Year : 2019 | Volume
: 35 | Issue : 1 | Page : 2--3
Department of Urology and Kidney Transplant, Medanta the Medicity, Gurugram, Haryana, India
Department of Urology and Kidney Transplant, Medanta the Medicity, Gurugram, Haryana
|How to cite this article:|
Mandhani A. Round up.Indian J Urol 2019;35:2-3
|How to cite this URL:|
Mandhani A. Round up. Indian J Urol [serial online] 2019 [cited 2019 May 21 ];35:2-3
Available from: http://www.indianjurol.com/text.asp?2019/35/1/2/249257
Urology as a specialty faces a plethora of choices to treat clinical conditions such as stone disease or benign prostate hyperplasia. Integrity of any evidence is predominantly based on altruistic inputs by the authors. As astute clinicians, we should keep questioning the essence of evidence in medicine. The philosophy of scientific evidence is based on the theory of falsification, where we need to consider each and every evidence in a published article as false evidence till we read more articles to prove that evidence to be correct.
Recently, I encountered a patient in his early twenties who came to me for a second opinion on the benefit of alpha-blocker for a 6 mm stone in lower ureter as a part of medical expulsive therapy (MET). He had an unfortunate adverse event when he fell down and sustained a lacerated wound over his head due to postural hypotension caused by Tamsulosin prescribed by his treating urologist. His prescription of MET was based on the recent guidelines. Interestingly, a recent article in JAMA challenges the very notion of usefulness of MET.
In this double-blind, randomized placebo-controlled trial 512 patients of ureteric stones of <9 mm who presented with a colic were recruited, the largest number of subjects recruited in any study so far on this subject. They were randomized to receive Tamsulosin 0.4 mg or matching placebo daily for 28 days. Their mean age was 40.6 years (range, 18–74 years). In the intention-to-treat analysis, stone passage rates were 50% in the Tamsulosin group and 47% in the placebo group (relative risk, 1.05; 95.8% confidence interval [CI], 0.87–1.27; P = 0.60), a rather insignificant difference. Hence, Tamsulosin did not significantly increase the stone passage rate compared to placebo.
Similarly, the extent of lymph node dissection is still a matter of debate. The role of lymphadenectomy (LND) in bladder cancer is unquestionable as it not only improves survival but also helps in doing a better cystectomy. A recent randomized trial comparing the extent of LND (obturator and internal and external iliac nodes) versus extended LND (in addition, deep obturator, common iliac, presacral, paracaval, interaortocaval, and para-aortal nodes up to the inferior mesenteric artery) in patients with T1G3 and T2 to T4 MO disease was designed to get 15% 5-year survival benefit.
Extended LND failed to demonstrate improved patient outcomes over limited LND with regard to 5-year recurrence-free survival (65% vs. 59%; hazard ratio [HR], 0.84 [95% CI, 0.58–1.22]; P = 0.36), and 5-year cancer-specific survival (76% vs. 65%; HR, 0.70; P = 0.10), and 5-year overall survival (59% vs. 50%; HR, 0.78; P = 0.12). A significantly increased rate of lymphoceles requiring drainage was reported in the extended template group (8.6% in the extended pelvic lymph-node dissection (PLND) vs. 3.4% in the limited PLND group; P = 0.04).
Although this may qualify for super extend template, the one message that could be drawn from this data set is to avoid going proximal to bifurcation of aorta if there are no lymph nodes of >1 cm size above the common iliac artery.
A thought-provoking follow-up study comparing survival between radical treatment and watchful waiting (not active surveillance) for “clinically detected” localized prostate cancer was published this month with a median follow-up of 23.6 years from Scandinavian Prostate Cancer Group Study Number 4. It is an interesting read as it is relevant to our practice patterns in treating prostate cancer in India. Of 695 patients recruited, 5% were screen detected and only 12% had T1c disease. Most of the patients had palpable disease with 50% of patients having prostate-specific antigen of >10 ng% and 31% of patients having a Gleason score of 6. Ideally, the best way to compare two treatments is to match death rates. Due to the long-term follow-up of 29 years and around 80% deaths of the study subjects, this study has shown that absolute reduction in the risk of death was 11.7%, which means we need to treat 8.4 patients with radical prostatectomy (RP) to prevent one death.
In absolute terms, there was a gain of 2.9 life years with radical treatment. Could this difference have been for the reason that for the first 14 years, no androgen deprivation therapy had been started and the fact that later progression was defined by change in rectal examination and the worsening of symptoms in the watchful waiting group? Moreover, 55% of patients treated with RP died of causes other than prostate cancer. Unfortunately, due to the morbidity attached, one needs to be careful in choosing radical treatment to say for those 45% of patients. Judicious judgment is warranted to offer radical prostatectomy.
Finally, it is high time we should care about our own health too. In India, healthcare is mainly provided by the private healthcare sector and its philosophy of providing service is aimed at the patient (customer) first but somehow ignores the interest of healthcare providers. This has led to as serious and prevalent but rather poorly acknowledged problem of physician burn out, which is defined as prolonged exposure to occupational stress, leading to emotional exhaustion, depersonalization, and reduced professional efficacy. This may also lead to higher risk for cardiovascular disease and shorter life expectancy, problematic alcohol use, broken relationships, depression, and suicide.,,
This interesting study addresses the important problem of physician burn out and its implications on delivering health care. This meta-analysis is based on 47 studies on 42,473 physicians of median age, 38 years [range, 27–53 years] analyzing the impact of physician burnout on patient safety incidents, suboptimal care outcomes due to low professionalism, and lower patient satisfaction. It was found that physician burnout was associated with an increased risk of patient safety incidents (odds ratio [OR], 1.96; 95% CI, 1.59–2.40), poorer quality of care due to low professionalism (OR, 2.31; 95% CI, 1.87–2.85), and reduced patient satisfaction (OR, 2.28; 95% CI, 1.42–3.68).
This risk was larger in residents and physicians early in their career; 5-year postresidency. This important piece of information is extremely relevant and stresses upon the health organizations of the need to work for an improvement of physician wellness.
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|2||Bill-Axelson A, Holmberg L, Garmo H, Rider JR, Taari K, Busch C, et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med 2014;370:932-42.|
|3||Gschwend JE, Heck MM, Lehmann J, Rübben H, Albers P, Wolff JM, et al. Extended versus limited lymph node dissection in bladder cancer patients undergoing radical cystectomy: Survival results from a prospective, randomized trial. Eur Urol 2018. pii: S0302-2838(18) 30737-1.|
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