Urologists discover Eden in South America

Raising money for The Urology Foundation (TUF)


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All 47 riders gather for the traditional group photograph.

Spectacular lakes, brooding volcanoes, incredible rainforests, breath-taking waterfalls, lush green vistas – are these the signs of Eden or perhaps heaven on earth? For 47 cyclists travelling through Patagonia from Argentina to Chile, such thoughts must have come to mind as they awakened every morning to another scenic adventure. Such were the magnificent settings for ‘Bike Argentina to Chile’, the latest fundraiser for TUF (http://www.theurologyfoundation.org).

The 10-day journey tested the endurance of urologists, friends, family, and cancer survivors as they cycled on roads and off-road trails before reaching the Pacific Ocean in Chile.

‘Patagonia was the fourth TUF challenge, and it really was the toughest one yet’, points out Ann Frampton, the director of Action for Charity and Dream Challenges (http://www.actionforcharity.co.uk), which coordinates the event every year. ‘It was great to see so many past participants taking part once again and bringing friends and colleagues to join the TUF family’. Ann Frampton was particularly impressed by the camaraderie displayed by all of the cyclists. ‘Everyone helped each other to achieve the challenge’.

Also impressed by how well people supported each other was urologist Richard Hindley, who is a first time participant in TUF challenges. ‘It was really a great trip with a good mix of urologists, patients, family members, and others’, he remarks. ‘I was amazed at how well everyone gelled together with the common goal of cycling 470km to raise money for TUF. There was a real buzz of excitement’. Mohan Gandeti, the only USA urologist on the trip also agrees ‘The team spirit was fantastic’, he says. ‘Everyone was so congenial and willing to help each other’.

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‘I had no idea what I was getting myself into!’

Mohan Gundeti proudly shows off his yellow jersey

CHALLENGES FUND EDUCATION AND RESEARCH

Previous TUF challenges have taken participants to Sicily, Malawi, Madagascar, and last year Nepal, where they trekked instead of biked across the Kingdom of Mustang. The funds they continue to raise increase every year. Professor Roger Kirby, a urologist who leads each year's challenge, notes that this year's Patagonia trip has raised £450,000 so far. ‘Together, Patagonia and Nepal have raised more than a million dollars for research and education’, he says proudly.

TUF has a particular mission to train young urological surgeons. ‘We send them and their entire team to the United States to train with the best urologists who are using the latest robotic-surgery techniques’, Roger Kirby explains. In addition, the challenges fund an important interview skills course designed to help urologists gain successful positions. Another course, ‘Surviving and Thriving as a First-Year Specialist Consultant’, helps urologists make the most of their first big appointment and avoid the mistakes made by experienced urologists in the past. All of these professional development initiatives are paid for through funds raised from these TUF challenges.

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Left: The majestic Osorno volcano with its glaciated horn lies dormant on the south-eastern shore of Llanquihue Lake (the third largest in South America) in Chile.

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Right: The riders encountered harsh, off-road conditions through forests and vegetation

The riders began their journey by flying from London to Buenos Aires, Argentina, where they spent their first night. On day two, they flew to Barloche situated in the foothills of the Andes where they rested before completing a warm-up cycle around the Circuito Chico and lake regions. By day four, they were off on their challenge, biking 800m above sea level and already discovering such varied scenery as forests, mountains, and desert-like landscapes.

Probably the hardest day for everyone was on day five, when the cyclists climbed to the Puyehue Pass at 1320 m before crossing into Chile. Anyone seeing the photograph of participants arriving at this highest point and greeted by the ‘Welcome to Chile’ sign would swear they had snow beneath them. Instead, the white stuff was actually volcanic ash still covering the area from an eruption last year. ‘The whole area was just decimated’, says Roger Plail, another urologist who had done all the previous challenges. ‘Roads were three-feet deep in ash and surrounded by what looked like grey snow drifts. We cycled through this lunar landscape and finally came out into verdant green forest’. Actually, volcanoes were a regular sighting once the cyclists got into Chile. Both the Osorno and Puntiagudo volcanoes provided dramatic backdrops to lake landscapes. Roger Plail also could not believe some of the tortuous, off-road sections they had to travel, some filled with 5cm chunks of rocks and stones. ‘Putting down marbles would have been better’, he says.

‘I WANT TO GO HOME!’

Right after Mohan Gundeti signed up for the challenge, he started getting grief from all sides. His children wondered if he was really up to the experience. Even his residents at Comer Children's Hospital in Chicago could not believe he was going. All of this started making Mohan Gundeti wonder himself if he had made a mistake. Of course he was preparing for the journey diligently, regularly cycling ≈32km on Lake Shore Drive to get ready for whatever would face him in Patagonia.

However, nothing prepared him for what he experienced on the challenge. ‘I've been through a lot of challenges in my life’, he says. ‘This was the greatest physical challenge I ever faced. It was so tough’! Mohan Gundeti recounts the crossing into Chile with 20km on high levels of cliffs and mountains ranging from 226 to 1524m. ‘I had a near-death experience’, he laughs. ‘I thought: I'm not going to make it back to Chicago!’

Not only did Mohan Gundeti make it back to Chicago, but he brought something with him that proved to his children and colleagues that he had the ‘right stuff’. After that gruelling cycle into Chile, he was awarded the coveted yellow jersey, similar to the one given during the Tour de France for the best rider of the day. This was quite an accomplishment for a beginner on his first TUF challenge.

Evenings were spent in various accommodations, including hotels, cabins, and tents. Both Roger Kirby and Roger Plail became noted for their polar bear plunges into ever colder lakes each night. ‘The accommodations were great – very close to nature as much as possible’, points out Mohan Gundeti. ‘Sometimes, having nature at your doorstep is better than the Ritz Carlton’!

NEXT STOP SOUTH AFRICA

In March of next year, TUF is planning its next cycling challenge, this time in beautiful South Africa. Those wanting more information are encouraged to contact Ann Frampton at Action for Charity at 0845-408-2698 or e-mail her at ann@actionforcharity.co.uk. It may be wise to start putting the pedal to the metal sooner rather than later. Heed the warning of Mohan Gundeti, then go for it and sign on. ‘I had no idea what I was getting myself into!’

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Above: After a 17 km uphill cycle on winding roads in Argentina, the riders arrived at the Puyehue Pass, the highest point of the ride at 1320 m and their crossing into Chile. That's volcanic ash, not snow, from the Cordón Caulle fissure, which erupted on 4 June 2011

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Middle: One of several lake vistas riders saw during their travels. and waterfalls, like this one above, were plentiful along the journey.

PARTICIPATING UROLOGISTS

Neil Barber, Frimley Park Hospital, Frimley, UK; Jo Cresswell, James Cook University Hospital, Middlesbrough, UK; Mohan Gundeti, University of Chicago Medicine, Comer Children's Hospital, Chicago, IL; Richard Hindley, North Hampshire Hospital, Basingstoke, UK; Roger Kirby, The Prostate Centre, London, UK; Paul Miller, East Surrey Hospital, Surrey, UK; Roland Morley, Kingston Hospital NHS Trust, London, UK; Roger Plail, Battle Hospital, Hastings, UK; Abhay Rane, East Surrey Hospital, Surrey, UK; Peter Rimington, Eastbourne Hospital, Eastbourne, UK.

PEOPLE & PLACES

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Ashutosh K. Tewari MD received the prestigious Gold Cystoscope Award from the AUA during its annual meeting in Atlanta, Georgia. The award is presented each year to a urologist who has demonstrated outstanding contributions to the specialty following 13 years after completing residency training. Dr Tewari was recognised for his development of novel robotic techniques to improve outcomes in prostate cancer. He is the Director of the Lefrak Center for Robotic Surgery at New York-Presbyterian Hospital/Weill Cornell Medical Center. In addition, Dr Tewari serves on the faculty at Weill Cornell Medical College as the Ronald P. Lynch Professor of Urologic Oncology and Professor of Urology and Public Health.

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Thomas Jefferson University in Philadelphia, Pennsylvania has received a $2.6 million grant from the National Institutes of Health to investigate positron-emission tomography (PET) for staging prostate cancer. The study will be conducted by researchers at the Kimmel Cancer Center and the Department of Radiology under the direction of Mathew Thakur, PhD, who is Professor of Radiology and Director of the Laboratories of Radiopharmaceutical Research and Molecular Imaging. They will evaluate two 64Cu peptides specific for vasoactive intestinal polypeptide receptor 1 also known as VPAC1 in mice and perform a feasibility study in 25 preoperative patients with prostate cancer. Under PET imaging, these biomolecules detect prostate cancer by finding the overexpressed biomarker VPAC1. If viable, the new noninvasive method of detection could reduce unnecessary biopsies.

DRUG AND TECHNOLOGY NEWS

MAJOR REPORT ON UROLOGICAL DISEASES PUBLISHED

Last published in 2007, the 500-page Urologic Diseases in America has been released by the USA National Institute of Diabetes and Digestive and Kidney Diseases. The national report details the demographic and economic impact of these conditions, including resource utilisation data and costs information. This latest update includes more information on paediatric conditions. It incorporates data from nine public- and private-sector databases covering outpatient and ambulatory care utilisation, inpatient and hospitalisation information, and prevalence data.

Researchers can now work with an interactive version of the free report that allows them to produce personalised tables and graphs. In addition, it can be downloaded as a Portable Document Format (PDF) to be used on computers, eReaders, and smart phones. These formats of the report can be found at http://www.udaonline.net. Printed copies can be ordered at: https://catalog.niddk.nih.gov/detail.cfm?ID=313. inhibitor of prostate cancer cell survival and their cell cycle. Compared with ADT alone, the spice augmented the results of ADT and reduced the number of cells. Similar results were also found in castrated mice.

The study was published in the March 1 issue of Cancer Research 2012; 72: 1248–1259.

OBESITY INCREASES KIDNEY STONE PREVALENCE

The number of people diagnosed with kidney stones in the USA has almost doubled from 2007 to 2010. Specifically, 8.8% of the population developed a stone, amounting to 1 out of every 11 people. Back in 1994, the rate was only 1 in 20.

These findings come from a study conducted by researchers at the University of California, Los Angeles and RAND. Responses were reviewed from 12,110 people who took park in the National Health and Nutrition Examination Survey (NHANES). The survey also includes information on each participant's height, weight, and health conditions. The researchers found a clear association between obesity and the increase in kidney stones. Other conditions, e.g. diabetes and gout, also contribute to the increased risk. The study was presented at the annual meeting of the AUA (Abstract #73) and will be published in the July issue of European Urology. ic-network/com/apps.

Clinical Trial

COMPARE CEFTAZIDIME-AVIBACTAM AND DORIPENEM FOLLOWED BY ORAL THERAPY FOR HOSPITALISED ADULTS WITH COMPLICATED URINARY TRACT INFECTIONS (UTIS)

PROTOCOL ID NCT 01599806

SUMMARY This Phase III, randomised, multicenter trial will compare the efficacy, safety, and tolerability of ceftazidime-avibactam to doripenem in this group of patients, including those with acute pyelonephritis. In the experimental arm, patients will receive i.v. therapy with 2000 mg ceftazidime and 500 mg avibactam. They will also receive either 500 mg ciprofooxacin or 800 mg/160 mg sulfamethoxazole/trimethoprim orally. Patients in the active comparator arm will receive 500 mg doripenem in addition to ciprofloxacin or sulfamethoxazole/trimethoprim. The first primary outcome measure will be the proportion of patients with resolved UTI symptoms except flank pain and the resolution or improvement in flank pain based on patient-reported symptom assessment response after 5 days of starting therapy. The second measure will be the proportion of patients with a per-patient microbiological eradication and resolution of all UTI-specified symptoms 21–25 days after randomisation.

ELIGIBILITY Participants can be men or women aged 18–90 years. Female participants must be surgically sterile, have undergone menopause, or if capable of having children, agree not to become pregnant while receiving i.v. study therapy and for 28 days after. The participant should have pyuria with ≥ 10 white blood cells/mL and a positive urine culture within 48 h of enrollment containing ≥ 105 colony-forming units/mL of a recognised uropathogen known to be susceptible to the drugs used in the study. Patients must have either acute pyelonephritis or complicated lower UTI without pyelonephritis.

LOCATIONS There are multiple sites around the world including the following countries: USA (seven sites), Argentina, Belgium, Brazil, Bulgaria, Canada, Croatia, Czech Republic, France, Germany, Greece, India (seven sites), Israel (six sites), Italy, Republic of Korea, Mexico, Peru, Poland, Romania, Russian Federation, Spain, Taiwan and the Ukraine. CONTACT AstraZeneca at 800-236-9933, e-mail: information.center@astrazeneca.com.

IMPORTANT PAPERS YOU MAY HAVE MISSED…

JOURNAL WATCH

inline imageUSA task force issues prostate cancer screening recommendations

Moyer VA on behalf of the U.S. Preventive Services Task Force. Screening for Prostate

Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2012; E-460 May 21 [Epub ahead of print].

inline imageUsing dynamic contrast-enhanced MRI in prostate cancer diagnosis and management. Verma S, Turkbey B, Muradyan N et al. Overview of dynamic contrast-enhanced MRI in prostate cancer diagnosis and management.

AJR Am J Roentgenol 2012; 198: 1277–88

inline imageSHBG levels are associated with bone loss and fractures in patients with prostate cancer. Varsavsky M, Reyes-Garcia R, Garcia A, Ramírez RG, Avilés-Perez MD, Muñoz-Torres M. SHBG levels are associated with bone loss and vertebral fractures in patients with prostate cancer. Osteoporos Int 2012 [Epub ahead of print]. DOI: 10.1007/s00198-012-2012-z

inline imageAjust single incision transobturator sling procedure for stress urinary incontinence: 1-year follow-up. Cornu JN, Peyrat L, Skurnik A, Ciofu C, Lucente VR, Haab F. Ajust single incision transobturator sling procedure for stress urinary incontinence: results after 1-year follow-up. Int Urogynecol J 2012 [Epub ahead of print].

DOI: 10.1007/s00192-012-1740-0.

inline imagePrognostic value of the modified Gleason grading system is validated increases risk of fractures requiring hospitalization Dong F, Wang C, Farris AB et al. Impact on the clinical outcome of prostate cancer by the 2005 International Society of Urological Pathology modified Gleason grading system. Am J Surg Pathol 2012; 36: 838–43

In this issue…

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Urological Oncology

CONSIDER CARDIOVASCULAR COMORBIDITY WHEN COUNSELLING MEN ABOUT PROSTATE CANCER TREATMENT OPTIONS P201

Once diagnosed with prostate cancer, men are faced with a daunting array of treatment options. Comorbidities are increasingly being considered when selecting a particular type of treatment. After the intervention, regret may occur about the decision, with some men wishing they had gone another route. Such regret may be particularly intense in men who have a recurrence of their cancer. In their study, Nguyen et al. investigate the impact of cardiovascular comorbidity on post-treatment regret. They find that men with recurrent prostate cancer and cardiovascular comorbidity were ≥ 50% more likely to regret the treatment they underwent than men without this comorbidity.

The study cohort consisted of 795 men participating in the Comprehensive, Observational, Multicenter, Prostate Adenocarcinoma (COMPARE) registry. All of the men had had a biochemical recurrence at a median of 5.5 years after treatment. Regret was measured by a two-item questionnaire. Cardiovasclar comorbidity was measured at the time of study entry when the prostate cancer recurred.

The percentage of men reporting regret was 14.8%. Among the factors associated with increased treatment regret, cardiovascular comorbidity was the highest, followed by younger age and bowel toxicity after treatment. Interestingly, men with cardiovascular comorbidity were more likely to have increased regret after treatment. Given these findings, clinicians and men may want to consider active surveillance when prostate cancer is newly diagnosed.

INCREASED RISK OF NON-PROSTATE CANCER DEATH FOUND IN MEN WITH PROSTATE CANCER P188

Most men with prostate cancer die of something else, e.g. cardiovascular disease. Van Leeuwen et al. assess whether or not men with screen-detected and symptomatically diagnosed prostate cancer are at increased risk of death and, if so, from what causes. They find that clinically diagnosed men had increased mortality unrelated to their prostate cancer. However, this was not the case for men with screen-detected cancer.

For this study, patients were recruited from participants in the European Randomized Study of Screening for Prostate Cancer. The intervention arm cases consisted of patients with screen-detected prostate cancer aged 55–74 years. They were matched to two controls where no cancer was found after biopsy and two controls where no cancer was found after screening. The control arm consisted of patients with clinically diagnosed prostate cancer. They were also matched to four controls without prostate cancer.

The men with clinically diagnosed prostate cancer were found to be at an increased risk of dying from non-prostate cancer causes compared with men without cancer. This excess mortality appears to be the result of a significantly increased risk of dying from neoplasms, circulatory diseases, and respiratory conditions. These findings suggest that men with prostate cancer should be encouraged to make significant lifestyle changes and manage any abnormal parameters, e.g. cholesterol, carefully.

Sexual Medicine

POLYPHARMACY IS ASSOCIATED WITH WORSE ERECTILE DYSFUNCTION P254

Various medications, including antihypertensives and psychogenics, can result in erectile dysfunction (ED). But, what about the number of medications taken? Does polypharmacy increase the severity of ED in men? Londoño et al. provide much-needed insight into this question with their population-based study. They find an association between polypharmacy and ED. In addition, worsening degrees of ED were related to the increasing number of medications taken, even after medical conditions and medication use were taken into account.

The cohort consisted of 37 712 men who were enrolled in the California Men's Health Study (CMHS) in 2002. Their ages ranged from 45 to 69 years. Questionnaires asked the men about ED and comorbidities. In addition, the number of drugs taken was determined from electronic pharmacy records and questionnaire responses 1 year before enrollment in CMHS.

In this group, 29% reported moderate or severe ED. This was more prevalent as the number of medications increased across all age groups. For men taking 0–2 medications, the percentage reporting moderate ED was 15.9%. This increased to 30.9% in men taking ≥ 10 medications. These men were more likely to have ED even after adjusting for such factors as age, race, smoking, diabetes, and other conditions. In this polypharmacy group, there was evidence of a dose-response relationship. The findings emphasise the importance of evaluating medication use as part of the evaluation for ED.

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