Section of Endourology - Retiring Chair's Newsletter

To borrow a quote from the American statistician/management theorist W. Edwards Deming: “In God we trust; all others must bring data”. Fortunately, we can manage the latter, as the BAUS section of Endourology has been well served by strong and reliable audit / registry data, initiated by Neil Burgess, curated by Olly Wiseman and most recently by Will Finch. In particular, the BAUS PCNL database has been extensively utilised for presentations and publications, for which our section has rightly won international acclaim and envy, and there is still more to come in the form of an artificial intelligence (AI) machine-learning model to help with patient counselling and outcome prediction. With this in mind, Bhaskar Somani is leading work within the committee to develop an app which we hope will be ready for clinical use by the end of 2022. In a similar congratulatory vein, well done to all of our section members who contributed to the BOO Snapshot Audit, the results of which have now been published in the BJUI.

This moves us nicely onto the “Acute Colic Audit”, which was designed and planned in conjunction with the Audit Steering Group (ASG) to be the first “pathway-based” BAUS audit. A huge effort from the whole of the UK endourological community resulted in 117 units submitting data for 2192 patients who had ureteric colic in November 2020.

The headline messages from the audit showed that a CTKUB to diagnose renal colic was often performed within 24 hours of presentation (NICE Quality Standard 1 - 91% achieved nationally) and that NSAIDS were usually given, first line, where appropriate (NICE Quality Standard 2 - 70% achieved nationally). Serum calcium levels were also checked for most patients (NICE Quality Standard 4 - 87% achieved nationally) and patients received stone-prevention dietary information (NICE Quality Standard 5 - 73% achieved nationally). As expected from all of our previous discussions regarding the challenge for the timing of emergency treatment, the audit confirmed that many units struggle to provide surgical treatments within 48 hours of diagnosis or readmission for a stone causing pain or unlikely to pass (NICE Quality Standard 3 - 41% achieved nationally). In keeping with this, 40% of patients suitable for acute stone treatment had a “temporising” ureteric stent inserted, rather than primary lithotripsy (34%) or primary ureteroscopy (23%).

Notwithstanding this having been conducted during the COVID-19 pandemic, the snapshot identified substantial variation in practice across the UK and helped kickstart the detailed conversations within the “GIRFT Acute Stone Team” (see below) about how to overcome them. We hope that your own unit level data has enabled your team to identify where to focus attention for quality improvement. If you have not had your Colic PDF (which was forwarded some time ago to your unit’s audit lead), please email Louisa Hermans at BAUS, including the name and correct contact details of your audit lead to ensure more reliable communications for future audits.

A national re-audit for ureteric colic is being planned for 2023/24 (i.e. approximately three years after the original snapshot) to allow time to change practice but not so long that it’s been forgotten.  A template for this audit, patient inclusion and exclusion criteria, OPCS codes and guidance on how to repeat the audit in your unit, is available by email from Louisa Hermans.

Since this study was intended to evaluate our practice against the NICE Stone Quality Standards of 2020, at Dickie Dickinson’s initiative, the audit process itself and the data generated have been presented at a higher national level to NICE and GIRFT, which has led to a follow-on project validating our BAUS audit dataset against HES, national Emergency department and Radiology datasets. So, a big "thank you" to everyone who participated – this really demonstrated the value and importance of snapshot audits and the particular power of endoscopic team collaboration.

Looking forward, there are three future national audits for BAUS Endourology members to be aware of. Our new vice-chair Subu Subramonian has been involved in the planning and delivery of the Ureteric Injury Audit (REJOIN), focusing on the endourological aspects of ureteric trauma management. The overall audit is being led by the SFNUU and launched recently - data collection started on 1 February 2022 iand continues until 30 September 2022.

Please also look out for a paediatric endourology practice questionnaire later this year, delayed due to the pandemic, for which your opinion and feedback will give an overview of current UK practice and will be much appreciated.

Finally, the Section of Endourology is planning a Nephrostomy Audit to start in 2023 to complement and inform the Non-Vascular Interventional Radiology (NVIR) nephrostomy work (see below). Initially, this will obtain details for nephrostomy provision in each hospital as a baseline, and enrol details of patients undergoing nephrostomy during the specific snapshot period and will audit outcomes.

Using the knowledge and influence of our new BAUS Endourology Secretary, Hari Ratan, who remains the BAUS SpR education lead, we are looking forward to a busy programme of educational events throughout the year.  Later this month, we will provide our usual contribution to the BAUS FRCS (Urol) revision course at the ExCeL Centre in London Docklands.  For any peri-exam colleagues, this is a great opportunity to consolidate your FRCS (Urol) viva knowledge and sharpen your technique – the current course is fully booked (with a waiting list) so, if you are sitting the exam later in the year, keep your eyes out for adverts for the course in the autumn and apply early.

Since the onset of the pandemic, there has been an understandable reduction in the number of simulation training courses in endourology across the country. We are hoping to provide some hands-on simulation training at the much-anticipated in-person BAUS 2022 Annual Scientific Meeting in Birmingham, which will include the usual range of educational activities on the plenary programme. We are also working with partners in Industry to re-introduce regular hands-on courses focussing on ureteroscopy and PCNL, which will appeal to both junior trainees as well as those who intend to subspecialise in endourology. The first of these is a URS / FURS course on Friday 29 April 2022 at the new Storz facility – look out for further details on these courses as the year unfolds.

BAUS Endourology WCE Fellowships

The WCE 2015 Fellowship Fund was generated using the surplus from our hosting of the World Congress of Endourology in London in 2015. Anne Bishop, the BAUS CEO, Tricia Hagan, the Deputy CEO and the curators of the fund, including Abhay Rane (who led the WCE 2015 organising team) met in early February to discuss changes in the application process and  to review who can apply for educational funding from the fund.

Suffice it to say that the requirements around eligibility and purpose are likely to be both simplified and broadened. We anticipate that trainees or Consultants wishing to visit a centre of excellence to learn and develop a new skill or techniqu, for the benefit of UK endourology patients, will be considered. Furthermore, given the ongoing challenges of international travel, support for these visits is expected to include UK centres as well as those abroad, and for shorter tenures will be supported than previously stipulated. Most importantly, given the important and central role they play in the delivery of endourological care across the country, support for our Specialist Nurses, both for knowledge / skill acquisition and for attendance at the BAUS Endourology Annual Meeting may also become possible from the WCE 2015 fund.

Look out for updates, including at the BSoT meeting on 8-9 March 2022, and on the website (and Twitter) about this in the next few months.

BAUS Meeting Feedback

This is a good time to give a substantial vote of thanks to Rob Calvert as the outgoing secretary, who has managed the endourological “grid” that is used to plan, control and co-ordinate our meetings, including the BAUS 2020 in November 2020, then BAUS 2021 in June 2021, quickly followed by our section meeting in October 2021.

The feedback from these has been very positive, especially from the BAUS 2021 Virtual Annual Meeting which was, as intended, our most international conference ever. This meeting included 1796 delegates, of whom just over two thirds considered themselves to be endourologists (67.5%, up from 62% at BAUS 2020). We had twelve Endourology sessions with an average of 484 delegates. Four of the top ten attended sessions were endourology, with the highest being the joint Endourology and FNUU session on BPE and its treatment, brilliantly co-ordinated by Suzanne Biers. It was not just attendance that was high, the quality was excellent too: viewers could rate each session to a maximum of 5 - all Endourology sessions scored above 4.5 and many were 4.8.

Our Endourology Section Meeting, the first face-to-face meeting since the pandemic began, ran very successfully in early October 2021 at the East Midlands Conference Centre in Nottingham with lots of interest from sponsors and good diversity across the meeting. Despite limited time, our IT/events partner, AV Events, and the local organising team managed to make this a hybrid meeting – useful as it turned out because of the effect of Covid on the Faculty as well as the audience. Special thanks go to Tim O’Brien and Jo Cresswell for attending. See the Jan / Feb 2022 issue of Urology News for a more detailed summary.

So, on behalf of the committee, thank you to everyone who spoke, chaired, presented papers and interacted at any of these meetings. Please liaise with the committee (see below) if you have ideas for sessions in the future, or you are keen to be involved in some way or other.

Our flagship endourology research continues to be led by Prof Sam McClinton and the CHaRT research unit in Aberdeen. TISU was published in European Urology last summer and work continues on PUrE, with an extension in the follow-up period to 31 August 2022 (due to the inevitable effect that COVID had on the study). So far, 466 patients have been recruited into RCT 1 (SWL vs FURS for less than 10mm stones) and 112 patients into RCT2 (FURS vs PCNL for 10-25mm stones), with over 90% in both studies having received their intervention. Congratulations again to Zara Gall and the team at Stepping Hill Hospital in Stockport for being the lead recruiting centre to both trials.

Our close ties with the British Urology Researchers in Surgical Training (BURST) Research Collaborative continue, including the recent submission of a NIHR Stage 1 HTA application. This has been enabled by the collaboration between BAUS, TUF and CHaRT as part of the Tim O’Brien / Caroline Moore, BAUS-led initiative to support the design and delivery of large, multicentre, randomised clinical trials.

The journey began at the inaugural “Dragons’ Den” competition at BAUS 2021, where Nikita Bhatt, the previous BURST representative on our Endourology Section committee, won support for a trial proposal to randomise patients undergoing uncomplicated ureteroscopic / ureterorenoscopic procedures to a stent vs no stent. Since receiving this award, Nikita has become the co-chair of BURST and we wish her well in this important role. The BURST research collaborative has worked closely with the CHaRT research unit and several members of the endourology section, including Kevin Byrnes (our current BURST representative), to design an RCT entitled “RESIST” (Randomized Evaluation of Stent Insertion) following uncomplicated endourological stone treatment. The study design is a pragmatic, single-blinded, multi-centre, non-inferiority RCT to investigate the need for ureteric stenting following uncomplicated ureteroscopy. Patient-reported outcome measures will feature as the primary outcome; the trial design also features cost-effectiveness analysis and qualitative components.

We hope that this research will help reduce unnecessary stenting after uncomplicated URS/FURS, with improved clinical and cost-effectiveness for the NHS, as well as an improvement in the patient experience. It will also provide robust, UK-relevant evidence on quality of life and complications following these procedures. Look out for updates on this, including a call to enrol as many centres as possible to gain wide representation across the UK

Moving from the beginning of the academic process (grant applications) to the other end of the spectrum (publications), Bhaskar Somani has taken over the Editorship of the Journal of Clinical Urology (JCU) with the aim of driving the quality of the journal even further towards PubMed recognition. This process will include a section-related, special issue on new technological developments and innovations in BPH and endourology, which will, hopefully, help the journal’s growth and development towards this goal.

Patient Information Leaflets

The update of the endourology BAUS Patient Information Leaflets has been completed, and the next step will be to create an online patient decision aid and shared decision-making tool as part of a patient-centred approach to treatment choice. This will be a large volume of work and may require a sub-group to take it forward, perhaps through a national approach via the GIRFT Academy. If this is something that you would be interested in contributing to, give the committee executive a shout.

NCIP (Rob Calvert)

As you may already know, urology has been chosen as the vanguard surgical specialty for the National Clinical Information Program (NCIP) to provide a web-based portal for surgical activity available to urologists in all trusts in England. This portal (ncip.model.nhs.uk) provides a dashboard for HES-based outcomes of the most common urological procedures and now includes ureteroscopy, following the coding changes last year. The rollout of this system is more than 50% complete: for further information you can revisit the BAUS Webinar on NCIP, hosted by Dickie Dickinson in November 2021.

The dashboard allows Consultant and unit level activity to be monitored and audited, and is supplemented by the BAUS snapshot audits, such as the Renal Colic Audit discussed above and other data sources through The Model Hospital and GIRFT. This real-time data will allow more responsiveness in service evaluation and improvement, for which urologists are encouraged to engage regularly with their expert coders, thereby ensuring good data quality. The dashboard is continually updated for improvement: please send any comments to Louisa Hermans at the BAUS office: all feedback is welcome.

NVIR and Nephrostomy Service

Harry Bardgett, Consultant Radiologist in Bradford has been a co-opted member of the BAUS Section of Endourology Committee for the last year, and has highlighted a potential problem with the provision of non-vascular interventional radiology. The issue is that Vascular Surgery services are being centralised, and therefore vascular interventional radiologists are moving with the service. Since vascular interventional radiologists often provide “non-vascular” services (such as nephrostomy insertion), many hospitals may be left without any viable interventional radiology cover, with obvious consequences for nephrostomy provision and urological care.

An initial meeting was held in November 2021 with representatives from interested organisations, including The British Society of Urogenital Radiology (BSUR), The British Society of Interventional Radiology  (BSIR), The British Society of Gastrointestinal and Abdominal Radiology (BSGAR), and The Association of Surgeons of Great Britain & Ireland (ASGBI) as well as BAUS (represented by our Vice President Jo Creswell) and BAUS Endourology (represented by Zara Gall). 

The initial meeting established that there is a substantial variation in the way that NVIR services are currently provided in different areas of the country. In order to predict what impact the vascular reconfiguration is likely to have, and to plan any mitigation, we first need to know the current provision in all acute hospitals. The ASGBI representative suggested that this information could potentially be gathered by adding a couple of questions to the next round of the National Emergency Laparotomy Audit (NELA) audit which typically has excellent response rates. In addition to this, the Section of Endourology would like to look at this in more depth and are devising a BAUS Endourology Snapshot Audit to look at emergency nephrostomy insertion. Zara Gall, Subu Subramonian and Max Johnston (our BSoT representative) are currently working on an audit proposal to put to the Audit Steering Committee. If you have an example of good practice in the area of nephrostomy insertion / management, please let them know.

GIRFT Acute Stone Pathway

One of the biggest workstreams over the last 18 months has been the creation of the "Acute Stone Pathway” GIRFT document. This has now been published as part of the GIRFT Academy, and can be found in the Best Practice Library together with three other urology guides covering outpatient transformation, bladder cancer and bladder outlet obstruction.

The Acute Stone Pathway document was produced by a clinical team from around the UK, consisting of urologists, nurses and radiographers, led by Steve Gordon and supported by NHS GIRFT. The document lists key components that determine high-quality acute urinary tract stone care including

1. Provision of an effective acute stone service;
2. A patient-centred approach with access to both primary lithotripsy and ureteroscopy;
3. Avoiding placement of temporising ureteric stents;
4. Prompt diagnostic and interventional radiology services, and support network-level interaction;
5. Early diagnosis and treatment of infection with expedited definitive stone treatment; and
6. Using stone service resources effectively.

The document has been based on the 2019 NICE guidelines and the 2019 standards, the BAUS Acute Colic audit from 2021, and on high-quality UK research, including TISU and the BURST MIMIC trial. It also recognises that any service development should include quality of life measures such as the USIQoL or the Cambridge Stone PROMs.

In addition to my thanks to Steve Gordon, many thanks are also due to the clinicians and units who have contributed, particularly to Sian Allen, Dhaval Bodiwala, Mark Cutress, Ranan Dasgupta, Will Finch, Catherine Owen, Jake Patterson, Joe Philip and Susan Willis for their regular meetings and tireless support for the project from start to finish; they are, therefore, rightly acknowledged in the report itself.

We hope this will act as a useful resource for clinicians and managers who are responsible for providing or commissioning acute stone services, including evaluation of your own service against various examples of “what good looks like”. It is also intended to be a “live document”, to add to and develop as services share their experiences and solutions to post-COVID working. Further discussion and debate is planned, as part of our endourology programme at BAUS 2022. Please share any other examples of good practice, or barriers to implementation with any of the GIRFT Academy Acute Stone Team or directly with Steve Gordon by email.

The famous RSM bi-annual endourology day took place on Friday 4 March 2022 and provided a full day of lectures from the evaluation of new technology for stone treatment, through the evidence for dietary and metabolic advice for reducing recurrence, to optimising upper tract urological cancer (UTUC) treatment. It will also included a debate over the treatment of symptomatic patients with an enlarged prostate / bladder outlet obstruction and ended with some challenging cases.

Other dates for your diary over the next few months:

• FRCS (Urol) Revision Course at the London ExCel: Mon 28 March to Fri 1 April 2022
• BAUS Endourology / Storz URS/FURS Training Day: Fri 29 April 2022
• BAUS 2022 - Birmingham: Mon 13 June to Wed 15 June 2022
• BAUS Endourology 2022 Hilton at the Ageas Bowl, Southampton: Thu 8 / Fri 9 Sep 2022

To conclude this newsletter, I must add a word or two about the BAUS Endourology Committee that has overseen and delivered all the above, give a few “thank-yous” & “welcomes”, and a hearty “good luck” to the new executive trio for the next two years.

Thank you to Ben Turney, who completed a 5-year term in December 2021 and who continues his editorial role with the BJUI and Will Finch, who has worked as a co-opted member for a number of years as the PCNL audit lead, and on the more recent Acute Colic Audit, from its inception, through its design, implementation and analysis, and continues to work on the various follow-up projects that are now underway. Thank you again to Rob Calvert, the outgoing secretary, who, as mentioned above, owing to the effects of Covid, ended up with co-ordinating three international quality meetings within 12 months in addition to his work with NICE and the BAUS ASG. Huge thanks to the three of you for all your hard work, enthusiasm and wisdom during your time on the committee.

This leads into congratulations and a warm welcome to the committee members successfully apopointed in the voting at the end of 2021. Bhaskar Somani has been re-elected for a further two years, and Feras Al Jaafari, Matthew Bultitude and Rashmi Singh each started a three-year term in January 2022; for more details see the committee’s webpage. The election has given your endourology committee representation from as far South as Southampton, and as far North as Fife, bringing new ideas and energy to the section, led by the “executive triumvirate” of Hari Ratan (Secretary), Subu Subramonian (Vice Chair) and Sri Sriprisad (Chair). I am sure it will be an excellent two years ahead!