ASSOCIATION OF OVERACTIVE BLADDER AND C-REACTIVE PROTEIN LEVELS: RESULTS FROM THE BOSTON AREA COMMUNITY HEALTH (BACH) SURVEY

Sir, We read with interest the above article by Kupelian et al. [ 1 ] where the authors have shown an association between overactive bladder (OAB) in both men and women with elevated levels of C-reactive protein (CRP). Levels of serum CRP were associated with both urgency and nocturia in men whereas in there was women an association with urgency only. The results thus provide further data to add to the accumulating evidence supporting a role of infl ammation in the development and progression of OAB.

CRP is excreted in the urine [ 2 ] and its level has also been measured in other body fl uids [ 3,4 ] . Can chronic infl ammation of the urinary tract lead to high levels of CRP in the urine, as the urinary bladder is in direct contact with it? If so, then we feel that urinary CRP rather than serum CRP would have been more useful because false-positive results of increased serum CRP due to confounding variables, e.g. obesity, smoking, diet and comorbid conditions, can affect serum CRP levels [ 5 ] .

Apul Goel , Swarnendu Mandal and

Rohit Kathpalia , Department of Urology, Chhatrapati Shahuji Maharaj Medical University

(Formerly, King George Medical College), Lucknow Uttar Pradesh 226003, India

REFERENCES

1 Kupelian V , Rosen RC , Roehrborn CG , Tyagi P , Chancellor MB , McKinlay JB . Association of overactive bladder and

C-reactive protein levels: results from the Boston Area Community Health (BACH) Survey . BJU Int [ Epub ahead of print ] . DOI: 10.1111/j.1464-410X . 2011 . 10769 . x

2 Ortiz RM , Mamalis A , Navar LG . Aldosterone Receptor Antagonism Reduces Urinary C – reactive protein Excretion in Angiotensin II-Infused, Hypertensive Rats . J Am Soc Hypertens 2009 ; 3 : 184 – 91

3 Shim SS , Romero R , Jun JK , Moon KC , Kim G , Yoon BH . C-reactive protein concentration in vaginal fl uid as a marker for intra-amniotic infl ammation/infection in preterm premature rupture of membranes . J Matern Fetal Neonatal Med 2005 ; 18 : 417 – 22

4 van de Laar R , van der Ham DP , Oei SG , Willekes C , Weiner CP , Mol BW . Accuracy of C-reactive protein determination in predicting chorioamnionitis and neonatal infection in pregnant women with premature rupture of membranes: a systematic review . Eur J Obstet Gynecol Reprod Biol 2009 ; 147 : 124 – 9

5 Heikkila K , Ebrahim S , Lawlor DA . A systematic review of the association between circulating concentrations of C reactive protein and cancer . J Epidemiol Community Health 2007 ; 61 : 824 – 33

REPLY

Sir, We thank Dr Goel, Dr Mandal and Dr Kathpalia for their comments about our paper on the association of overactive bladder (OAB) and C-reactive protein (CRP) levels [ 1 ] . Assessment of urinary CRP was not possible in our study as urine samples were not collected in the BACH Survey. Additionally, a study comparing CRP levels in both serum and urine among patients with LUTS has shown that urinary CRP was rarely detected while serum CRP levels were elevated [ 2 ] . These results suggest that

urinary CRP is not a viable biomarker for local bladder infl ammation. We disagree that the results presented in our paper using serum based CRP levels are likely to have been confounded, as our analyses take into account the potential confounding effect of obesity, smoking, and comorbid conditions. Results of multivariable analyses of the association of CRP levels and symptoms of OAB, presented in Table 3 and Figure 3 of the manuscript, are adjusted for potential confounders including sociodemographic factors (age, socioeconomic status, race/ethnicity), body mass index, lifestyle factors (smoking, alcohol consumption, physical activity), comorbid conditions (heart disease, diabetes, hypertension) and prescription medications use including anti-infl ammatory medications. The association of CRP levels with OAB symptoms reported in our paper is consistent with results from previous studies suggesting a role of infl ammation in the development and progression of LUTS.

Varant Kupelian , Raymond C. Rosen ,

Claus G. Roehrborn , Pradeep Tyagi ,

Michael B. Chancellor and John B. McKinlay ,

on behalf of the authors

REFERENCES

1 Kupelian V , Rosen RC , Roehrborn CG , Tyagi P , Chancellor MB , McKinlay JB. Association of overactive bladder and C-reactive protein levels: results from the Boston Area Community Health (BACH) Survey . BJU Int [ Epub ahead of print ] . DOI: 10.1111/j.1464-410X . 2011 . 10769 . x

2 Chuang YC , Tyagi V , Liu RT , Chancellor MB , Tyagi P . Urine and serum C-reactive protein levels as potential biomarkers of lower urinary tract symptoms . Urol Sci 2010 ; 21 : 132 – 6

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W R I T E T O T H E E D I T O R B Y S U B M I T T I N G Y O U R L E T T E R O N L I N E A T H T T P : / / M C . M A N U S C R I P T C E N T R A L . C O M / B J U I

UROLOGY TRAINING: PAST, PRESENT AND FUTURE

Sir, Gohil et al . [ 1 ] describe the current career pathway for a graduating doctor pursuing a career in Urology. They mention the effect that the European Working Time Directive (EWTD) has had on the training time available. As Gohil et al . point out, urology has developed swiftly in the last few decades and training programmes must adapt accordingly. With laparoscopic, robot-assisted and single-port surgery developing rapidly, urology trainees have to turn increasingly to simulation to supplement workplace training. Whilst simulation is becoming essential, it cannot replace real world experience.

Spare a thought for the junior doctor hoping to pursue a career in urology. It feels like there is great momentum in the specialty with new and exciting urological developments at the Consultant end of the career. All of whom ‘ cut their teeth ’ in the pre-EWTD era and have a sound base of operative exposure on which to pursue the latest advances. This is contrasted sharply with the impact of the EWTD, which has most changed the situation at the earliest stages of surgical training. Work rota commitments as a result of the EWTD have been shown to reduce the amount of time a senior house offi cer can spend in surgery, and therefore impact the development of their basic operative skills [ 2 ] . It does seem as if the top end of the specialty is leaving behind those at the bottom. One has to wonder if it is now at all realistic to expect a doctor graduating in 2011 to be a well-rounded and safe consultant urological surgeon with just 9 years of training.

Daniel J. Stevens , General Surgery, North Bristol NHS Trust,

Southmead Hospital Westbury on Trym, Bristol BS10 5NB, UK

REFERENCES

1 Gohil R , Khan RS , Ahmed K et al . Urology training: past, present and future . BJU Int 2011 [ Epub ahead of print ] . DOI: 10.1111/j.1464-410X.2011.10653.x

2 Parsons BA , Blencowe NS , Hollowood AD , Grant JR . Surgical training: the impact of changes in curriculum and experience . J Surg Educ 2011 ; 68 : 44 – 51

REPLY

ARE WE PRODUCING COMPETENT AND TECHNOLOGY-ATTENTIVE UROLOGISTS?

Sir, Urology is an innovative fi eld, which is continually evolving to embrace technological developments. According to these changes methods of training and assessment have also adapted.

Innovative technology is primarily for higher levels of training because the initial phase of technology development and evaluation needs to be limited to experts. Once it is deemed safe, training methods for trainees are developed and validated. Furthermore, it is essential for trainees to master the basic skills fi rst, before moving onto using more advanced techniques. High fi delity simulation and fellowship programmes can address this disparity.

Newly appointed specialists are equally competent, as most of them have gone through fellowship programmes before embarking on this senior role. Although the duration of specialist training seems to have been reduced, the amount of time spent in mastering skills remains the same with addition of fellowship years. Trainees are more aware than ever and they start exploring into options from the very beginning of their specialist training years. The training programmes across various regions, e.g. Intercollegiate Surgical Curriculum Programme (UK); European Board of Urology (Mainland Europe); and American Board of Urology (USA), have delineated more focused and comprehensive training programmes that are in accordance with the European Working Time Directives.

Current training and assessment of technical and non-technical skills rely heavily on the experience gained from clinical practice. Simulation is increasingly used as an adjunct, with the potential to supplement workplace training. Research has shown the benefi t of simulators, both as learning tools

and assessment tools [ 1, 2 ] . Simulation not only minimises the initial stages of the ‘ learning curve ’ associated with the acquisition of new surgical skills, but also provides a time-independent environment in which urologists can learn, without compromising on patient safety [ 3, 4 ] . However, simulation is not an alternative to real environment training. It is imperative that specialists obtain surgical skills whilst in theatre. Mentoring programmes and preceptorship aid the learning trainees through exchange of tacit knowledge and constructive feedback [ 5 ] .

Despite changes in the working times, urology is adapting well in terms of embracing new technologies and developing new training and assessment tools. Equally competent urologists are produced to ensure patient safety.

Kamran Ahmed , Rishma Gohil ,

Reenam S. Khan , Pardeep Kumar ,

Ben Challacombe , Mohammed Shamim Khan

and Prokar Dasgupta , on behalf of the authors

REFERENCES

1 Ahmed K , Jawad M , Dasgupta P , Darzi A , Athanasiou T , Khan MS . Assessment and maintenance of competence in urology . Nat Rev Urol 2010 ; 7 : 403 – 13

2 Ahmed K , Jawad M , Abboudi M et al . Effectiveness of procedural simulation in urology: a systematic review . J Urol 2011 ; 186 : 26 – 34

3 McClusky DA 3rd , Smith CD . Design and development of a surgical skills simulation curriculum . World J Surg 2008 ; 32 : 171 – 81

4 Ahmed K , Amer T , Challacombe B , Jaye P , Dasgupta P , Khan MS . How to develop a simulation programme in urology . BJU Int 2011 ; 108 : 1698 – 702

5 Gagliardi AR , Wright FC . Exploratory evaluation of surgical skills mentorship program design and outcomes . J Contin Educ Health Prof 2010 ; 30 : 51 – 6

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INCIDENCE OF LYMPHOCELES AFTER ROBOT-ASSISTED PELVIC LYMPH NODE DISSECTION

Sir, We commend Orvieto et al . [ 1 ] for highlighting the important subject of pelvic lymphadenectomy (PLND) for intermediate- and high-risk prostate cancer but respectfully disagree with their conclusions.

They found a 51% incidence of pelvic lymphocele on CT and a 7.9% incidence of symptomatic lymphoceles in 76 patients who had undergone standard PLND. They had no intraoperative complications. These results prompted them to conclude fi rstly that transperitoneal radical prostatectomy (RP) fails to protect against lymphocele formation and secondly that the benefi t of PLND should be counterbalanced by ‘ the elevated risk of lymphocele formation and its potential complications ’ .

Updating our previously published experience [ 2 ] in 403 patients who underwent an extended PLND (ePLND) during transperitoneal laparoscopic RP (LRP), we found a 0.5% incidence of symptomatic lymphocele and a 2% incidence of intraoperative complications related to ePLND (postoperative bleeding in four patients, two ureteric injuries and two obturator nerve injuries). This is in contradiction to the conclusion by Orvieto et al . [ 1 ] , that a more extensive PLND template would likely increase the rate of lymphocele formation. However, we do agree with their conclusion that the difference in the rate of symptomatic lymphocele between the two series is likely to be explained by the fact that Orvieto et al . used ‘ no surgical clips ’ whereas we use titanium clips to secure lymphatics liberally, having learned the lesson from our open surgical predecessors that diathermy provides poor control of lymphatic vessels [ 3 ] . We also routinely administer low-molecular-weight heparin into the arms of our patients (as opposed to the thighs or

abdomen), as evidence suggests that this reduces the concentration of heparin in pelvic drainage fl uid, which in turn correlates with postoperative lymphatic leak [ 4 ] . The authors do not mention the route of administration of heparin in their patients.

We feel that the conclusions reached by the authors are fl awed because their use of thermal energy rather than clips on lymphatic vessels during PLND could be predicted to result in a high rate of lymphocele formation, as they acknowledge. In addition, whilst we agree that ‘ the benefi t of PLND. . . . should be weighed against the elevated risk of lymphocele formation and its potential complications ’ , we would assert that their results in fact support the addition of PLND in intermediate- and high-risk patients. Despite not using clips on lymphatic vessels, and despite these cases representing their learning curve for this procedure, only one patient developed a symptomatic lymphocele requiring intervention (1.3%) and there were no intraoperative complications.

We also feel that it is unfortunate that the authors ’ conclusions will bolster the stance of those of our laparoscopic and robot-equipped colleagues who fi nd it more convenient not to perform a PLND during RP [ 5 ] . There is now compelling and growing evidence in favour of ePLND benefi tting men with intermediate- and high-risk prostate cancer in terms of improving disease-specifi c survival regardless of nodal status [ 6,7 ] . This is refl ected by the most recent evidence-based guidelines on prostate cancer [ 8 ] .

Christopher G. Eden , Evangelos Zacharakis , Philip E. Dundee and Anthony C. Hutton ,

Department of Urology, Royal Surrey County Hospital, Egerton Rd,

Guildford GU2 7XX, UK

REFERENCES

1 Orvieto MA , Coelho RF , Chauhan S , Palmer KJ , Rocco B , Patel VR . Incidence of lymphoceles after robot-assisted pelvic lymph node dissection . BJU Int 2011 ; 108 : 1185 – 90

2 Eden CG , Arora A , Rouse P . Extended vs standard pelvic lymphadenectomy during laparoscopic radical prostatectomy for intermediate- and high-risk prostate cancer . BJU Int 2010 ; 106 : 537 – 42

3 Porter KA , O ’ Connor S , Rimm E , Lopez M . Electrocautery as a factor in seroma formation following mastectomy . Am J Surg 1998 ; 176 : 8 – 11

4 Khoder WY , Trottmann M , Buchner A et al . Risk factors for pelvic lymphoceles post-radical prostatectomy . Int J Urol 2011 ; 18 : 638 – 43

5 Bolenz C , Gupta A , Hotze T et al . Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer . Eur Urol 2010 ; 57 : 453 – 58

6 Joslyn SA , Konety BR . Impact of extent of lymphadenectomy on survival after radical prostatectomy for prostate cancer . Urology 2006 ; 68 : 121 – 5

7 Withrow DR , DeGroot JM , Siemens DR , Groome PA . Therapeutic value of lymph node dissection at radical prostatectomy: a population-based case-cohort study . BJU Int 2011 ; 108 : 209 – 16

8 European Association of Urology . Guidelines on Prostate Cancer , 2010 . Available at: http://www.uroweb.org/gls/pdf/Prostate%20Cancer%202010%20June%2017th.pdf . Accessed January 2012

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