Global Connections Fall 2016

GLOBAL CONNECTIONS A PUBLICATION OF THE AMERICAN UROLOGICAL ASSOCIATION

VOLUME 11

CANCER MOONSHOT 2020

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CONTENTS 4

U P C LO S E & P E R S O N A L

Fernando J. Kim, MD, MBA, FACS

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FE AT U R E

Cancer Moonshot 2020

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

In Their Words – The Value of Belonging to the AUA 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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Bladder Cancer

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BY T H E N U M B E R S

AUA2015 census

U P C LO S E & P E R S O N A L

FERNANDO J. KIM, MD, MBA, FACS CHIEF OF UROLOGY, DENVER HEALTH MEDICAL CENTER, DENVER, COLORADO, USA. PROFESSOR OF SURGERY/UROLOGY, UNIVERSITY OF COLORADO DENVER

Fernando J. Kim, M.D, MBA, FACS Chief of Urology, Denver Health Medical Center, Denver, Colorado, USA. Professor of Surgery/Urology, University of Colorado Denver

To expand its global reach, the AUA has partnered with U.S.based urologists to assist in fostering a strong and collegial partnership between the AUA and international urological associations. Dr. Fernando Kim has been the AUA’s Host Country Liaison to Brazil since 2010 and has been invaluable towards establishing the strong relationship and collaborations that the AUA now shares with the Sociedade Brasileira de Urologia (SBU).

In addition, Dr. Kim is the Program Director for the Brazilian Portuguese Urology Program held during the AUA Annual Meeting each year. He also serves as an AUA representative at the SBU National Meetings and the Highlights of the AUA – Brazil program, which celebrated its fifth anniversary in June 2016. Dr. Kim has hosted several AUA/SBU Academic Exchange Scholars at his institution and serves as a mentor for the AUA/SBU Residents that attend the Annual Meeting. We recently reached out to Dr. Kim to find out more about his experience in this role with the AUA.

Q A

as many Brazilians, I grew up loving soccer and music. In the early 80’s my parents decided to move to Los Angeles due to the family business, but I diverged and pursued my career in medicine. Initially, trauma surgery was my passion and I dedicated several years in Denver under Dr. Ernest E. Moore’s mentorship, but after I saw the first ureteroscopy, I knew I had to be an Urologist. Luckily, Dr. Robert Flanigan took me under his wing and after I finished my fellowship with Dr. Louis Kavoussi in Baltimore we went back to the Mile High city.

Q A

Tell us a little bit about your background.

I consider myself a citizen of the world. I am a proud Korean Brazilian American. My parents escaped from North Korea during the Korean War and started our family in South Korea. Soon after I was born we lived in Argentina for 5 years. Then we immigrated to Sao Paulo, Brazil and,

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How did you first become involved in the AUA?

My first interaction with the AUA was as a presenter during the North Central Section meeting when I was a resident. But my active involvement with the AUA began through the AUA leadership program (class of 2006). I learned the different ways I could serve the AUA and its

U P C LO S E & P E R S O N A L

AUA and SBU leaders pose for a photo at the AUA2016 Annual Meeting in San Diego.

valuable domestic and international members. Since then, I have been serving on different AUA committees with a specific focus on creating a greater awareness of the value of the AUA membership to our international Urology friends.

Q A

What interested you in becoming the AUA host country liaison (HCL) for Brazil?

Undeniably, my Brazilian culture was a major reason to become the AUA host country liaison for Brazil. In 2009, Dr. Flanigan, Secretary of the AUA, initiated a successful campaign to reach out to our international members.

One of our initiatives was to create the annual Brazilian Portuguese Urological program during our AUA annual meeting. The program has become a very well attended session including all Portuguese speaking Urologists and other domestic and international members, which serves as a great a platform to network with other urologists.

Q A

How did you get involved with the Sociedade Brasileira de Urologia (SBU)?

Initially, the SBU invited me to be a speaker during their sectional and annual meetings and quickly they opened their arms to my friendship. They helped me to bring the AUA and SBU closer together resulting in a solid relationship with very important scientific and academic collaborations.

Q

How has the relationship between the AUA and SBU evolved over the last seven years (since a formal relationship between them was established)?

A

The relationship between the AUA and SBU has been successful and fruitful. Initially, we streamlined the AUA membership process and as a result we were able to recruit and maintain new generations of Brazilian urologists to become AUA members. In terms of educational and scientific programs, we solidified our partnership with the SBU by licensing the AUA annual highlights for SBU members that could not attend our meeting in the US, and we have been organizing a joint AUA/SBU session during the SBU meetings and vice-versa during our AUA annual meetings (the Brazilian Portuguese Urological Program).

Finally, the exchange of residents and visiting scholars cemented a strong bridge between our associations establishing new collaborations in research projects, training and friendships, especially among new Urologists.

Q A

What is your favorite memory from traveling as the HCL for Brazil?

It was during the 2011 SBU meeting in Florianopolis when the SBU leadership recognized the AUA’s friendship and relevance in the education of urologists around the world by awarding Dr. Robert Flanigan and I with their Presidential Medal of Honor and Drs. Gopal Badlani and Sushil Lacy with SBU honorary membership. It was incredible to have my family present during the ceremony.

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U P C LO S E & P E R S O N A L

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What is your proudest accomplishment as the HCL for Brazil?

My proudest accomplishment as the HCL for Brazil is the recruitment of young members as AUA international members. New generations of Urologists will continue to bring more value to our membership by sharing the global challenges they face in their practices. Through such educational exchange, better solutions will be found and a sense of global community is created that will ultimately improve patient care. It is great when Urologists from the Amazon and other remote parts of Brazil tell me that our discussions and educational programs often bring practical management skills and knowledge to them, in contrast to discussions of top notch technology that are not part of their reality.

What are the biggest differences between how Urology is practiced in Brazil and the U.S.?

I believe that if there were any gaps in the past, these gaps are very narrow today. Certainly, the passion for the specialty is the same in both countries. The amount of resources and cost of healthcare are different. In the last 16 years I have learned that the Brazilian Urologists are talented surgeons with a great sense of improvisation when technological resources are not available. Their understanding of Urology and surgical techniques is superb. The majority of Brazilian Urologists have 2 specialty board certifications (General Surgery and Urology). The training in average takes 5 years and academicians often seek fellowships to specialize like we do here in the US.

Q A

Are you working on any other initiatives in Brazil related to urology?

We are continuously working together to increase our collaboration and friendship. Recently, we signed an agreement to organize an AUA Lessons in Urology Program for Brazilian residents. Soon, we will be releasing the AUANews in Portuguese, which will be available digitally. The unintended consequences of this important relationship have been gratifying. The waves of initiatives and collaborations between academic centers and hospitals, and the number of exchange scholars from Brazil that are coming to the US to finish their research training have been record in the past 5 years.

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How do you see Urology evolving in Brazil in the next five years, and how does the AUA fit into that?

The cost of healthcare and cost-effectiveness of treatments will be challenging issues for both countries. Brazil is going through a very important period in history. Our Brazilian friends are struggling with the political leadership of the country. The public healthcare system has been challenging due to the Zika virus and other public health issues, but Brazilians have the determination and the will to overcome these difficulties. With a population of over 200 million people and more than 3,500 urologists, the demand of urological care will only grow in Brazil. I honestly believe that the AUA and SBU will continue to see their partnership grow creating novel educational and scientific collaborations that will impact other cultures and training programs in the world.

You’ve recently gotten involved in the AUA’s educational efforts in Korea as well. What opportunities do you see in that area?

A

My Korean heritage is a very important part of me and I feel extremely honored to serve as a bridge between our associations (AUA and KUA). I can fully appreciate their rich culture and customs and, as any other community, the Korean urologists face their unique challenges to practice medicine and educate their specialists. Fortunately, advanced technology and a well-structured society create a solid foundation for advancements in medicine. I believe that our communities can learn from each other in many areas, especially in new robotic technology. The AUA can customize educational programs to meet specific needs and engage new generations of Korean Urologists in our international membership. It is our hope that we can establish a productive relationship between our associations and get familiar with the local challenges for Korean urologists so we can work together to improve the value of our membership and provide better care for our patients.

F E AT U R E

C ANCER MOONSHOT 2020 Inderbir S. Gill, MD, MCh and Taylor Titus, Social Media Specialist, AUA

On January 12, 2016 Patrick Soon-Shiong, MD, FRCS(C), FACS was involved in the launching of Vice President Joseph Biden’s “Cancer Moonshot 2020” initiative with the goal of changing the course of cancer by developing a cancer vaccine for all cancer types at every stage by the start of the next decade. This collaboration of community oncologists, academic cancer centers, pharmaceutical groups, biotechnology companies, insurance agency and a fortune 500 company strives to accelerate the development of an effective vaccine-based immunotherapy to be used as the next generation standard of care in cancer patients.

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F E AT U R E

Cancer moonshot 2020 lecture from AUA2016

Over the next 36 months, randomized Phase II trials in patients at all stages of disease in 20 different tumor types in 20,000 patients will occur. The findings will inform Phase III trials, resulting in a vaccine-based immunotherapy.

“With the advent of next generation genomic sequencing and precision immunotherapies, the exciting possibility of bringing 21st century precision medicine to patients today is very real,” said Dr. Soon-Shiong. “Imagine the possibility of creating patient-specific cancer vaccines that can treat and prevent the recurrence of cancer.”

IDEA BEHIND CANCER MOONSHOT 2020 Dr. Soon-Shiong’s thinking on this subject began when he addressed the assumption that cancer is a single clone cell. Dr. Soon-Shiong discovered cancer progression is a result of genetic expression of a multiclonal disease. This genetic expression is driven by tens, hundreds and possibly even thousands of mutation, rearrangements and structural changes in the genome.

“In order for us to understand the tumor microenvironment, it’s not the genes – it’s the protein pathways deep within the system that we need to identify,” said Dr. SoonShiong.

WHAT IS GPS CANCER? The GPS Cancer test was established to more accurately identify the protein pathway that drives tumor growth and allows doctors to match the results of the test to the appropriate FDA-approved drug or drugs in clinical trials to the patient. GPS stands for Genomic, Proteomic and Spectrometry. The steps of the GPS Cancer test involve FFPE director slide, laser energy to create liquid tissue, which generates peptides that get pushed through a triple quadruple mass spectrometer to find the mAb and targeted proteins at the attomol level of detection allowing personalized chemotherapy. This GPS Cancer Report takes less than 21 days.

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F E AT U R E

“WITH THE ADVENT OF NEX T GENER ATION GENOMIC SEQUENCING AND PRECISION IMMUNOTHER APIES, THE EXCITING POSSIBILIT Y OF BRINGING 21ST CENTURY PRECISION MEDICINE TO PATIENTS TODAY IS VERY REAL,” SAID DR. SOON-SHIONG. “IMAGINE THE POSSIBILIT Y OF CREATING PATIENTSPECIFIC CANCER VACCINES THAT CAN TREAT AND PREVENT THE RECURRENCE OF CANCER.” G LO B A L CO N N EC T I O N S • VO L U M E 11

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“ONLY THROUGH COLL ABOR ATION WITH SHARING OF OUTCOMES DATA ON A GLOBAL SCALE CAN WE HOPE TO R APIDLY ADVANCE THE FIELD AND UNR AVEL THE COMPLEXIT Y OF THE BIOLOGY OF THIS DISEASE”

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There is highly advanced technology that allows the GPS Cancer test to take place. The technology takes peptides and reduces them down to a stream to find infinite molecules that actually allow researchers to diagnose the patient’s condition.

The technology includes: • Electrodynamic Ion Funnel (EDIF) which captures ions as they leave a transfer tube. It’s broad transmission curve reduces ion losses, increasing sensitivity. The EDIF also reduces in-source fragmentation.

• Ion Beam Guide with Neutral Blocker stops neutrals and highvelocity clusters, keeping the ion optics cleaner, reducing noise and increasing sensitivity.

• Hyperquad Quadrupole Mass Filter (Q1) with asymmetric RF drive increases ion transmission and SRM sensitivity, as well as provides industry-leading 0.2 FWHM resolution for highresolution selected-reaction monitoring (HSRM).

An infrastructure and oncology knowledge database was developed to house all of the information researchers gathered from the GPS Cancer test to give physicians validated evidencebased information. Dr. Soon-Shiong’s goal was to put super computers in institutions that requested it to interconnect the nation and build a learning system. This system, formatted in a downloadable decision support app called Eviti, is available in all 50 states.

“Only through collaboration with sharing of outcomes data on a global scale can we hope to rapidly advance the field and unravel the complexity of the biology of this disease,” said. Dr. SoonShiong.

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GPS CANCER NOW Previously, doctors would get questions similar to “What information do you have from my tumor tissue that could help inform us that the treatment being prescribed has a probability of being effective?” and “What new information could we uncover that might impact the clinical treatment decision before therapy begins?”

Now doctors can answer those types of questions for literally all tumor types because the GPS Cancer Test looks at the protein level and the molecular profile of that patient before treatment begins. There is potential improvement to the physician’s understanding of a patient’s response to different therapeutic modalities, including: GPS Guided Chemotherapy, mAb therapy, Hormonal Therapy, Targeted Therapy and Immunotherapy.

SCIENCE BEHIND THE CANCER VACCINE There are three types of cells in the human immune system that affect cancer cells: dendritic cells, killer t-cells and natural killer cells. Dendritic cells educate killer t-cells and natural killer cells to destroy cancer cells, but cancer cells have learned how to shut off the immune system and put the killer t-cells and natural killer cells to sleep allowing the cancer cells to grow and mutate. The cancer vaccine will arm the dendritic cells to reactive the killer t-cells and natural killer cells.

F E AT U R E

THE PATH TO THE CANCER VACCINE The first step in the path to an adenovirus cancer vaccine is taking a part of the tumor and performing the GPS Cancer Test to uncover the cell mutations and protein sequences of that specific tumor. A super computer then identifies and decodes the mutations and abnormal proteins produced by the cancer cells named the tumor associate antigen and neoepitope. This information makes it possible to manufacture a cancer vaccine customized to the patient’s tumor and genome by putting the discovered sequence into a specially engineered virus known as the Adenovirus. The virus is injected into the patient’s arm, similar to a flu shot, and aids the dendritic cells. This gives dendritic cells the power to reactivate the natural killer and killer t-cells to seek out and destroy the cancer cells. The vaccine can also be given multiple times to help build immunity. Since the vaccine is tailored to a patient’s specific cancer, the cancer is no longer able to hide from the immune system and puts us on the path to orchestrate our immune system to win the war on cancer.

“I believe overcoming dogma and the “comfort” of pursuing “tried-and-true” regimens is going to be the largest impediment to advances in cancer care, but, hopefully, we will be able to over-ride that dogma and drive cancer advances based on 21st century molecular science,” said Dr. Soon-Shiong. “To achieve that objective, there is a need to establish an adaptive learning system to validate molecular-driven cancer care.”

“I BELIEVE OVERCOMING DOGMA AND THE ´COMFORT´ OF PURSUING ´ TRIED-ANDTRUE´ REGIMENS IS GOING TO BE THE L ARGEST IMPEDIMENT TO ADVANCES IN CANCER CARE, BUT, HOPEFULLY, WE WILL BE ABLE TO OVER-RIDE THAT DOGMA AND DRIVE CANCER ADVANCES BASED ON 21ST CENTURY MOLECUL AR SCIENCE”

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

IN THEIR WORDS – THE VALUE OF BELONGING TO THE AUA During the 2016 AUA Annual Meeting in San Diego, CA, we sat down with several members of the AUA to find out what they value most about belonging to the AUA. Here is what they had to say!

“There are a number of urology associations around the world, I belong to a number of them, but I think the AUA represents the one global membership communit y that represents people, or urologists, from around the world.”

Rajeev Kumar, MD, MCh (India) Member Since 2005

“I’ve never regretted a single second of it when I joined the AUA. Early in my career, the AUA Annual Meeting in particular was the platform for my research as a fellow and started that whole process of being able to net work with colleagues on a ver y large scale.”

Mark Frydenberg, MD, MBBS FRACS (Australia) Member Since 1992

“The AUA brings you a large spectrum of benefits. It’s not only the Annual Meeting or the subscription to The Journal of Urology, but it’s the other educational opportunities that the association offers throughout the year.”

“I joined the AUA for several reasons. The most important one being the education...to learn urology from the most proficient, the most professional urologists and researchers from around the world.”

Riccardo Autorino, MD, PhD (USA/Italy) Member Since 2009

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Jakub Dobruch, MD, PhD (Poland) Member Since 2015

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

No matter where you are in your career or where you are in the world, there is value in belonging. To become a member of the AUA, visit AUAnet.org/Join.

“What I think the AUA has done, personally, which is a great job, is reaching out to get the younger generations involved early on.”

“As a resident, you have the core curriculum. And then, you have the AUAUniversit y...you have the guidelines – and you can have them in the palm of your hand if you want it.”

Celeste Alston, MD (Panama) Member Since 2008

“The exposure in this global communit y, or what I can say is family, has helped me to advance my career.”

“The membership to the AUA , international or other wise, comes along with access to the website, which is of immense value. It also comes with the subscription to The Journal of Urology, which is a hot read from cover to cover.”

E. Oluwabunmi OlapadeOlaopa, MD, FRCS, FWACS (Nigeria) Member Since 2002

Fernando Kim, MD, MBA/MHA, FACS (AUA Host Country Liaison – Brazil) Member Since 1998

Peggy Sau Kwan Chu, MD (Hong Kong) Member Since 2010

“Whenever I go to another meeting in another countr y, other than the USA , there’s always the presence of the AUA.”

Andrés Hernandez Porras, MD (Mexico) Member Since 1995

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F E AT U R E

BL ADDER CANCER Hooman Djaladat, MD, MS, Associate Professor of Clinical Urology, Institute of Urology, Norris Cancer Center, USC and Taylor Titus, Social Media Specialist, AUA

Bladder cancer occurs when tumors form in the bladder, a hollow, balloonshaped organ made mostly of muscle used to store urine until it is ready to be emptied. Inside the bladder is a thin surface layer known as the urothelium.

Next is a layer of connective tissue called the lamina propria, which is covered by the bladder muscle and outside the muscle is fat. More than 90 percent of all bladder cancers begin in the urothelium and most tumors stay superficial with no or minimal invasion to deeper layers.

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Doctors don’t know all of the causes of bladder cancer, but some notable risk factors that can increase the chance of bladder cancer are: smoking, chemicals in the workplace, frequent or long lasting bladder infections, certain drugs for other cancers, radiation therapy in the pelvic area and high levels of arsenic in drinking water as well as chronic irritation by stones or foreign bodies. Infection with schistosomisasis following exposure to infested water is another cause of bladder cancer specifically in Africa and the Middle East.

Rates of new cases of bladder cancer are more than four times higher in Northern America than Central America. North America and Europe have the highest incidence, and Asia, Latin America and the Caribbean have the lowest incidence of bladder cancer. About 59 percent of bladder cancer cases occur in more developed countries, according to the World Cancer Research Fund International.

Half of all bladder cancer cases in the United States are caused by cigarette smoke. In 2016, more than 77,000 Americans will be diagnosed with bladder cancer and about 16,000 will die from the disease. In the United States, men are almost 4 times more likely than women to be diagnosed with bladder cancer.

In Europe, bladder cancer is the 5th most common cancer. In 2012, Belgium held the highest incidence rate of bladder cancer for men and Hungary for women. The lifetime risk of developing bladder cancer is 1 in 39 for men and 1 in 110 in women according to Cancer Research UK. The Australian Institute of Health and Welfare estimated 2,880 people will get bladder cancer and 1,165 people will die of bladder cancer in 2016. The Canadian Cancer Society says bladder cancer predominately affects Canadians over the age of 70. In 2015, there was an estimated 8,300 new cases of bladder cancer in Canada with the probability of 1 in 27 men and 1 in 84 women developing the disease. In Japan men also have a higher incidence and mortality rate of bladder cancer than women.

“IN AN AT TEMPT TO AVOID A ONE-SIZE-FITS-ALL STR ATEGY, WE WANTED TO TAKE INTO ACCOUNT THAT THE RISK OF RECURRENCE AND/OR PROGRESSION OF NON-MUSCLE INVASIVE BL ADDER CANCER (NMIBC) DEPENDS ON SEVER AL CLINICAL AND PATHOLOGIC FACTORS, AND SO WE TRIED TO PERSONALIZE TREATMENT CHOICES AND FOLLOW-UP PROTOCOLS” VO L U M E 11 • G LO B A L CO N N EC T I O N S

F E AT U R E

GRADES AND STAGES OF BLADDER CANCER

BLADDER CANCER GUIDELINES IN THE UNITED STATES

In order to determine the best treatment option, doctors must determine the grading and staging of bladder cancer.

The AUA with the Society of Urologic Oncology (SUO) released a guideline on non-muscle invasive bladder cancer (NMIBC) this year. This guideline states to start with cystoscopic examination of the patient’s entire urethra and bladder that evaluates and documents tumor size, location, configuration, number and mucosal abnormalities and then perform a transurethral resection of bladder tumor (TURBT).

GRADING The grade tells how fast and aggressive the tumor can grow and spread. The grading system includes low-grade where tumors grow slowly and typically don’t spread to other parts of the body and high-grade where tumors grow quickly, often recur after treatment and are more likely to spread to other parts of the body.

STAGING Staging determines how extensive cancer growth has been; if the cancer cells have spread into muscle of the bladder (stage T2), peri-bladder fat (stage T3) or nearby organs like prostate or vagina/uterus (stage T4).

Bladder Cancer Treatment Bladder cancer treatment varies upon the stage of the bladder cancer. Different countries also have varying approaches to the treatment of bladder cancer. The American Urological Association (AUA) and European Urological Association (EAU) both have widely used guidelines on bladder cancer. Treatment options for stages Ta, T1 and Tis include endoscopic surgery to remove the tumor, intravesical therapy and sometimes surgery to remove the bladder. Treatment options for stages T2, T3 and T4 include surgery to remove the bladder, chemotherapy and radiation therapy.

After determining the grade and stage (that might include imaging as well), the AUA and SUO guideline recommends performing a repeat transurethral resection of the primary tumor site within six weeks of the initial TURBT if the patient is high-risk and has high-grade Ta or T1 disease.

The guideline recommends a single postoperative instillation of intravesical chemotherapy within 24 hours of TURBT in a patient with low- or high-risk bladder cancer. Intermediate or high-risk patients should receive induction intravesical chemotherapy or BCG as well as maintenance therapy.

“In an attempt to avoid a one-size-fits-all strategy, we wanted to take into account that the risk of recurrence and/or progression of non-muscle invasive bladder cancer (NMIBC) depends on several clinical and pathologic factors, and so we tried to personalize treatment choices and follow-up protocols,” said Dr. Sam Chang, professor of urologic surgery and oncology, Vanderbilt University Medical Center, Nashville, TN.

BLADDER CANCER GUIDELINES IN EUROPE The EAU has guidelines on non-muscle invasive bladder cancer, muscle-invasive bladder cancer and metastatic bladder cancer.

This guideline also recommends starting with a transurethral resection to diagnose and classify the stage of the patient’s bladder cancer. The EAU guideline suggests applying the European Organization of Research and Treatment of Cancer (EORTC) risk tables and calculator for individual prediction of recurrence and progression of the tumor.

For NMIBC patients, immediate instillation of chemotherapy is recommended following TURBT for low/intermediate-risk cases.

Moreover, induction and maintenance intravesical chemotherapy or BCG for minimum of 1-year is recommended in intermediaterisk patients. High-risk patients also benefit from induction and maintenance intravesical therapy with selected cases undergoing early removal of bladder.

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BY T H E N U M B E R S

AUA2015 CENSUS The AUA would like to thank all members of the global urologic community for their continued support and participation in the AUA Annual Census. As the global population grows and ages, the demand for urologic care is increasing. The objective of the AUA Census is to understand, characterize, and compare urologists across the globe. A detailed report including continents and countries with 20 or more respondents will be included in an online report that will be available on www.auanet.org later this year.

In 2015,

3,813 practicing urologists from

106 countries completed the AUA Census including 2,108 samples representing 11,990 practicing urologists in the United States and 1,705 practicing urologists from the rest of the world.

TOP 10 COUNTRIES COMPLETING THE CENSUS (outside of the U.S.)

TOP 4 UROLOGY SUBSPECIALTIES AROUND THE WORLD:

Brazil

278

Japan

66

1

Oncology

Mexico

114

Philippines 65

2

Endourology/Stone Disease

India

100

Egypt

55

3

Laparoscopic Surgery

4

Erectile Dysfunction

Argentina

82

Germany

48

Canada

77

China

43

Statistics reported on international practicing urologists represent the AUA 2015 Census participants only and may not necessarily represent the countries they practice.

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BY T H E N U M B E R S

MOST LIKELY TO HAVE FELLOWSHIP TRAINING:

USE OF PAPER HEALTH RECORDS MORE COMMON IN

Republic of Korea, China, Israel, Germany, Japan and Australia

Bangladesh, the Philippines, and India

VACATION LEAVE IS GREATER IN LONGEST MEDIAN WORK HOURS AND HOURS ON CLINICAL DUTIES PER WEEK:

Canada, Japan and the United States

Germany and United Kingdom at 6 weeks per year WITH

Japan and Republic of Korea taking 2 weeks of leave per year PRACTICING UROLOGISTS SAW THE MOST PATIENTS PER WEEK IN

Republic of Korea, India, and Germany

MEDIAN PLANNED RETIREMENT AGES FALL INTO A FIVE-YEAR RANGE AS HIGH AS 70 IN

MOST LIKELY TO HAVE CONCURRENT ROLE AS RESEARCHER IN

Chile, the Philippines, Mexico, Argentina, Brazil, Israel, Peru, Italy, India and Japan

Canada, Egypt, and Japan

AND AS LOW AS 65 IN PRACTICING UROLOGISTS WITH CONCURRENT PROFESSIONAL ROLE AS AN EDUCATOR WAS MORE LIKELY IN

the United Kingdom, Canada, Egypt, China, the Dominican Republic and Republic of Korea

Chile, Egypt, and Canada

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A SINCERE

Thank You

TO OUR INTERNATIONAL PRESIDENT’S CIRCLE PATRONS

AND OUR CONTRIBUTORS:

MEDICAL