Urology

To the Editor:We read with interest the recent position statement on the management of non-neurogenic overactive bladder (OAB) published in the Journal.1 This considered statement reflects recent guidelines from national and international urological societies, including the American Urological Association, the European Association of Urology, the International Continence Society, the Urological Society of Australia and New Zealand and the UroGynaecological Society of Australasia. In recognition of the often repeated phrase in urological research “the bladder is an unreliable witness”, there has been an increasing emphasis on addressing factors beyond the bladder when managing patients with OAB and lower urinary tract symptoms (LUTS).2 The authors of the MJA statement deal with this issue more than most by encouraging their readers to be mindful of known OAB risk factors and comorbid conditions. However, one condition in particular, obstructive sleep apnea (OSA), continues to be overlooked in the diagnosis and management of OAB and LUTS. Our group has previously shown a substantial burden of undiagnosed OSA in a large sample of community-based men aged 40 years and over, with 53% of men without prior diagnosis shown to have some degree of OSA, of which 14% and 12% were found to have moderate and severe OSA, respectively.3 We also demonstrated an independent association between nocturia — the most frequent and bothersome of the OAB symptoms2 — and the presence of moderate to severe OSA, with such men showing a 52% adjusted risk increase for the presence of nocturia.3 Recent systematic reviews of continuous positive airway pressure in the treatment of nocturia indicated a mean standardised difference of −2.28 episodes per night (95% confidence interval, −2.42 to −2.15) between treatment groups in patients with nocturia.4 This difference is comparable to the efficacy observed with frontline treatments for this condition. Nocturia and other OAB symptoms are also known to be sentinel markers of cardiovascular disease,5 providing further motivation for dealing with known risk factors, such as OSA, in the management of OAB. We believe that it would be helpful to include recommendations to assess for the presence of OSA in patients presenting with nocturia, either alone or in combination with other OAB-related symptoms.

Sean A Martin · Nicholas R Brook · Gary A Wittert

In reply

Eric Chung

Clinical pediatric nephrology, 3rd edition

Steven J McTaggart

To the Editor:Ahern and colleagues1 explore the potential benefits and pitfalls of benchmarked reporting in the Australian context. As a binational registry of patients on renal replacement therapy in Australia and New Zealand, the Australia and New Zealand Dialysis and Transplant Registry has been producing and distributing centre-specific performance reports to renal units for over 20 years; these share many of the challenges faced by clinician-level reporting. In the past few years, this has extended to provision of an abridged version of the report on our website, containing unit-specific risk-adjusted outcome data for each dialysis and transplant unit (http://www.anzdata.org.au/v1/hospitalreport.html). The authors highlight the challenges of low case numbers resulting in statistical models that are underpowered to detect poor performance and require long observation periods that will limit timely detection of outliers and opportunities for remedial action. Co-opting statistical techniques used for quality control in other industries may present an opportunity to address these issues in the health care sector. Cumulative sum control charts2 provide a method for sequentially monitoring cumulative performance over time, which may permit early detection of poor performance and account for varying activity levels by including the number of procedures performed, rather than just a fixed time frame. Similarly, Bayesian approaches that involve updating prior probability distributions within a dynamic model may address these concerns3 and offer the conceptual advantage of explicitly testing not just the statistical difference from average but the likelihood of performance falling into a defined poor performance category. Finally, there are systems that use differing criteria for smaller and larger units.4 Ahern and colleagues discuss the potential consequences of poor performance, but omit any reference to exactly who should oversee this process. We assert that the relevant specialty or subspecialty body has a crucial role in overseeing the interpretation of reports. The detection of an outlier is dependent on the nature of the boundaries set for acceptable performance, and the vulnerability of the statistical adjustment model to bias and unmeasured confounders. Such interpretation requires detailed knowledge of the relevant field, an appreciation of the variation between centres, and substantial epidemiological knowledge.

Matthew P Sypek · Matthew D Jose · Stephen P McDonald

In reply

David Scott · Barbora de Courten · Peter R Ebeling

Editor’s note: The Lancet recently published an important Australian randomised controlled trial of robotic and open prostatectomy. We publish the following non-commissioned correspondence by Hutchison and colleagues together with an invited response from the corresponding author of the trial, Robert Gardiner, because of the relevance of the debate to Australian health care. To the Editor: Robotic prostatectomy took off quickly, despite the cost. In Australia, most prostatectomies are now done with a robot that costs almost $10 000 in capital and maintenance per procedure, or between $442 and $3548 more than an open prostatectomy.1 The robotic option was meant to reduce side effects relating to impotence and incontinence; however, preliminary findings from the world’s first randomised controlled trial suggest that this is not the case.2 Uptake of innovative surgery tends to outpace evidence because it is hard to design and run randomised studies. In addition, placebo surgery is rare and controversial, and recruitment is challenging, as surgeons and patients often prefer one option. Trial results may also be difficult to interpret: if the same surgeon performs both operations, they may be better at one; or if different surgeons operate, one may be superior.3 Australia is not immune to these challenges, despite local initiatives to improve quality of care4 and evaluate the benefits of the robotic procedure.5 The industry understands this. Intuitive Surgical aggressively marketed its robot while the jury was still out on its comparative benefits. Celebrity stories have also driven demand; for instance, radio personality Alan Jones has been an outspoken advocate.6 But even when evidence commends a surgical innovation, introducing it to the public health care system may create or exacerbate inequity. Suppose that the robot, or some successor, eventually proves superior to alternatives. Expensive equipment and difficult procedures require high patient throughput to justify the costs and maintain surgeons’ skills, so they tend to be concentrated in the biggest, busiest hospitals. Therefore, patients in regional areas are often expected to travel for treatment, with little or no financial support; and the barrier is even higher for people who do not have the social and economic resources to get themselves to a big city hospital.7 We should resist the hype of a new technology and wait for good evidence before expending scarce health care dollars. This will sometimes mean lagging behind other countries and saying no to patients. However, it will also mean safeguarding patients and the public purse from innovations that turn out to be no better, or maybe worse, than existing options. Moreover, when a new technology is introduced, we should also fund the supports that people need to access it.

Katrina Hutchison · Drew Carter · Jane Johnson

In reply

Mark Frydenberg · Robert (Frank) A Gardiner

To the Editor:Hepatitis E virus (HEV) genotype 3, the most common genotype in high income countries, is transmitted by ingestion of high risk food — including pork, deer and shellfish — and by blood transfusion. Rural residence, travel to hyperendemic areas (eg, southern Europe) and animal exposure are other risk factors.1 Both de novo and reactivated HEV infection can lead to chronic infection in up to 60% of immunocompromised patients, particularly in solid organ transplant (SOT) recipients.1,2 Moreover, 10% of patients who are chronically infected develop cirrhosis.1 In a 2013 study, the seroprevalence of HEV in Australian blood donors was 5.99%.3 Autochthonous transmission in Australia, including one patient who was a liver transplant recipient, is well documented.4,5 However, the seroprevalence and rate of chronic HEV infection in SOT recipients in Australia are unknown. We carried out a study to investigate this in an Australian tertiary hospital. In phase 1 of our study, we recruited renal transplant recipients attending routine outpatient follow-up in 2014–15; phase 2 was limited to seropositive participants from phase 1. The study was approved by the Northern Sydney Local Health District Human Research Ethics Committee (LNR/14/HAWKE/300). Seventy-four patients consented to participate in phase 1, and post-transplant stored serum was tested for HEV IgG. Six participants were HEV IgG positive. One seropositive participant died of invasive fungal infection before phase 2. The remaining five participants who were seropositive consented to phase 2, of whom one was HEV IgM positive. We tested plasma for HEV RNA and no phase 2 participants had evidence of ongoing chronic infection. While our study had limitations and we did not identify any participant with chronic infection, it is important to note that Australian SOT recipients are exposed to HEV and are at risk of chronic infection. Effective therapy for chronic HEV is available; therefore, we recommend that SOT recipients who have abnormal liver function tests should be tested for HEV RNA in blood to maximise early diagnosis. In addition, with respect to risk mitigation, previous Australian research supports a link between local pork consumption and HEV infection,4 and French guidelines suggest that SOT recipients should avoid consuming food containing pork liver.6 We believe that similar advice should be given to SOT recipients in Australia. Moreover, consideration should be given to screening donated blood in Australia for HEV RNA, as done in France and the United Kingdom, with experts calling for such screening across the European Union.7,8 The Australian Red Cross Blood Service has undertaken a large scale screening study of donated plasma for HEV RNA to estimate the local risk of HEV transmission by blood transfusion, with results currently pending.9

James P Newcombe · Stella McGinn · Bruce Wong · Archie Darbar · George Kotsiou