CUAJ is a key partner for academic urology

On the occasion of the 20th anniversary of the Canadian Urological Association Journal (CUAJ), we would like to thank the Canadian Urological Association (CUA) and the CUAJ editorial staff, past and present, for providing Canadian urologists with an invaluable vehicle for disseminating knowledge and showcasing Canadian urologic innovations and excellence. The urology program at Western University, formerly University of Western Ontario (UWO), has been one of the beneficiaries of the forum provided by CUAJ.

ACADEMIC HINTERLAND BUT CLINICAL POWERHOUSE

The UWO urology program started in the mid-1950s with Dr. Lloyd McAninch and a small staff, which included Drs. Jack Wyatt and Jack Sales. Dr. McAninch set the example for his junior colleagues and trainees. He reportedly had just completed two radical cystectomy and ileal conduit cases when a patient with a known history of bladder cancer presented to the emergency room with gross hematuria. Dr. McAninch promptly proceeded with the third cystectomy and diversion of the day.

A dedicated workhorse and exemplary leader, Dr. McAninch, who suffered from a duodenal ulcer, once felt unwell and scrubbed out during a radical cystectomy and urinary diversion. He received a blood transfusion and then returned to the operating room to complete the procedure!

SURGICAL VOLUME & SUBSPECIALIZATION

With a community of 700 000 for primary and secondary care referral bases in Southwestern Ontario, the UWO “teaching hospitals” was responsible for tertiary care for over 2 million people.

The large clinical and surgical volume from the start was ideal for instilling trainees with a strong work ethic and high-level technical abilities. Even in its earliest days, most of the elective operating rooms at Victoria Hospital (now part of London Health Sciences Center) routinely ran till 6 pm daily, a relative rarity in Canada. The founding faculty members focused on clinical care and aimed to train capable surgeons who could manage any urologic problem.

Fast forward to the early 1980s, when a couple of junior recruits decided that being “jack of all urologic trades” was not conducive to academic advancement. The gradual transition to more subspecialization in the mid-1980s was facilitated by the abundance of clinical work, which obviated competing for cases, resulting in freer referrals to respective colleagues with more subspecialty expertise. The shift in practice pattern was complemented by the allocation of some protected academic time (albeit modest) and by enthusiasm to be early adopters of novel technologies and therapies. The consequences of the transition from a high-volume factory to a high-volume training center with academic aspirations have been numerous.

Increasing emphasis on academics, without sacrificing clinical and technical training, “rubbed off” on many of the trainees, whose academic productivity and publications increased, facilitated by CUAJ and other journals.

GROWTH OF POSTGRADUATE FELLOWSHIPS

With assurance that residents’ clinical experience would not be adversely affected, postgraduate fellowships in targeted subspecialties were established—initially in endourology, urologic oncology, and transplantation. These fellowship programs all gained international recognition and were among the first in Canada, if not the first to receive official accreditation (respectively, from Society of Endourology, Society of Urologic Oncology, and American Society of Transplant Surgeons).

Additionally, the UWO solid organ transplantation area of focused competence is now a Royal College of Physicians and Surgeons of Canada-accredited postgraduate fellowship program. Over the past couple of decades, the UWO transplantation fellowship program has trained most of the renal transplant surgical leaders in Canada, as well as many international fellows. Postgraduate fellowships have since been established at UWO in almost all subspecialties, attracting trainees from all over the world.

A HISTORY OF “FIRSTS”

Over time, attention and interest in UWO from various industries—biotechnology, biomedical engineering, and pharmaceutical companies—increased. This, coupled with the large centralized clinical volume and research interests of several faculty members, resulted in the department’s involvement in several novel therapeutic areas. Early adoption of new technologies and therapies led to several initial Canadian experience papers published by CUAJ (Table 1)^1–11 and some putative global firsts (Table 2).^12–19 CUAJ has provided invaluable support in documenting these academic achievements.

Table 1.

Initial Canadian experience papers by UWO staff, the majority having been published in CUAJ

Procedure/therapy	References
Experience with 3 robotic platforms	Nguan et al. Can J Urol 20071
Robotic laparoscopic radical prostatectomy	Chin et al. CUAJ 20072
High-intensity focused ultrasound prostate ablation	Chalasani et al. PCan 20093 Chin et al. CUAJ 20234
3D US-guided prostate biopsy & MRI-3D US fusion biopsy	Cool et al. Med Phys 20085 Cool et al. CUAJ 20166
Kidney-pancreas transplant	Jiang et al. CUAJ 20147
Robotic proximal uretero-pyelostomy	Olvera-Posada et al. J Endourol Case Rep 20158
Robotic single-incision pyeloplasty	Law et al. CUAJ 20169
Robotic laparo-endoscopic single-site live donor nephrectomy	Luke et al. CUAJ 201810
Pediatric robotic urologic surgery program	Stern et al. CUAJ 202111

Table 2.

Putative global urologic firsts at UWO

Procedure/therapy	References
Intracorporeal lithotripsy with Swiss Lithoclast	Denstedt et al. J Urol 199212
Holmium:YAG laser for lithotripsy	Denstedt et al. J Endourol 199513
Cryoablation prostate with intraoperative 3-D ultrasound guidance	Chin et al. J Urol 199814
Robotic partial cystectomy for endometriosis	Sener et al. J Minim Invas Gyne 200615
Robotic renal artery aneurysm repair	Luke et al. J Vasc Surg 200616
Cytoprotection for reperfusion injury with Hydrogen sulfide in renal transplant	Lobb et al. CUAJ 201417
TULSA Transurethral ultrasound prostate ablation with MR guidance in phase 1 study *	Chin et al. Euro Urol 201618

^*TULSA was first actually performed in human by Dr. Laurie Klotz at Sunnybrook Health Sciences Centre in prostate cancer patients prior to radical prostatectomy, but the prostate was resected immediately afterwards for histologic studies, and not left in situ for prospective followup.¹⁹

The increased academic productivity had a domino effect, attracting high-quality fellows and residents, as well as research scientists from various disciplines. The local clinical databases also afforded opportunities for collaborative studies with other Canadian and international centers in several fields (some examples shown in Table 3).^20–33

Table 3.

Selected examples of clinical studies with major/prominent UWO contribution

Topic/trial	Participating centers	References	UWO participating author(s)
APPEAL trial: Antimicrobial prophylaxis after ESWL	Multi-national, global	Eur Urol 202520	Razvi, Denstedt, Pautler
CROES: URS ureteroscopy study	Multi-national, global	J Endourol 201421	Denstedt, Razvi, Pautler
REACTT trial: Tadalafil in erectile function recovery after prostatectomy	Multinational, global	Euro Urol 201622	Brock
SELECT trial: Chemo-prevention prostate cancer selenium & vit. E	Multinational, North America	JAMA 201123	Chin, Winquist
ASIST & PRECISE: Role of mpMRI active surveillance and in prostate bx diagnosis	Multicenter, Canada	Euro Urol 201924 JAMA Oncol 202125	Chin, Izawa
Vardanafil for erectile dysfunction after radical prostatectomy	Multicenter, North America	J Urol 200326	Brock
External validation of Stone scoring systems PERC nephrolithotripsy	Multinational, global	J Endourol 201627	Denstedt, Razvi, Huynh
Topical 2% testosterone on hypogonadal men	Multi-national, global	J Urol 201628	Brock
Salvage HIFU prostate cancer	Multicenter North America	J Urol 202129	Chin
MTOR: Donor-derived cell-free DNA in multi-organ recipients	Multinational, global	Transpl Int 202630	Sener
Sildenafil after nerve-sparing radical prostatectomy	Multi-national, global	Int J Impot Res 200831	Brock
“AC-DC” Neoadjuvant systemic therapy for high-risk prostate cancer	Univ. of Toronto, UWO	Clin Can Res 202332	Chin, Winquist
PDL1 + BCG high-risk non-muscle-invasive bladder ca	Multicenter, U.S.	Eur Urol Oncol 202333	Inman

GUIDELINES & CONSENSUS STATEMENTS

One of the CUA’s mandates is to develop evidence-based management guidelines for urologists. As the association’s official publication, CUAJ has supported this goal by publishing guidelines, position statements, and consensus reports in most urologic areas.

Aside from the CUA Guidelines Committee, several other professional bodies, such as the Institute of Clinical Evaluative Sciences (ICES) and Cancer Care Ontario (CCO), have published in CUAJ. Fueled by large clinical volumes and enthusiasm, several UWO urology staff members have been key contributors to many of these clinically impactful exercises. Selected examples are listed in Table 4.^34–48

Table 4.

Selected examples of practice guidelines and position papers published in CUAJ

Topic of guideline/position statement	Reference in CUAJ
Metastatic castrate-resistant prostate cancer	Saad et al. CUAJ 202534
Genetic testing for kidney cancer	Reaume et al. CUAJ 201935
Non-muscle-invasive bladder cancer	Bhindi et al. CUAJ 202136
Small renal masses	Richard et al. CUAJ 202237
Transvaginal mesh:
Management38	Welk et al. CUAJ 201738
Revision/removal39	Welk et al. JAMA Surg 201539
Brachytherapy for prostate cancer:
Low-dose for low- and intermediate-risk40	Rodrigues et al. CUAJ 201340
Joint ASCO/CCO guideline41	Chin et al. JCO 201741
Peyronie’s and penile curvature	Bella et al. CUAJ 201842
Quality performance of surgical & pathology practices radical prostatectomy	Chin et al. CUAJ 201043
mpMRI clinically significant prostate cancer	Haider et al. CUAJ 202244
5-alpha reductase inhibitors:
Psychiatric outcomes45	Welk et al. JAMA Intern Med 201745
Use in post-TURP recurrent hematuria46	Welk et al. CUAJ 202146
Muscle-invasive bladder cancer	Kulkani et al. CUAJ 201947
Surveillance for upper tract urothelial cancer	Locke et al. CUAJ 201848

VOLUNTEERISM

Numerous UWO faculty members have served as section editors or editorial board members of CUAJ. Many have volunteered their time as editors or editorial board members of various other publications as well, including subspecialty journals and other national urology journals.

Aside from editorial functions, several UWO faculty members, past and present, have served in key leadership positions both nationally and internationally in various urologic organizations, contributing significantly to the advancement of our field.

CONCLUSIONS

Kudos to CUA and CUAJ for their foresight in establishing an academic forum for Canadian urologists and trainees. CUAJ has been an invaluable vehicle for disseminating knowledge, showcasing Canadian urologic innovations and excellence, and serving as a partner for academic urology.