Update from Arthur’s South African Endofari - Day 2
Dr. John Denstedt launched the day with “Africa and kidney stones: from Tsetse fly to fruit fly.” Dr. Denstedt, professor and chairman of the department of surgery at University of Western Ontario impressed the audience with a novel study. In his presentation Dr. Denstedt presented on the use of the fruitfly in urologic research. Continuing the safari theme for the lectures, he started with a bang referring to the Tsetse fly which causes sleeping sickness; a disease that affects the nervous system and has killed millions of people in sub-Saharan Africa. Dr. Denstedt then went on to discuss his work with the fruit fly which was inspired by earlier work by Dr. Marshall Stoller. Fruit flies are a wonderful translational model due to the relatively simplicity of their genetic makeup and the cost-effectiveness of the model. The goal of the research was to evaluate pharmacologic models. This was done by feeding the fruit flies a diet high in oxalate. Their team was then able to excise the simple fly kidneys (Malpigian tubules) which could be micro-dissected for their crystals. Dr. Denstedt and his team the screened over 350 compounds in an effort to evaluate their effect on oxalaye excretion. Six separate compounds appeared promising for diminishing calcium oxalate crystallization, and one in particular may be a target for future drug development. Discussion between Dr. Marshall Stoller and Dr. Denstedt ensued confirming the promising nature of this research.
Dr. Raju Thomas from Tulane University Hospital and Clinic presented “From endopyelotomy to robotic pyeloplasty.” Dr. Thomas’s presentation emphasized how the treatment of the ureteropelvic junction (UPJ) obstruction has evolved tremendously over the past several decades. He reviewed the many factors which differentiate the level of challenge with managing a UPJ obstruction including crossing vessels, renal function and the degree of hydronephrosis. Dr. Thomas noted how Dr. Arthur Smith helped define the evolution of UPJ obstruction management when he performed the first antegrade endopyelotomy using a cold knife incision at the UPJ laterally. Initially the success rate of this approach was from 57% to 100% based largely on the duration of follow-up. Today, antegrade incision is rarely used as it was been supplanted by a retrograde approach by rigid and later flexible ureterocopes. Similar to the antegrade approach, the retrograde approach has increasing failure with increasing follow-up time. As such, the retrograde approach has diminished and has largely been supplanted by the laparoscopic and later the robotic-assisted laparoscopic approach. Laparoscopic pyeloplasty had a high success rate around 90%, but was challenging for urologist due to the need for laparoscopic reconstructive skills. In the US, the robotic procedure has taken over with 8000 urologist performing approximately 4500 cases per year. Dr. Thomas noted that despite the advanced technology of the robot, the general principles of pyeloplasty have not changed, but that UPJ obstruction patients in the contemporary robotic reconstructive era are treated with a relatively minimally invasive technique that has excellent longer-term outcomes.
Education for future generations of urologist will be increasingly important. Dr. Elspeth McDougall made it clear that her life-long interest in education was inspired by Dr. Smith. In her presentation, “Teaching communication skills in the jungles of the health care system,” Dr. Elspeth McDougall, MD, FRCSC, MHPE who is Professor of Urologic Sciences, Provincial Coordinator of Health Simulation education at the University of British Columbia in Vancouver, explained how she recruited a large number of centers throughout Canada to help improve patient handover communication. She created an on-line curriculum using the Delphi technique to create a cognitive curriculum which was combined with simulation to practice the skills of handover communication. She started the research with nurse handover training. The nurses were already using SBAR which is an urgent handover technique. The key component of the curriculum was establishing a dialogue between sender and receiver of communication. She stated that she was able to capture 427 students to participants, but only 46 (11%) participated. Despite the small amount of participation, there was improved information transfer using the technique in combination with simulation. Dr. McDougall stated that she is continuing the research which will be an important area of future training for improved communication and safe patient transfer. Dr. Clayman inquired as to the patient outcomes which have resulted. Dr. McDougall resonded that this data is actively being captured and will hopefully be reported in the near future.
Dr. Benjamin Lee, Professor and Chief, Urology program director, University of Arizona in Tucson presented, “Heat sensitive encapsulated tyrosine kinase liposomes activated by HIFU for RCC: Waking the sleeping lion.” Dr. Lee started with a story of how his father migrated from Taiwan in 1962 looking for a better life for his family. This story paralleled Dr. Smith’s experience emigrating from South Africa looking for a better and safer life for his family. Dr. Lee shared touching stories of how Dr. Smith was a great mentor. Dr. Lee then discussed how nanoparticles can be used for imaging and cancer treatment by modulating drugs and particles. Initial work with carbon and gold rods failed due to technical factors. Later work with liposomes to encapsulate a tyrosine kinase inhibitor (TKI) has shown more promise. Dr. Lee and his team created a tumor model which he treated with TKI loaded liposomes. The liposomes would release the drug at a high level when activated directly in the tumor. Dr. Lee demonstrated an increased renal cell carcinoma cell model kill rate which was five times higher using the nanoparticle technology.
Dr. Sarah Best, Assistant Professor of Urology, University of Wisconsin School of Medicine then presented, “Surgical treatment of 4-10cm renal cell carcinoma (RCC): a survey of lions and gazelles.” Dr. Best explained how we generally know how to manage T1a RCC, but that there was more variation in the management of T1b (4-10 cm tumors). Dr. Best and her team disseminated a survey with 400 responses with over 20,000 patients represented. Results indicated that for exophytic lesions only comfort level was responsible for weather these were treated with laparoscopic or open technique. This was largely determined by fellowship training. Thirty eight percent of respondents stated that there is inadequate knowledge regarding how to treat these tumors. Overall, it was clear that training was the factor most correlated with minimally invasive training and that we as a community should focus on training to improve the standard of care for these challenging tumors.
Written by: Jaime Landman Professor of Urology and Radiology Chairman, Department of Urology University of California, Irvine