urologists/patients may have other important questions in endourology that well-conducted trials could answer.

Submit your proposal before the end of April for consideration at a Dragon's den style competition at BAUS.

Click here for more information from TUF. This process is open to everyone, and part of the remit is to encourage and provide a framework for research to units that are not already associated with a research organisation. Please get in touch with Professor Ben Turney or Professor Caroline Moore for a steer in the right direction ... or register for the "So, you have an idea for a trial ... " webinar on 15 April at 19:00hr.

The BAUS Section of Endourology has continued its strong commitment to education throughout the pandemic, especially via the link with the BAUS Education Committee with Hari Ratan as the lead for SpR education.

Members of the section have contributed to the BAUS Specialist Trainee Educational webinar series, with excellent talks on metabolic stone disease and endourological management of upper tract urothelial cancer.  A combined BAUS/AUA webinar on controversies in stone disease is being planned, and will be broadcast in May. 

We recognise that the pandemic has resulted in trainees being unable to access “hands-on” surgical skills courses, such as the Urology Boot Camp for ST3 trainees, but we look forward to being able to contribute to these courses again later this year.

Speaking of education, one of the “jewels in the crown” for the BAUS Endourology year has always been the Residential Course, which is being run this year by Bhaskar Somani in Southampton from 1 to 3 November 2021.

We hope this will be an in-person opportunity for four final year endourology/laparoscopy themed trainees to learn, discuss, operate and network with some of the “Best of British”, including two days of mentored “one-to-one” operating.

Further details will be available via the website.

We have just welcomed Dr Harry Bardgett from Bradford Teaching Hospitals NHS Foundation Trust as the BSUR (British Society of Urogenital Radiology) representative on our committee. This is timely, as there is a substantial amount of interventional radiology reorganisation work across the country, as part of the centralisation of Vascular Interventional Radiology within the national GIRFT recommendations.

This does, of course, have implications for interventional uroradiology support, particularly with regard to emergency nephrostomy provision.

As for the stent database questions mentioned above, please respond to the survey regarding your hospital’s situation with out-of-hours radiological support when we send this; we can then have a full session on these important clinical issues at BAUS Endourology in October.

Plans continue at pace for the “most international BAUS ever” at the summer virtual conference.

Rob Calvert and the committee have put together a fantastic programme of endourology including “Tips and tricks – nonsurgical ways to optimise care”, “Making ureteroscopy safer”, a “Mini-PCNL vs RIRS” 15mm stone debate, “Stents in 5D (Down-sides, Deployment, Design, Drugs and of course Don’t Forget it)", “Lasers and scopes”; “The ureteric stone" (including the findings from TISU and the initial renal colic audit data); “Progress in PCNL”; “Advances in upper tract TCC management” and our traditional trainee-delivered “Endourology literature update”. 

Our international faculty includes Dr Guido Giusti, Professor Silvia Projetti, Professor Olivier Traxer, Dr Ben Chew, Dr Michelle Semins, Dr Saeed Bin Hamri, Dr Andrew Portis, Dr Joyce Baard, Dr Nir Kleinmann and Dr Marianne Brehmer, with others to come…

With two poster sessions, and the joint FNUU-Endo BOO plenary session, this will be a packed three days for sure!

Having needed to defer BAUS Endourology 2020 and incorporate it into the November virtual meeting, we are looking forward to an in-person conference in Nottingham from Monday 4 to Tuesday 5 October 2021. You can be sure of a full academic and social programme, so put this date in your diary right away!

Other Dates for your diary

• Final Closing Date for Renal Colic Audit – Wed 14 April 2021;
• “Big BAUS” – Summer virtual conference Mon 21 – Wed 23 Jun 2021; and
• BAUS Endourology Residential Course – Southampton - 1 to 3 November 2021