Statewide public radiotherapy services in Victoria: Getting out of service provider silos to improve equity of care and access to optimal treatment

Aim: The healthcare technological revolution has seen many treatment innovations become available to optimise cancer treatments. Radiotherapy has benefited from numerous such innovations however some of this unique equipment is expensive and often targeted towards specific anatomy or tumour types. To enable public radiotherapy services to offer these advanced treatments when very high capital cost was involved, the Victorian government-funded particular specialist radiotherapy machines, designating these as statewide services. This approach aimed to ensure Victorian patients that might benefit most could access these services without cost, while still receiving the rest of their care as close to home as possible. Methods : Government funded public MR linear accelerator (MR-linac) and Gamma Knife™ radiotherapy treatment machines. Both are significantly more expensive than a standard linac and only two of each existed in Australia - none in Victoria - prior to their acquisition. The Victorian 'Statewide radiotherapy services framework' was developed and published to underpin these new services and a website created covering indications information to support and facilitate appropriate referrals of suitable patients from within the state. Additionally, patient-reported outcomes were introduced as a routine part of these services. Results : The Victorian Gamma Knife™ service commenced treatments in 2021 and has already delivered over 135 courses of radiotherapy, 25% of these being for new indications. Treatments have been provided to patients from 85 different locations across the state. Although delayed due to the COVID-19 pandemic and limited worldwide installation expertise of this novel technology, the MR-linac service has just commenced clinical treatments. Conclusions : Statewide specialist radiotherapy services have been developed and implemented, providing fee free access to all Victorians irrespective of their place of residence. With more personalised cancer treatments becoming routine, a cost-effective way to have expensive equipment available to treat those who could most benefit has been established.

Ambulatory percutaneous nephrolithotomy is safe and effective in extended criteria patients

Introduction & Objective: Ambulatory tubeless percutaneous nephrolithotomy (aPCNL) has been shown to be safe and effective in highly selected patients. However, these selection criteria preclude the vast majority of patients that undergo PCNL. The objective of our study was to compare complication and stone free rates after aPCNL in standard selection criteria vs. extended criteria patients. Methods: Retrospective review of prospective data on all patients who underwent aPCNL at one academic center from 2007-2018. Extended criteria patients were defined as any: Age >75 years, BMI >30 kg/m2, ASA >2, bilateral stones, solitary kidney, staghorn calculi, stone burden >40 mm, multiple tracts, or prior nephrostomy tubes/stents. Primary outcomes were complication rates (Clavien-Dindo classification) and stone free rates (no fragments >/ = 3 mm). All patients were discharged with a ureteric stent and no nephrostomy tube after meeting discharge criteria which included hemodynamic stability, no fever, and no significant pain. Results: We identified 118 patients of which 92 (78%) met extended criteria. Mean BMI was 31 kg/m2 and 45% were ASA 3 or higher. Mean sum maximum stone diameter was 24 mm. Multiple stones were present in 25%, bilateral stones in 7%, staghorn stones in 4%, and pre-existing tubes/stents in 4%. There was no difference in complication (12% vs. 18%, p = 0.56), Emergency department visit (12% vs 18%, p = 0.56), or readmission (4% vs. 5%, p = 1) rates between standard and extended criteria patients respectively (Table 1). Of the complications, 85% were Clavien-Dindo grade 1. Stone free rates were not different between standard (84%) and extended (83%) criteria patients (p = 1). No extended criteria variables were associated with complications in univariate analysis. Stone burden >40mm (OR 5.8, 95% CI 1.4-25.2, p = 0.018) and multiple tracts (13.1, 95% CI 1.1-154.7, p = 0.041) were associated with residual stone fragments. Conclusions: Complication and stone free rates were not different between standard and extended selection criteria patients undergoing aPCNL. This data supports the safety and efficacy of aPCNL in patients using extended selection criteria. As the COVID-19 pandemic continues to strain hospital resources, aPCNL offers a solution to deal with a growing backlog of patients with complex stone disease.

Influence of the COVID-19 pandemic on the burnout rates of graduating Canadian urology residents

INTRODUCTION AND OBJECTIVE: Burnout is a work-related psychologic syndrome characterized by emotional exhaustion decreased sense of personal accomplishment, and depersonalization.1 Burnout among surgeons is increasing with prevalence rates exceeding 50%.2COVID-19 has affected the medical system with evidence of increased stress and levels of depression in our medical trainees. This study aims to assess the influence COVID-19 is having on burnout rates in Canadian Urology trainees. METHODS: Thirty-seven chief residents among the Canadian Urology residency programs attended the Queen's Urology Exam Skills Test (QUEST) on December, 2019 pre-pandemic and thirty-nine chief residents attended virtually on November, 2020 during the pandemic. The Maslach Burnout Inventory (MBI) questionnaire was administered anonymously. The MBI covers emotional exhaustion, depersonalization and personal accomplishment.4 Descriptive statistics were used to analyze the data. RESULTS: There was 100% response rate in the convenience sample (n=37) in 2019 and 64.1% response rate (n=25) in 2020. 70% of chief residents in Canadian Urology programs showed evidence of burnout in 2019 compared to 88% in 2020. There was a statistically significant difference between the two cohorts in emotional exhaustion (45.9% in 2019 and 68% in 2020, p=0.005) and depersonalization scores (62.2% in 2019 and 80% in 2020, p=0.02). CONCLUSIONS: This study is the first to examine the impact of the pandemic on burnout rates in urology trainees. Burnout rates are high in trainees at baseline, and the pandemic appears to have exacerbated this problem. Vigilance and proactive steps need to be implemented to alleviate this crisis.

Ambulatory percutaneous nephrolithotomy is safe and effective in extended selection criteria patients

INTRODUCTION AND OBJECTIVE: Ambulatory tubeless percutaneous nephrolithotomy (aPCNL) has been shown to be safe and effective in highly selected patients. However, these selection criteria preclude the vast majority of patients that undergo PCNL. The objective of our study was to compare complication and stone free rates after aPCNL in standard selection criteria vs. extended criteria patients. METHODS: Retrospective review of prospective data on all patients who underwent aPCNL at one academic center from 2007- 2018. Extended criteria patients were defined as any: Age >75 years, BMI >30 kg/m2, ASA >2, bilateral stones, solitary kidney, staghorn calculi, stone burden >40 mm, multiple tracts, or pre-existing nephrostomy tubes/stents. Primary outcomes were complication rates (Clavien-Dindo classification) and stone free rates (no fragments >/ =3 mm). All patients were discharged with a ureteric stent and no nephrostomy tube after meeting discharge criteria which included hemodynamic stability, no fever, and no significant pain. RESULTS: We identified 118 patients of which 92 (78%) met extended criteria. Mean BMI was 31 kg/m2 and 45% were ASA 3 or higher. Mean sum maximum stone diameter was 24 mm. Multiple stones were present in 25%, bilateral stones in 7%, staghorn stones in 4%, and pre-existing tubes/stents in 4%. There was no difference in complication (12% vs. 18%, p=0.56), Emergency department visit (12% vs 18%, p=0.56), or readmission (4% vs. 5%, p=1) rates between standard and extended criteria patients respectively (Table 1). Of the complications, 85% were Clavien-Dindo grade 1. Stone free rates were not different between standard (84%) and extended (83%) criteria patients (p=1). No extended criteria variables were associated with complications in univariate analysis. Stone burden >40 mm (OR 5.8, 95% CI 1.4-25.2, p=0.018) and multiple tracts (13.1, 95% CI 1.1-154.7, p=0.041) were associated with residual stone fragments. CONCLUSIONS: Complication and stone free rates were not different between standard and extended selection criteria patients undergoing aPCNL. This data supports the safety and efficacy of aPCNL in patients using extended selection criteria. As the COVID-19 pandemic continues to strain hospital resources, aPCNL offers a solution to deal with a growing backlog of patients with complex stone disease.