Testosterone replacement statement by FDA

Testosterone replacement statement by FDA

A recent release from the U.S. Food and Drug Administration (FDA) has highlighted that caution is needed with the use of testosterone replacement treatments for men.

US FDA statement on Testosterone Replacement

Their advice suggests that replacement should only be used for men who have low testosterone levels caused by certain medical conditions such a primary hypogonadism (examples are failure of the testes to produce testosterone due to chemotherapy, genetic conditions, damage from infection), or disorders of the brain or pituitary gland that result in decreased testosterone.

Increasingly, testosterone replacement is being used to treat symptoms in men who have low testosterone for no other apparent reason other than due to ageing. The USFDFA state that the benefits and safety of testosterone replacement have not been established for this use.

Some studies suggest there may be an increased risk of cardiovascular problems (heart attack and stroke) with testosterone replacement, although not all studies have demonstrated this.

It is very important that you talk with your doctor about these risks, and the indications for starting testosterone replacement.

Categories: Updates, Other


Rapid Access Kidney Stone Service

Rapid Access Kidney Stone Service

Kidney stones are a common problem in Australia and can be very painful. Patients with severe pain may need to be seen urgently by a urologist. One option is to present to an emergency department, where the condition can be diagnosed with a consultation and CT scan, and then referral if necessary to a urologist.

From early 2015 we will be offering a rapid access stone assessment service based in the rooms at Calvary Hospital in North Adelaide. You will need a referral from your GP, and can then be seen the same day, with a CT scan organised at Radiology SA (in the same building as our office). CT usually needed to confirm the diagnosis, and show the size and location of the stone.

If necessary, you can be admitted directly to Calvary North Adelaide Hospital, and have the necessary treatment undertaken. Often, it is enough to be admitted with pain killing drugs, anti-inflammatories, and a tablet called an alpha-blocker – many kidney stones will pass on their own with this treatment and this may be sufficient to relieve your kidney stone pain. If the stone is larger or there are complications such as infection, you can have your surgery at the same time.

The aim of this rapid access kidney stone service is to shorten the time from presentation to definitive treatment.

Categories: Updates, Kidney Stones


Kidney stone infection and surgery

Kidney stone infection and surgery

Patients with kidney stones that need surgical treatment are at risk of urinary tract infection, and sometimes sepsis. Stones often have bacteria attached to them, and these bacteria can be hard to eliminate. A recent study from Tel Aviv University looked at post-operative infection in patients undergoing percutaneous nephrolithotomy (PCNL). Stone samples retrieved during surgery were sent for culture, to see if there were bacteria associated with the kidney stones.

Urinary sepsis (an infection that spreads from urine into the bloodstream and causes a patient to be unwell) occurred in 31% of patients who had a positive stone culture, compared to 5.9% of those patients who had a negative stone culture. E coli (gram negative bacteria) and Enterococcus sp. (gram positive bacteria) were the most common organisms found.

The problem is that it takes a number of days for the culture to come back, and the patient will have developed sepsis by that time. However, what it does highlight is that doing a urine culture 1 to 2 weeks before PCNL surgery can help the situation. If the urine culture is positive, the patient should have a course of antibiotics for 7 days to try to sterilise the urine, and then intravenous antibiotics at the time of surgery. If the urine is sterile pre-operatively, then intravenous antibiotics at the time of surgery are sufficient.

Two other interesting points were raised. First, that resistance to ciprofloxacin and norfloxacin was high, and this is something that is of concern. These antibiotics may be overused in the general population, causing resistance. This is something we are also seeing in patients who need a prostate biopsy for a raised PSA.

Second, we know that some patients cannot reach a point where the urine is sterile (free of bacteria) if they have stones, because the stones themselves are colonised with bacteria, and antibiotics cannot get into stones. These patients pose a specific problem and are at higher risk of infection.

Reference - Ohad Shoshany et al. Percutaneous nephrolithotomy for infection stones: what is the risk for postoperative sepsis? A retrospective cohort study. Urolithiasis (online) 01 Jan 2015

You can read more about kidney stone surgery and the risk of infection by following this link to an article by Michael Wong.

Categories: Updates, Kidney Stones


Hamlin Fistula Ethiopia break the $6M mark

Hamlin Fistula Ethiopia break the $6M mark

Towards the end of 2014, Hamlin Fistula Ethiopia smashed the $6M mark in income since the charity in Australia was created just over two years ago.

Dr. Hamlin and the whole team at Hamlin Fistula Ethiopia in Australia and Ethiopia have had a huge impact on the lives of the women with obstetric fistula they treat and train.

Our practice will be supporting the work of this charity in 2015 and encourage you to read about the amazing work they do.

Please read more about the work of Hamlin Fistula Ethiopia and stay up to date with latest news from Nick Brook Urology, as we support this work throughout 2015.

Follow this link to a short youtube video

And please pass on the links to Hamlin Fistula Ethiopia, via word of mouth, email and social media - the work they do is so important. You can follow Hamlin Fistula on Twitter.

Categories: Updates


Nick Brook Urology supporting Hamlin Fistula Ethiopia in 2015

Nick Brook Urology supporting Hamlin Fistula Ethiopia in 2015

In 2015, we will be supporting the incredible work of Australian surgeon Dr Catherine Hamlin and her team. They work in Ethiopa and have been transforming the lives of young women devasted by obstetric fistula.

The work of Hamlin Fistula Ethiopia

During 2015, Nick Brook Urology will be supporting Hamlin Fistula Ethiopia. This incredible organisation has been changing the lives of young women who have been devastated by obstructed labour.

In the 1950s, Australian surgeons Dr Catherine Hamlin AC and her husband Reg visited Ethiopia to help train midwives. But they were struck by the terrible plight of young women who had suffered obstructed labour. More often than not, the baby would die, and the women were left with permanent damage to their bladders (and sometimes rectum). This leads to permanent and constant leakage, and these women are pushed to the edge of their societies, considered too dirty to be part of village life, and considered a curse.

The Hamlins devoted their lives to helping these women; they perfected modern techniques for obstetric fistula surgery and
 have treated more than 40,000 women, more than 90% of them cured. Reg died in 1993 but Catherine continues the work.

The Addis Ababa Fistula Hospital and its five regional hospitals treat obstetric fistula patients at no cost, thanks to the generosity of donors. Not only are these women treated, they are rehabilitated, taught a craft, and re-integrated into society. The Hamlins have also set up the Hamlin College of Midwives to help to support women during childbirth, and reduce the rate of obstetric fistula in Ethiopia. These trained midwives are then deployed back into rural areas where the need is greatest.

The amazing work of the Hamlins has turned around the lives of these women, and is only made possible by the generosity of donors.

Please read more about the work of Hamlin Fistula Ethiopia and stay up to date with latest news from Nick Brook Urology, as we support this work throughout 2015.

And please pass on the links to Hamlin Fistula Ethiopia, via word of mouth, email and social media - the work they do is so important. You can follow Hamlin Fistula on Twitter.

Categories: Updates


TeleHealth - A Revolution in Healthcare?

TeleHealth - A Revolution in Healthcare?

Video consults for distant patients offer many advantages for patients who live long distances from their specialists. This article is written by Nick Brook and Rajiv Singal, and covers many of the issues for this exciting development in healthcare.

What is Video Telehealth?

There is nothing clever about Telehealth, and it’s remarkable that uptake has been so slow. The technology, as voice-over-internet protocol, has been available for a long time - Skype was released 11 years ago. Telehealth simply uses similar or identical technology to link doctors and other health professionals to patients. Travel for remote patients and associated costs are reduced, and in urgent settings, Telehealth can provide rapid access to expert medical opinion.

What are the advantages in Big Countries – Australia and Canada?

Australia is a big place; the sixth largest country after Russia, Canada, China, the USA, and Brazil. Its land size is 7,692,024 km2 with a small population (24.5m). Eleven percent of the population are classified as living in remote/country/rural areas. Canada shares the same challenges as Australia with a similar population spread out over an even greater area.

Australian map showing population density.

There is a marked disparity in health provision between urban and remote areas of Australia, which is extensively discussed elsewhere.

This disparity relates primarily to the practicalities and economics of provision of comprehensive health care in remote areas, and is by no means unique to Australia. In Canada 80% of the population lives within 150km of the US border. With borders that extend past the Arctic circle, the needs of small isolated communities become obvious. Travelling great distances can also be hindered by unpredictable, harsh weather during the winter months.

South Australia is a stand out example of how and why Telehealth can help distant patients. SA has a population of only 1.67m. The Australian Bureau of Statistics give the following figures for population distribution:

South AustraliaMajor CitiesInner regionalOuter regionalRemoteVery remote

SA has traditionally had a close relationship with the Northern Territory in terms of health care provision, and many patients travel to Adelaide from NT for secondary and tertiary care. You can see that travel distances involved for some patients are huge. Much of the care provided must, by its nature, be delivered at metropolitan centres, but much work up and follow up could be performed by Telehealth, reducing costs (economic and social) for patients and government.

As an example, a typical series of encounters for a prostate cancer patient, from GP referral to surgery, is as follows:

  • Initial consult
  • Biopsy appointment
  • Biopsy results
  • CT/MRI/Bone scan (often cant be arranged at the same visit)
  • Appointment for Results
  • Second clinic for decision
  • Pre-anaesthetic clinic
  • Day of surgery

Those highlighted in orange could possibly be replaced with Telehealth appointments. When we consider that some patients make a 2000km round trip for a hospital appointment, the potential advantages become crystal clear.

As well as distant patients, there are potential advantages for Residential Aged Care Facility (RACF) residents, and Medicare Australia has made special allowances for Telehealth to such patients.

It similarly follows that after surgery and the initial recovery phase that many traditional post operative visits could be conducted electronically, particularly when a stable situation is apparent and monitoring of blood work is the main task. Another good fit for urology would be stone follow up for patients on surveillance programs for renal calculi.

Are there any disadvantages to Telehealth?

Inherent in electronic communication is the inability to make physical contact with patients. Nothing can replace an in-person consultation for building the patient-doctor relationship and establishing trust. A handshake is the foundation of consultation, and the ability to examine is lacking. If a patient-end doctor is present, this can be circumvented to some extent, but the quality of interaction is less. Nevertheless it is clear that patients are generally grateful for email access with their treating physicians. A robust Telehealth service would potentially improve upon that.

Co-ordination of appointments can be challenging, as there should be a health-care provider at the patient end. Patients may still need to travel large distances to get to a health care provider with Telehealth facilities.

Electronic communications can break down, although this is rare. More important are potential security issues, which are discussed below.

Why has it taken so long to get this going?

This is difficult to answer. Perhaps established patterns of behaviour are hard to break; as medics, we have become wedded to the in-person consultation. Clearly, advantages and disadvantages of both in-person and Telehealth consults need to be weighed carefully for individual patients.

Set-up costs are minimal, and most specialist and GP practices will have easy access to the readily available technology.

Although government has been leading the Telehealth drive, patient demand is increasingly a factor in health care policy, but rural/country/distant patients may be the least vocal in terms of health care requirements, despite often having the greatest need.

Financial Incentives/reimbursements for Doctors

Various financial incentives are in place from Medicare Australia, through the Medicare Benefits Schedule, with the aim of driving Telehealth uptake. These are categorised as follows:

  • Telehealth On-Board Incentive
  • Telehealth Service Incentives
  • Telehealth Bulk Billing Incentives
  • RACF On-Board Incentive
  • RACF Hosting Service Incentives

These taper over time, and more information can be found here.

Interestingly, rebates for Telehealth are actually higher than for in-person consultations, and this is said (by Medicare) to reflect the infrastructure costs involved.

Systems in use

There is a range of complexity in Telehealth technology. At the top end, very fast connections (where available) combined with fully integrated complex software and hardware allow monitoring of medical information from skin, eyes, ears, pharynx, heart, lungs and other parts of body. Advanced telemedicine can also manage ECG, spirometry, dermatoscopy, pharyngoscopy and endoscopy sessions.

Less complex and costly are installed systems, which essentially build on business teleconferencing platforms. Digital quality is high, and this standard is needed if there is need for diagnosis beyond history taking. These systems still require substantial investment and on-going cost.

The easiest to install, run and pay for are widely utilised software programs such as Skype and Facetime. Most computerised practices will be able to set these up easily, and most health care providers are conversant in their use, so no additional training is required. Quality can be low, and these systems are only really suitable for communication based on discussion and history taking. For example, clinical signs cannot be reliably demonstrated. However, on the principle of ‘the greatest good for the greatest number’, this method of Telehealth probably will have the greatest uptake.

Security issues

Just as in a standard face-to-face consultation, privacy (and digital security) must be absolutely respected. Medical records made at the time of video consultation are recorded and stored in exactly the same way as a standard consultation.

The more costly systems have security built into their frameworks. Systems like Skype and FaceTtime have raised some concern.

The Royal Australian College of General Practitioners has produced an advice document on using Skype, which can be viewed here.

Briefly, that document outlines the concern that the routing path used by Skype often involves data transfer outside of Australia, through countries that may not have the same privacy laws as Australia. For this reason, the RACGP advises that medical content, such as still images or desktop screen shots should not be exchanged during a video consultation using Skype. The RACGP also highlights that configuration is required to ensure that the Skype default of retaining history files, which record all episodes of communication, are set correctly as these files are potentially accessible with spyware. The RACGP do not have a FaceTtime policy.

Both Skype and FaceTime employ Secure Real Time Protocol (SRTP) using AES (Advanced Encryption Standard) 256-bit encryption (also used by the US Government to protect sensitive information).

Likewise, Wi-Fi and wired systems at a health care practice must be encrypted as a further layer of security. As both of these encryptions work separately, it would be very difficult indeed for these systems to intercepted by a third party.

In summary, it is highly unlikely (although theoretically possible) that a Telehealth consultation could be breached, but the risk is probably no greater than the risk of standard computerised medical records being breached by a ‘professional’ and determined hacker. It is the health care provider’s responsibility to ensure the privacy and security of the consultation, that the technical system is reliable, secure and fit for clinical purpose, and that risk management protocols are in place.

The foreseeable future

Increased utilisation of Telehealth may be one of the strategies to help address the huge and unprecedented growth in Healthcare need, which is forecast to continue.

The tables below are taken from the MBS Telehealth Statistics.

The first demonstrates a steep uptake of Telehealth since 2011, but perhaps a developing plateau, which would be typical of saturation of the technology savvy medics. Hopefully, over time the service will expand further, but this will rely on patient acceptance and satisfactory feedback.

Number of Providers by Selected Subspecialty - claims processed as at 31 March 2014

The second table shows claims processed by specialty, and it is encouraging to see urology near the top. Further expansion in our specialty will be partly patient driven, but also requires support from specialty bodies.

Services by Year and Quarter – claims processed as at 31 March 2014

The Australian Telehealth Society has produced a position paper on a National Telehealth Strategy to 2018 that is worth reading.


Essentially, the aim of Telehealth is to improve access to health care for patients who are disadvantaged by their location – its all about taking health care delivery in the direction where we can better scale the doctor to patient time.

Nick Brook is an Associate Professor in Surgery at the University of Adelaide, and Consultant Urologist and Director of Urological Cancer at the Royal Adelaide Hospital in South Australia. You can follow Nick @nickbrookMD on Twitter

Rajiv Singal leads the Surgical Robotics Program (jointly run by TEGH and Sunnybrook Health Sciences Centre) and is an Assistant Professor in 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.

You can follow him @DrRKSingal on Twitter

Categories: Video, Updates


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    Kimberley House
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    North Adelaide,
    Adelaide SA 5006
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