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GLOBAL CONNECTIONS A PUBLICATION OF THE AMERICAN UROLOGICAL ASSOCIATION

ADVANCING UROLOGY

VOLUME 7

A GLOBAL PERSPECTIVE

AUAUniversity All your educational needs, all in one place! The AUA is a leader in providing quality, evidence-based urologic education. The AUA is proud to introduce AUAUniversity, a new online portal that will transform your learning experience! n Simple and intuitive interface, accessible from your tablet or computer anytime, anywhere n Powerful new search engine, putting courses, abstracts and educational resources at your fingertips n  F lexible user management, enabling you to easily claim CME credits and to view or print your transcripts n Integrated learning solution, allowing you to customize your University and content, explore the new Core Curriculum and track your training needs n A  ccess to AUA Clinical Guidelines to help guide your decisions for diagnosis, management and treatment of urologic conditions

www.AUAnet.org/University

CONTENTS 4

FE AT U R E

Advancing Urology: A Global Perspective

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E XC H A N G E S

Up Close & Personal: Urology in Haiti

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FE AT U R E Global Connections is published twice-yearly by the American Urological Association Education and Research, Inc. (AUA). The AUA believes that the information in this newsletter is as authoritative and accurate as is reasonably possible and that sources of information used in preparation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any kind are disclaimed. This newsletter is not intended as legal advice, nor is the AUA engaged in rendering legal or other professional services. For comments or questions email us at communications@AUAnet.org.

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ADVANCING UROLOGY: A GLOBAL PERSPECTIVE BY: HENRY WOO, MD, AND CHRISTINE FREY

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lthough recognition of urology as a separate specialty or subspecialty of general surgery is relatively recent, many urologic diseases and certain surgical procedures can be traced back to ancient times. Circumcision, the first surgical procedure thought ever to be performed on a regular basis, is said to have been practiced in Egypt as early as 4000 BCE, and a mummified body of a child in Egypt, probably at least 4800 years old, contained a large bladder stone. Ancient India often recommended herbal roots, along with the chanting of certain hymns, to alleviate sexual dysfunction and to manage urinary retention. Bladder function dates back to antiquity when Roman physicians utilized reeds and the Ancient Chinese used onion stalks as catheters to relieve urinary retention, making them one of civilization’s first therapeutic inventions – and a powerful example of how ingenuity can turn an ancient remedy into a modern mainstay. Urology became more prevalent during the Middle Ages, when ‘stonecutters’ traveled the lands of medieval Europe aiming to cure patients of their bladder stones. Many patients did not survive the inadequate and painful operation techniques of the day, which often made the life of a ‘stonecutter’ very difficult. Urology has advanced substantially since the days when reeds were used to relieve bladder obstruction. With the exploration of human anatomy came the understanding of how organs functioned, followed by the search for treatment and prevention of problems. Further discoveries, such as anesthetics and medicine in the 19th century, improved surgical outcomes; and

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when Nitze invented the cystoscope in 1907, he opened the way to the gradual separation of urology as a specialty from general surgery throughout the civilized world. Over the years, urologists have moved from understanding how to diagnose and treat urologic conditions to understanding how to prevent these diseases, as well as minimize the effects urologic surgery has on a patient’s quality of life. Management of renal tumors nearly 30 years ago included open radical nephrectomy, but today physicians recognize that tumor size dramatically determines the choice of treatment. Even stone management nearly 30 years ago was different from what it is today and possibly what it will look like in the next 30 years when treatments will be individualized through genetic screenings. The key to what has advanced and will continue to advance the specialty is research and the belief that some of our most critical medical challenges will be solved by pursuing new developments and progress in the field. Urologic research aims to improve the understanding, prevention and treatment of urologic diseases, but innovation is improbable without proper funding, which is why it is important to understand how political developments and economic conditions around the globe can affect research and development support for years to come.

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GLOBAL STATISTICS ON RESEARCH AND DEVELOPMENT There is an important relationship between economic growth and research and development (R&D) and between the nurturing of research and advancing science and technology to benefit humankind. Scientific and technological innovations are critical to helping patients live longer, healthier and more productive lives. While R&D funding isn’t the sole indicator for how an industry will perform, its options are often closely linked to gross domestic product (GDP) and the economic outlook, and certainly are a fundamental consideration among factors such as science, technology and health care. According to the annual forecast by Battelle and R&D Magazine1, global R&D spending is forecasted to grow by 3.8 percent—or $60.0 billion—to $1.6 trillion in 2014. For the past six years, the top 10 countries funding R&D have remained mostly the same. There has, however, been a dramatic change in the number of countries involved in research, as well as shifts in the way funds are spent.

HIGHLIGHTS OF THE GLOBAL RESEARCH FUNDING ENVIRONMENT:

• Asian share of global R&D continues to increase, driven by China, Japan and Korea, while U.S. and European shares decrease. • African, Middle East and South American R&D remain relatively small, albeit some noteworthy national health care initiatives. In 2013, spending slowed, which was due primarily to unsettled European and U.S. economies that, in turn, affected global performance. Based on these factors: • R&D rankings have not changed significantly in the past five years, but funding levels between countries have narrowed. • No large increases in R&D investments are expected in Europe for the next several years due to the economic environment. • R&D growth in Asian countries has slowed; however, the investments in research and development still outpace the rest of the world. • U.S. R&D investment is back on track for 2014, but projections estimate slight-to-modest growth through 2020. • Multinational collaboration has become a preferred strategy for research projects in the Americas, Europe, the Middle East and Asia.

• U.S. and Europe remain global leaders in high-quality research output, but the balance is shifting. 1

Battelle and R&D Magazine, “2014 GLOBAL R&D”, 2014

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RESEARCH TRENDS U N I T E D S TAT ES

EU RO PE

The U.S. remains the world’s largest R&D investor of research, being recognized as the leader in biopharmaceutical R&D, with more than 3,500 drugs and therapeutics in development or under U.S. Food and Drug Administration review. The Battelle-R&D Funding Forecast projects U.S. investments to equal 2.8 percent of the U.S. GDP, and research activity is projected to increase by 3.2 percent to $465 billion in 2014, a 1 percent increase in real dollar terms. The U.S. federal government is expected to fund $123 billion of R&D in 2014—an increase of 1.5 percent. This will largely go to agencies that focus on basic research, like the National Institutes of Health (NIH) and the National Science Foundation (NSF). Reports from NIH state they funded a total of $497 million in 2013 for urologic research through grants, contracts and other funding mechanisms. This was down from a high of $542 million in 2011; however, projections for 2014 and 2015 forecast urologic research funding at $510 million.

With the large number of European Union (EU) member states, Europe’s research community is diverse in its genetic economic makeup and national interests. Europe’s R&D spending is projected to grow at about 1 percent per year through 2017. R&D funding is expected to follow a similar track. Over the next decade, it is also expected that Europe’s research priorities will shift to focus more on environmental and life sciences.

Highlights within the United States research enterprise: • Academic research programs have long been recognized as an essential scientific foundation of U.S. innovation, performing about 60 percent of all U.S. basic research. • Federal funding for academia is expected to increase 2.5 percent in 2014.

Anticipated urologic research trends in the United States: • Regenerative medicine, including the growth of human cells, tissues and organs. • Biological agents, antiangiogenic treatments and other targeted therapies for advanced and metastatic urologic cancers. • Genomic testing and risk stratification to help gauge prostate cancer aggressiveness and those at risk for the disease.

“ E ver y 30 second s a patient dies f rom di sea ses th at coul d be treated with ti ssue repl acement ,” said Dr. Anthony Atal a , director of the Wake Forest In stitute for R egenerative Medicine, and professor and ch air of the department of urolog y at Wake Forest Bapti st Medical Center, Win ston-Sal em , NC . “ Ef fort s to provide an alternative to dialysi s and live /decea sed donor tran spl antation i s one focu s of regenerative medical research . Our hope i s th at project s to develop cell therapies or impl antabl e ‘ in sert s’ to boost organ f unction will provide viabl e alternatives to tran spl antation in the f uture.”

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Highlights within the European research enterprise: • The amount of R&D performed in Europe is expected to remain flat for 2014. • The performance of European Universities is well-regarded in the global standings.

Anticipated urologic research trends in Europe: • Biological agents, antiangiogenic treatments and other targeted therapies for advanced and metastatic urological cancers. • Improved diagnostic techniques, especially in multiparametric magnetic resonance imaging to increase the accuracy of tumor localization and staging. • Erectile dysfunction repair using transplantation of human stem cells.

ASIA While 2013 R&D investment growth was minimal in the U.S. and Europe, growth in most Asian countries—especially China— continued. Southeast Asia has become the world’s largest region for research investments—a trend that is expected to continue through at least the end of the decade. Asian R&D investment growth rates are expected to return to their pre-2013 levels in 2014 and 2015. The exception to this outlook may be Japan, which is more correlated with trends in the U.S. and Europe than with neighboring Asian countries. Collaborations with technology firms and research organizations in the U.S. and Europe are also increasing as Asia seeks to leverage global scientific knowledge and capabilities.

Highlights within the Asian research enterprise: • China continues its unrivaled economic growth and doubledigit R&D increases. • China and Singapore have invested heavily in improving their state of science, technology, engineering and math (STEM) education in order to increase the number of STEM graduates.

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Anticipated urologic research trends in Asia: • Phytotherapy as a therapeutic option in the prevention and management of urologic diseases. • Non-invasive therapies involving targeted gene and stem cell therapies and nanotechnology. • Genetic variants of those with chronic kidney disease.

“ Urolog y i s a rather developed specializ ation in China with many universities and hospital s undertaking exten sive research in the f iel d ,” said Li-P ing Xie, M D, vice president of the Chinese Urological Association. “Our hope i s to improve patient s’ lives by targeting and identif ying stem cell s a s a potential therapeutic application for certain urologic di sea ses.”

AUS T R A L I A Australia remains a global leader in many areas of health and medical research, with health R&D expenditures estimated to be 1.1 percent of the total global spend. This spend has consistently exceeded GDP growth over the last decade and, due to an aging population, is forecasted to continue. Australia funds health and medical research through a range of programs administered by state and government agencies, academics and private investors. Prostate cancer is the most common cancer in Australia; and although it has a heavy impact on the Australian population, the continuing pace of research and medical advancements means developments in prevention and treatment can be channeled from ‘the bench to the bedside’ very quickly.

Highlights within the Australian research enterprise: • Health and medical research spending represents 3.4 percent of the total Australian government spending on health. • Despite having only 0.3 percent of the world’s population, Australia contributes slightly more than 3 percent of the medical research publications.

Anticipated urologic research trends in Australia: • Cellular function and how it relates to the growth of cancerous tumors. • Effectiveness of using the PSA test to detect prostate cancer in asymptomatic men. • Novel hormonal therapy for castrate-resistant prostate cancer.

“Our abilit y in Au stralia to tran sl ate science into new hope for patient s around the worl d hinges on the abilit y to prepare our next generation of urologic researchers,” said A ssociate P rofessor and urological surgeon at the Sydne y Adventi st Hospital Clinical School of the Universit y of Sydne y, Henr y Woo. “Current research interest s driving innovation and global competitiveness include l a ser prostatectomy outcomes, anal gesia for prostate biops y, pain management following radical prostatectomy, management of advanced prostate cancer, prostate cancer treatment outcomes and minimally inva sive treatment option s for benig n prostate di sea se.”

REST OF THE WORLD The “Rest of the World” countries are expected to undergo moderate growth in R&D investment in 2014. Most Middle East countries will experience strong GDP growth in 2014, but they are constrained by weak R&D infrastructure. The exceptions include Israel and Qatar, which invest in R&D at globally competitive levels. Africa is expected to see strong GDP growth, but is also limited by underdeveloped R&D capabilities—the exception is South Africa. Although significant strides have been made to define the burden of disease in such countries as the United States, the true burden of urologic disease in developing countries remains almost a guess. For example, issues like incontinence are expected to increase in the “Rest of the World” countries, possibly due to a combination of aging populations and lack of research funding. It is expected that by 2018 overactive bladder will have increased by 20 percent, affecting an estimated 546 million people, with the biggest increase in Africa (31 percent), followed by South America (22 percent). Urinary incontinence will have increased by 22% between 2008 and 2018, affecting an estimated 423 million people, with the largest increase in Africa (31 percent), followed by South America (25 percent). Strong GDP growth is expected in South America, but this region trails in R&D capacity. Health care spending as a proportion of GDP varies throughout the region from a low of just 1.8 percent in Venezuela to a reported 8 percent in Colombia, 8 percent in Argentina and 5.2 percent in Brazil.

Anticipated urologic research trends in the “Rest of the World” countries: • Antimicrobial susceptibility of enterobacteriaceae causing urinary tract infections in adults. • Genetic variants associated with increased prostate cancer risk, to be used as markers for population-based genetic screening and early diagnosis. • Genetic change intelligence to help doctors develop better methods for diagnosing adrenal cancer. CO N T I N U E D O N P G 8 ▼ G LO B A L CO N N EC T I O N S • VO L U M E 7

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MEDICAL DEVICES AND PHARMACEUTICALS

FUTURE OF UROLOGIC RESEARCH

Urology has also been an early beneficiary of many advances in medical technology and pharmaceuticals. The urology device market is one of the largest markets of the medical devices industry, comprised of devices for the treatment of urinary incontinence, prostate cancer, benign prostatic hyperplasia and kidney stones. This market is expected to see growth in the period of 2012 –2022, as we experience a global aging population and the continued rise in chronic diseases and conditions such as obesity and diabetes, which are considered to be significant risk factors in the development of several urological diseases. In the pharmaceutical market, annual global spending on medicines will reach nearly $1.2 trillion2 by 2016, with most of the revenue generated by the U.S. and Europe, followed by Asia and Australia. This trend is expected to shift slightly over the next five years, as China is expected to move Asia into second place in terms of revenue generation, behind the U.S. This growth reflects the loss of patent protection from leading products in developed markets, as well as the result of China’s efforts to hone a more skilled workforce in life sciences. Oncology is the leading urologic therapeutic class; other focus areas include pain management, incontinence and diabetes. Leading companies operating in the urology devices market will continue to focus R&D investments on the development of minimally invasive and non-invasive technologies that are cost-effective and with improved safety profiles. Constrained health care budgets across several key regional markets have significantly increased the demand for these technologies, as they are often able to reduce procedure time and hospital stay.

An aging population, the rising incidence of chronic diseases, technological advancements and product innovations are the drivers expected to lead R&D growth over the next decade. The future of urology is expansive and exciting, and the possibilities are endless. Future achievements could include improved accuracy of imaging, enhanced genetic testing and more precise surgical approaches using robotics. This is why the American Urological Association (AUA) and its Foundation, the Urology Care Foundation, are committed to funding future generations of young scientists and their research. “For nearly 40 years, the AUA has focused on funding urologic research in support of innovative treatments to improve the quality of patients’ lives,” said Leo Giambarresi, PhD, Director of Research for the American Urological Association. “Through our Research Scholars Program and other funding awards, we are committed to providing young scientists with the opportunity to begin a strong career in urologic research excellence.”

Urologists with advanced training and experience in urologic research are essential to future success; and by continuing this support, the urological communit y will ensure unbroken progression for succeeding generations of urologic research for many decades to come. For more information about the AUA and the Urology Care Foundation’s Research Awards, visit w w w. AUAnet.org.

The Global Use of Medicines: Outlook Through 2016. Report by the IMS Institute for Healthcare Informatics.

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UROLOGY IN HAITI For more than 20 years, several American urologists have independently provided direct patient care or conducted educational seminars in Haiti. Several volunteers brought to the AUA’s attention the need to better coordinate these efforts. Recognizing the importance of this issue, the AUA organized an on-site meeting at the AUA Annual Meeting in San Diego to coordinate a collaborative program in Haiti that included volunteer urologists and representatives from the AUA, the Societe Internationale D'Urologia (SIU), IVUmed, the Association of Haitian Physicians Abroad (AMHE), Project Haiti and the Haitian Society of Urology. Subsequently, the first Annual Joint Haitian American Urology Conference was held in Haiti on November 15, 2013. Lectures were given by both U.S. and Haitian urologists on a variety of subjects. Global Connections has asked some of the meeting participants to provide their thoughts on the current state and future of urology in Haiti.

DR. PIERRE BONCY Chief of Urology, Residency Program Director, State University Hospital, Port au Prince, Haiti

GC:

What are the key points in the history of urology in Haiti that have most strongly influenced how urology is currently practiced in Haiti?

Boncy: Doing my rotation in the University Hospital (HUEH), my choice for residency became obvious after my experience in the Urology department. The unit was well run with strong leadership and without obvious personal or academic problems. I discovered later that the same reasons influenced many of my colleagues to choose Urology. Following my predecessors, I try to maintain a tradition of respect, unity and scientific honesty among the Urological Staff, both inside and outside of the University Hospital.

Dr. Michael Ziegelbaum reviewing surgical cases with residents from Justinien University Hospital, and visiting resident, Dr. Nikeal Waingkanker, from North Shore/Long Island Jewish hospital.

GC:

What is the biggest strength among Haitian urologists and/or within Haitian urology today?

Boncy:

Traditionally, many physicians left the country after their residency for economic reasons and did not return. Nowadays, some stay or return after post-graduate programs which improve their skills. We believe that this new wave of young Urologists, with the proper training programs, have an interesting future.

DR. CLAUDE PAULTRE Urologist, State University Hospital President, Societe Haitienne d’Urologie

GC:

What is the typical process for becoming a urologist in Haiti?

Paultre: First, you have to sit an exam given to all the graduates who want to pursue a surgical specialty. Secondly, the graduates are allowed to choose according to merit from the residency posts made available. At the end of the selection process, I am impressed to discover that about half of those who choose urology have smart minds and a particular love for the specialty. To become a urologist, you have to complete a four-year program. Since the earthquake, training has suffered from negligence and lack of discipline. A change is necessary.

DR. PIERRE-ALIX NAZON Urologist, State University Hospital, Port au Prince, Haiti

GC:

What are the most common urological diseases treated in Haiti? What are the most common procedures and surgeries performed?

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Dr. Jory Desir, urologist at Justinien University Hospital, discusses urology training requirements in Haiti during the Joint Haitian American Urology Conference in November 2013.

Haitian doctors and nurses host a reconstructive urology workshop with volunteers from IVUmed and Project Haiti in Pignon, Haiti.

Nazon:

Prostatic diseases constitute the most common urological problem treated in Haiti, mostly BPH, but also prostate cancer. Hydrocele and varicocele, and undescended testicles are regularly addressed, as well as stone diseases and urethral stenosis. Few institutions are equipped to perform basic urological endoscopic procedures like TURP, ureteroscopy and JJ stent placement, therefore open surgery is common. Transvesical prostatectomy; surgical cure of hydrocele and varicocele; open surgery for the removal of the bladder, kidney and ureter stones; and blind internal urethrotomy are common surgeries performed in Haiti.

GC:

What is the biggest strength among Haitian urologists and/or within Haitian urology today?

Nazon: Haitian urologists can work in difficult conditions. They have developed skills in clinical diagnosis due to the lack of imaging and biological exams. Haitian urologists have good expertise in open surgeries, such as transvesical prostatectomy and kidney stone surgery. DR. YOURY DREUX Urologist, State University Hospital, Port au Prince, Haiti

GC:

What are the biggest obstacles towards improving urologic training in Haiti?

Dreux:

The biggest obstacle is teaching residents. The best help the AUA and other U.S. organizations can give us is to provide equipment to the main university hospital and teach urologists and residents how to use and maintain the equipment. We should decentralize urology into different sub-specialties and have the sub-specialties distributed throughout Haiti.

GC:

What is the biggest strength among Haitian urologists and/or within Haitian urology today?

Dreux: Haitian urologists, even established urologists, want to learn how to do better surgery. They have a will to learn VO L U M E 7 • G LO B A L CO N N EC T I O N S

despite sometimes bad conditions. They do the best they can to have the maximum amount of teaching and learning in their environment. As Dr. Joe Babiaz told me at Pignon, “Youry, you are like a sponge seeking knowledge as water.”

DR. JORY DESIR Urologist, Justinien University Hospital, Cap-Haitien, Haiti

GC:

What are the biggest obstacles towards improving urologic training in Haiti?

Desir: The biggest obstacles are the training framework and lack of supervision. We have inadequate infrastructure, lack of input and obsolete equipment, inadequate salaries of the residents (<U.S. $200) and the trainers (state urologist salary is less than U.S. $650) that influence the motivation and the compliance of both urologists and residents. We don’t have a standardized training program; the curriculum is ill-defined. There are no existing quotas or procedures for validation and accreditation after the training. We don’t know the levels of technical expertise acquired.

DR. JEAN GÉTO DUBÉ Chief Administrator & Urologist, Residency Program Director, Justinien University Hospital at Cap-Haitien, Haiti

GC:

What are the biggest challenges that a Haitian urologist faces on a day-to-day basis?

Dubé:

Urologists interviewed at the First Joint Meeting of American and Haitian Urologists have noted numerous challenges. These include: •U  rologists must bring their own equipment to hospitals which refuse to invest in an infrastructure whose profitability remains uncertain to them. • T he availability of intravenous urography, CT scanner, endoscopy equipment or even some routine tests remain a barrier to the diagnosis of urologic disorders or their management.

GC:

What is the biggest strength among Haitian urologists and/or within Haitian urology today?

Gousse: Haitian urologists are eager to learn and acquire new surgical skills. Most Haitian urologists are well aware of their clinical strengths and weaknesses. They welcome new technological advances to improve the quality of life of their patients. They welcome foreign medical missions and appreciate the altruism of the participants. Haitian urologists are motivated to improve urologic care in their country. Dr. Angelo Gousse flanked by Dr. Pierre-Alix Nazon (left) and Dr. Claude Paultre (right) at Bernard Mevs Hospital during a GURS mission to Haiti for reconstructive surgery.

DR. LOUIS AUGUSTE Associate Clinical Professor of Surgery, Hofstra North Shore/LIJ School of Medicine Program Co-Director, Association of Haitian Physicians Abroad

•A  lack of mastery of procedures requiring technological skills remains a problem. The practice of endoscopic surgery is not available to most urologists.

GC:

• Lack of subspecialties: Everyone does everything.

Auguste:

•A  ccessibility of urological care in remote areas of the country is lacking because of inadequate and poor distribution of the urologic workforce. • T he Haitian urologists have never agreed on the direction for the practice of national urology and how to serve the population, especially in remote areas.

GC:

What is the biggest strength among Haitian urologists and/or within Haitian urology today?

Dubé: Many recognize Haitian urologists have a great mastery of open surgery, even when complicated. The lack of resources sharpens their technical skills, creativity and clinical acumen. Despite these shortcomings, there remains a certain willingness to pursue further learning.

DR. ANGELO GOUSSE Clinical Professor of Urology – Herbert Wertheim College of Medicine – FIU, Miami, FL

GC:

What steps can be taken to improve the urologic training system in Haiti?

Gousse:

Improvement of urologic instrumentation and technology in teaching programs will strengthen urologic teaching and attract the brightest minds to the field of Urology in Haiti. It remains imperative to develop a basic urology residency curriculum which can be modified to account for the socioeconomic environment of Haiti. Core competencies of residency training should be established. Telemedicine opportunities and foreign medical missions should regularly partner with residency training programs. A Haitian Board of Urology should be established in order to certify that graduating urologists can safely practice urology in the community.

What were the main “takeaways” from the first Annual Joint Haitian-American Urology Conference?

The purpose of this meeting was to establish a clear understanding of the status of Urology in Haiti. The conference revealed that for a country of more than 9 million people, there were only 26 urologists, and urology was available only in eight locations. It was decided that the Haitian Society of Urology must further define its needs so that a coordinated effort by the AUA, SIU and IVUmed can be undertaken. Once these needs are defined, donated equipment, instruments, supplies and volunteer time will be required.

GC:

What is the biggest strength among Haitian urologists and/or within Haitian urology today?

Auguste: Haitian urologists have awakened to the reality of their limitations and are actively looking for ways to fulfill their deficiencies. They are eager to learn, and they show the incredible ability to do a lot with so little. A website has been created to better coordinate these efforts at www.UroHaiti.org. For more information on how you can volunteer your time or donate urological equipment for philanthropic efforts in Haiti, please visit www.UroHaiti.org or email the AUA at International@AUAnet.org. U.S. participants in the conference included: Samuel Broaddus, MD; Raymond Paul-Blanc, MD; Derrick Black; Frank Burks, MD; Lars Ellison, MD; Angelo Gousse, MD; Henri P. Lanctin, MD; Curtis Peterson, MD; Daniel Rosenstein, MD; Fran Schneck, MD; Josh Wood; and Michael Ziegelbaum, MD. The Association of Haitian Physicians Abroad (AMHE) was represented by its President, Maxime Coles, MD, and the program co-directors, Louis Auguste, MD, and Jean Michel Loubeau, MD. Haitian participants in the conference included: Drs. Pierre Boncy, Bernard Brutus, Mitelot Clervil, Jory Desir, Youri Dreux, Jean Geto Dube, Jacques Jeudy, Pierre-Alix Nazon, Claude Paultre, Myril Sahmonde and Guy Theodore. G LO B A L CO N N EC T I O N S • VO L U M E 7

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Advancing Urology through

Patient Advocacy By: Rajiv K. Singal, MD, and Jennifer Larche According to World Cancer Research Fund International, there were an estimated 14.1 million cancer cases globally in 2012. Of those cases, there were 1.1 million prostate; 430,000 bladder; 338,000 kidney; and 55,000 testis cancer cases. The number of cancer cases worldwide is expected to increase to 24 million by 2035. To battle and eventually overcome urological cancers and other conditions, including erectile dysfunction, male infertility and incontinence, it requires an international approach. Coming together to create awareness, raise funds and advocate for increased research and education is crucial to the diagnosis and treatment of urologic conditions affecting the lives of men and women around the world.

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ROLE OF UROLOGIST AS PATIENT ADVOCATE As medicine becomes increasingly complex, it is incumbent upon all physicians and health care providers to not only interpret the best available evidence at hand, but also frame the advice given in aiding the clinical decision-making process. However, there is a larger, at times neglected, role physicians must play as they work through busy clinical days â&#x20AC;&#x201C; the patient advocate. Physicians must understand that their patients, local communities and even society at large look to them for leadership in bringing clarity to their health care issues. With an increasingly stressful practice environment that strives to balance quality with fiscal responsibility, this becomes even truer today, and the concept of physicians as patient advocates is especially valid for urologists. Urologists must be strong advocates for their patients. It is not only necessary but also good patient care and ultimately very rewarding.

F E AT U R E

Urologists look after both routine and complex urological problems that affect men and women, and are the leaders in the delivery of urological health care. Improving awareness of disease, understanding treatment options and research funding should be central to the work of urologists. This is at the heart of patient advocacy. The urologist’s role as an expert in urologic conditions and diseases is crucial, as is supporting patients and their families and being a strong voice for the future of their health. “To provide the best treatment for our patients, patient advocacy should permeate everything we do — from the clinic consult right up to government representation,” says Dr. Nicolas Brook, urologist and Director of Urological Cancer at the Department of Urology Royal Adelaide Hospital in Australia.

INTERNATIONAL ADVOCACY GROUPS Patient support groups and advocacy organizations, such as the Urology Care Foundation, The Urology Foundation and Men’s Health Network, are some other strong voices for the future of urologic health care, and share the common goal of raising awareness around urologic diseases and conditions in hopes of one day eliminating them.

THE UROLOGY CARE FOUNDATION The Urology Care Foundation is based in the United States, but is committed to promoting urology research and education internationally. The Urology Care Foundation is the world’s leading nonprofit urological health foundation — and the official Foundation of the American Urological Association. The Foundation partners with physicians, researchers, health care professionals, patients, caregivers, families and the public to support and improve the prevention, detection and treatment of CO N T I N U E D O N P G 14 ▼

“TO PROVIDE THE BEST TREATMENT FOR OUR PATIENTS, PATIENT ADVOCACY SHOULD PERMEATE EVERY THING WE DO — FROM THE CLINIC CONSULT RIGHT UP TO GOVERNMENT REPRESENTATION” – Follow Dr. Brook on Twitter @nickbrookMD G LO B A L CO N N EC T I O N S • VO L U M E 7

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urological diseases through research and education.

PROSTATE CANCER CANADA Prostate Cancer Canada (PCC) is dedicated to the elimination of the disease through research, education, support and awareness. The organization holds and participates in several awareness events throughout the year. They also have the Prostate Cancer Canada Network, comprised of over 70 prostate cancer support groups from coast to coast, which provides services at the grass roots level through monthly peer meetings, special educational events, outreach programs and presentations to service clubs, community health fairs, and more.

THE UROLOGY FOUNDATION Based in the United Kingdom, The Urology Foundation (TUF) organizes fundraising and special events throughout the year. These events generate funds for the Foundation’s vital work, and help spread the message about urological conditions and treatment. Since 1995, TUF has funded more than 170 scholarships and research grants, and arranged training programs for hundreds of urologists.

US TOO INTERNATIONAL PROSTATE CANCER EDUCATION & SUPPORT NETWORK Us TOO is a grassroots, nonprofit prostate cancer education and support network of 325 support group chapters worldwide. The organization was founded in 1990 by five men who had been treated for prostate cancer. Us TOO strives to help men and their families by providing free information, materials and peer-to-peer support so they are able to make informed decisions on detection, treatment options and coping with ongoing survivorship. The organization also supports patients and their families through education and advocacy.

MEN’S HEALTH NETWORK Men’s Health Network is a national, nonprofit organization whose mission is to reach men, boys and their families where they live, work, play and pray with health prevention messages and tools, screening programs, educational materials, advocacy opportunities and patient navigation.

INTERNATIONAL AWARENESS CAMPAIGNS Hundreds of awareness campaigns are employed each year in the United States and abroad to raise awareness around men’s health and urologic conditions, and thousands of events — many run by volunteer patient supporters — are held throughout the world. The Urology Care Foundation has teamed up with the National Football League to create the Know Your Stats About Prostate Cancer ® (KYS) campaign, encouraging men to talk with their doctors about their risk of prostate cancer. The KYS® campaign has a new initiative, first promoted during Super Bowl XLVIII, involving signing the “Pledge” to tackle prostate cancer. By signing the pledge, you agree to: 1) Know my risk or encourage men in my life to know their risk — men with a family history and African American men have an increased risk; 2) Talk to my doctor or encourage men in my life to talk to their doctors about prostate cancer testing; 3) Raise awareness — spread the word on Facebook, Twitter or in the community; and 4) Support prostate cancer research. The Urology Care Foundation has also developed active campaigns for overactive bladder (OAB) and stress urinary incontinence (SUI) conditions. These campaigns strive to provide an abundance of educational materials and support to patients struggling with these conditions, as well as the physicians treating them. There are three known months of the year, globally recognized, that are dedicated to raising awareness around urology and its conditions and diseases. June is known as Men’s Health Month, which also incorporates Men’s Health Week as the week leading up to and including Father’s Day; September is Prostate Cancer Awareness Month; and November is host to one of the most famous campaigns for men’s health awareness … “Movember”! Since its beginnings in 2003 in Melbourne, Australia, when 30 “Mo Bros” first grew moustaches, “Movember” has grown to become a truly global movement inspiring more than four million “Mo Bros” and “Mo Sistas” to participate across 21 countries worldwide. In November each year, the “Movember” campaign is responsible for the sprouting of millions of moustaches on men’s faces. Participants support the campaign and men’s health causes from Moscow to Rio de Janeiro, and everywhere in between — including the United States. To date the campaign has raised $446 million, funding 577 projects aimed at achieving an everlasting impact on the face of men’s health.

“IN NOVEMBER EACH YEAR, THE ‘MOVEMBER’ CAMPAIGN IS RESPONSIBLE FOR THE SPROUTING OF MILLIONS OF MOUSTACHES ON MEN’S FACES.” VO L U M E 7 • G LO B A L CO N N EC T I O N S

F E AT U R E

An initiative of Men’s Health Network and anchored by a Congressional health education program, Men’s Health Month is celebrated in June across the country and internationally with screenings, health fairs, and other health education and outreach activities. Men’s Health Week is usually held within the first half of the month with the purpose of heightening awareness of preventable health problems among men and boys. The month of June gives health care providers, public policymakers, media and individuals an opportunity to encourage men and boys to seek regular medical advice and early treatment for disease and injury. The response has been overwhelming, with hundreds of awareness activities in the United States and around the globe. September is internationally designated as Prostate Cancer Awareness Month and host to Urology Week during the second week of the month each year. Urology Week is an initiative of the European Association of Urology that brings together national urological societies, urology practitioners, urology nurses and patient groups with the aim to create awareness of urological conditions among the general public, and is promoted in as many as 23 countries in Europe and abroad. November Blue is known in Brazil as a prostate/penile-cancerfocused campaign initiated by the Sociedade Brasileira de Urologia (SBU) to urge Brazilian men to take their health seriously and seek care from physicians. Dr. Aguinaldo Nardi, SBU Immediate Past President, revealed an alarming statistic during a presentation in 2013 to parliamentarians — 43% of men never went to the urologist, and penile cancer causes thousands of amputations per year in Brazil. This fact alone stresses the importance of creating awareness and collaborating

internationally to work toward eliminating urological cancers and conditions. “The urgency of the warnings that men begin to pay more attention to health is necessary,” stated Dr. Nardi.

IMPACT OF AWARENESS ON ADVANCING UROLOGY Real change is being seen with increased awareness and advocacy surrounding urological conditions such as prostate cancer, kidney disease and urinary incontinence. Getting involved will foster a greater spirit of collaboration and create a robust dialogue, ultimately advancing care and ensuring patients are treated with the respect they deserve. Patients need support to continue the fight to improve the diagnosis, treatment and management of urological conditions. Simply caring for them after diagnosis or waiting for a research grant to materialize is not good enough. Dr. Rajiv K. Singal is a urologist at Toronto East General Hospital and an assistant professor in the Department of Surgery at the University of Toronto. Follow him on Twitter at @DrRKSingal.

SOURCES: http://www.knowyourstats.org/: Accessed 3/7/14 http://us.movember.com: Accessed 3/10/14 http://www.theurologyfoundation.org/: Accessed 3/14/14 http://www.jurisway.org.br/en/article.asp?id_dh=10780: Accessed 3/14/14 http://www.uroweb.org/?id=192&act=showfull&aid=113: Accessed 3/18/14 http://prostatecancer.ca: Accessed 3/18/14 http://www.wcrf.org/cancer_statistics/world_cancer_statistics.php: Accessed 3/18/14

INTERNATIONAL CAMPAIGN INFORMATION UROLOGY WEEK: Whether you are a urologist, nurse, patient or supporter of this important cause, organize an event in your hometown. However large or small, every effort counts! UrologyWeek.org has many tips and materials to get you started. “MOVEMBER”: More Information about joining an event in your community, or starting one, can be found at Movember.com.

MEN’S HEALTH WEEK: Find a list of activities at mensheatlthmonth.org/week. NOVEMBER BLUE: Brazil’s Cristo in the month of November during SBU’s prostate health campaign.

KNOW YOUR STATS ABOUT PROSTATE CANCER®: Join the Team! Sign the Pledge to Tackle Prostate Cancer and receive KYS information, at knowyourstats.com.

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CO L L A B O R AT I O N S

COLLABORATIONS THROUGH THE SANDS OF TIME By Lori Agbonkhese The medicine of Ancient Egypt is some of the oldest documented in the world with the existence of bronze surgical instruments discovered in the tomb of Qar, a doctor who lived and worked in Egypt under the 6th dynasty nearly 4,000 years ago1,2. While the history of collaborations between the Egyptian Urological Association (EUA) and the American Urological Association (AUA) does not date back quite that far, both organizations have developed a close friendship and partnership in the spirit of standardizing urologic education and patient care around the world. According to EUA President Dr. Mohamed Eissa, “In the past few years the collaboration with the AUA has flourished immensely, and this reflected very positively on the Egyptian urologists, now being part of the international urological arena, all urologists in any discussion are referring to the AUA guidelines, and Egyptian publications have tripled in The Journal of Urology®.” In May 2012, the AUA and EUA executed a Memorandum of Understanding (MOU) to formalize collaborations between the two organizations, and since that time have held two Lessons in Urology courses in Cairo, Egypt, as well as joint symposia at the EUA’s annual meetings. The Lessons in Urology course is specifically designed for senior residents, and features a combination of North American and Egyptian experts. The program covers a wide array of urologic topics and provides attendees with knowledge in all topic areas of urology. Dr. David Diamond, chief at the Boston Children’s Hospital, who served as one of the inaugural AUA faculty members, says, “We lectured to 300 young Egyptian urology trainees, and the quality of questions raised and ensuing discussions was quite high. It was

Leaders from the AUA and EUA codify collaborations in May 2012.

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particularly gratifying for me in that I have been on three medical missions to different centers in Egypt to promote improved pediatric urological care. I hope that we have the pleasure of interacting with our Egyptian colleagues through the AUA for many years to come.” In just two short years, the Lessons in Urology course and exam have become extremely popular. According to Dr. Eissa, “Our [EUA] members consider it as the most important and best achievement that this Board has done for Egyptian urologists. The problem is that even practicing urologists want to attend!” The 2014 course is scheduled for September 14 – 16, and will not only see an increase in participants from Egypt, but will also be available to senior residents from other countries in the region. “It is my belief that the educational bridge between the AUA and EUA will fulfill a training and educational need and foster the interchange of urological skills, expertise and knowledge, which is critical to the continued success of urology in the world community,” says AUA Secretary Dr. Gopal Badlani. With 1,950 active members in the EUA, urology in Egypt is flourishing, despite the periodic outbreaks of political instability experienced over the past several years. Urologists are even playing an active role in drafting the country’s new constitution, and these efforts will certainly result in positive milestones for Egyptian urology, which is “on the same wavelength as urology in the Western hemisphere, [except for] just needing some robots. As for the current political turmoil, we feel it will end soon. Urology practice is the same, and our annual conference [in December] went great. We definitely appreciate AUA’s support and participation, especially the presence of AUA Secretary Dr.

Attendees of the 2nd Annual Lessons in Urology Course in Cairo, Egypt, in December 2013.

CO L L A B O R AT I O N S

Gopal Badlani, who traveled to the course when many chose not to participate,” says Dr. Eissa. Twenty-three percent of EUA members work outside of Egypt—15 percent in Arab states and 8 percent in Western countries—making the AUA’s Annual Meeting one of the forums where EUA members from around the world can come together to network and participate, not only in the AUA Annual Meeting, but the EUA scientific program held during the AUA Annual Meeting each year. Dr. Eissa says, “It has become the dream of young urologists to attend the AUA meeting.” Nearly 100 urologists attended last year’s EUA scientific program in San Diego, and attendance for this popular program is expected to increase at AUA2014 in Orlando. The 2014 program will be held on Monday, May 19, from 1 to 4 p.m.

Participants of the 2013 AUA/EUA Lessons in Urology course take the AUA International Exam.

Dr. Badlani says, “I would also like to thank two special people for without whom these programs would not have been possible— Dr. Mohammed Eissa, EUA President, and Dr. Gamal Ghoniem from the University of California, Irvine.” Because of Dr. Eissa’s significant contributions to urology and the partnership between the EUA and AUA, it was truly the privilege of the AUA to recognize his efforts in May 2013 with one of the highest honors the AUA can bestow – AUA Honorary membership. It is clear that the future of the EUA and urology in Egypt is very bright. “We have a lot of dreams and goals that we would like to achieve, and most important is the recognition of our urological degrees. Self-confidence of our junior staff is sky high, especially after most of them have attended the AUA/EUA Lessons in Urology course, which is the fruit of the partnership,” says Dr. Eissa. Dr. Gopal Badlani remarked, “The partnership between the AUA and EUA is a natural one. Strong bonds of friendship have been developed between our organizations, and it has been my honor and privilege to represent the AUA in Egypt. Our partnership will not only directly impact the educational opportunities for residents and practicing urologists in Egypt, but also across the region, which can only result in improved quality and delivery of care to patients.”

Leaders from the EUA and AUA network prior to the EUA program at AUA2013.

AUA Immediate Past President Dr. Dennis Pessis presents EUA President Dr. Mohamed Eissa with AUA Honorary membership.

“THE PARTNERSHIP BET WEEN THE AUA AND EUA IS A NATUR AL ONE.” REFERENCES: 1 "Imhoteb Museum." Egypt Tourism Board. Egypt Tourism News, 3 Jan. 2013. Web. 23 Mar. 2014. <http://egyptourism.wordpress.com/tag/jeanphilippe-lauer/>. 2 Jackson, Russell. "Mummy of ancient doctor comes to light - Scotsman. com News". News.scotsman.com. Retrieved 2014-03-24. <http:// www.scotsman.com/news/world/mummy-of-ancient-doctor-comes-tolight-1-733144/>.

EUA and AUA leaders enjoy a night of friendship at the EUA Presidential Dinner during the EUA 2013 Annual Meeting in Sharm El Sheikh.

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International Researchers Gain Support through their AUA Membership AS THE GLOBAL PROJECT TO END UROLOGICAL DISEASE AND EXPAND INNOVATION INTENSIFIES AROUND THE WORLD, INTERNATIONAL HEALTH CARE PROFESSIONALS CONTINUE TO FIND SUPPORT THROUGH AMERICAN UROLOGICAL ASSOCIATION (AUA) MEMBERSHIP.

Dr. Joao Luiz Amaro, a full professor of urology at Sao Paulo State University (UNESP) in Brazil joined the AUA in 2013.

Dr. Kamel conducts scientific research in the fields of prostate, erectile dysfunction and infertility. As a consultant of uroandrology, Dr. Kamel started his scientific career at the Free University of Brussels in Belgium. He has published over 20 scientific papers in scientific journals related to andrology and urology.

“The AUA is a very important association (within) urology,” he said. “The AUA’s different activities permit my professional actualization.”

“(I joined the AUA) in order to update my scientific level and to follow the newest scientific information and research in my field,” he said.

Over the past five years, the AUA Board of Directors has recommitted to research as one of the three pillars of AUA’s strategic plan. Throughout that time, the investment in research by the Board has been substantial, and the presence of basic and translational research at the AUA Annual Meeting has steadily increased.

Dr. Amaro said he spends the majority of his professional time engaged in research, and about 10 percent of his time practicing urologic patient care.

“AUA membership has influenced my career. I show my patients that I am an AUA member, and I bring them the most updated treatment following the AUA Annual Meeting,” said Dr. Ahmed Kamel, an AUA member since 1997.

For Dr. Antonio Zaccara, an AUA member practicing at Bambino Gesu Children’s Hospital in Rome, Italy, his decision to join the AUA in 2006 was based on its reliable stream of information and education.

Every year, AUA members can register to attend the Annual Meeting at a discounted rate. They are also eligible to receive free or discounted subscriptions to a host of AUA publications and media, including The Journal of Urology®. The new AUA journal, Urology Practice, will also be available when it debuts at the 2014 AUA Annual Meeting.

“(I joined) because the AUA is the most outstanding and updated association of urologists worldwide,” he said.

The AUA offers an opportunity to join its global membership through categories for researchers, scientists and non-urologist physicians who are significantly contributing to urology.

“AUA MEMBERSHIP HAS INFLUENCED MY CAREER. I SHOW MY PATIENTS THAT I AM AN AUA MEMBER, AND I BRING THEM THE MOST UPDATED TREATMENT FOLLOWING THE AUA ANNUAL MEETING”

“I love research because I can try to improve my patient’s life and my practice of urology,” he said.

Dr. Zaccara is a pediatric surgeon who devotes a lot of his work to reconstruction and the tissue handling of complex urogenital malformations. To further recognize the research community’s value to the progress in urology, the AUA Board of Directors approved clearly identifiable and defined membership categories to include those in training, such as graduate students and post-doctoral fellows, and more senior research scientists or independent investigators. These new AUA member categories will become available in the fall of 2014. Please visit AUAnet.org/Join for more information about becoming an AUA member.

AUA GUIDELINES-ATA-GLANCE APP Have you already downloaded the APP? Check out the NEW FORMAT and interactive features! The APP now includes Quality White Papers, Choosing Wisely and many other new features! Download this mobile app for FREE via the iTunes and Google Play stores by searching for AUA Guidelines.

We would like to sincerely thank Astellas Pharma US, Inc. for providing the educational grant to support the promotion and distribution of this App. Consistent with the AUA strict conflict of interest policy, Astellas Pharma US, Inc. had no access to the AUA guidelines panels, played no part in the research or development of AUA guidelines and did not review them prior to publication. The support offered by Astellas Pharma US, Inc., and gratefully accepted by the AUA, advances the educational mission of the guidelines to help you and your practice.

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Global Connections Spring 2014