Cytoreductive Nephrectomy In Clinical Practice

Cytoreductive Nephrectomy In Clinical Practice

David Nicol is a Consultant Urological Surgeon at the Royal Marsden Hospital in London where he is also Chief of Surgery. His clinical work deals with complex kidney and testis cancer including surgery in patients with advanced and metastatic disease. Here, he explains the use of cytoreductive nephrectomy in metastatic kidney cancer.

David, can you explain what is meant by cytoreductive nephrectomy?

Cytoreductive nephrectomy refers to the removal of the primary kidney tumour in patients who have metastatic disease. Historically it had been noted that occasional patients experienced spontaneous regression of metastatic disease when this was performed. This however only occurred in a very small number of cases and general opinion was that cytoreductive nephrectomy as the overwhelming majority died within 12-18 months from metastatic disease. In the late 1980’s and early 1990’s, drugs which stimulated the immune system(immunotherapy) had an effect on metastatic kidney cancer.

Small trials with 2 agents interferon-alpha (IFN-a) and interleukin-2 (IL-2) showed response rates better than what had been observed with conventional cytotoxic chemotherapy. Analysis of these studies suggested that patients who had a nephrectomy performed prior to treatment resulted in a better response to both INF-a and IL-2. The basis for this was uncertain with possibilities including a selection bias with only fitter patients, who would otherwise expect to live longer, having nephrectomy. Alternatively it was also proposed that cytoreductive nephrectomy may exert some biological effect improving the effectiveness of immunotherapy and thus overall survival.

Which patients with metastatic kidney cancer are suitable for cytoreductive nephrectomy?

Cytoreductive nephrectomy is really only an appropriate option for patients who are otherwise well. Patients whose performance status is impaired are at high risk of complications from major surgery and also generally have poor survival that is not improved with cytoreductive nephrectomy. Therefore patients who have noted significant weight loss, are anemic or who feel tired and generally unwell are not considered candidates for cytoreductive nephrectomy. Some patients may present with significant symptoms including pain and bleeding for which nephrectomy is recommended. This is regarded as a palliative intervention to control symptoms rather than a cytoreductive nephrectomy which is performed with the expectation that it may improve survival.

Can you outline the evidence that cytoreductive nephrectomy can be beneficial in some patients?

There are 2 trials – one performed in Europe and another in the United States that have demonstrated a survival benefit with cytoreductive nephrectomy in patients who are subsequently treated with IFN-a. These were both randomised controlled trials - in which patients, who all received IFN-a were randomly allocated to either cytoreductive nephrectomy or no surgery. Comparing the 2 groups which were of equal size revealed that patients undergoing cytoreductive nephrectomy had a median survival of 14 months compared to 8 months without. These studies also reinforced the lack of benefit in patients with poor performance status.

This is obviously difficult surgery. Are complication rates much higher compared to other forms of kidney cancer surgery?

Patients with metastatic kidney cancer usually have quite large primary tumours with a rich blood supply being a common feature. Both of these factors can make surgery very difficult and associated with a higher risk of complications, particularly major bleeding, compared to other forms of kidney cancer surgery. Most patients with kidney cancer have relatively small tumours and are able to have surgery performed either laparoscopically or robotically with low risk of complications. In contrast cytoreductive nephrectomy, in almost all cases, requires major open surgery as minimally invasive procedures are usually neither feasible nor safe. Patients with metastatic cancer are also generally at higher risk of complications with major surgery. Deep venous thrombosis and pulmonary embolism are 2 specific examples of this.

A relatively new treatment for metastatic kidney cancer is a class of drugs called tyrosine kinase inhibitors (TKIs). Is there any evidence that cytoreductive nephrectomy followed with TKIs is beneficial for patient outcomes and survival?

The treatment of metastatic kidney cancer has rapidly changed and now IFN-a and IL-2 are rarely used. Both agents have been largely replaced by a new group of drugs – termed targeted therapies due to their effect as tyrosine kinase inhibitors (TKIs). These drugs have a completely different mechanism of action – rather than stimulating the immune system they target tumour blood vessels. Essentially they reduce the blood flow to tumours.

At this point in time it is unknown whether or not cytoreductive nephrectomy improves the outcome in patients treated with TKI’s. It is important to note that the previous studies on cytoreductive nephrectomy only addressed the question as to whether or not this improved survival when patients were treated with IFN-2. Accepting the lack of clear evidence at this time it can still be considered in some patients. For example a patient who is otherwise well presenting with a kidney cancer and small volume metastatic disease I would suggest a cytoreductive nephrectomy as their initial management. The patient would then be observed, avoiding drug treatment until they show clear evidence of substantial progression of their metastatic disease. The rationale behind this is that TKI’s can have significant toxicity and also that resistance to treatment inevitably develops. By removing the kidney and delaying drug therapy the patient avoids toxicity of treatment and also emergence of resistance at a time when their metastatic disease may be stable or only slowly progressing(ie reserving it for maximum effect when it is really needed).

A different approach to cytoreductive nephrectomy would be considered in the patient with high volume or symptomatic metastatic disease. In this scenario I would not recommend cytoreductive nephrectomy as an initial step. Rather the patient should consider commencing a TKI from the outset. Surgery could delay therapy during which time his disease may progress with an overall deterioration in his condition such that he is never suitable for a TKI (as again these drugs only appear of benefit in patients with good performance status).

Categories: Other


Aerospace Medicine and Urology

Aerospace Medicine and Urology

This week’s Guest Post is by Dr. Gordon Cable, a specialist in Aerospace Medicine, based in Adelaide. He discusses what this specialty involves and its relevance to Urology. He also talks about some of the big names at NASA he has met.

Gordon, can you explain what Aerospace Medicine involves?

Aerospace medicine is a specialty area of medicine that deals with the determination and maintenance of the health, safety and performance of all those who fly in the atmosphere or in space. It is an important specialty because those environments are so hostile to the anatomy, physiology and psychology of humans adapted to an earth-bound existence.

What sort of Urological problems do you encounter, and how do these affect pilots?

Pilots can of course develop any urological problem, just like any other member of the community, but the problem is how those conditions interact with the hostile aviation environment, and most importantly, how they affect a pilot’s performance and safety. Another important consideration is how any treatments for urological conditions might affect pilot performance, whether they be surgical or medications. The aerospace industry is still very heavily gender biased towards males, so mens’ health issues such as testicular cancer in younger males, prostatic hypertrophy and cancer in older males are common problems. Asymptomatic haematuria is a common finding at routine aviation medicals, which must be investigated thoroughly because the biggest showstopper of them all is the potential for renal calculus disease.

Kidney stones are a particular concern. Can you explain how the management of kidney stones in pilots differs from those in the general population?

The primary concern with renal calculi in pilots is the risk of sudden acute incapacitation due to renal colic. The presence of any calculi in the renal tract is bad news for pilots. Generally unrestricted medical certification is not possible, even if there is parenchymal calcification. When stones are present, even if asymptomatic, definitive treatment and proof of stone clearance is required before a pilot will be allowed to fly unrestricted. After an episode of renal colic, the risk of recurrence is also quite concerning, so careful management of stone-forming risk factors is particularly important, as is regular follow-up. Low-dose CT scanning is the preferred method of screening over ultrasound. Dehydration is common in many types of aviation operations, and some pilots are even known to intentionally dehydrate prior to flight so they don’t get caught short in the aircraft! This does not bode well for renal calculus risk.

What are the key areas of research in Aerospace Medicine?

Current hot topics and areas of ongoing work include fatigue management, especially as long haul flying now becomes commonplace with extended range aircraft. Aviation has always been a 24-hour a day industry, and combating the effects of shift work, long hours of “vigilant boredom”, and circadian dysrhythmia across multiple time zones are critical in maintaining pilot performance. The “ageing pilot” is an area of increasing interest with more and more pilots flying into their senior years beyond 60 years of age.

Cardiovascular risk, and determining the subtle effects of altered cognition are important areas of inquiry. Looking beyond earth, commercial space tourism is coming to a Spaceport near you – will you be fit to become an astronaut? This is a big question facing our specialty, and medically risk-managing a large cohort of the general public venturing into the near-vacuum microgravity conditions of suborbital flight is a topic we need to grapple with. Finally, maintaining the health of astronauts for long duration space flight will be essential if we ever intend to land humans on Mars, or travel beyond that on exploration class deep space missions to asteroids and beyond. Here radiation protection and the psychological aspects of isolation are important concerns.

You must have met some interesting people in your work. Who are the standouts?

Gordon Cable with Navy CAPT (Ret) Jim Lovell, Mission Commander of the famous but ill-fated Apollo 13.
Gordon with Navy CAPT (Ret) Jim Lovell, Mission Commander of the famous but ill-fated Apollo 13.

Attending international conferences in the field always affords the opportunity to meet some really interesting people, even some boyhood heros! I think the highlights have to be the NASA astronauts and flight surgeons I have met over the years. Last year I had the privilege to meet Jim Lovell, commander of the Apollo 13 mission, and Dr Charles “Chuck” Berry, NASA flight surgeon for the same mission. Previously I have met CAPT (Dr) Joe Kerwin, former USN Flight Surgeon and first US physician to fly in space as science-pilot aboard Skylab 2. Dr Story Musgrave, who flew on 6 Space Shuttle missions, attended one of our Australian conferences some years ago and in many ways was the most impressive individual I have ever met – physician, scientist, military and civilian pilot, astronaut – not sure how one can achieve so much in one lifetime!

Gordon Cable: Biography

A graduate of the University of Sydney, Gordon is a specialist in aerospace medicine, and a designated aviation medical examiner for CASA and CAD Hong Kong. His professional affiliations include:

  • Fellow of the Australasian College of Aerospace Medicine
  • Clinical Senior Lecturer, Discipline of Public Health, University of Adelaide
  • Past President/Honorary Member of the Australasian Society of Aerospace Medicine
  • Member of the International Academy of Aviation and Space Medicine
  • Fellow of the Aerospace Medical Association
  • Fellow of the Royal Aeronautical Society

Gordon is a Senior Aviation Medical Officer for the ADF, and has been a consultant to the RAAF Institute of Aviation Medicine since 1996. He has worked part time as a medical officer for CASA's aviation medicine section in aeromedical certification and complex case management. He holds a Postgraduate Diploma in Aviation Medicine from the University of Otago (NZ), and a Graduate Diploma of Occupational Health and Safety Management from the University of Adelaide. The author of many scientific publications, his professional interests include:

  • Altitude physiology of hypoxia and hypobaric decompression illness
  • Hypoxia awareness training of military and civilian aircrew
  • Postgraduate education in aerospace medicine for medical professionals

In his civilian clinical practice Gordon takes a particular interest in the management and certification of complex aeromedical cases, and education of aircrew in health, safety and performance issues.

Categories: Other


Movember ­- Casting a Line for Men's Health

Movember ­- Casting a Line for Men's Health

A Fishing Story

Time flies, and the month of Movember is already halfway over. As my mustache begins to grow, so does my understanding of why it is important for physicians to participate in this global men's health campaign. But before all of that, a quick fish story...

The Woolly Bugger

The Woolly Bugger

One of the many great things about living in Western Michigan, USA, is the fishing. Our lakes and streams are loaded with a wide variety of freshwater fish including salmon and trout. So a few years ago, I decided to learn how to fly fish.

I quickly found fly fishing to be a beautiful and elegant sport. A "fly" is simply a hand-tied imitation of a fish's natural food source. One of the first ties that I was introduced to was the woolly bugger. Depending upon how it is fished, this fly can be used to resemble or imitate a nymph, drowning insect, baitfish, crayfish, shrimp or crab.

Woolly bugger in, and fly rod in hand, it's then a matter of casting, retrieving, and waiting for a fish to show interest and strike.

Fish On!

What happens next is difficult to explain. When the hook is set, the fisherman and the fish become engaged in a conversation by way of the fly line. The fish typically first runs downstream. Then jumps, turns, and tries to find cover, all the while attempting to break the line. Meanwhile, the fisherman keeps steady pressure on the line, either letting it out or reeling it in line, depending upon the actions of the fish.

Sometimes the fisherman is able to land the fish. Other times, the fish escapes. Either way, the experience is not soon forgotten by either the fish or the fisherman.

Fishing to Improve Men's Health

This Movember, I have come to realize, I am fishing for men to take better care of themselves. Toward that end, this ridiculous mustache has become my bait and hook. When patients see my mustache, it breaks the ice.

Suddenly, it's not about me being a doctor, it's about the mustache. The mustache initiates a conversation that might include a Movember specific topic, such as prostate cancer, testicular cancer, and men's mental health. Alternatively, the conversation might center around threats to a patient's long term health, such as untreated obesity, hypertension, diabetes, or sleep apnea.

Sometimes, I am able to reel patients in with these conversations, and they choose to make a positive lifestyle change, or seek additional medical treatment. Other times, patients "get away." Either way, I believe these conversations leave a lasting impression with the patient.

Fishing with Friends

Male urological system

Fly fishing and Movember have one more thing in common. They are more fun when you participate with others. That's why this year I've gone "North of the Border" and joined my friend, Dr. Rajiv Singel's International Toronto East General Hospital Movember Team. If you haven't yet signed up for Movember, or joined a team already, you are welcome to join us.

Signing up is easy. However, if you join our team you will need the post code for Toronto, Canada, which is M4C 5T2.

Mo season runs thru the end of November. However, the conversations it helps facilitate, and the changes it can make in a man's health, can continue throughout the year.

Dr. Brian Stork

Guest post by Dr. Brian Stork. Dr. Stork is a urologist from the U.S. in private practice at West Shore Urology, in Muskegon, Michigan. Dr. Stork has a passion for patient education, healthcare technology and healthcare social media. You can read more from Dr. Stork on his blog, and follow him at @storkbrian on Twitter and Google+ .

Categories: Prostate Cancer


Kidney stones - prevention and treatment

Kidney stones - prevention and treatment

Matthew Bultitude is a consultant urological surgeon practising at Guy's and St. Thomas' Hospital in London. He has a subspecialist interest in stone disease, and in this article he answers questions about the common problem of kidney stones.

Matt, how did you become interested in urological stone disease?

I was fortunate to work as a junior doctor in the stone unit at Guy's and St. Thomas' Hospital and following on from that I was offered a research position which I gladly took up. I undertook a number of clinical projects during that period including an MSc thesis assessing the safety of flexible ureteroscopy. I really enjoyed the challenges that stone disease creates and this has carried on throughout my career.

Do you see an increasing rate of stone disease in the UK, and what is the cause of this?

There is no doubt that there has been a steady increase in the number of stone cases in the western world and the UK is no exception. The lifetime risk may now be as high as 12% (American data) and although more common in men, they are becoming increasingly prevalent in women. This is essentially due to a combination of increasing obesity with poor diets (high in animal protein, fizzy drinks, processed foods, salt etc) and low fluid intake.

What have been the major developments in surgery for stone disease in the last few years?

I remember (as a boy with a urological father) when the first public lithotripter arrived in the UK (St. Thomas' Hospital) in the 1980's. This revolutionised stone treatment and continues to be a common treatment. What has changed over the last decade has been the development of smaller (diameter) and more robust instruments allowing us to pass telescopes up the urinary tract to the kidney to treat stones (flexible ureteroscopy). For large stones percutaneous surgery (PCNL) remains the standard and recent developments have seen some interesting changes to how this is done with smaller and smaller instruments and also in new surgical positions with many surgeons now choosing the supine position (so lying on side) rather than prone (lying on front).

Does shock wave therapy have an ongoing role in stone management?

There is no doubt that shock wave lithotripsy has been on the decline but in my opinion it is still a useful treatment for many patients. Choosing the correct stone for this treatment is important and as it works better in a thin patient with a smaller stone, rather than trying it in everyone. However I increasingly find patients prefer the more definitive choice of surgery with ureteroscopy to fragment the stone with a laser as although it is more invasive, the outcomes are more predictable.

Calcium oxalate stones are the most common kind of kidney stones. What is your advice to someone who has had a stone like this, to prevent future stone formation?

I often give quite detailed advice about stone prevention, although the summary of this is a normal healthy diet with lots of fluid (which is what we should all be doing!). In principal we should aim for a diet with:

- Enough fluid to produce at least 2 litres of urine per day. The actual amount will be different for everyone but usually a minimum of 2.5 litres in per day is required. This is the most important advice.

- Limited animal protein (meat and fish)

- Low salt

- Plenty of fruit and vegetables

- High fibre

- A normal calcium intake - so cutting back is often the wrong thing to do.

For calcium oxalate stone formers there are some foods high in oxalate and limiting intake of these may also help.

What developments do you see on the horizon for kidney stone treatment?

I think surgery will continue to improve with better quality and smaller instruments becoming available. Shockwave lithotripsy will probably continue to decline (as discussed above). What would be a game changer is the development of effective medication that could reduce the chance of stones growing in urine although I suspect we are many years away from this!

You can read more about Matt Bultitude by following these links to the Guy's and St. Thomas' Hospital website and the London Bridge Hospital website.

Click here for a link to his personal website.

You can also follow Matt Bultitude on twitter

Categories: Kidney Stones


Ketamine and chronic physical damage to the urinary tract

Ketamine and chronic physical damage to the urinary tract

This week’s Guest Post is by David Gillatt, Professor of Urology and Medical Director of the Bristol Urological Institute in the UK. David has considerable experience in the management of pelvic cancer, including prostate and bladder cancer, and is a world expert in the relatively recently discovered effects of ketamine on the urinary tract. In this article, Prof. Gillatt outlines current understanding of this increasing problem.


Although ketamine has been in use as a pharmaceutical agent for 50 years and a recreational drug since the early 1990s, it has only relatively recently been recognised as a cause of potential physical harm, damaging the urinary tract, hepatobiliary system and gut. Isolated case reports documenting bladder symptoms and a form of cystitis associated with prolonged recreational usage of ketamine began to appear in around 2007 mainly from Hong Kong, Canada and the United Kingdom.

The effects of ketamine

Bladder symptoms tend to occur in recreational ketamine users, usually those snorting the drug. The severity of the symptoms and the degree of bladder damage is in proportion to the amount taken, how often and for how long. Those taking five grams or more for a period of months or longer invariably develop bladder problems. However, some taking lower doses or even for medical reasons can develop symptoms with small numbers of cases being reported in those being treated with ketamine as part of a chronic pain programme or as palliation.

Symptoms typically include pain with passing urine, frequency and urgency of voiding, blood and matter in the urine, usually the bladder lining, and incontinence. The urine is usually clear of infection.

The changes that occur in the bladder are a direct result of ketamine and its metabolites being excreted via the kidneys into the urine, and coming into direct and prolonged contact with the bladder lining.

This initially results in inflammation and ulceration of the bladder lining. Prolonged exposure can result in damage to nerve endings and result in persistent pain, often a deep-seated pain requiring strong analgesics. Ultimately the bladder can become scarred and will shrink and at this stage the damage may be irreversible.

Managing ketamine side effects

Removing the insult to the bladder by stopping the ketamine gives the best chance of relief. In many cases the bladder will heal and although some symptoms may persist, these will become manageable. One major problem is control of the bladder pain during healing.

If cessation of ketamine is not possible, a variety of methods of symptom control may be used including anticholinergic drugs to reduce frequency and urgency, amitriptyline as an anticholinergic and sedative, and analgesics. Bladder protective agents such as hyaluronic acid may help in some cases. Bladder distension under anaesthetic may play a role in giving temporary relief of symptoms.

A small proportion a users will have persistent symptoms, despite stopping the drug. Reduced bladder capacity with severe frequency/urgency, persistent bladder pain and incontinence may all be indications for surgical intervention. This would usually involve removal of all or part of the bladder and replacement with an intestinal segment. As those affected are usually in their twenties this is a drastic step with potential long term sequelae including renal problems, continence issues and cancer.

Damage to the upper urinary tract

The upper urinary tract is also exposed to the same potential damage by being bathed in urine containing ketamine and its metabolites. Transit of urine through the upper tracts is more rapid than the bladder, therefore damage in the upper tract is less frequently seen. However scarring and narrowing of the ureters is well documented and can be seen at its early stages radiologically in a large percentage of users with bladder damage.

Upper urinary tract symptoms seem commoner in Asian countries, including hydronephrosis, possibly reflecting obstruction of the ureters causing toxic effects or scarring in the ureters. In one sample 51% had hydronephrosis, which was bilateral in 44% and unilateral in 7%, and 13% had papillary necrosis. Hydronephrosis may be the result of smooth muscle relaxation. Ultimately if obstruction is prolonged and not relieved the end result may be renal failure.

Ketamine users with bladder symptoms should have imaging of their upper urinary tract and measurement of renal function. Those with obstruction, with or without symptoms, require surgical or radiological intervention to drain the kidneys and later correction of the blockage if it does not resolve.

David Gillatt is a Consultant Urologist with an interest in surgery for prostate and bladder cancer. He has one of the largest experiences in Europe of complex pelvic cancer surgery with more than 2000 major resections in a 20-year career. He was pivotal to the centralisation of complex Urological cancer surgery within the region. During this time, he introduced many innovations in service delivery including an Enhanced Recovery Programme for cystectomy, and a robotic pelvic surgery programme. Under his direction, the Centre has become the highest volume Urological cancer centre in t he UK and one of the busiest robotic centres in Europe.

Nationally he has served two five-year periods on the council of the British Association of Urological surgeons and is past Chair of the Section of Uro-Oncology. He sat on the NCRI trials groups for both bladder and prostate cancer and is on the Urology group for the NCIN as well as the Department of Health Prostate Cancer Action group. He was also a member of the NICE Guidelines development group for prostate cancer.

His research interests include recovery from surgery and aspects of prostate and bladder cancer. David founded the Bristol Prostate Cancer Research Network. He has visiting Chairs at the Universities of Exeter, West of England and Malaya. He has been visiting specialist or Professor at over 20 overseas institutions or groups. Active research projects include: 1) The evaluation of anti-angiogenic factors in prostate cancer, 2) Insulin derived growth factors in prostate and bladder cancer, 3) Enhanced recovery after surgery, 4) the influence of lifestyle intervention on recovery from cancer and surgery, 5) Circulating tumour cells and prognosis in prostate cancer.

He has a major interest in clinical trials being a chief investigator for the ProtectT trial in Bristol (total grants >£32m) and for RADICALS and BOXIT. He is on both trial management groups and trial steering committees.

You can follow this link to the Bristol Urological Institute website BUI

Categories: Updates


Movember Hits Town

Movember Hits Town

November sees the yearly highlight of Movember, where mens' health and cancer support is highlighted. Urologists have a particular interest in this area. Rajiv Singal, a Toronto Urological Surgeon, gives us a rundown of what Movember is all about. Last year, his fund raising team ranked in the worldwide top 7 for money raised for Movember.

Rajiv, when did you first become involved with Movember?

I first became involved with Movember in 2009. It was actually a resident on my service at the time, Dr Dean Elterman that brought this to my attention. I had no inclination to participate but was very quickly impressed by Dean's enthusiasm as well as the maturity that he brought at a relatively junior stage to the importance of being visible advocates for our patients.

I understand that you and your team ranked highly in the world in 2012 for the amount of money raised for prostate cancer. Where does this money go and how does it help prostate cancer patients?

We had a very successful 2012 campaign. Personally I was #1 briefly worldwide on November 20 and then faded to #7. There was tremendous interest in the message that was promoted around men's health. The money both in Canada and around the world goes to a number of different ventures, ranging from basic science and educational initiatives to survivorship and support programs. In 2012 a number of Mental Health initiatives were also supported. A full report card of Movember disbursements is available for people to review.

Can you outline the role that Prostate Cancer Canada plays in the current landscape of prostate cancer?

Prostate Cancer Canada is a large foundation that has plays an important role in Canada to support men during all aspects of the prostate cancer journey. This includes hosting regular support groups across the country, funding research and a variety of survivorship initiatives. It's biggest role in my view this year has been to try and address the vacuum that has been created by a variety of different screening guidelines around the world. There is much confusion around who to screen and when. With the USPTF recommendations the genuine fear is that many men with potentially significant disease will never be found. We have reduced mortality in the PSA era but have also over-treated many men, causing unacceptable consequences. Prostate Cancer Canada’s terrific #knowyournumber campaign this past September during prostate cancer awareness month attempted to try and address this need for assessing individual risk. We don’t want to throw the baby out with the bathwater

What does your wife think of the 'mo?

My wife, as you might imagine from the picture, is not very fond of the look but has generally been very supportive albeit somewhat resigned as she has seen my efforts take off over the years. She knows it is for a good cause but usually cannot wait for November 30 to arrive. I am hoping my oldest son, who just went off to university this year will join the effort this year. We will see.

Rajiv Singal currently leads the Surgical Robotics Program jointly run by Toronto East General Hospital and Sunnybrook Health Sciences Centre. He was Head, Division of Urology, Department of Surgery at the Toronto East General Hospital from July 2001 until October 2012 and is an Assistant Professor within the Department of Surgery at the University of Toronto. He supervises the Clinical Endourology Fellowship program at TEGH under the umbrella of the University of Toronto and also teaches undergraduate and postgraduate medical trainees. His clinical interests include the surgical management of urinary stones, minimally invasive urological surgery and the surgical treatment of genitourinary malignancies including prostate and kidney cancer.

A detailed item on this topic can be found at the BJUI blog site

You can follow Rajiv on LinkedIn and on Twitter

Categories: Prostate Cancer


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