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European Urology Today Official newsletter of the European Association of Urology

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Vol. 27 No.2 - March/May 2015

Honour in Madrid

Worldwide BCG shortage

New kid on the block

A complete list and photos of awardees and winners in this year’s Anniversary Congress

The EAU-RF's NIMBUS trial encounters setbacks due to BCG shortage

Is Thulium laser a new tool with potentials?

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Dr. Wim Witjes

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Dr. Iason D. Kyriazis

Urology to face more challenges in the next decade Madrid congress explores pitfalls and opportunities By Joel Vega

Personalised medicine A special roundtable meeting tackled the issue of In a year that marked three decades of providing a personalised medicine on the first day. ‘We recognise dynamic platform where urological issues and the need for personalised medicine as we move away opportunities are examined, the 30th EAU from old diagnoses and therapies to those which Anniversary Congress in Madrid from March 20 to 24 specifically identify high-risk from low-risk diseases,” was replete with cautionary words- admonishing said session chairman Arnulf Stenzl. Stenzl was joined both young and experienced urologists to take a step by other experts such as Freddie Hamdy who forward by pursuing technical innovations whilst discussed prostate cancer. “There are many agents stressing the role of effective collaboration with other that work but we don’t see the effect because the specialists. tumour volume is too high. The crucial task is to identify patients with high-risk disease and act within “The main challenge for urology in the future is to the (limited) window of opportunity,” said Hamdy. stay as a ‘comprehensive’ specialty, ” said Laurent Boccon-Gibod, Willy Gregoir Medal awardee. He noted the rapid advances in urology and reminded young urologists that “…several different pathologic A full auditorium during the Opening Ceremony and awards presentation conditions that used to be the ‘core business’ of urology disappeared due to therapeutic breakthroughs.” is clear and justifies the treatment burden, and they Offices Joint Meetings, the well-attended Live need to be chemo-fit.” (Christopher Sweeney). Surgeries session led by the EAU Section of Uro“Young urologists should be prepared for the Technology (ESUT), Poster Sessions and the 16th consequences of technological progress and redefine On radical cystectomy for bladder cancer: “RobotInternational EAUN Meeting (See inside articles for the core business of urology in the next 10 to 15 assisted radical cystectomy (RARC) is feasible… but detailed reports). years,” Boccon-Gibod said, shortly before he came to RARC cannot yet be considered as a standard treatment the stage to accept the EAU’s most prestigious award for invasive bladder cancer. Regarding RARC, our initial The three-day Technical Exhibition held at the IFEMA during the opening ceremony. The ceremony also Prof. Hamdy one of the speakers of the round table on expectations are not yet met. Why not? Because the Feria de Madrid attracted a high number of visitors to marked the formal transition from Per-Anders personalised medicine surgeon makes the difference, not the instrument,” the 150 companies exhibiting the latest hospital Abrahamsson to Christopher Chapple as new EAU (Urs Studer). equipment, bio-medical technologies, pharmaceutical Secretary General. Abrahamsson, who said it was his developments and institution-based services and aim “to see the association better off when I leave,” Meanwhile, the 2nd ESO Prostate Cancer Observatory On cytoreductive nephrectomy: “Surgery will always research projects. Munich will host, for the first time, expressed his optimism for future EAU successes even meeting gathered multi-disciplinary cancer experts remain an essential step in order to achieve cure,” the 31st Annual Congress from March 11 to 15 next as he reiterated that the EAU’s core strategy will stay who looked into prostate cancer issues. Speaker (Simon Tanguay). year, the third time for Germany to host the annual focused on Europe. Karim Touijer echoed the sentiment of participants event, following two congresses both held in Berlin in that there is much to gain from collaboration. “We Simultaneous meetings 1994 and 2007. have to put our heads together, get out of our comfort The anniversary event also presented a wide range of zones and rethink the paradigm,” said Touijer as he parallel meetings such as the Urology Beyond Europe (With additional reporting from A. Leon, L. Keizer and urged urologists to play a central role in managing (12 sessions), 19 Thematic Sessions, the EAU Section M. Van Hout) PCa. “They are going to start exploring -in a thoughtful and scientific way- the role of surgery in oligometastatic PCa. In other malignancies, we have seen great value in treating primary cancer through surgical excision,” he said. The PCa Observatory, chaired by Riccardo Valdagni and Hein Van Poppel, invited speakers to look at innovation and care in the next 12 months. Prof. Laurent Boccon-Gibod receives the Willy Gregoir Medal from Prof. Per-Anders Abrahamsson

Humberto Villavicencio, Frans Debruyne Life Time Awardee, echoed Boccon-Gibod’s statements: “Urology is possibly the specialisation with the most technological advances booked to date. The hospitals without enough vision to invest in technology can become obsolete.” Other awardees were Simon Horenblas (EAU Innovators in Urology Award), Morgan Rouprêt (18th Crystal Matula Award), Stavros Tyritzis (Hans Marberger Award), Martin Spahn (EAU Prostate Cancer Research Award) and Gopal Badlani, Keong Tatt Foo and Ladislav Jarolim as the new EAU honorary members. A total of 11,991 participants attended the five-day congress including 2,319 exhibitors, 303 nurses and 137 members of the press. Urologists and other medical professionals came from around 117 countries, from as far as Congo, Nepal and Mozambique, to name a few. Germany, the UK, Italy and host country Spain posted the biggest number of participants.

Key messages A plenary session was presented during each congress day with bladder and kidney cancer, prostate malignancies, functional urology and controversies in stone management as topics for the sessions presented over four days, respectively. Below are some of the key messages from the plenary lectures: On aggressive prostate cancer: “There are multiple mechanisms of resistance, and the resistance is at the cellular and genetic levels. Some resistances are induced by treatment and some are pre-existing (and rapid),” (Norman Maitland). “The combination of standard androgen deprivation therapy (ADT) and six cycles of docetaxel significantly improved overall survival compared to standard ADT alone in men with hormone sensitive prostate cancer... The benefit in patients with a high volume of metastases

Prof. Karim Touijer speaking at the ESO Prostate Cancer Observatory

March/May 2015

30th Anniversary EAU Congress

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Abstract submission opens 1 July 2015 European Urology Today

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Highlight Sessions: Reconstruction Madrid showcased latest research in reconstructive urology Mr. Nadir I. Osman Urology resident Airedale General Hospital Steeton, Yorkshire (UK) nadir.osman@ sheffield.ac.uk

The 30th EAU Anniversary Congress in Madrid showcased state-of-the-art contemporary research in reconstructive urology. Participants from across the globe presented over 60 high-quality abstracts on upper and lower urinary tract reconstruction. Below is a summary and review of the highlights: Male urethral reconstruction Urethroplasty is widely accepted as an effective treatment for urethral stricture disease in men. However, there is a variable incidence of stricture recurrence, depending on factors such as stricture location, complexity and surgical technique. The group from Leuven performed a retrospective study to assess the success rate of a second urethroplasty after recurrence compared to a first urethroplasty (Castiglione et al. #1064). In a total series of 288 patients, previous urethroplasty had failed in 61 patients. Mean follow-up was 27.39 months. Mean stricture length was 3.43 cm. The failure-free rates of naïve and revision urethroplasty cohorts were comparable, 85.9% and 83.6%, respectively. This study supports similar recent reports that in patients whose strictures recur consideration should be given to further reconstruction. Men with long complex urethral strictures often present a significant reconstructive challenge and are at greater risk of stricture recurrence. Perineal urethrostomy is often considered as a palliative measure after substitution procedures have failed.

Belsante and colleagues (#1069) presented the results of their contemporary series of perineal urethrostomies. In total, 56 patients underwent the procedure, 50 of whom had failed a prior urethroplasty. At mean follow-up of 21 months, only 3.6% of patients developed a stenosis of the urethrostomy requiring intervention. The avoidance of repeat intervention in the vast majority of patients supports the use of perineal urethroplasty in men with complex strictures and perhaps earlier consideration should be given to this option in such patients. Female urethral reconstruction In recent years, there has been increasing interest in female bladder outlet obstruction and in particular the entity of female urethral stricture. Whilst dilatation is often performed in women, true strictures are rare. Patients found to have a stricture are often managed with palliative dilatation. Mukhtar and colleagues, (#156) presented their series of 16 patients who underwent urethral reconstruction using a graft augmentation technique which utilised either a vaginal or buccal mucosal graft placed dorsally. At a median follow-up of 26 months they reported cure (no need for further intervention) in 92%. De novo stress incontinence occurred in one patient, which should be considered the major risk of the procedure. This data supports the emerging literature that in expert centres, female urethral reconstruction is a feasible and effective option for urethral strictures refractory to dilatation. Bladder reconstruction The advent of intravesical botulinum toxin has revolutionised the management of drug therapy refractory detrusor overactivity, yet in select patient groups augmentation cystoplasty may be necessary. There is a paucity of series with long-term follow-up after augmentation in the contemporary literature; the group from University College London sought to address this by analysing their long-term outcomes (Frost et al. #472). A total of 169 patients were included with a mean follow-up of 24 years. The

majority of patients had congenital or acquired neuropathic bladder. Revision surgery was required in 17.8% of patients, usually at 10 years postoperation. Approximately 80% of patients were dry (+/-artifical sphincter), 18% required urinary diversion and 6% were incontinent. Common complications included urinary tract infections (19%) and bladder stones (10%). The findings of this work suggest that augmentation cystoplasty remains a good option for patients with neuropathic bladder with sustainable functional outcomes. Tissue engineering and regenerative medicine Tissue engineering once again featured heavily in the programme. This principally involves the use of the methods of material science and engineering combined with cell culture techniques to develop functional tissue substitutes to replace or repair diseased tissue. Urologists have been at the vanguard in applying these technologies to clinical problems, such as in bladder and urethral substitution. The group from Zurich (Eberli et al. #1000) demonstrated that modification of degradable polymer-based scaffolds led to improved muscle cell performance and myotube formation in a model of urethral sphincter generation. This study nicely demonstrates the principle that cell behaviour can be strongly influenced by scaffold structure and composition. The group from Sheffield similarly demonstrated the utility of modifying scaffold composition. By introducing polyurethrane based scaffolds, greater elasticity and recoil in a tissue-engineered implant designed for pelvic floor reconstruction was achieved, these implants were found to elicit a more favourable host response compared to polypropylene mesh in a rabbit model (Roman et al. #1005). The authors of these abstracts, as well as those of the many other interesting abstracts which were presented, are to be congratulated on their contributions to progress in this field. We eagerly look forward to further advances in both clinical and basic scientific research in Munich next year.

European Urology Today

30th Anniversary EAU Congress

Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Dr. F. Sanguedolce, London (GB) Dr. S. Sarikaya, Ankara (TR) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team L. Keizer, Arnhem (NL) A. Leon, Arnhem (NL) H. Lurvink, Arnhem (NL) J. Vega, Arnhem (NL) EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680 F +31 (0)26 389 0674 EUT@uroweb.org Disclaimer No part of European Urology Today (EUT) may be reproduced without written permission from the Communication Office of the European Association of Urology (EAU). The comments of the reviewers are their own and not necessarily endorsed by the EAU or the Editorial Board. The EAU does not accept liability for the consequences of inaccurate statements or data. Despite of utmost care the EAU and their Communication Office cannot accept responsibility for errors or omissions.

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European Urology Today

EAU embraces ESRU in Madrid Furthering opportunities for residents through the YUO By Alba Leon The European Association of Urology (EAU) prides itself on being at the forefront of technological and scientific advances in the urological field. It also recognises that this position as a thought leader is possible thanks to the input and energy of its more than 14,000 members. In an effort to step up its work for the improvement of urology throughout Europe, the EAU is pleased to officially welcome the European Society of Residents in Urology (ESRU) under the EAU umbrella, as part of the Young Urologists Office (YUO). “This is a win-win situation,” according to Michiel Sedelaar, Chairman of the YUO Board. The incorporation of the ESRU into the YUO became a formal reality during the 30th Anniversary Congress of the EAU, which took place in Madrid, Spain in March of 2015. Yet the move has been in the make for a long time. Even though in the past both the ESRU and the YUO had sought to operate independently, joining forces seems the best approach to benefit urologists and residents alike at a time when collaboration within medical teams is more important than ever.

The Young Urologists Office Board in Madrid

To address this need, a training in basic surgical anatomy was created. The course made available to residents in Madrid was sold to capacity very quickly. Through this synergy, ESRU helped the EAU identify the needs of an important subset of the urological community, providing insights for tailored training. Better training for the benefit of all The EAU has always recognised the advantages of The EAU in turn has the infrastructure to organise and deliver improved courses that meet residents’ needs. listening to residents. After all, these are the urologists who will later on guide and further develop Better yet, the improved courses with state-of-the-art methodology that are developed in this setting also urology as a specialty, and their unmet needs are benefit the wider EAU community. fertile ground for organisational innovation. Take training. “ESRU includes residents from different countries, with different realities in terms of the Room for growth development of the specialty, and with a different— The new YUO structure gives residents more opportunities for participation within the several and sometimes insufficient—level of training. sections and areas of the EAU. It makes them aware The ESRU showed the EAU that residents wanted more and better training,” said ESRU Chairman that their training and participation are valuable, and Giulio Patruno. gives them a sense of belonging in the urological

community that is often difficult to find in their daily work, in Patruno’s view. Moreover, while the ESRU already offered residents benefits such as reduced fees to meetings, the new form of collaboration can also increase young doctors’ opportunities to benefit from even more perks of EAU membership. “Accessing specialised knowledge and networks has never been easier. The door is now wide open for promising residents to fully work within the EAU framework,” said Sedelaar. Residents are encouraged to join and profit from the renewed structure of the Young Urologists Office. Opportunities such as becoming junior members of EAU sections, or becoming involved with research carried out by EAU members and publishing in the most important journals are there for residents to take. March/May 2015


Highlight Sessions: Stone Disease Hot topics in stone management Dr. Francesco Sanguedolce King's College Hospital Dept. of Urology London (UK) fsangue@ hotmail.com During the 30th EAU Anniversary Congress in Madrid stone disease has been a topic thoroughly covered throughout all the congress: there have been five dedicated poster sessions: one in SWL, one in ureteroscopy, two in open and PCNL and one miscellaneous- all very well attended with 74 high-quality abstracts presented. Based on the quality of the studies and the relevance of the outcomes, four hot topics have been selected: the first is on the “optimisation of SWL settings.” The EAU Guidelines in Urolithiasis are unable to provide robust recommendations with regards the specific frequency and total number of shock waves (SW) to be delivered during a session of SWL. Two randomised trial have addressed this issue: abstract #92 from a group in Berne (S. Hnilicka et al - CH) randomised 127 and 113 patients undergoing one session of SWL for the treatment of ureteral stones with 60 vs. 90 pulse SW delivered per minute, respectively. They found a significant difference of the proportion of patients receiving a successful stone disintegration rate (no fragments: 79 vs 81%, respectively. p = 0.012) without an increase of complication rate.

only for the use of alpha-blocker (LE 1a) as no strong evidences are available on the role of the antimuscarinics. Four groups have addressed this issue with randomised controlled trials: authors of abstracts #1076 (A.R. El-Nahas et al. – EG) and #1079 (A. Dellis et al – GR) designed similar studies by testing Tamsulosin vs Solifenacin vs Placebo by reporting Ureteric Stent Symptoms Questionnaire (USSQ) scores in patient with an indwelling JJ stent. In both the studies Tamsulosin and Solifenacin showed an improvement of the USSQ, confirming that both were significantly more effective in relieving stent-related symptoms respect to placebo.

randomised trial; 75 patients were recruited per arm affected by renal stones of 2-3 cm. They found a significant difference of blood transfusion rate (1.2 vs 9.8%, respectively. p = 0.03) with equivalent SFR (95.4 vs 97.1%. p = 0.86).

The last hot topic selected has been the utility of nephrolithometry score systems in planning PCNL and predicting outcomes. Currently, there are three score systems validated, the S.T.O.N.E, the Guy’s and the CROES scores. Four abstracts were presented on this topic: #690 (Z, Okhunov et al, USA) compared the abilities of the three scores in predicting surgical outcomes and complications; all scoring systems were predictive of stone-free status with the S.T.O.N.E. score V. Boulos et al. (#1077, EG) compared in their being the most accurate predictor; S.T.O.N.E. and randomised controlled trial the combination of Tamsulosin + Tolterodin vs Tamsulosin vs Tolterodin vs CROES score were independent predictors of longer operative room time; Guy’s score was predictive of a Control (analgesia on demand); in this case a non longer length of stay. None of the scores was helpful specific questionnaire was used -IPSS-QoL- . They in predicting post-operative complications. found that treatments groups were more effective in improving the scores for urinary symptoms and quality of life than the control group, especially when A similar study was presented by Y. Noureldin et al (#601, EG) by comparing STONE and Guy’s score. They the two drugs were given in combination. showed that both the scores were significantly associated with stone-free status, (OR=0.4, [95% CI “Optimising SWL settings, 0.2-0.5]; p < 0.001) and that they were significantly associated to the estimated blood loss (p = 0.01; and p medication for JJ stent-related = 0.005). When analysing the AUC at the Receiving symptoms, miniaturised PCNL and Operator Characteristic, Guy’s score was more accurate than S.T.O.N.E in predicting the SFR status. nephrolithometry score systems

have been the hot topics…”

Finally, H. Khouni et al (#1078, TN) recruited 100 patients randomly allocated to four groups to compare Tamsulosin vs Tolterodin vs Serenoa Repens vs Control (no medication); also in this case IPSS and In terms of the number of SWs to be delivered in one VAPS (Visual Analogue Pain Score) were used as tools session of SWL, a group from Valencia, Spain (#89, for comparison. They found that Tolterodine performed significantly better than the other three J.D. Lopez-Acon et al) randomised one group of 136 patients subjected to a standard treatment with 3500 groups in relieving the irritative symptoms, and that SWs and another one where 7000 SWs were delivered Serenoa Repens correlated to a significant higher VAPS at follow-up. in a same session to 171 patients. Also in this case, they found in both univariate (75 vs 87.7%. p = 0.012) Miniaturised PCNL is another hot topic with mounting and multivariate (OR: 7,25 (IC 95%= 3,13-16,75) analysis a significant improvement of the stone-free interest as reflected in numerous recent publications; rate associated to the group of patients treated with unfortunately, evidence is not yet robust for the Guidelines to provide any recommendation on this the extended number of SWs, without any change in the complication rate (27,2% vs 25,7%, p = 0.77). regard. There have been three abstracts presented dealing with indication and feasibility of mini-PERC in Another relevant topic has been the role of supine position, ultra-mini PERC and supine anticholinergic drugs in the relief of the ureteric micro-PERC, respectively. Strongest evidence was provided by authors of abstract #584 (Fawzi et al, EG) stent-related symptoms. In this regard, the EAU which compared mini-PCNL vs standard PCNL in a Guidelines in Urolithiasis provide recommendation

Abstract #696 (J. Withingthon et al, UK) performed a multicentre validation of Guy’s score on behalf of the British Association of Urological Surgeon. They found a fair inter-observer reliability with substantially better agreement for stone scores of IV. This suggests the potential for GSS IV to be used as a possible criterion for tertiary referral. Finally, abstract #694 (M.H. Ather et al, PK) assessed STONE score performance in predicting stone clearance and complication of PCNL and found significant inverse correlation between low STONE score with SFR and OR. No correlation was seen with the score and the complication rate. This selection is not exhaustive and does not render adequate coverage to the other 60 abstracts presented during the congress. Overall, it has been a successful year for research in stone disease, in particular with regards the increasing number of randomised controlled trials which will provide more robust evidences for the clinical management of urolithiasis.

Annual Congress section: Urology to face more challenges in the next decade. . . . . . . . . . . . . . . . . . . . . . . . . . 1 Highlight Session 1: Reconstruction . . . . . . . . 2 EAU embraces ESRU in Madrid. . . . . . . . . . . . 2 Highlight Session 2: Stone Disease. . . . . . . . . 3 Highlight Session 1: Lower urinary tract dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Royals, Posters and Picasso . . . . . . . . . . . . . . 4 Overview of prizes and awards at the 30th Anniversary EAU Congress . . . . . . . . . 5-7 Quality training at one of Poland’s premier medical centres. . . . . . . . . . . . . . . . . 8 Obituary Miroslav Hanuš . . . . . . . . . . . . . . . . 8 European Tour 2015 Academic Exchange Programme . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Ensuring a solid future by working on our core goals. . . . . . . . . . . . . . . . . . . . . . . . .9 Worldwide BCG shortage affects recruitment in NIMBUS trial. . . . . . . . . . . . . 10 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 11 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . 12-15 EAU Membership Update. . . . . . . . . . . . . . . 15 From Print, Apps to Tweets: GO widens its reach. . . . . . . . . . . . . . . . . . . 16 Obituary Mário João Gomes. . . . . . . . . . . . . 17 Thulium laser: New kid on the block . . . . . . 19 Ten questions: Maria De Santis. . . . . . . . . . . 20 Outstanding opportunity for development . . 20

30th Anniversary EAU Congress

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ESU section: Laparoscopy and endourology training. . . . . 21 ESU Course impressions from Madrid. . . . . . 22 European Urology Forum in Davos. . . . . . . . 23 Dynamic days in wintry Davos . . . . . . . . . . . 23 Who’s Who in the ESU Board. . . . . . . . . . . . 24

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Full Colour

30th Anniversary EAU Congress Delegates per country

MADRID 20-24 March 2015 Sharing knowledge - Raising the level of urological care

MADRID 20-24 March 2015 Sharing knowledge - Raising the level of urological care

MADRID 20-24 March 2015 Sharing knowledge - Raising the level of urological care

YUO section: Survey insights on labour issues among young urologists. . . . . . . . . . . . . . . . Complications after laparoscopic radical prostatectomy. . . . . . . . . . . . . . . . . . The YAU Urothelial Cancer Working Group. . EAU Congress: A resident’s viewpoint. . . . . . Residents’ Day in Madrid. . . . . . . . . . . . . . . Elaut Prize 2015 . . . . . . . . . . . . . . . . . . . . . . The best for practising minimal invasive surgical skills . . . . . . . . . . . . . . . . . Spain retains lead in organ donation and transplant . . . . . . . . . . . . . . . . . . . . . . .

26 27 27 28 28 29 29 29

Obituary Rolf Ackermann. . . . . . . . . . . . . . . 30 Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 30

The red colour corresponds to the number of delegates per country (the more intense the colour, the larger the representation)

Long-term strategies to boost reconstructive urology . . . . . . . . . . . . . . . . . 31 15th Russian Society of Urology Congress. . . 31

EAU/EAUN 2015 Registrations per category EAU members Non EAU members Residents EAU member Residents non EAU member Total delegates EAU Congress

March/May 2015

3,180 4,443 1,352 257 9,232

Nurses EAUN member Nurses non EAUN member Total delegates EAUN Meeting Total delegates EAU Congress/EAUN Meeting

175 128 303

9,535

Exhibitors 2,319 Press 137

Total participants

11,991

4th ESUT Expert Meeting on interventional stone treatment . . . . . . . . . . . . . . . . . . . . . . 36 EAU-JUA Academic Exchange Programme . . 37 EAUN section: 16th EAUN Meeting in Madrid. . . . . . . . . . . . 38 EAUN Workshop at Madrid Congress . . . . . . 39 Applying guidelines in actual clinical nursing practice. . . . . . . . . . . . . . . . . . . . . . 40

European Urology Today

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Highlight Sessions: Lower urinary tract dysfunction Proper LUTS management tremendously important for patient’s quality of life Ass. Prof. George Kasyan Moscow State University of Medicine and Dentistry Dept. of Urology Moscow (RU) g.kasyan@gmail.com Male and female lower urinary tract symptoms (LUTS) remain the most bothersome problems for urology patients. With modern medicine becoming more patient-oriented, the proper management of LUTS is tremendously important for the patients’ quality of life. At the 30th EAU Annual Meeting in Madrid there were 137 abstracts presented that covered the topic of LUTS in eight poster sessions. Long-term follow-up of the patients following treatment of female stress urinary incontinence (SUI) is very important in terms of efficacy and safety. Bock et al. (#65) presented 10 years follow-up after tension-free vaginal tapes with more than 95% long-term efficacy. For the current analysis only women who reached the 10-year follow-up were eligible. The baseline investigation included free uroflowmetry, post-void residual volume and full urodynamic testing. Outcome was assessed using a detailed questionnaire on continence status and several other aspects of lower urinary tract function. More than 97% of patients reported no-stress urinary incontinence at two-year, five-year and ten-year follow-up. There was a sharp decline regarding degree of nocturia at two-year control yet it reached baseline levels at the ten-year follow-up. At baseline,

urgency was reported by 62%; this number dropped to 18% at two years and increased thereafter constantly to 32% (five years) and 41% (10 years). The percentage of patients with a high degree of satisfaction declined from 82.4% and at two years to 75.6% at five years and 66.1% at 10 years. Despite having perfect outcome, many women develop overactive bladder (OAB) symptoms, five to 10 years after the procedure which may largely contribute to an unsatisfactory long-term outcome.

treatment is efficient irrespective of incontinence severity at the baseline. At the same time, De Ridder and co-authors (#149) investigated the durability of BTXA in OAB – an extension study of a total of 543 patients. Almost half of them have completed the study (51.2%). The authors concluded that regardless of the number of treatments, a high proportion of the patients reported benefit with no new safety issues.

Mirabegrone, a new b3-adrenomimetic agent for the treatment of OAB, shows promising results in everyday practice. Wagg and co-authors (#267) Obstructive voiding Obstructive voiding after TVT slings could be managed investigated the persistence rate of mirabegrone in comparison with traditional antimuscarinics within 12 with sling release. Baekelandt (#66) reported months after starting the treatment. Persistence was satisfactory long-term functional results after numerically higher with mirabegron than with unilateral, mid-urethral sling release for voiding solifenacin, tolterodine ER and oxybutynin IR at dysfunction with 73.9% as dry rate at six months. all-time points, although the number of patients taking mirabegrone was significantly lower compared Tutolo (#74) presented five-year follow-up and outcomes of comparative prospective trial comparing to other medications. transobturator midurethral sling (Monarc) to single Male incontinence incision mini-sling (Miniarc). Despite relatively equal Male incontinence is a major functional complication results (87% vs 89%) in the treatment of stress urinary incontinence, there were significant along with erectile dysfunction after radical prostatectomy. There were several studies difference in OAB-free survival in favor of investigating predictive and risk factors for this transobturator slings. condition. According to Satake (#357), minimal There are some newcomers in the field of mini-slings. residual membranous urethral length ≥ 6.5 mm on Kocjancic (#64) presented two-year follow-up pre-operative MRI can be an independent predictor outcomes for a novel single-incision sling for the for continence after radical prostatectomy. treatment of female stress urinary incontinence. Altis Other authors (Honda et al #358) stratified patients sling is an adjustable single-incision device. According to the study results, almost 81% of women into two groups: high-risk and low-risk for urinary incontinence via measuring the lengths of were dry in two years after the surgery. membranous urethral length and levator thickness on Although sufficiently studied, Onabotulinumtoxin A preoperative MRI. Authors reported that the membranous urethral length less than 9.5 mm or (BTXA) studies remain the hot topics in many levator thickness less than 9.0 mm is associated with international urology meetings. Drake (#148 and #151) reported the results of a large post-hoc analysis a high rate of UI within six months after the surgery of two major BTXA studies that showed that this (57.1%), while longer urethra and thicker levators

provide high dry rate (only 1.7% incontinence in six months). Embolisation of prostate arteries remains a controversial method in managing male LUTS. Dyer (UK) (#569) presented short-term results of the first UK prospective study of prostate artery embolisation for BPE with bladder outlet obstruction. Sixty-seven men were enrolled in the trial with at least six months follow-up. Analysed data revealed significant decrease in IPSS level (from 24.7 to 12.4) with improvement of Qmax from 7.4ml/sec to 11.2ml/sec. At the same time, the prostate volume decreased up to 45%. Despite these promising results Russo and co-authors (#570) have reported negative results after performing a matched-pair analysis of functional outcomes and morbidities for embolisation versus open prostatectomy within one-year of follow-up. Conclusions In conclusion, the long-term results of TVT are still firm, but, at the same time, concomitant OAB may compromise patients’ satisfaction with the procedure. Comparative studies showed that mini slings are not inferior to conventional mid-urethral slings for the treatment of female SUI, but they may cause more storage symptoms. Pre-op MRI urethral length could serve as an independent factor for post-prostatectomy incontinence. Onabotulinum toxin type A appears to be effective long-term and regardless of initial symptoms severity. Extension of the treatment revealed no additional adverse events. B3adrenomimetic Mirabegrone shows sufficient persistence among patients suffering from OAB when compared to anti-muscarinics. Finally, the prostate artery embolisation is a promising but still experimental treatment option for LUTS.

Royals, Posters and Picasso The EAU History Office in Madrid By Loek Keizer The EAU History Office added culture, colour and of course history to the scientific programme of the 30th Anniversary EAU Congress in Madrid.

birthday, a rudimentary autopsy was performed, with the following results: “a very small heart, lungs corroded, intestines putrefactive and gangrenous, three large stones in the [!] kidney, a single testicle black as coal, and his head full of water.”

• True hermaphroditism: expression of ovarian and testicular tissue, most commonly 46-XX/46-XY/47XXY mosaicism, an intra-abdominal ovary (unconfirmed in the case of Charles II), cryptorchid testicle, hypospadias.

In addition to two poster sessions, in which research into the history of urology were presented, a special, in-depth “Hispanic Urological Tales” session took place on Saturday, 21 March. Three presentations were given in the space of an hour, each highlighting a different national urological topic.

Prof. Van Kerrebroeck used this description to paint a clinical picture: “We can conclude that Carlos suffered from posterior hypospadias, monorchism and an atrophic testicle. He probably had an intersexual state with ambiguous genitalia, and a congenital monokidney with stones and infections.”

• Sexual Inversion: male phenotype, XX karyotype with anomalous translocation of Y to X. Small size, ambiguous genitalia, hypospadias and testicular atrophy.

Prof. Remigio Vela Navarrete (Madrid, ES) looked at the discovery and spread of syphilis, in the New World and in Europe in the early 16th Century. Prof. Schultheiss (Giessen, DE), EAU History Office Chairman, discussed the hypersexuality that is evident in the works of Pablo Picasso. What emerged was a changing perspective of the artist; from participant in erotic scenes to being a spectator in his later years.

Physical phenotype Van Kerrebroeck postulated that Charles’s condition tended towards true hermaphroditism, though he was most probably XX male. He gave several possible diagnoses: • Klinefelter syndrome: which includes small testicles and a short penis, 47-XY/47-XXY.

It was perhaps the presentation of Prof. Philip Van • Fragile X syndrome: a cause of 30% mental Kerrebroeck (Maastricht, NL) that raised the most retardation, a long face, prominent ears and eyebrows among the audience. Instructed to speak on macrophelia, joint slackness, hyperextensibility the “urological problems in Spanish Royalty”, Van and muscular hypotonia. Kerrebroeck began with some trepidation in a room full of historically-minded Spaniards. Charles II Beginning with a general background on some of the Spanish dynasties of the Middle Ages, the focus soon lay on the extraordinary case of Charles II, the last and heirless Habsburg King of Spain. The result of several generations of royal inbreeding, Charles II was already born with several difficulties. Throughout his childhood he was extremely fragile and developmentally challenged. Intellectually stunted, his thirty-year rule was ineffective and dominated by the absence of heirs. Despite being married twice, Charles II produced no offspring. After his death, just short of his fortieth

Prof. Van Kerrebroeck concluded that a combination of sexual inversion and fragile X was the most likely correct diagnosis, yielding the extraordinary symptoms that Charles II suffered with his entire life. Poster sessions From surgeons who performed procedures on themselves, to European royals with innovative solutions to impotence, the two Poster Sessions on the History of Urology (73 and 82) were nothing if not colourful. Ms. Li June Tay (London, GB) presented two posters, each featuring some remarkable personalities from the history of our field. In her first presentation, she gave some examples in the literature of (amateur) surgeons who took matters into their own hands. A notable case was that of a lithotomy that was performed in 1651 by Dutch blacksmith Jan de Doot. He suffered pains from a bladder stone, and decided to remove it with the assistance of his brother and a kitchen knife. An incision was made over his perineum, and he successfully removed a stone the size of a hen's egg. His tools and the stone are on display in Leiden, the Netherlands to this day.

Poster Sessions 73 and 82 presented a wide variety of topics on the History of Urology

Another case was that of Colonel Martin of Lucknow, who was grappled by pain from his bladder calculi in 1782. He performed self-lithotripsy using a metal file with the diameter of a straw. This metal file was

Aside from his presentation on the urological conditions of Spanish Royalty, Prof. Van Kerrebroeck (right) also chaired Poster Session 82 together with Dr. Erik Felderhof

placed between the stone and his flesh in his bladder neck. He then repeated the process of filing up to 10-12 times daily for over 6 months, until his symptoms were gone and the stone was reported to be completely eradicated. Ms. Tay’s second poster covered the urological achievements of Nobel Prize winners, which also included a case of self-surgery. The 1956 Winner, Berlin-born Werner Forssmann (1904-1979) performed the first human cardiac catheterisation. With the assistance of the nurse in charge of sterile supplies, he inserted a urethral catheter into his own antecubital vein before walking to the X-ray department where he advanced the catheter into his right atrium. Instead of being lauded for his discovery at that time, he faced disciplinary action for selfexperimentation and for not meeting scientific expectations. His supervisor, Prof Sauerbruch marked the occasion with the following words: “With work like this you qualify in a circus, but not in a reputable clinic.”

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Overview of prizes and awards at the 30th Anniversary EAU Congress EAU Willy Gregoir Medal 2015

Opening Ceremony

L. Boccon-Gibod, Paris, France - Handed out by P-A. Abrahamsson

Friday, 20 March

EAU Crystal Matula Award 2015 M. Rouprêt, Paris, France Supported by an unrestricted educational grant from LABORIE - From left to right: P-A. Abrahamsson, M. Rouprêt and P. Bulla (LABORIE)

EAU Frans Debruyne Life Time Achievement Award 2015 H. Villavicencio, Barcelona, Spain - Handed out by P-A. Abrahamsson

EAU Hans Marberger Award 2015 EAU Innovators in Urology Award 2015

S. Tyritzis, Athens, Greece Supported by an unrestricted educational grant from KARL STORZ GMBH & CO.KG - From left to right: P-A. Abrahamsson, S. Tyritzis and H. Wehrstein (KARL STORZ GMBH & CO.KG)

S. Horenblas, Amsterdam, The Netherlands - Handed out by P-A. Abrahamsson

New EAU Honorary Members EAU Prostate Cancer Research Award 2015 M. Spahn, Berne, Switzerland Supported by an unrestricted educational grant from the FRITZ H. SCHRÖDER FOUNDATION - From left to right: P-A. Abrahamsson, M. Spahn and F.H. Schröder (FRITZ H. SCHRÖDER FOUNDATION) G. Badlani, Winston-Salem (NC), United States of America - Handed out by P-A. Abrahamsson

K.T. Foo, Singapore, Singapore - Handed out by P-A. Abrahamsson

L. Jarolim, Prague, Czech Republic - Handed out by P-A. Abrahamsson

Prize for the Best Paper published on Fundamental Research in the Urological Literature P. Uvin, M. Boudes, A. Menigoz, J. Franken, S. Pinto, T. Gevaert, R. Verplaetse, J. Tytgat, R. Vennekens, T. Voets, D. De Ridder (Leuven, Belgium) For the paper: "Chronic administration of anticholinergics in rats induces a shift from muscarinic to purinergic transmission in the bladder wall" European Urology, Volume 64 Issue 3, September 2013, Pages 502–510. - Handed out by P-A. Abrahamsson

Prize for the Best Paper published on Clinical Research in the Urological Literature R. Karlsson, M. Alya, M. Clements, L. Zheng, J. Adolfsson, J. Xu, H. Grönberg, F. Wiklund (Stockholm, Sweden; Winston-Salem, NC, United States of America) For the paper: "A population-based assessment of germline HOXB13 G84E mutation and prostate cancer risk" European Urology, Volume 65 Issue 1, January 2014, Pages 169–176. - Handed out by P-A. Abrahamsson

Prize for the Best Scientific Paper published in European Urology C. Rentsch, F. Birkhäuser, C. Biot, J. Gsponer, A. Bisiaux, C. Wetterauer, M. Lagranderie, G. Marchal, M. Orgeur, C. Bouchier, A. Bachmann, M. Ingersoll, R. Brosch, M. Albert, G. Thalmann (Basel, Berne, Switzerland; Paris, France) For the paper: ‘Bacillus Calmette-Guérin strain differences have an impact on clinical outcome in bladder cancer immunotherapy’ European Urology, Volume 66 Issue 4, October 2014, Pages 677-688. Supported by an unrestricted educational grant from ELSEVIER - From left to right: J. Catto, C. Rentsch, F. Birkhäuser and S. Boer Iwema (ELSEVIER)

Prize for the Best Scientific Paper published on Fundamental Research in European Urology by a urologist in training (max. 40 years) E. Bancroft, et al. (London, United Kingdom) For the paper: "Targeted prostate cancer screening in BRCA1 and BRCA2 mutation carriers: Results from the initial screening round of the IMPACT Study" European Urology, Volume 66 Issue 3, September 2014, Pages 489-499. Supported by an unrestricted educational grant from ELSEVIER - From left to right: E. Castro, who accepted the award on behalf of E. Bancroft, J. Catto and S. Boer Iwema (ELSEVIER)

Award Gallery Friday, 20 March

Prize for the Best Scientific Paper published on Clinical Research in European Urology by a urologist in training (max. 40 years) E. Scosyrev, E. Messing, R. Sylvester, S. Campbell, H. Van Poppel (Rochester, Cleveland, United States of America; Brussels, Leuven, Belgium) For the paper: "Renal function after nephron-sparing surgery versus radical nephrectomy: Results from EORTC Randomized Trial 30904" European Urology, Volume 65 Issue 2, February 2014, Pages 372-377. - Handed out by J. Catto to H. Van Poppel, who accepted the award on behalf of E. Scosyrev

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Overview of prizes and awards at International Friendship Dinner

The European Urology Platinum Award 2015

Sunday, 22 March S. Freedland, Durham, United States of America - Handed out by J. Catto

A. Heidenreich, Aachen, Germany - Handed out by J. Catto

F. Montorsi, Milan, Italy - Handed out by J. Catto

K. Parsons, Liverpool, United Kingdom - Handed out by J. Catto

First Prize for the Best Abstract (Non-Oncology)

First Prize for the Best Abstract (Oncology)

C. Ruf, M. Port, C. Matthies, V. Meineke, B. Müller-Myhsok, W. Wagner, H.-U. Schmelz, M. Abend (Koblenz, Munich, Hamburg, Germany) For the abstract: "594 Discriminating metastasized from non-metastasized seminoma using small RNA-expression in tumour tissue and peripheral blood" - Handed out by A. Stenzl

T. Cai, P. Verze, A. Brugnolli, D. Tiscione, G. Malossini, L. Luciani, C. Eccher, F. Wagenlehner, V. Mirone, T. Bjerklund Johansen, R. Pickard, R. Bartoletti (Trento, Naples, Verona, Florence, Italy; Giessen, Germany; Oslo, Norway; Newcastle, United Kingdom) For the abstract: "136 Adherence to European Association of Urology guidelines on prophylactic antibiotics: An important step in antimicrobial stewardship" - Handed out by A. Stenzl

Second Prize for the Best Abstract (Oncology)

Second Prize for the Best Abstract (Non-Oncology)

A. Feber, M. Arya, P. De Winter, S. Muhammad, R. Nigam, P. Malone, W. Tan, S. Rodney, M. Lechner, A. Freeman, C. Jameson, A. Muneer, S. Beck, J. Kelly (London, United Kingdom) For the abstract: "702 Epigenomics of penile squamous cell carcinoma" - Handed out by A. Stenzl

E. Weyne, J. Hannan, X. Liu, D. De Ridder, F. Van Der Aa, T. Bivalacqua, M. Albersen (Leuven, Belgium; Baltimore, United States of America) For the abstract: "40 Neurite outgrowth of pelvic neurons is stimulated by the neurotrophic peptide galanin" - Handed out by A. Stenzl

Third Prize for the Best Abstract (Oncology)

Award Gallery

J. Lestingi, J. Pontes Jr, L. Borges, J. Ravanini, G. Guglielmetti, M. Cordeiro, R. Coelho, W. Nahas (Sao Paulo, Brazil) For the abstract: "904 Extended vs limited pelvic lymphadenectomy during radical prostatectomy for intermediate- and high-risk prostate cancer: A prospective randomized trial" - Handed out by A. Stenzl

Friday, 20 March

Third Prize for the Best Abstract (Non-Oncology) Y. Wang, T. Kunit, F. Strittmatter, B. Rutz, A. Ciotkowska, R. Waidelich, C. Liu, C. Stief, C. Gratzke, M. Hennenberg (Munich, Germany; Salzburg, Austria; Guangzhou, China) For the abstract: "891 Inhibition of prostate smooth muscle contraction and prostate stromal cell growth by NSC23766 and EHT1864, two novel inhibitors of the small GTPase Rac" - Handed out by A. Stenzl to C. Gratzke who accepted the award on behalf of Y. Wang

First Video Prize

Video Award Session

S. Secco, A. Galfano, D. Di Trapani, G. Petralia, E. Strada, A. Bocciardi (Milan, Italy) For the video: "V31 Much beyond the learning curve of Retzius-sparing robotic-assisted radical prostatectomy" - From left to right: J. Van Moorselaar, S. Secco and A. Messas

Sunday, 22 March

Second Video Prize

Third Video Prize

R. Papalia, G. Simone, M. Ferriero, R. Mastroianni, S. Guaglianone, M. Gallucci (Rome, Italy) For the video: "V29 Totally intracorporeal robot-assisted vescica ileale padovana (vip) using staplers: A stepwise approach" - From left to right: A. Messas, R. Papalia and J. Van Moorselaar

A. Hoznek, P. Castellan, M. Chiaradia, B. Parier, M. Khan, A. De La Taille (Creteil, France; Chieti, Italy; Keighley, United Kingdom) For the video: "V30 Micropercutaneous nephrolithotomy in Galdakao modified supine Valdivia position" - From left to right: J. Van Moorselaar, H. Hoznek and A. Messas

Section Awards Saturday, 21 March

Best Booth Award 2015 Astellas Pharma Europe Ltd. - From left to right: K. Jones (Astellas Pharma Europe Ltd.), P-A. Abrahamsson and M. Moss (Astellas Pharma Europe Ltd.)

ESUI Vision Award 2015 V. Pasoglou, Brussels, Belgium For the study: "Whole-body 3D T1-weighted MR imaging in patients with prostate cancer: Feasibility and evaluation in screening for metastatic disease" Supported by an unrestricted educational grant from HITACHI MEDICAL SYSTEMS EUROPE - From left to right: A. Hoppe (HITACHI MEDICAL SYSTEMS EUROPE), V. Pasoglou and J. Walz

ESTU - René Küss Prize 2015 C.D. Vera Donoso, Valencia, Spain For the abstract: "Is it possible to create a biobank of kidney precursors for successful transplantation?" - From left to right: C.D. Vera Donoso, E. Lledo Garcia, F.J. Burgos Revilla, M. Giessing and A.J. Figueiredo

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the 30th Anniversary EAU Congress Campbell Team Challenge Quiz

First Prize for the Best Abstract by a resident

The winner of the Campbell Team Challenge Quiz is M.L. Vrang (Frederiksberg, Denmark) - From left to right: J.L. Vasquez, M.L. Vrang and M. Sedelaar

Residents Day Saturday, 21 March

A. Grenabo-Bergdahl, S. Carlsson, J-E. Damber, M. Frånlund, K. Geterud, A. Khatami, A. Socratous, J. Stranne, M. Hellström, J. Hugosson (Gothenburg, Sweden; New York, United States of America) For the abstract: "760 Role of magnetic resonance imaging in prostate cancer screening; results from a pilot study within the Gothenburg randomized screening trial" - From left to right: J.L. Vasquez, A. Grenabo-Bergdahl and M. Sedelaar

Second Prize for the Best Abstract by a resident T. Arends, O. Nativ, M. Maffezzini, O. De Cobelli, A. Van Der Heijden, J. Witjes (Nijmegen, The Netherlands; Haifa, Israel; Genova, Milan, Italy) For the abstract: "944 Results of the first randomized controlled trial comparing intravesical radiofrequency induced chemohyperthermia with mitomycin-C versus BCG for adjuvant treatment of patients with intermediate- and high-risk non-muscle invasive bladder cancer" - From left to right: J.L. Vasquez, T. Arends and M. Sedelaar

Third Prize for the Best Abstract by a resident Y. Wang, T. Kunit, F, Strittmatter, B. Rutz, A. Ciotkowska, R. Waidelich, C. Liu, C. Stief, C. Gratzke, M. Hennenberg (Munich, Germany; Salzburg, Austria; Guangzhou, China) For the abstract: "891 Inhibition of prostate smooth muscle contraction and prostate stromal cell growth by NSC23766 and EHT1864, two novel inhibitors of the small GTPase Rac" From left to right: J.L. Vasquez, Y. Wang and M. Sedelaar

Resident’s Corner Awards - Awards for the two Best Scientific Papers published in European Urology by a resident J. Leow, S. Reese, W. Jiang, S. Lipsitz, J. Bellmunt, Q-D. Trinh, B. Chung, A. Kibel, S. Change (Boston, Stanford, United States of America) For the paper: "Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: A contemporary population-based analysis in the United States" European Urology, Volume 66, Issue 3, Pages 569–576. - Handed out by J. Catto to Q-D. Trinh, who accepted the award on behalf of J. Leow

N. Kroeger, T. Choueiri, J-L. Lee, G. Bjarnason, J. Knox, M. MacKenzie, L. Wood, S. Srinivas, U. Vaishamayan, S-Y. Rha, S. Pal, T. Yuasa, F. Donskov, N. Agarwal, M-H. Tan, A. Bamias, C. Kollmannsberger, S. North, B. Rini, D. Heng (Calgary, Toronto, Ontario, Halifax, Vancouver, Edmonton, Canada; Boston, Stanford, Detroit, Duarte, Salt Lake City, Cleveland, United States of America; Asan, Seoul, South Korea; Tokyo, Japan; Aarhus, Denmark; Singapore; Athens, Greece) For the paper: "Survival outcome and treatment response of patients with late relapse from renal cell carcinoma in the era of targeted therapy" European Urology, Volume 65, Issue 6, Pages 1086–1092. - Handed out by J. Catto

EUSP Best Scholar Award 2015 C. Rönnau, Greifswald, Germany For her report: "Establishing a panel of microRNAs for the detection and monitoring of prostate cancer in bodily fluids, and unraveling the microRNAs functions to better understand prostate cancer biology"

EUSP Session Friday, 20 March

Second Prize for the Best EAUN Poster Presentation First Prize for the Best EAUN Poster Presentation C. Paterson, A. Robertson, A. Smith, G. Nabi (Dundee, United Kingdom) For the poster: "A systematic review of the empirical evidence identifying the unmet supportive care needs of men living with and beyond prostate cancer: Are we there yet?" Supported by an unrestricted educational grant from AMGEN (Europe) - From left to right: K. Szczepanska (AMGEN Europe), C. Paterson and L. Drudge-Coates

L. Lydom, T. Thomsen (Copenhagen, Denmark) For the poster: "Beyond one’s depth – he experience of postoperative complications following radical cystectomy" Supported by an unrestricted educational grant from AMGEN (Europe) - From left to right: K. Szczepanska (AMGEN Europe), L. Lydom and L. Drudge-Coates

EAUN Meeting Monday, 23 March Third Prize for the Best EAUN Poster Presentation E. La Cognata, B. Necchi, L. Caiazza, A. Crescenti, M. Boarin, G. Villa (Milan, Italy) For the poster: "Nutritional status and postoperative functional outcomes in patient undergoing radical cystectomy: A prospective observational study" Supported by an unrestricted educational grant from AMGEN (Europe) - From left to right: K. Szczepanska (AMGEN Europe), B. Necchi and L. Drudge-Coates

Prize for the Best EAUN Nursing Research Project H. Syhler (Copenhagen, Denmark) For the Project Plan: “Improving male patients coping with urinary incontinence after prostatectomy.” - Handed out by L. Drudge-Coates

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Quality training at one of Poland’s premier medical centres EBU accredits Jagiellonian University Hospital’s urology department Mr. Tomasz Golabek Dept of Urology Jagiellonian University Hospital Krakow (PL)

elementare@op.pl

Dr. Tomasz Wiatr Dept of Urology Jagiellonian University Hospital Krakow (PL)

unit1. Pisarski was succeeded by five consecutive department heads. Currently, Prof. Piotr Chlosta is department head since December 2012. The Department of Urology has seven full-time faculty staff members, 10 post-graduate residents and two interns, all committed to provide exceptional and innovative patient care and perform research in urology. It has a 42-bed capacity (including two ICU beds), an outpatient department (OPD) and three modern operating theaters. Each year more than 2,500 patients are admitted and more than 11,000 are seen at the OPD. Offering medical care for the whole range of urological sub-specialties, the department is equipped with comprehensive diagnostic tools and is one of Poland’s leading laparoscopy centres with more than 85% of surgeries performed with this minimally invasive method.

Specialty Training Programme in Urology In Poland, the Specialty Training in Urology begins with an internship of one year followed by a six-year dr.wiatr@gmail.com structured Specialty Training Programme in Urology (STPU) for which there are competitive entry The European Board of Urology (EBU) has recently requirements. The STPU starts with a two-year Basic certified the Department of Urology at the Surgical Training Programme in general, vascular, Jagiellonian University Hospital in Krakow as an transplant and paediatric surgery. The succeeding EBU-accredited training centre in urology, recognising four years are based in urology departments and team efforts towards maintaining the highest quality include training in all urological aspects. training standards. The Urology Curriculum2 has been formulated by the Postgraduate Medical Education Center in Poland and The Jagiellonian University Hospital in Krakow, a approved by the Polish Urological Association (PUA). tertiary referral centre, is the largest hospital in It is based on the European Association of Urology southern Poland and a leading medical centre on a guidelines3. During the training, residents are national scale. It serves over three million people expected to gain knowledge and skills for them to living in the Malopolska region. manage a wide range of elective and emergency The Jagiellonian University Hospital (initially known as conditions in urology including uro-oncology, endourology, trauma, female and reconstructive the General Hospital of Saint Lazarus) was founded urology and andrology. more than 400 years after the establishment of the Medical School by King Kazimierz the Great in 1364. Many famous general surgeons of the times, who had worked in the hospital, maintained a special interest and were actively practising in urology. In 1788, soon after the hospital had been built, it became apparent and necessary to separate what was then known as genitourinary practices from general surgery and to establish a dedicated service. Dr. Tadeusz Pisarski, specialist in genitourinary diseases, became the first head of the Department of Urology, which in 1929 was founded as a separate EBU Certified Centres

Prof. Piotr Chlosta, Professor and Chairman Department of Urology

Trainees achieve satisfactory progress through the programme by demonstrating the required competence. The regular appraisals by an educational supervisor include case-based discussions, clinical skills evaluation to ensure good and safe clinical care, and assessment of the trainee’s operative and professional skills. Moreover, all residents are expected to sit at least one EBU In-service Assessment Exam. However, in many centres, including the Department of Urology at the Jagiellonian University Hospital, trainees are encouraged to take the assessment each year to objectively and regularly evaluate their progress. During residency all trainees are required to keep a log book of surgical activities which are assessed at the final year of their urology training and before they take the exit exam. Apart from work-based practice, the Specialty Training Programme in Urology is complemented by a variety of educational activities and courses, local postgraduate teaching sessions arranged by the regional branches of the PUA and regional, national and international meetings and conferences. Self-directed learning is also encouraged. In many institutions trainees are also obliged to present challenging and interesting cases, contribute to journal clubs on a daily basis, participate in clinical research and disseminate project results. After successfully completing the STPU, trainees are eligible to sit the European Board Examinations in Urology, consisting of written and oral exams. Only candidates who succeeded in both exams receive the Fellow of the European Board (FEBU) Diploma and

View of the historic Church of Our Lady Assumed into Heaven, an early Gothic church located near the Department of Urology, Jagiellonian University Hospital

may be included in the country’s Urology Specialist Register. References 1. Krakowski J. History of Cracow Urology (Background). Urol Polska 1993/46/2. 2. http://www.cmkp.edu.pl/wp-content/uploads/ akredytacja2014/0729-program-1.pdf; accessed on: 16.02.2015. 3. EAU Guidelines, edition presented at the 29th EAU Annual Congress, Stockholm 2014, ISBN 978-90-79754-65-6.

MADRID

Visit the EAU15 Resource Centre: www.eaumadrid2015.org 20-24 March 2015 The building which houses the Department of Urology at the Jagiellonian University Hospital in Krakow

Sharing knowledge - Raising the level of urological care

Miroslav Hanuš Dedicated educator and surgeon 1940-2015 Prof. Miroslav Hanuš, 74, passed away on January 22 of this year. He was one of the leading opinion leaders and educators in urology.

In November 2008 Prof. Hanuš was elected president of the Czech Urological Society of ČLS-JEP, and headed the society until 2011. In 2010, together with Professor Haas from Germany, Prof. Hanuš helped organise the ESU course during the EAU Congress in Barcelona. His active involvement in European urology endeared him to many colleagues in the European Association of Urology.

Born in May 27, 1940 Prof. Hanuš graduated as a pedagogue and began his medical career as a surgeon and urologist. In 1976 he worked for the newly opened urology clinic in Prague as assistant to Prof. Eduard Hradec, MD., the founder of modern Czech urology.

In 2010, on the occasion of his 70th birthday, Prof. Hanuš became an honorary member of the Slovak Association of Urology. For his lifetime contribution to Czech urology he was granted in 2011 honorary membership with the Czech Urological Society of JEP and became the Laureate for the Professor Eduard Hradec Prize.

Shortly thereafter, he joined the activities of the Czech and Slovak Association of Urology, and also became a member of the European and World Association of Urology, the European Organization for Research and Treatment of Cancer and the American Academy of Sciences. He lectured in the USA, Japan, Australia, Indonesia, and Taiwan and practically in all European countries. In 1989 he helped in organising the EORTC meeting in Prague, the first of its kind held in post-communist countries. More than 200 participants attended the meeting which was widely considered as a landmark event in Czech urology.

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European Urology Today

In 1990 Prof. Hanuš was appointed head of the Department of Urology at the 1st Medical Faculty of the Charles University in Prague and head of the Department of Urology at ILF – Institute which trains doctors and pharmacists. The following year he left the clinic to establish the outpatient Urocentrum in Prague. In 1992 he founded the Association of Outpatient Urologists (SAU) and became its first and also most recent chairman, as of this writing. SAU is

now considered as the representative body of the Czech outpatient urologists’ society. In 2001 he founded the Czech Society for the Health of the Elderly (CSZS), and as chairman of the organising committee he has significantly contributed to organising the 4th ISSAM World Congress on "Aging Male" in Prague in 2004. CSZS was later affiliated as a full member of ISSAM, an honour to Czech medicine.

Until his last days he remained active in publishing and lecturing activities. His demise is a loss not only to Czech urology but also to the European urological community. We will miss a dedicated urologist, a conscientious surgeon and a dear friend. We honour his memory! -By Michaela Matoušková and Ivan Kawaciuk

March/May 2015


European Tour 2015 Academic Exchange Programme

Canadian Urological Association (CUA)

Everything new in the Old World: The 2015 CUA-EAU Exchange Visit Dr. Peter Anderson Dalhousie University Urology Clinic Halifax, Nova Scotia (CA)

peter.anderson@ iwk.nshealth.ca

This year the lucky participants were Gavin Langille (Saint John, NB), Neal Rowe (Halifax, NS), Naji Touma (Kingston, ON), and Peter Anderson (Halifax, NS). Our whirlwind tour started in Dresden, Germany, hosted ably by Prof. Manfred Wirth, whose new facilities were the definition of efficiency. We also were treated to warm spring weather and had a fascinating tour of the rebuilt city that has emerged from the ashes of World War II.

After a wonderful meal in a castle overlooking the River Elbe, we were off to Leuven, Belgium. Our host In March this year, the Canadian Urological Association Prof. Hein Van Poppel personally met us at the (CUA) sent four urologists to Europe to participate in airport, transported us to our hotel, and then joined the sixth edition of the alternating exchange us for a nightcap. The Leuven facilities are in the programme with the European Association of Urology midst of a major modernisation, with shiny new (EAU). The delegation was selected by the Office of operating rooms and state-of-the-art research labs. Education based on the criteria set by the EAU.

UK and Spain Next stop was jolly old England, Sheffield to be precise, where Prof. Chris Chapple served as our host and tour guide. He dedicated an entire weekend to making sure we saw the local sights despite our visit being just days prior to the Annual EAU Congress, during which he was inaugurated as the new Secretary General of the organisation. In Sheffield we saw some inspiring surgery, including a complex urethroplasty by the professor and a robotic prostatectomy done slickly by Jim Catto. Proudly presenting the awards of the CUA-EAU Exchange Programme

The trip concluded with attendance at the 30th Anniversary EAU Congress in Madrid, where the science and the culture were superb. We then had to return to reality, not a moment too soon as far as our waistlines and livers were concerned.

The junior members must be under age 42 years, have excellent records in research and/or education, and be active CUA members. The senior delegate must have a minimum of 10 years in practice, be recognised internationally in his/her field, have a demonstrated interest in medical education, and show evidence of long-term commitment to CUA activities.

Observing an urothroplasty by Prof. Luis Martinez at Infanta Sofía Hospital in Madrid

Discussing procedures with Hein Van Poppel (right)

Our final stop was in Madrid, hosted by Prof. Luis Martinez, who presides over a brandnew facility with some brilliant and enthusiastic young staff urologists. We observed a second stage urethroplasty, which was the perfect follow-up to the Sheffield case. We also toured the Santiago Bernabeu Stadium, home to storied Real Madrid and had a wonderful meal overlooking Time to relax in Leuven the playing field.

The Canadian delegation with Dr. Johannes Huber (right) at the urology department of University Clinic Carl Gustav Carus in Dresden

Leuven is also the home centre for one of last year’s European visitors to Canada in the Exchange Programme, so we had an enjoyable reunion with Frank Van Der Aa. We took the opportunity of some spare time to visit nearby Bruges, and also did some sightseeing in Brussels, home of the “Patron Statue” of urology, the Manneken Piss or “Pissing Boy,’ who has been doing his business in the same place since 1619.

This exchange programme continues to be a highly successful means to create links between our two organisations, and hopefully will continue for many years to come. Next year it will be Canada’s turn to host the European delegates, and with the CUA annual meeting scheduled for June 26-28, 2015 in beautiful Vancouver, the delegates are guaranteed to have a memorable experience.

Ensuring a solid future by working on our core goals Prof. Chris Chapple EAU, Secretary General Sheffield (GB)

C.R.Chapple@ sheffield.ac.uk It is a pleasure to write to you in my new position as Secretary General of the European Association of Urology (EAU). I am very grateful to the members of the European Association of Urology who have elected me to this position. The EAU is clearly well-established and has a number of key attributes due to the hard work of its members, particularly those who serve in many committees and are performing other activities related to the work of the organisation. However, a number of challenges lie ahead. Clearly, Europe is the main bedrock for the EAU and we want to further strengthen our close links with the many national associations in Europe. There are a number of issues relating to financial support available to the societies, as well as other regulatory and legislative changes which are likely to be coming up over the next few years. One of the key assets of our organisation are the EAU Guidelines. We will continue our emphasis on further improving the EAU Guidelines. As part of the publication programme, the EAU Guidelines have undergone a number of developments - not only in terms of a more rapid updating process, but also in terms of the technology being applied to increase the effectiveness of evidence-based assessment. It is also evident to everyone that the journal European Urology is now accepted as a premier March/May 2015

international journal, with an impact factor of 12.48, and as you know we have released a new publication, the European Urology Focus, to complement the existing European Urology Supplements. Also, we have a number of other publications, including this newsletter, European Urology Today, and the excellent patient information leaflets which have been produced over the last two years. An enormous amount of work has gone into all these activities and I am sure you would agree that they all have proven to be extremely successful and have prompted very positive feedback from our members. Coupled with these publishing activities is the re-launch of our newly designed portal Uroweb at www.uroweb.org. I would also strongly encourage you to look at the newly launched UROsource.com, which provides an enormous amount of information, with over 50,000 items of scientific content. In the next few years this website will further expand its coverage as we continue to update and add to its contents. The European School of Urology (ESU) has received international acclaim with its continuing efforts to deliver a very comprehensive series of programmes, both within Europe and around the world. There has been an increased emphasis in recent years on hands-on training and courses related to important aspects of our clinical work, besides existing programmes such as the superb courses being offered during our annual congress, the EUREP and the courses organised at national society meetings. The emphasis on hands-on training in collaboration with the relevant EAU section offices has also been successful and appreciated by the membership. In the coming year the ESU will focus strongly on the development of new e-courses, prepared by urologists from all over Europe, and supported by e-learning specialists to deliver high standard, up-to-date continuing medical education.

The Annual Congress this year was enormously successful, with nearly 1,000 more attendees than the previous year. The Scientific Congress Office did us proud by virtue of the excellent standard of the meeting which encompassed all aspects of new developments in urology. The hands-on training was again hugely successful, and both ESUT and ERUS provided an excellent programme. The Young Urologists Office has taken great strides to further expand its activities, and it is a great pleasure to welcome the ESRU who are now formally joining the EAU. In addition, the Young Academic Urologists programme is proving very successful and its officers are looking at a portfolio of new developments in urology. A bedrock of the society is, of course, our individual supraspecialties, and without doubt the Section Offices have expanded their activities as reflected in the high number of participants at their meetings during the annual congress. The Sections provide an excellent opportunity to allow members to engage with specialists, exchange experiences with likeminded experts, become involved in educational activities, and help participate and organise Section

meetings. If you are interested to play an active role in your urological subspecialty, you might be interested to become an affiliate or associate member of an EAU Section Office. More information on who qualifies to become an Affiliate or Associate member of the Section Office and how to apply can be found at: http://uroweb.org/sections/ I am extremely honoured to be working with such a huge number of committed people who strive continuously and aim to provide the best quality of education in our specialty, and by nurturing not only our skills but also those of our younger colleagues to advance knowledge and expertise. Things don't just happen though, they have to be made to happen, and in this context I would like to acknowledge the hard work, tenacity and support provided by the members of the Central Office; without their expertise and dedication none of this would have been achieved. Whilst we are first and foremost a European association, it is very clear that we have a global reach and we take very seriously the importance of working closely with colleagues across the globe. We have been grateful for the strong support, friendship and collaboration coming from national and international societies. We look forward to further boost these strong links by nurturing joint activities in the coming years. Don't hesitate to get in contact with me if at any stage you want to discuss anything, or have any concerns or suggestions as to how we could improve matters. And the same goes for my colleagues in the Executive committee.

EAU Executive Board members during the General Assembly in Madrid

I look forward to seeing you over the course of the next year, and, if not before, then at the Annual Congress in Munich from 11-15 March 2016.

European Urology Today

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Worldwide BCG shortage affects recruitment in NIMBUS trial Steering Committee members discuss strategies to overcome BCG shortage period Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ uroweb.org

Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ uroweb.org The NIMBUS trial assesses whether a reduced number of BCG instillations is not inferior to standard number and dose intravesical BCG treatment in patients with high grade non-muscle invasive bladder cancer (NMIBC). The target is to enrol 1000 patients with high grade Ta-T1 urothelial carcinoma of the bladder with or without CIS and who did not receive any previous BCG intravesical instillation therapy. Intravesical instillation of BCG is a widely accepted strategy to prevent recurrence of non-muscle invasive bladder cancer. The most accepted treatment schedule is induction of BCG: weeks 1 through 6 plus maintenance (weeks 1,2,3) at months 3,6 and 12, but it is unknown how many administrations are really necessary. Scientific evidence supports the hypothesis that after an initial sensitisation to BCG antigens has occurred, the number of instillations can be reduced for a proper anamnestic immune response resulting in similar clinical efficacy and potentially less side-effects and costs. The NIMBUS study is a multicentre prospective, randomised, parallel group, not blinded, trial to compare the efficacy and safety of two different adjuvant treatment schedules: 1) Induction cycle BCG-full dose; weeks 1 through 6 plus maintenance cycles at months 3, 6 and 12 (wks 1,2,3); total 15 full dose BCG instillations 2) Induction cycle BCG-full dose (reduced frequency); weeks 1,2, and 6 plus maintenance cycles at months 3, 6 and 12 (wks 1,3); total 9 full dose BCG instillations. The primary endpoint for inferiority analysis is time-to-first-recurrence. The secondary objectives are to identify if number and grade of recurrent tumours, rate of progression to a higher stage (T2 or higher) of the disease and safety, specifically the presence of treatment related toxicity > grade 2 differ between the two study arms. Study status As of press time (cut-off date 21 March 2015, 31 of 34 centres are initiated in Germany of which 9 sites randomised, in total, 24 patients. In the Netherlands 9 of 17 are initiated and the first two initiated centres each randomized 3 patients. The start-up of other countries (e.g., United Kingdom, France, Spain, Czech Republic) has been delayed due the worldwide BCG shortages as discussed below. Worldwide BCG shortage In 2012 , Sanofi Pasteur (Lyon, France) suspended the production of ImmuCyst (the Connaught strain of BCG), after the FDA found contamination in the sterile manufacturing area of the Toronto, Canada, plant following a flood. This put added pressure to Merck Sharp & Dohme Limited (Hertfordshire, UK)—the manufacturer of OncoTICE (TICE strain of BCG), which themselves experienced a manufacturing problem resulting in substantial shortages of their product during 2014. The production of the RIVM BCG strain by Medac (Wedel, Germany) has been on hold for some time during the fourth quarter of 2014 due to a combination of increasing demand and manufacturing problems. The stoppage led to a severe worldwide shortage of BCG which is expected to improve only slowly. Merck EAU Research Foundation

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European Urology Today

has started to resupply OncoTICE BCG, but given back orders, supplies will be limited through the rest of the year. Medac has again started accepting orders and is releasing the product as it becomes available. Sanofi expects that ImmuCyst will not be available during the second quarter of 2015.

clinical efficacy, specifically in high grade patients as published in the EORTC study published by Oddens et al in European Urology. It was also decided not to allow new strains to the study but to wait for the BCG strains (e.g., Connaught ) to become available again (in e.g., Spain).

The fermentation process used for the production of BCG is still highly unreliable and together with the increasing demand of the high BCG doses used in bladder cancer, the current BCG shortage might remain an issue in the future.

The current situation of BCG shortage is clearly distressing for patients with high-risk NMIBC who are already undergoing BCG treatment and for those who may be diagnosed in the next 12 months. It is important that all patients with high-risk NMIBC are counselled appropriately and reassured that their care will not be substantially compromised. The British Association of Urological Surgeons on their website has indicated the possibilities to overcome the time that the availability of BCG is limited as suggested by Hugh Mostafid in European Urology.

In response to this shortage, several organizations and experts have put forward recommendations on alternatives if BCG resources are limited or not available at all. These include the use of 1/3 dose BCG for induction courses and maintenance up to 1 year, stopping maintenance therapy in all patients after one Remarkably, one of the possibilities mentioned there year, and for selected patients, to offer intravesical is the reduced frequency schedule as defined in our chemotherapy, radical cystectomy or device-assisted therapy (DAT). For more detailed information on these NIMBUS protocol. It would be worthwhile to ask recommendations, see Mostafid et al. Therapeutic Options in High-risk Non–muscle-invasive Bladder Cancer During the Current Worldwide Shortage of Bacille Calmette-Guérin. Eur. Urol. 67, 359-360 (2015). BCG shortage affects start-up and recruitment NIMBUS trial The current BCG shortage has a negative effect on the start-up and recruitment of the NIMBUS trial which investigates if the number of BCG instillations can be reduced (9 versus 15 installations) without affecting clinical efficacy. The effects of BCG shortage on the NIMBUS trial was discussed at The NIMBUS Steering Committee meeting held on 22 March, coinciding with the 30th Annual EAU Congress (20-24 March 2015) in Madrid, Spain. This meeting was attended by the national coordinating investigators from Germany (Prof. Marc-Oliver Grimm), The Netherlands (Dr. Toine Van Der Heijden, Prof. Bart Kiemeney), United Kingdom (Dr. Hugh Mostafid), France (Prof. Marc Colombel), Spain (Prof. Luis Martinez-Pineiro) and Czech Republic (Prof. Markus Babjuk). The EAU Research Foundation was represented by Dr. Anup Patel (Steering Committee member), and on behalf of EAU RF: Dr. Wim Witjes (Scientific and Clinical Research Director EAU-RF), Dr. Raymond Schipper (Clinical Project Manager), Drs. Christien Caris (Clinical Project Manager), Sheik Nurmohamed (Clinical Project/data manager) and Ria Janzing (Clinical Research Associate). In Germany, the NIMBUS study was put on hold on July 2014 due to delivery problems of BCG by Medac and accrual was not restarted until December 2014. In The Netherlands, several centres have reported BCG shortage during the first months of 2015 which may have impact on further recruitment of patients. Spain, where only the Connaught BCG strain is registered, was forced to switch to BCG strains developed in Japan (Tokyo strain) and Russia (for the Russian strain there is limited literature on efficacy available). United Kingdom will start with the NIMBUS study later in 2015 when BC Connaught will again be available.

doctors, who treat patients with a similar schedule as mentioned in NIMBUS, to enter patient data in our existing EAU RF web-based database management system which would allow us to monitor what is going on in daily standard practice. Unfortunately, we need ethical committee submission and a registry protocol which takes a couple of months and by the time with have approval - hopefully - the BCG shortage problem could be solved. Discussions in the direction of setting up such a registry are continuing. It is really ironic that BCG shortage hinders us to recruit patients and to start in new countries and centres participating in NIMBUS, specifically because this trial is designed to show that less BCG instillations could have a similar effect as the standard number of BCG instillations.

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The Steering Committee members discussed whether the protocol has to be adapted to overcome the current and possibly future BCG shortages: Do we allow the use of 1/3 dose BCG for induction courses? Do we allow the use of BCG strains other than the ones (OncoTice, Medac and Connaught) mentioned in the current protocol? The members agreed that 1/3 dose BCG should not be allowed for induction courses as a reduced dose might have inferior effects on

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Clinical challenge Prof. Oliver Hakenberg Section editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem. Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org

Case study No. 42 This 65-year-old man suffers from severe peripheral vascular disease including an abdominal aortic aneurysm with bilateral ureteral obstruction. This was initially treated by bilateral DJ stenting and systemic prednisolone which did not have any effect on the obstruction. In 2010, a transfemoral aortic stent was successfully inserted into the infrarenal aortic aneurysm. Over the following years, two attempts to permanently remove the ureteral stents with continued prednisolone treatment failed. With stents in situ,

the patient is well, serume creatinine is 163 µmol/l and renal parenchyma is as shown on CT scan (Fig. 1). The patient is tired of having to undergo regular changing of stents and would prefer a definitive solution.

Case study No. 43 This 49-year-old woman suffers from recurrent headaches and a cystic lesion is detected on abdominal ultrasound which is further investigated by CT scan (Figures 1 and 2). There are no urological or abdominal symptoms at all. All routine laboratory investigations are normal. The patient is worried about the possibility of having cancer but she is also worried about surgery as one sister died years ago during renal surgery but she does not know what this surgery had been for. With the CT scan the patient is referred for further management. The radiologist reports a density of 20-30 Hounsfield units of the lesion without uptake of contrast material.

Discussion point: What management options are advisable?

Case provided by Oliver Hakenberg, Department of Urology, Rostock University Hospital, Germany. Figures 1 and 2: Abdominal CT scan

Open surgery has the best long-term chance of cure Comments by Christian Schwentner, Tübingen (DE)

limit the quality of life. This patient belongs to this select group of relatively young men with significant vascular disease. He is 65 years old and retroperitoneal fibrosis with associated bilateral ureteral strictures is his main problem. Yet there is no clear-cut recommendation for such a case.

Retroperitoneal fibrosis secondary to aorto-iliac aneurysm is a common finding in an aging population being treated by endovascular techniques. Ureteral morbidity, however, is not frequently perceived as a significant clinical problem by the interventional vascular surgeons.

In my opinion there are three possible options: 1. Open surgery with intra-peritonealization of both ureters supplemented by an omental wrap. 2. Thermoexpandable permanent stents. 3. Detour©System, i.e. subcutaneous catheter tunneling between renal pelvis and bladder.

Overall survival may be limited due to the vascular disease in this sub-group of patients. Nevertheless, some still have a considerable life expectancy and hence would undergo repeat stent exchange procedures. In addition, recurrent urinary tract infections as well as urgency and frequency are bothersome to the patient and

The general performance status of the patient determines the preferred treatment. In case of good overall condition my primary option would be open surgery as it has the best long term chance of cure. Given the nature of secondary retroperitoneal fibrosis open surgery would treat the cause of the

problem most effectively. The latter two endourological options may be employed in more critically ill patients as both use foreign materials. Such foreign bodies in the urinary tract may remain patent over months but not years. Even though they are coated and pretreated to prevent encrustation they are still prone to calculus formation and subsequent occlusion. Subsequent stent exchanges are inevitable at some point. This directly points at the cost-issue as both treatment options are expensive due to the sophisticated stent materials used. Other options appear less attractive in this scenario. Auto-transplantation is precluded by a poor iliac vasculature and the aortic stent itself. Bilateral complete ureteral replacement using whole-mount ileum is effective but still remains a morbid operation and may be reserved for very few select cases with excellent general status.

Abdominal aortic aneurysm with inflammatory bilateral ureteral obstruction Comments by Joachim W. Thüroff, Mainz (DE)

In the reported case of a 65-year-old male, a transfemoral aortic stent was placed into an abdominal infrarenal aortic aneurysm in 2010. Bilateral inflammatory ureteral obstruction had been treated with prednisolone without resolution and since the endovascular stent placement with indwelling ureteral double-J stents which have been replaced at regular intervals. Since 2010, two attempts to permanently remove the stents have failed. Abdominal aortic aneurysms are associated with ureteral obstruction in a relevant number of cases. Hydronephrosis from ureteral obstruction may be pre-existent before open surgical or endovascular repair of an aortic aneurysm (such as in the reported case) or develop de novo after such a repair. If hydronephrosis was present at the time of diagnosis of an abdominal aortic aneurysm, open surgical or endovascular repair may result in regression of hydronephrosis, persistence or progression. In a systematic review of a total of 56 studies with 999 patients with open surgical repair (OSR) and 121 patients with endovascular aneurysm repair (EVAR), seven studies reported on hydronephrosis after OSR and 11 studies after EVAR. In studies after OSR, aortic aneurysms were associated with hydronephrosis in 45/85 patients (53%) and in studies after EVAR, association with hydronephrosis was seen in 29/52 patients (56%)1. After the repair of aortic

March/May 2015

aneurysm, regression of hydronephrosis was reported in 69% after OSR and 38% after EVAR (p = 0.01). Hydronephrosis remained unchanged in 22% after OSR and 41% after EVAR (p = 0.1). Progression was noted in 9% after OSR and 21% after EVAR (p = 0.1). De novo hydronephrosis was noted in 6% after OSR and 2% after EVAR (p = 0.2)1. Peri-aortic inflammation (PAI) as seen on CT is in the majority of cases the cause of ureteral obstruction1,2 and is consistent with (secondary) Ormond’s disease in urological literature. In nephrectomy cases, one finds small lymphoplasmocytic infiltrates in the connective tissue around the muscular layers of the ureter3. Ureteral obstruction can be managed by ureteral stenting only, awaiting spontaneous regression of the peri-aortic inflammation after open surgical or endovascular repair with1,2,4,5 or without1,2,6 anti-inflammatory medication. Such antiinflammatory medication comprises steroidal and non-steroidal anti-inflammatory substances such as in primary Ormond’s disease: cortisone, tamoxifen and azathioprine. In the reported case, prednisolone was used and failed. If medical treatment with and without stenting fails, surgical ureterolysis remains the only option to be relieved from repeated double-J stenting. Significantly higher rates of regression of hydronephrosis after OSR as compared to EVAR and the possibility to combine surgical repair with ureterolysis of an obstructed ureter favour OSR in patients with pre-existent hydronephrosis, which is the conclusion of the excellent systematic review of open surgical versus endovascular repair of Paravastu et al.1.

Since in the reported case neither endovascular repair of the abdominal aortic aneurysm nor medical treatment and stenting resulted in an unobstructed drainage of the upper urinary tracts, surgical repair remains the only realistic option to achieve a stent-free unobstructed upper urinary tract drainage. In this 65-year-old man with bilateral ureteral obstruction and with a significant size of abdominal aneurysm, this should rather be performed by open surgery than by laparoscopic/ robotic surgical techniques and should – as in primary Ormond’s disease – involve ureterolysis and wrapping of the ureters either by peritoneum (intraperitonealisation) or by greater omentum. References 1. Paravastu SC, Ghosh J, Murray D, et al. A systematic review of open versus endovascular repair of inflammatory abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2009 Sep;38(3):291-297. 2. van Bommel EF, van der Veer SJ, Hendriksz TR, et al. Persistent chronic peri-aortitis ('inflammatory aneurysm') after abdominal aortic aneurysm repair: systematic review of the literature. Vasc Med. 2008 Nov;13(4):293-303. 3. Simons PC, van Overhagen H, Bruijninckx CM, et al. Periaortitis with ureteral obstruction after endovascular repair of an abdominal aortic aneurysm. AJR Am J Roentgenol. 2002 Jul;179(1):118-120. 4. Jetty P, Barber GG. Aortitis and bilateral ureteral obstruction after endovascular repair of abdominal aortic aneurysm. J Vasc Surg. 2004 Jun;39(6):1344-1347. 5. Alomran F, de Blic R, Mallios A, et al. De novo periaortic fibrosis after endovascular aortic repair. Ann Vasc Surg. 2014 Feb;28(2):493 6. Goswami R, Rathod K, Coker J. Ureteric obstruction of solitary kidney following endovascular repair of infrarenal abdominal aortic aneurysm: a case report. Vasc Endovascular Surg. 2009 Jun-Jul;43(3):312-316.

Figures 1 and 2: Abdominal CT scan Discussion points: 1. What is the likelihood of this patient having cancer? 2. Are there any further useful investigations? 3. What management options are advisable? Case provided by Oliver Hakenberg, Department of Urology, Rostock University Hospital, Germany.

Readers are encouraged to provide interesting and challenging cases for discussion.

Case Study No. 42 continued Since the patient wanted a definitive solution without any stenting he underwent complete ileal substitution of both ureters with one 35 cm loop, which was anastomosed with its proximal end to the left renal pelvis, side-to-side with its middle portion to the right renal pelvis and with its distal end to the right bladder dome. Postoperative recovery was uneventful and the patient has been well since, with stable renal function as assessed by serume creatinine (around 140µmol/l). Sonographically, the right renal dilatation remains.

European Urology Today

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Key articles from international medical journals Prof. Truls Erik Bjerklund Johansen Section editor Oslo (NO)

tebj@medicin.uio.no

Efficacy of non-carbapenem antibiotics in treating community-onset acute pyelonephritis Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli has become an important cause of community-onset urinary tract infections. The authors aimed to evaluate the efficacy of non-carbapenem antibiotics for acute pyelonephritis (APN) due to ESBL-producing E. coli. They conducted a retrospective cohort study of patients with community-onset APN due to ESBLproducing E. coli at a single centre in Korea from 2007 to 2013. Outcomes included both microbiological and clinical failure. To adjust for non-random assignment of antibiotics, the propensity score method of inverse probability of treatment weighting and a multivariable analysis using Cox proportional hazards modelling were employed to estimate the efficacy of non-carbapenem antibiotics as compared with carbapenems. Of 152 eligible patients, 85 (55.9%) received carbapenems and 67 (44.1%) received noncarbapenems. Non-carbapenem antibiotics used in this cohort included aminoglycosides (n=30), beta-lactam/ beta-lactamase inhibitors (n=13), fluoroquinolones (n=12) and trimethoprim/sulfamethoxazole (n=5).

…their results suggest that noncarbapenem antibiotics were as effective as carbapenems as definitive therapy for treating community-onset APN caused by ESBL-producing E. coli if they are active in vitro Microbiological failure was observed in 16 patients receiving carbapenems (16/83, 19.3%) versus four patients receiving non-carbapenem (4/67, 6.0%). After weighing, the risk of microbiological failure was similar between the two groups [weighted hazard ratio (HR) 0.99; 95% CI 0.31–3.19]. In a multivariable regression analysis combined with weights, the estimate did not change (weighted adjusted HR 0.96; 95% CI 0.41–2.27). The clinical failure rate was also similar in the two groups (weighted HR 1.05; 95% CI 0.24–4.62).

Between 2007 and 2013, 237 patients (150 antimicrobially-naive and 87 antibiotically pretreated) with acute epididymitis underwent comprehensive investigation comprising microbiologic cultures, polymerase chain reaction (PCR) for sexually transmitted infections (STIs), 16S ribosomal DNA (rDNA) analysis, and PCR detection of 23 viruses. Clinical management followed international guidelines.

… even in antimicrobially pretreated patients, acute epididymitis is mainly of bacterial origin. STIs are not limited to patients aged <35 years Aetiology, clinical management, and outcome after three months were assessed. A causative pathogen, predominantly Escherichia coli (56%), was identified in 132 antibiotic-naive patients (88%) and 44 pre-treated patients (51%); 16S rDNA analysis increased the detection rate by 10%. STIs were present in 34 cases (14%) (25 patients with Chlamydia trachomatis) and were not restricted to a specific age group. Enteroviruses were found in only two patients (1%). In naive patients, cultured bacteria were susceptible to fluoroquinolones and group 3 cephalosporins in >85% of cases (preateted patients: 42% and 67%, respectively). Primary empirical therapy was continued in 88% of naive patients for 11 days and in 77% of pretreated patients for 13 days with indwelling urinary catheters, rendering patients as high-risk for switching. Only six patients (2.5%) underwent semi-castration. Prostatespecific antigen levels halved within three months, except in patients who were antibiotic-naive and without detected pathogens. Study limitations included a lack of susceptibility testing in cases of STIs. The authors concluded that even in antimicrobially pretreated patients, acute epididymitis is mainly of bacterial origin. STIs are not limited to patients aged <35 years. Viral epididymitis seems a rare condition. Current guideline recommendations on empirical antimicrobial therapy are adequate.

Source: Acute Epididymitis Revisited: Impact of Molecular Diagnostics on Etiology and Contemporary Guideline Recommendations. Pilatz A, Hossain H, Kaiser R, et al. Eur Urol. 2014 Dec 23. pii: S0302-2838(14)01260-3. [Epub ahead of print]

Impact of biofilm-producing bacteria on chronic bacterial prostatitis treatment The authors aimed to evaluate the role of biofilmproducing bacteria in the clinical response to antibiotic therapy among patients affected by chronic bacterial prostatitis (CBP).

All patients attending the centre for chronic bacterial prostatitis from January to December 2008 due to The authors concluded that their results suggest that prostatitis-like symptoms with a positive Meares– non-carbapenem antibiotics were as effective as Stamey test were enrolled. The clinical symptoms carbapenems as definitive therapy for treating were assessed according to the NIH-CPSI, and the community-onset APN caused by ESBL-producing E. bacterial strains isolated from the patients enrolled coli if they are active in vitro. were identified and tested for antibiotic sensitivity using cards of the Vitek II semi-automated System for Microbiology (BioMerieux). Quantitative bacterial Source: The efficacy of non-carbapenem antibiotics for the treatment of community-onset slime production was assessed by the Christensen acute pyelonephritis due to extended-spectrum microwell assay. All patients were treated with fluoroquinolones for four weeks and reevaluated beta-lactamase-producing Escherichia coli. clinically and microbiologically after three months. Park SH, Choi SM, Chang YK, et al. J Antimicrob Chemother 2014; 69(10):2848–2856.

Acute epididymitis: Impact of molecular diagnostics on etiology and guideline recommendations

…in their CBP population, biofilmproducing bacteria were commonly found and had a significant negative impact on the clinical response to antibiotic therapy

Acute epididymitis is a common infectious disease of unknown aetiology in about 30% of cases with guidelines based on studies published >15 years ago. The objective of this study was to investigate the aetiology of acute epididymitis using state-of-the-art methods and to provide rational data for antimicrobial therapy and clinical management.

One hundred and sixteen patients were enrolled, and 150 bacterial strains were isolated from all patients. About 85 % of these strains were strong or moderate biofilm producers. Patients with strong or moderate biofilm-producing bacteria had a higher NIH-CPSI symptom score than those without biofilm-producing bacteria (mean 17.6 ± 5.6 vs. 14.1 ± 3.3; p = 0.0009). At

Key articles

12

the follow-up, 68 patients (58.6 %) had negative microbiological tests, but only 11 (9.48 %) reported a reduction in NIH-CPSI score. Improvement of symptoms was found statistically significantly less frequent in patients with biofilmproducing bacteria than in those without (p = 0.03). Ultra-structural analysis showed cellular forms in active replication with aberrant morphology of unknown cause and confirmed strong slime production with consistent bacterial stratification. The authors concluded that in their CBP population, biofilm-producing bacteria were commonly found and had a significant negative impact on the clinical response to antibiotic therapy.

Source: The impact of biofilm-producing bacteria on chronic bacterial prostatitis treatment: results from a longitudinal cohort study. Riccardo Bartoletti R, Tommaso Cai T, Gabriella Nesi G, et al. World J Urol. 2014 Jun;32(3):737-42.

Partial nephrectomy in older patients: Does it add anything? Partial nephrectomy (PN) is currently the recommended treatment for renal cell carcinoma (RCC), when technically feasible. It is accepted that radical nephrectomy (RN) increases the risk of chronic kidney disease (CKD), which increases the probability of cardiovascular events and contributes to higher rates of non-cancer related death. However, data about overall survival (OS) is still controversial. Indeed, the randomised phase III EORTC study showed similar outcomes for both approaches. There appears to be no increased risk of either kidney failure or death amongst individuals donating kidneys. Furthermore, it remains unclear how the balance of risks and benefits might be affected in elderly patients with limited life expectancy. This study compared OS and renal function after RN and PN in patients aged ≥65 years. Data from 3567 patients treated from 1999–2011 in one of five institutions in Korea was collected. Patients with solitary kidney, bilateral RCC, stage pT2 or greater cancer, lymph node or distant metastases, preoperative hemodialysis, or preexisting stage IV CKD (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2) were excluded.

…this data should help inform patient discussions especially if complex tumour anatomy or co-morbidities would increase the risks associated with PN To account for inherent differences among patients undergoing RN and PN, such as baseline characteristics or uneven patient distribution between the two groups, they used 1:1 propensity score matching to adjust for age, sex, BMI, tumour size, Fuhrman grade, comorbidities (diabetes, hypertension), ECOG performance status and preoperative nutritional status (albumin and haemoglobin levels), and kidney function (preoperative eGFR). This left 622 propensity-score matched patients who underwent RN and a corresponding 622 PN patients. To investigate the affect of age, a cut off of 65 years was used which left 170 patients in each arm for this subgroup analysis. As might be expected in this cohort of patients with a median follow-up of 48 months for the RN patients and 41 months for the PN patients, the number of events was small. However, this was sufficient to demonstrate a significant benefit in five-year OS rates for PN in the under 65 cohort (99.7% vs 96.3%; p=0.015). In the older group this effect disappeared (94.7% vs 91.9%; p-0.698) and there was also no detectable benefit in terms of cancer-specific survival or recurrence-free survival. Kidney function was significantly better preserved in the PN arm but the rate of CKD IV was no different between the groups (p=0.7555) and none of the patient developing CKD IV required dialysis.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com It has been previously shown that recovery of renal function after RN is less likely after age of 70 years and on that basis this group expected the benefits of PN to be more obvious in the elderly patients. Instead, they suggest the negative effect of decreased post-operative kidney function on survival may be smaller than expected. This is not a reason to avoid PN in patients over the age of 65 years especially as many small incidental lesions have a reasonable probability of being benign. However, this data should help inform patient discussions especially if complex tumour anatomy or co-morbidities would increase the risks associated with PN.

Source: Overall survival and renal function after partial and radical nephrectomy among older patients with localised renal cell carcinoma: A propensity-matched multicentre study. Chung JS, Son NH, Lee SE, Hong SK, Lee SC, Kwak C, Hong SH, Kim YJ, Kang SH, Byun S-S. European Journal of Cancer 2015; 51: 489-97.

When should we start ADT after biochemical failure? The optimal timing of androgen deprivation therapy (ADT) in patients that present with a biochemical relapse following attempted curative treatment for apparent localised prostate cancer is unclear. Patients are anxious as they realise their condition although they have no symptoms; and current imaging can’t detect a tumour even though it is likely they are carrying a small focus of prostate cancer. The initiation of ADT is associated with a decrease on quality of life, increased risk of metabolic syndrome and associated cardiovascular risk plus the development of osteoporosis and the loss of cognitive function. Not all of these men will need treatment whilst a few will have aggressive disease and would benefit from the commencement of ADT prior to the development of symptomatic disease. This study extracts information from a prospectively collected database to try and help answer the question: “When to start ADT therapy in PSA-only relapsed patients?” Using the CaPSURE registry of over 14,000 consecutive men with biopsy-proven prostate cancer, they selected men with ≤cT3a, N0, M0 who had primary treatment with either radical prostatectomy or radiotherapy and a subsequent PSA relapse. They compared two dynamic PSA-based strategies: ADT initiation at PSA relapse (immediate initiation) and ADT initiation at disease progression (deferred initiation). ADT was defined as the use of any LHRH-agonist or orchiectomy and progression as cancer relapse based on any imaging technique, severe cancer-related symptoms (fatigue, bone pain, weight loss or anorexia), a PSA doubling time <12 months for PSA ≥10 ng/mL, or PSA doubling time ≤6 months based on three consecutive measurements obtained ≥2 months apart.

This study suggests no survival benefit for immediate ADT initiation compared with deferred for patients with biochemical-only relapse Of 2,096 eligible patients who had relapsed by PSA criteria (median age 69, interquartile range 63–75 years), 88% were white, 35% had a Gleason score ≥7, 69% were treated with radical prostatectomy and 31% received radiotherapy only as primary treatment. The mean time from primary treatment to PSA relapse

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Dr. Francesco Sanguedolce Section editor London (UK)

endpoint was overall survival with secondary endpoints of progression free survival; the proportion of patients who achieved an objective response and safety.

fsangue@ hotmail.com

Toxicity was higher in the lenalidomide group although there was no increased mortality associated with the toxic effects of the combination

was 37.4 (SD 34.2) months. Mean follow-up from primary treatment was 91.4 (SD 48.4) months. Progression occurred in 337 patients: 86 developed symptoms, 226 had progression based on imaging techniques and 92 had short PSA doubling time. 473 patients initiated ADT during the follow-up. The adjusted mortality hazard ratio for immediate versus deferred ADT was 0.91 (CI: 0.52–1.60), which would be translated into a similar five-year survival (difference between groups: -2.0% (CI: -10.0 to 5.9%).
 At 10 years, the survival difference was 0.5% (CI: -16.7% to 17.6%). There were few prostate cancer-specific deaths during the period of follow-up This study suggests no survival benefit for immediate ADT initiation compared with deferred for patients with biochemical-only relapse. It is an observational study and so the results of the on-going randomized study (NCT00110162) may yet show an advantage, but at this time it would suggest the majority of men with biochemical recurrence should be reassured and monitored, and ADT should only be initiated if there is clinical or radiological evidence of recurrence.

Source: Immediate versus deferred initiation of androgen deprivation therapy in prostate cancer patients with PSA-only relapse. An observational follow-up study. Garcia-Albeniz X, Chan JM, Paciorek A, Logan RW, Kenfield SA, Cooperberg MR, Carroll PR, Hernan MA. European Journal of Cancer (2015) http://dx.doi. org/10.1016/j.ejca.2015.03.003.

Combination chemotherapy for mCRPC fails again? Despite case finding, early treatment and a raft of new drugs in 2013, 92,237 men are thought to have died of metastatic castration resistant prostate cancer (mCRPC) in Europe alone. Although the vast majority of prostate cancers respond to androgen deprivation initially with time, patients become refractory to castration. In 2004 docetaxel became the first chemotherapeutic agent to show a survival advantage in patients with mCRPC. Preclinical studies have shown that immunomodulatory drugs are anti-angiogenic and potent immunomodulators. In prostate cancer trials, thalidomide showed improved survival and encouraging decreases in PSA when used as a monotherapy and in combination with docetaxel. Lenalidomide is a thalidomide derivative, which has proven effectiveness in multiple myeloma. It has been shown to enhance the anti-prostate cancer activity of docetaxel in a mouse xenograft model and in clinical studies it showed immunomodulation in patients with solid tumours. Phase 1 and 2 clinical trials with lenalidomide as a monotherapy and in combination with other agents provided evidence of activity in patients with advanced prostate cancer. A reduction in PSA progression of more than 50% was reported in almost a quarter of patients with metastatic castration-resistant prostate cancer when treated with lenalidomide. It led to stable disease in more than two-thirds of patients with solid tumours, including those with metastatic castration-resistant prostate cancer in one study, and in just fewer than threequarters of patients with metastatic castrationresistant prostate cancer in another. As a consequence the phase 3 MAINSAIL study was initiated to assess the efficacy and safety of lenalidomide versus placebo in combination with docetaxel and prednisone in chemotherapy-naïve patients with mCRPC. 1,059 patients were enrolled and randomly assigned between November 2009 and November 2011 (533 to the lenalidomide group and 526 to the control group). All patients received intravenous docetaxel (75 mg/ m2) on Day One of each cycle plus prednisolone 5mg twice daily on Days 1-21. Patients were then randomized in 1:1 ratio to either placebo or lenalidomide 25 mg/day on Days 1-14. The primary Key articles

March/May 2015

A total of 1,046 patients received study treatment (525 in the lenalidomide group and 521 in the placebo group). At data cutoff (13/1/12) after a median follow-up of 8 months (IQR 5–12), 221 patients had died: 129 in the lenalidomide group and 92 in the placebo group. Median overall survival was 17·7 months (CI 14·8–18·8) in the lenalidomide group and not reached in the placebo group (HR 1·53, CI 1·17–2·00, p=0·0017). The trial was subsequently closed early due to futility. The number of deaths that occurred during treatment or less than 28 days since the last dose were similar in both groups (18 [3%] of 525 patients in the lenalidomide group vs 13 [2%] of 521 patients). 109 (21%) patients in the lenalidomide group and 78 (15%) in the placebo group died more than 28 days from last dose, mainly due to disease progression. Adverse events are shown in the table below. Lenalidomide plus Docetaxel and pred

Docetaxel and pred

Grade 3+ neutropenia

114 (22%)

85 (16%)

Febrile neutropenia

62 (12%)

23 (4%)

Diarrhoea

37 (7%)

12 (2%)

pneumonia

24 (5%)

5 (1%)

Dyspnoea

22 (4%)

9 (2%)

Asthenia

27 (5%)

17 (3%)

Pulmonary embolism

32 (6%)

7 (1%)

Despite a number of encouraging early phase studies suggesting docetaxel-based combination therapy could potentially improve survival, there remains no combination that improves overall survival. Lenlidomide joins bevacizumab, aflibercept and zibotentan as another blind ending in the search for combination chemotherapy for mCRPC. Toxicity was higher in the lenalidomide group although there was no increased mortality associated with the toxic effects of the combination. Moving chemotherapy earlier in the disease pathway may improve result but we are no closer to developing docetaxel-based combination therapy.

Source: Docetaxel and prednisone with or without Lenalidomide in chemotherapy-naïve, patients with metastatic castration-resistant prostate cancer (MAINSAIL): a randomised, double-blind, placebo- controlled phase 3 trial. Petrylak DP, Vogelzang NJ, Budnik N, Wiechno PJ, Sternberg CN, Doner K, Bellmunt J, Burke JM, de Olza MO, Choudhury A, Gschwend JE, Kopyltsov E, Flechon A, Van As N, Houede N, Barton D, Fandi A, Jungnelius, U, Li S, de Wit R, Fizari K. Lancet Oncol 2015; 16: 417-25.

Erectile function after radical prostatectomy: Robot might do a better job At least two randomized trials have suggested the superiority of robot-assisted laparoscopic radical prostatectomy (RALP) over pure laparoscopic procedure regarding the erectile function preservation. Systematic reviews and large population-based data tended to show benefits favoring laparoscopy regarding hospital stay, transfusion and overall complication rates. However, no high level of evidence data was available.

with RRP. In this article, the authors focused on functional outcomes.

Mr. Philip Cornford Section editor Liverpool (GB)

Fourteen centers included 2,625 patients during a three-year period (1847 RALP, 778 RRP). The primary endpoint was urinary incontinence 12 months after surgery, assessed by the need for pads, and a 39-item questionnaire about urinary function. The secondary endpoint was the self-reported erectile dysfunction using the IIEF score. Neurovascular bundle preservation was performed in 84% of RALP patients compared with only 68% of RRP patients (p < 0.001). However, bilateral preservation rate was comparable in both groups (46% versus 44.7%). Lymph node dissection was more frequently performed in RRP arm (27% versus 13%). There was no significant difference between groups regarding frequencies of treatment with radiation or androgen deprivation therapy. Positive margin rate was comparable between both groups.

The improvement was small, but significant and persisted after using various definitions of erectile dysfunction and after adjustments No statistically significant difference for any urinary incontinence definition was reported between both groups, even after adjustment for possible confounders. Regarding erectile function, RALP was modestly beneficial in preserving it compared with RRP. Overall, erectile dysfunction was reported in 70% of men undergoing RALP compared with 75% after RRP. After adjustment for age, pathological variables and the degree of neurovascular bundle preservation, the odd ratio for erectile dysfunction was 0.75 (95% CI 0.58-0.96), meaning that the risk of erectile dysfunction was reduced by 25% by RALP. The strengths of this study are the prospective controlled design, the sample size, the short inclusion period, and the low number of missing data. Validated questionnaires were also used for endpoints assessment. Unfortunately, case volume of each institution and surgeon experience were not taken into account while both factors are extremely linked to functional outcomes after radical prostatectomy. However, given the good methodology of this study and the other compiling data available, RALP seemed to improve erectile function preservation. It makes sense that the instrument dexterity and the improved vision provided by the robotic assistance facilitate nerve preservation and peri-prostatic tissues. The improvement was small, but significant and persisted after using various definitions of erectile dysfunction and after adjustments.

Source : Urinary Incontinence and Erectile Dysfunction after robotic versus open radical prostatectomy: A prospective, controlled, nonrandomised trial. Haglind E, Carlsson S, Stranne J, et al. Eur Urol 2015 http://dx.doi.org/10.1016/j. eururo.2015.02.029

When to start chemotherapy after radical cystectomy for locally advanced or positive node bladder cancer: Results from a phase 3 trial While the benefit of neoadjuvant chemotherapy is proven by high level of evidence studies, the number of patients who don’t receive this regimen before radical cystectomy remains significant. In these patients, in case of adverse pathology features, we cannot state when to start postoperative chemotherapy. High level of evidence is lacking. Thus, the choice between adjuvant chemotherapy and deferred treatment at the time of recurrence remains debatable.

In this randomized controlled trial driven by the EORTC, patients without preoperative chemotherapy and who exhibited a pT3-T4 and/or pN+ M0 bladder In Sweden, a prospective, controlled, non-randomized cancer on radical cystectomy specimens were assigned to immediate or to deferred chemotherapy. trial in which the intervention was RALP and the Overall, 284 patients were enrolled in six years. control was retropubic radical prostatectomy (RRP) was initiated in 2008 (LAPPRO study). The short-term Immediate chemotherapy consisted in four cycles and was given within the three months of cystectomy results of this trial have yet demonstrated longer operative time, less blood loss and complications, and (median time from surgery to randomization: 63 days). Allowed regimens were MVAC, high-dose shorter length of hospital stay for RALP compared

philip.cornford@ rlbuht.nhs.uk

MVAC, or gemcitabine plus cisplatin. Gemcitabine plus cisplatin was given to 85% of all patients. The primary endpoint was overall survival (52% of deaths at the end of follow-up). Analyses were stratified by institution, pT and pN statuses. The median follow-up was seven years. The study was originally designed to detect an increase of 7% in five-year overall survival in the immediate chemotherapy arm.

…sub-groups analysis revealed that immediate chemotherapy might extend overall survival in patients without lymph node metastasis Both arms were well balanced, with comparable rates of pN+ disease (70%). No significant difference regarding overall survival was reported at final analysis (47% versus 57% of deaths, p = 0.13). Nevertheless, survival curves looked quite different when illustrated by the Kaplan-Meier model. This not statistically significant trend could be explained by the lack of power. Indeed, because of poor accrual, the study was closed prematurely (initial estimated ample size: 1344 patients). Interestingly, sub-groups analysis revealed that immediate chemotherapy might extend overall survival in patients without lymph node metastasis. The duration of survival after progression was significantly longer in the deferred treatment, meaning that salvage chemotherapy at recurrence was less active when adjuvant chemotherapy was previously given. Secondary endpoints favored immediate chemotherapy versus deferred treatment. Immediate chemotherapy significantly prolonged the five-year progression-free survival compared with deferred treatment (48% versus 32%, p < 0.0001). Interestingly, chemotherapy was better tolerated when given in the adjuvant setting. High-grade myelosuppression was more frequently reported in the deferred chemotherapy arm. Thus, although improvement in overall survival by immediate chemotherapy was not significant and could not be definitively proven, post-hoc exploratory analyses and secondary endpoints assessment tended to suggest a benefit from immediate treatment, at least in patients without lymph node involvement. Confirmation by individual patient data meta-analysis including all published randomized trials is awaited.

Source: Immediate versus deferred chemotherapy after radical cystectomy in patients with pT3-pT4 or N+ M0 urothelial carcinoma of the bladder (EORTC 30994): an intergroup, open-label, randomised phase 3 trial. Sternberg CN, Skoneczna I, Kerst JM, et al. Lancet Oncol 2015;16:76-86 .

Sexually transmitted infections, benign prostatic hyperplasia and lower urinary tract symptom-related outcomes The exact pathogenesis of benign prostatic hyperplasia (BPH) and related lower urinary tract symptoms (LUTS) remains unclear; however evidence supports a role of inflammation. One possible source of prostatic inflammation is sexually transmitted infections (STIs), which have been found to be positively related to LUTS in some mostly small case-control studies or cross-sectional surveys. The objective of this analysis is to examine whether a history of STIs or positive STI serology is associated with prevalent and incident BPH/LUTS-related outcomes in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO). Self-reported history of STIs (gonorrhea, syphilis) was ascertained at baseline, and serological evidence of STIs (Chlamydia trachomatis, Trichomonas vaginalis,

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Prof. Oliver Hakenberg Section Editor Rostock (DE)

baseline, or occurrence of urinary incontinence, or acute urinary retention (AUR). Baseline clinical parameters including concomitant medication use were determined. Kaplan-Meier curves and multivariate Cox proportional hazard models were used to determine risk for progression.

Inflammation as measured by CD45, CD4, and CD68 increased risk for clinical progression of BPH. CD4 showed the highest risk where men in the highest tertile of moderate/severe inflammation were at twice the risk of progression compared to men in the lower two tertiles combined [Hazard ratio (HR)=2.03, p = HPV-16, HPV-18, HSV-2, HHV-8, and CMV) was detected in baseline serum specimens. Data was 0.001]. Inflammation was more strongly associated collected on a baseline questionnaire, as well as with progression defined by AUR or incontinence [HR results from baseline PSA test and digital rectal exam ranging from 2.39 (CD8, p = 0.03) to 3.08 (CD4, p = 0.01] than an AUA-SS increase (CD4: HR=1.86, p = (DRE), to define prevalent BPH/LUTS-related outcomes as evidence of LUTS (self-reported diagnosis 0.01). Men who reported use of NSAIDs or steroids at of an enlarged prostate/BPH, BPH surgery, or nocturia baseline tended to be at higher risk for progression. (waking ≥ 2 times/night to urinate)) and evidence of prostate enlargement (PSA >1.4 ng/mL or prostate Although the data show that inflammation increases volume ≥ 30 cc). the risk of progression, the findings suggest that inflammation plays a greater role in men who have conditions requiring anti-inflammatory medications. Oliver.Hakenberg@ med.uni-rostock.de

Generally null results were observed for a self-reported history of STIs and positive STI serologies with prevalent and incident BPH/LUTSrelated outcomes, with the possible exception of T. vaginalis infection The authors created a similar definition of incident BPH using data from the follow-up questionnaire completed five to13 years after enrolment (selfreported diagnosis of an enlarged prostate/BPH or nocturia), data on finasteride use during follow-up, and results from the follow-up PSA tests and DREs. Poisson regression with robust variance estimation was used to calculate prevalence ratios (PRs) in our cross-sectional analysis of self-reported (n=32,900) and serologically-detected STIs (n=1,143) with prevalent BPH/LUTS, and risk ratios in our prospective analysis of self-reported STIs with incident BPH/LUTS (n=5,226). Generally null results were observed for a selfreported history of STIs and positive STI serologies with prevalent and incident BPH/LUTS-related outcomes, with the possible exception of T. vaginalis infection. This STI was positively associated with prevalent nocturia (PR 1.36, 95% confidence interval (CI): 1.18-1.65), prevalent large prostate volume (PR 1.21 95% CI 1.02-1.43), and any prevalent BPH/LUTS (PR 1.32 95% CI 1.09-1.61). The authors concluded that their findings do not support associations of several known STIs with BPH/ LUTS-related outcomes.

Source: Prostate biopsy markers of inflammation are associated with risk of clinical progression of benign prostatic hyperplasia: Findings from the MTOPS Study. Torkko KC, Wilson RS, Smith EE, Kusek JW, van Bokhoven A, Lucia MS. J Urol. 2015 Mar 28. pii: S0022-5347(15)03572-7. doi: 10.1016/j.juro.2015.03.103. [Epub ahead of print]

Characteristics of men undergoing testosterone replacement therapy and adherence to follow-up recommendations This trial sought to identify the frequencies of treatment and recommended laboratory follow-up for men with low serum testosterone levels. The Electronic Data Warehouse was queried to identify men of ages 18-85 years, who obtained a testing for serum total testosterone level from 2009 to 2012. The frequency of testosterone replacement therapy (TRT), patient demographics, and clinical characteristics were collected. The frequency of follow-up with serum total testosterone and complete blood count levels was documented.

A significant proportion of men of reproductive age are being treated with significant impacts on potential fertility. Less than half of the patients treated are being monitored appropriately after testosterone replacement

Source: Sexually transmitted infections, benign prostatic hyperplasia and lower urinary tract symptom-related outcomes: Results from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Breyer BN, Huang WY, Rabkin CS, Alderete JF, Pakpahan R, Beason TS, Kenfield SA, Mabie J, Ragard L, Wolin KY, Grubb Iii RL, Andriole GL, Sutcliffe S. Among 9176 men who underwent testing for low BJU Int. 2015 Jan 20. doi: 10.1111/bju.13050.

Prostate biopsy markers of inflammation linked to risk BPH clinical progression Factors associated with worsening of benign prostatic hyperplasia (BPH) are not well understood. The investigators measured inflammatory markers from prostate biopsies to study if inflammation is related to BPH clinical progression.

…the findings suggest that inflammation plays a greater role in men who have conditions requiring anti-inflammatory medications The authors measured inflammatory cell markers CD45, CD4, CD8, and CD68 in transition zone biopsies from 859 men in the Medical Therapy of Prostatic Symptoms (MTOPS) biopsy sub-study. Using novel imaging techniques, they quantified amounts of moderate/severe inflammation. BPH clinical progression was defined as a confirmed ≥4 point increase in the AUA Symptom Score (AUA-SS) from Key articles

14

testosterone levels, 3320 (36%) of them were hypogonadal with a mean serum total testosterone level of 194.3 ± 64.9 ng/dL. Of them, 17.7% men were treated with TRTs. The treatment frequency significantly increased from 8.3% in 2009 to 24% in 2012. A total of 4.8% of men of reproductive ages (age, 18-35 years) were placed on TRTs. Within 180 days of initial testing, only 40% of treated men received follow-up with liver function tests and/or complete blood count, and only 49% had a follow-up serum testosterone level. Although the frequency of TRT is increasing, only a small percentage of hypogonadal men are actively undergoing treatment. A significant proportion of men of reproductive age are being treated with significant impacts on potential fertility. Less than half of the patients treated are being monitored appropriately after testosterone replacement. This highlights the importance of further education for providers prescribing testosterone replacement.

Percutaneous and laparoscopic cryoablation for small renal masses Focal therapy for small renal masses (SRM) is becoming more and more a hot topic in urology. Expanding worldwide experience, improvement of technology and technique are reflected by a significant increase of publications. In particular, the development of manoeuvres for the displacement of surrounding organs/structures off the targeted lesions – like the infusion of fluid or gas has increased interest on Percutaneous Cryotherapy (PCA) as a possible alternative to Partial Nephrectomy (PN) and Observation at the expense of the Laparoscopic Cryotherapy (LCA) and Radiofrequency Ablation (RFA). The main advantages are the minimal invasiveness, the possibility to perform it under local or regional anaesthesia and less risk for complication combined with similar oncological and functional outcomes provided by the other ablation techniques. A recent collaborative review published by leading experts on cryoablation (CA) has been focused on selection criteria, complications, and functional and oncologic results retrieved only from high-volume series (>100 patients). Main indications for CA highlighted by the authors included patients not suitable for surgical approach, previous renal procedures and patient choice; authors also mentioned additional data from small single institutions suggesting a possible indication for PCA in the treatment of oligometastatic renal cell carcinoma (RCC) as part of a multimodal or palliative approach. In terms of complications, overall rates for CA have been reported as from 7.8 to 20%; however, complication rates for PCA are lower than those documented for LCA (7.8-12.9% vs 15-20%), even though this difference does not involve the rate for major complications (Clavien≥ 3) where the figures are similar for both PCA and LCA. Bleeding has been the most common complication reported for PCA.

More robust data are needed to support the use of cryotherapy as a valid alternative to PN and observation in selected patients

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikummuenchen.de All together, these data need to be carefully considered since case selection is a major bias that may play a significant role in the results published. More robust data are needed to support the use of cryotherapy as a valid alternative to PN and observation in selected patients; PCA is gaining more popularity by providing similar oncological outcomes to LCA with (likely) less risk for complications and a more cost-effective use of cryoablation.

Source: Cryoablation for small renal masses: Selection criteria, complications, and functional and oncologic results. Zargar H, Atwell TD, Cadeddu JA, de la Rosette JJ, Janetschek G, Kaouk JH, Matin SF, Polascik TJ, ZargarShoshtari K, Thompson RH. Eur Urol. 2015 Mar 25. [Epub ahead of print]

Metabolic evaluation and recurrence prevention for urinary stone patients: EAU Guidelines The EAU Guidelines Panel on Urolithiasis has recently published a review to provide a strategy for the management of patients affected by urinary stones (either first-time or recurrent stone formers) after stone passage/clearance. The report was based on data extracted from a revision of literature conducted through the Cochrane, Medline and Embase databases; according to the quality of data extracted, the authors provided recommendations for specific actions assigning a relevant Grade of Recommendation.

After stone passage, all patients should undergo a basic evaluation which include stone analysis if available/possible (infrared spectroscopy or X-ray diffraction), medical history (stone history, dietary habits, medication chart), diagnostic imaging Different methods in different settings of patients have (ultrasound +/− CT KUB), blood analysis (creatinine, calcium, uric acid) and urinalysis (dipstick and urine been used to evaluate functional outcomes when comparing LCA and PCA. Anyway, in no case there has culture). there been a significant difference in the decline of This basic evaluation should help practitioners in renal function with respect to baseline and between categorising patients in low- and high-risk stone the two different approaches; similar results have been reported also when comparing ablative against formers. The authors provided a list of factors and conditions for patients to be classified as high-risk extirpative nephron-sparing approaches. stone formers; unfortunately, most of these factors/ conditions are relatively uncommon or hard to identify The main problems for CA are the evaluation of the with only the aid of basic evaluation. Also, they might oncologic outcomes; most of the series include outcomes with patients without a biopsy-proven RCC not necessarily have the same weight or impact in the likelihood patients develop further stones; but or benign lesions in the evaluation of the survival rates. Moreover, definition of treatment success has probably the lack of robust evidences in literature can been variably adopted and only more recently has make this kind of distinction difficult. been standardised with the absence of tumour enhancement or enlargement at three-month CT scan In the case of low-risk stone formers, a list of general post-ablation. Finally, survival rates are altered by the measures for prevention were provided and included patient selection bias, as patient and tumour drinking, nutritional and lifestyle advices. characteristics vary significantly across the subgroups of patients treated with the different approaches in …regardless of the limitations the different series. Follow up for LCA are generally longer than PCA, but long-term follow-up data are limited across all CA series. Recurrence-free survival rates for PCA range from 93% at two-year follow-up to 87% at 30-month follow-up, whilst for LCA the ranges were reported to be among 81% at five-year estimated follow-up, to 89% at 44 months of follow-up. In a comparative series, no difference of recurrence-free survival was showed between LCA and PCA.

Other retrospective studies investigated oncological outcomes comparing CA versus PN (robotic/open/ Source: Characteristics of men undergoing laparoscopic) and results showed a higher risk for CA testosterone replacement therapy and adherence of developing disease recurrence even when to follow-up recommendations in Metropolitan adjusting for patient and tumour characteristics. Multicenter Health Care System. Malik RD, Wang Cost-analysis studies showed that both LCA and PCA CE, Lapin B, Lakeman JC, Helfand BT. were both more cost-effective than RFA because of Urology.2015 Apr 7. pii: S0090-4295(15)00106-5.doi: higher risk of retreatment for the latter; on the other 10.1016/j.urology.2015.01.027. [Epub ahead of print] hand, PCA was found to be less expensive than LCA at 3.5 times in average.

implied in the paper, it is obvious that the main problem to provide strong recommendations consists in the lack of robust evidence in literature.

In the case of high-risk stone formers, patients are included in a specific group according to the stone composition and relevant therapeutic/prevention algorithms have been proposed. The authors recommend for all these patients a specific metabolic evaluation by two consecutive 24-urine samples analysis to be done minimum 20 days after the stone passage/removal; they also recommend to perform the metabolic evaluation ideally when patients are stone-free, even though in clinical practice it is not unusual to find patients with multiple stones at presentation or after stone passage/clearance.

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There are two arguments that may be raised at this point: 1) not always stones or fragments are available for analysis; 2) most of stones have a hybrid composition. In both conditions it is hard to clearly include a patient in one of the identified groups, and the subsequent algorithms recommended for follow-up and treatment might not entirely be applicable in clinical practice. Moreover, stone composition can change in the medical history of the stone former patients, making even more difficult the categorisation of the patients in a given group.

procedures were performed in prone position; no details are provided in terms of number and location of the stones.

Regardless the algorithms proposed, the authors have highlighted that the levels of evidence supporting these recommendations are low, particularly when it comes to the treatment and strategy for prevention. The strongest evidences have been identified in the effectiveness of thiazides in decreasing calciuria and in preventing calcium stone recurrence from randomised controlled trials and a subsequent meta-analysis.

However, the authors demonstrated a significant lower cost for UMP than fURS which requires more expensive disposables (ureteral access sheath, basket, etc); moreover, flexible ureteroscopes are affected by a limited durability which increases the average cost of this reusable device prior to repair or substitution.

Weaker evidences have been identified in support for the use of alkaline citrates for the prevention of nonselective calcium oxalate stone formers and in patients with hypocitraturia, and in support for the use of allopurinol for hyperuricosuric calcium oxalate stone formers without other metabolic abnormalities. In the other setting of patients, the authors have recognised the need for more robust evidences to support their recommendations. The EAU Guidelines Panel in Urolithiasis needs once again to be congratulated for their effort to provide standardised guidance in the management of stone patients. Regardless of the limitations implied in the paper, it is obvious that the main problem to provide strong recommendations consists in the lack of robust evidence in literature. Aetiology of stone formation is still not fully understood and this is the main cause affecting the management of stone former patients and, in particular, to what corresponds to the correct diagnostic processes and algorithms for prevention.

No significant differences were found for the variables in observation, even though several parameters have not been reported: there is no description of the definition of the stone-free rate, and there is no explanation on how and when the patients were evaluated in the follow-up and which complications were recorded.

On the other hand, it is not clear how long the life-span of a UMP is, since details on this regard have not been published. Even though the paper is very interesting in providing more information about feasibility, efficacy, safety and cost-effectiveness of UMP, there are several limitations across the paper that minimise the level of evidence provided. Moreover, UMP is more likely to be effective in case of solitary stone or multiple stones in the same calyx; navigation in the rest of the collecting system is almost impossible, so the surgeon should be highly skilled in performing the puncture exactly in the targeted calyx.

Source: Metabolic evaluation and recurrence prevention for urinary stone patients: EAU Guidelines. Skolarikos A, Straub M, Knoll T, Sarica K, Seitz C, Petrík A, Türk C. Eur Urol. 2015;67(4):750-63.

World J Urol. 2015 Jan 23. [Epub ahead of print]

Mini-Perc: A new way to go?

Renal diagnoses after living kidney donation

Ultra-miniPerc (UMP) is one of the latest variants introduced in endourology on this regard: it consists of a 6 Fr mini-nephroscope which is introduced through an 11–13 Fr metal sheath to perform holmium:YAG laser lithotripsy. The tract is obtained as usual for any PCNL but dilating the tract only until 14 Fr with PTFE dilators or hydraulic balloon dilation. The instrument involves a 3.5 Fr scope, one working channel connected to two separate exits –one to attach the irrigation fluid and another one to accommodate the laser fibre. The system does not allow the extraction of fragments, except by draining the stone fragments through the working channel, thanks to the whirling effect produced with the irrigation fluid or by simple gravity; as it is easily understandable, a key part of the procedure is the adequate fragmentation of the stone with the laser.

UMP is more likely to be effective in case of solitary stone or multiple stones in the same calyx A retrospective study has been recently conducted in two tertiary European centres (Freiburg and Royal London Hospital) by matching 30 consecutive UMP to 30 historical fURS performed on patients with renal stones between 10-20 mm; the authors compared the two groups in terms of patients and stones characteristics, surgical outcomes, complication rate and need of ancillary procedures. Interestingly they also evaluated the costs associated to each procedure by calculating the expenses for the disposable devices and the average cost of the reusable devices weighted by the volume of procedures performed in each centre. All the UMP

Long-term graft function can be predicted by early renal scintigraphy but not by the resistive index The value of renal transplant scintigraphy and sonographic measurement of the resistance index (RI) in the assessment of renal graft function is well known. The aim of this study was to evaluate the predictive value of renal transplant scintigraphy and RI for long-term graft function.

Scintigraphy seems to be of higher predictive value than Doppler sonography and measuring the RI… A total of 119 patients were analysed retrospectively. Renal transplant scintigraphy with technetium Tc 99 mDTPA and color Doppler ultrasonography for RI were performed in all patients within two days after transplantation. Resistance index and the results of the tests in perfusion/renographic curve analysis of scintigraphy were compared with the serum

creatinine (sCr) levels at three months, one year, and five years after transplantation. A sCr level of more than 1.5 mg/dL was considered abnormal. Differences of the mean values of T½ of graft washout (GW½), time difference between peak renal perfusion and arterial count (ΔP), and accumulation index (R20/3) were significantly higher in patients with high follow-up sCr (>1.5 mg/dL) (p < 0.01). The correlation of these tests with the follow-up sCr levels was significant (p < 0.01). The number of recipients with high perfusion curve grade was also significant in the follow-up groups with high sCr levels. However, difference of the mean value of RI was insignificant between the follow-up groups, and there was no correlation between the RI and sCr levels. Although retrospective, this study on renal transplant scintigraphy performed within two days after transplantation is useful in the prediction of longterm graft function at three months, one year, and five years. Importantly, scintigraphy seems to be of higher predictive value than Doppler sonography and measuring the RI. Although of high interest, it remains to be seen what clinical consequences can be taken from early scintigraphy.

Source: Evaluation of Renal Transplant Scintigraphy and Resistance Index Performed Within 2 Days After Transplantation in Predicting Long-Term Graft Function. Yazici B, Oral A, Gokalp C, Akgün A, Toz H, Ozbek SS, Yazici A. Clin Nucl Med. 2015 [Epub ahead of print]

Finally, since a key part of the procedure is the fine fragmentation of the stone to ease the drainage of the fragments, it is also likely that efficacy of UMP may increase if the procedure is performed in supine position, through maximising the gravitational effect for the expulsion of the stone fragments.

Source: Ultra-mini PCNL versus flexible ureteroscopy: A matched analysis of treatment costs (endoscopes and disposables) in patients with renal stones 10-20 mm. Schoenthaler M1, Wilhelm K, Hein S, Adams F, Schlager D, Wetterauer U, Hawizy A, Bourdoumis A, Desai J, Miernik A.

Miniaturised Parcutaneous Nephrolithotomy is gaining popularity as an alternative to Retrograde Intrarenal Surgery (RIRS) with the use of flexible Ureteroscopy (fURS) in the treatment of medium-size renal stones, a procedure that combines the excellent surgical outcomes provided by standard PCNL and reducing the risk of complications for patients.

Source: Race, Relationship and Renal Diagnoses After Living Kidney Donation. Lentine KL, Schnitzler MA, Garg AX, Xiao H, Axelrod D, Tuttle-Newhall JE, Brennan DC, Segev DL. Transplantation 2015 [Epub ahead of print]

Recent studies have suggested that living renal donation carries a higher risk of later renal disease than previously assumed. In response to these recent studies, the authors examined a database linking U.S. registry identifiers for living kidney donors (1987-2007) to billing claims from a private health insurer (2000-2007 claims) to identify renal condition diagnoses categorised by International Classification of Diseases 9th Revision coding. Cox regression with left and right censoring was used to estimate cumulative incidence of diagnoses after donation and associations (adjusted hazards ratios, aHR) with donor traits. Among 4,650 living donors identified, 13.1% were African American and 76.3% were white and 76.1% were first-degree relatives of their recipient. By seven years post-donation, after adjustment for age and sex, greater proportions of African-American compared with white donors had renal condition diagnoses: chronic kidney disease (12.6% vs 5.6%; aHR, 2.32; 95% confidence interval [CI], 1.48-3.62), proteinuria (5.7% vs 2.6%; aHR, 2.27; 95% CI, 1.32-3.89), nephrotic syndrome (1.3% vs 0.1%; aHR, 15.7; 95% CI, 2.97-83.0), and any renal condition (14.9% vs 9.0%; aHR, 1.72; 95% CI, 1.23-2.41).

In the US, Afro-Americans are more likely to develop renal disease after live renal donation

EAU Membership Update Steady membership growth in recent months Prof. Igor Korneyev Chair Membership Office St. Petersburg (RU)

iakorneyev@ yandex.ru

The mission to raise the level of urological care throughout Europe and beyond has connected more than 14,000 members of the EAU in 2015, and today the EAU has grown to an international community of medical professionals from over 120 countries. This year 7,500 European specialists are active EAU members and have direct access to the largest knowledge base in the field of urology. Meanwhile, the number of International EAU members is steadily increasing from year to year and has exceeded 3,000 in 2015.

This year we recorded more than 3,500 junior EAU members, boosting the ranks of young urologists in Europe and giving us the confidence in the future development of urology in the region with the next generation of experienced specialists. Moreover, the General Assembly at the 30th Anniversary EAU Congress in Madrid has unanimously voted to open the EAU membership category for medical students to boost the promotion of urology as specialty and career choice. The EAU maintains an “en-bloc” agreement membership option with 25 national urological societies which provides both national and EAU memberships at the same time. In cases where all members of a society join the EAU as a group, a reduced membership fee applies. Application for the EAU membership is open for online access at http://www.uroweb.org. For low currency countries applicants, the EAU Board provides membership support upon request. If en-bloc membership agreement is of interest to your national society and you would like to receive further information on membership options, contact Mrs. Jessica Bijlsma-Hatzmann at j.hatzmann@uroweb.org.

Apply for your EAU membership online!

First-degree biological relationship to the recipient was not associated with renal risk. Associations of African-American race persisted for these conditions and included unspecified renal failure and reported disorders of kidney dysfunction after adjustment for biological donor-recipient relationship. Thus, it seems that in the US, African-Americans donors more commonly develop renal conditions after living kidney donation, independent of donorrecipient relationship. From these date, the reasons for this increased risk of Afro-American donors cannot be explained.

www.uroweb.org

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Key articles

March/May 2015

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From Print, Apps to Tweets: GO widens its reach Guidelines Office pursues new media channels to expand coverage The EAU Guidelines Office has seen a flurry of activities in the last few weeks prior to the 30th EAU Anniversary Congress held in Madrid, but its range of projects, meetings and other accomplishments continue well beyond the congress events. Below are some of the highlight activities of the Guidelines Office: The 2015 Guidelines Print The EAU Annual Congress in March marked the publication of the 2015 Guidelines compilations; both pocket and extended versions (See photo 1). This year in particular, significant changes were made to the Guidelines, namely:

The Guidelines Thematic Sessions at the Congress The Guidelines hosted two highly interactive sessions. Prof. James N’Dow (Guidelines Chair) (See photo 3) and Prof. Nicolas Mottet (Prostate Cancer Panel Chair) chaired the first session on ‘Localised prostate cancer – Hot topics’, which included a state-of-the-art lecture on assessment of surgeons, followed by debates on “Surgical outcome: does volume matter?” and individual screening for prostate cancer.

• The incorporation of new data • Blinded peer review of all Guidelines by urology experts • Feedback from patient advocacy groups and lay reviewers • Restructuring and a new layout to the text • Text reduction across the majority of the Guidelines     

Photo 1: Pocket Guidelines Print and App 2015

The key aim of restructuring and text reduction has been to make consultation for the reader easier and we hope this has been achieved. Background information on the Guidelines, including systematic review protocols, can be viewed online on the new Uroweb pages under ‘Individual Guidelines’. These online pages will be constantly updated in the coming months, so please take a look.

Photo 7: The Guidelines Office Board meet with Chinese Urological Association representatives

Photo 4: Prof. Morgan Roupret

The second Guidelines thematic session, chaired by Prof. Morgan Roupret (NMIBC and UTUC Panel) (See photo 4) tackled the topic ‘Controversies in the management of bladder cancer.’ The session presented lively point-counterpoint discussions, providing a forum for debate on topics such as: • MIBC: Does the extent of LND change our approach to perioperative chemotherapy. Prof. Witjes (Guidelines MIBC Panel Chair) presented the pro arguments while Prof. Clarke gave the contrary viewpoint; • NMIBC: Is a second TUR necessary. Prof. Babjuk (Guidelines NMIBC Panel Chair) took the pro viewpoint while the opposing view was given by Prof. Lebret; and • Guidelines in the jungle of new media: How to use, behave, interact. Dr. Loeb gave the American perspective while Mr. Catto presented the European view.

Interviews with the Guidelines Board and Chairs The Congress was an excellent opportunity for some face-to-face interviews with a number of key contributors to the EAU Guidelines, specifically board members and panel chairs. Board members Prof. Thomas Knoll and Prof. Jacques Irani gave their perspective on the importance and role of the EAU Guidelines, and how these guidelines are continually updated and improved over the years. Prof. Fred Witjes (MIBC Panel Chair) and Prof. Nicolas Mottet (Prostate Cancer Panel Chair) were interviewed for their perspectives regarding the crucial role of the Guidelines, what has changed in the 2015 version and their plans for future versions and updates. The interviews can be viewed online under News/Video interviews at: http://eaumadrid2015.uroweb.org/ (See photos 8a-d). Potential collaboration with the Chinese Urological Association The Guidelines Office Board recently met with

Chinese Urological Association (CUA) representatives Prof. Huang, Prof. Xie and Prof. Xu, regarding a potential collaboration between the CUA and the EAU GO (See photo 7). Prof. Huang, CUA SecretaryGeneral Elect and Chair of the CUA guidelines committee, presented the CUA history during the meeting. Potential collaboration opportunities were discussed including training of young urologists in evidence synthesis methodology, and dissemination, implementation and impact assessment of guidelines. The Guidelines and Social Media The EAU GO can be found on Facebook and Twitter (#eauguidelines) and your engagement is most welcome. Look out for our weekly tweets from the Guidelines Panels. Our congratulations to the most popular tweet from the past few months from the Male Sexual Dysfunction Panel (panel social media representative: Dr. Paolo Verze) with a considerable 6,000 impressions.

The 2015 Guidelines App The Guidelines Office recently launched the 2015 Pocket Guidelines App (See photo 2). The App follows the same format as the pocket print version with a user-friendly interface making all Guidelines available at your fingertips! The response to the 2015 App was extremely positive and we hope that this will continue. Both iphone and Android compatible versions are available. The App is free to all EAU members (just enter your EAU login) with a nominal fee for non-members. Photo 5: Prof. Magnus Grabe 

     

Photo 8a-d: Prof. Fred Witjes, Prof. Nicolas Mottet, Prof. Thomas Knoll and Prof. Jacques Irani (Clockwise from top left)

Photo 2: Pocket Guidelines App 2015 Photo 6: Prof. Serdar Tekgül

The 2016 Guidelines Print Attention now moves swiftly to the preparation of the 2016 version, where the main focus will be on: • ensuring all Guidelines are based on evidencebased literature searches and • standardising the phrasing of recommendations.

Photo 3: Prof. James N’Dow (Guidelines Office Chair) Guidelines Office

16

European Urology Today

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There were also EAU Guidelines Snapshot presentations from panel chairs including: • Prof. Magnus Grabe (Urological Infections Panel) (See photo 5) lectured on perioperative antibiotic prophylaxis. Prof. Grabe gave a cautionary message on antibiotic resistance and demonstrated the model from the EAU Guidelines of a general antibiotic prophylaxis strategy for all categories of urological interventions; and • Prof. Serdar Tekgül (Paediatric Urology Panel) (See photo 6) discussed contemporary management options for different hypospadias variants and referred to the recommendations in the EAU Guidelines for surgical technique selection. All of these sessions and presentations can be viewed online at the EAU15 Resource Centre.

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March/May 2015


ADVERTORIAL

New data on HAL–guided bladder resection presented Recently published study demonstrates favourable overall survival outcome in bladder cancer patients1 In a retrospective study previous HAL-guided TURBT significantly improved overall survival and recurrence-free survival of patients after radical cystectomy (RC) compared to resection performed with standard white light alone. Leading author Dr. Georgios Gakis said during an interview at this year’s EAU congress in Madrid: “These data indicate for the first time that improved patient management with HAL-guided TURBT can make a difference in outcomes even for those bladder cancer patients who later progress to advanced disease and require radical cystectomy.” Dr. Georgios Gakis and colleagues investigated the impact on survival in bladder cancer patients of photodynamic diagnosis (PDD)-guided bladder tumour resection (TURBT), including that guided by hexaminolevulinate (HAL). In patients who underwent RC it was retrospectively investigated whether patients had previously undergone PDD-guided versus white light (WL)-TURBT. It was shown for the first time that HAL-guided TURBT can be of prognostic importance for those patients who will have to undergo radical cystectomy during the course of their disease. The findings from this retrospective study of 224 patients demonstrate that HAL-guided TURBT in bladder cancer patients, who later progressed to requiring RC, significantly improved the 3-year overall survival (p=0.037) and the median 3-year recurrence-free survival (p=0.002) compared to patients in the reference group. When asked for the value of the study results for bladder cancer therapy management, Dr. Gakis stated: “We, as urologists, need to focus more on improved bladder cancer management right from the beginning of the disease, which may pave the way towards improved bladder

cancer outcomes even for those patients who harbour advanced disease at initial diagnosis.” Of the investigated patient population, prior to RC, 29.5% underwent hexaminolevulinate (HAL)-guided TURBT (2006 to 2010), 10.3% 5-aminolevulinate (ALA)-guided TURBT (2002 to 2005) and 60.2% white light (WL)-guided TURBT. The 3-year overall survival (OS) was 74.0% in patients with HAL-TURBT, 60.9 % with ALA-TURBT and 56.5% with WL-guided TURBT (p=0.037 for HAL vs. ALA/WL). The median 3-year recurrence-free survival (RFS) was 77.8% for patients with HAL-based TURBT, 53.6% for ALA-based TURBT and 52.4% for WL-guided TURBT before RC (p=0.002 for HAL vs. ALA or WL). Bladder cancer is the most common malignancy involving the urinary system and the 9th most common malignancy worldwide. About 1 in 25 Western men and 1 in 80 women will be diagnosed with bladder cancer sometime in life.2 Bladder cancer has one of the highest lifetime treatment costs per patient of all cancers.3 One of the reasons behind this heavy economic burden is a high risk of recurrence, associated with repeated treatment procedures in non-muscle-invasive bladder cancer (NMIBC). HAL-guided blue-light cystoscopy showed the potential to increase detection and improve the quality of resection, thereby reducing the risk of recurrence and improving outcomes for patients.4 Moreover, a lower risk of progression to muscleinvasive bladder cancer (MIBC) has been reported for patients with primary NMIBC randomized to HAL-based TURBT when compared with WL-guided TURBT (p=0.06).5

“Today, bladder cancer represents one of the most expensive malignant diseases for the healthcare system in Western countries. In the next decades, it is expected that the burden of bladder cancer will steadily increase in our societies. For this reason, we definitely need to exploit the potential of sophisticated treatment strategies in order to improve our patient management. In this regard,

HAL-guided TURBT represents a very promising technique.” References 1. Gakis et al., World J Urol 2015 Jan 17; Eur Urol Suppl 2015;14/2;e531. 2. Ploeg et al., World J Urol 2009; 27:289–293. 3. Sievert et al., World J Urol 2009; 27:295–300. 4. Burger et al., Eur Urol 2013 Nov; 64:846–54. 5. Grossman et al., J Urol 2012; 188:58–62.

TOPIC OF THE YEAR Innovators in BC® topic of the year 2015 “Identification and management of NMIBC high-risk patients” was voted the Innovators in BC® topic of the year 2015.

The final voting took place 2015 during the first two days of the 30th annual meeting of the European Association of Urology (EAU), March 20th to 24th in Madrid, Spain. Almost 300 participants from several countries selected the identification and management of NMIBC high-risk patients (e.g. sub-classification of T1 patients, early cystectomy in highest high-risk patients) as their most relevant subject.

During a preselection phase, urologists and oncologists were asked for their most important topic in the field of bladder cancer management. From all submissions, 3 themes clearly stood out: identification and management of high-risk patients, new surgery techniques and new imaging technologies.

The result was presented by Prof. J. Alfred Witjes (Radboud UMC, Nijmegen, The Netherlands) in a conference session.

Final result 50% 45% 40%

Innovators in BC® (www.innovators-in-bc.com) is an international, educational, science-based forum for healthcare professionals about bladder cancer to raise awareness and support the fight against the “forgotten tumour”. The platform provides up-to-date information on bladder cancer, notably congress news, clinical cases, best practices and expert videos.

43

35% 30%

Identification & management of high-risk patients

31.5

25%

25.5

New surgery techniques

20% 15%

New imaging technologies

10%

Dr. Georgios Gakis of the Department of Urology, Eberhard Karls University at Tuebingen, Germany, commented on the use of photodynamic diagnosis:

5% 0%

Mário João Gomes Dedicated physician and beloved friend 1960-2015

Abstract Submission Deadline

1 November 2015

It is with deep sadness that we learnt the passing of our great friend Dr Mário João Gomes on March 20 after he courageously fought a long illness. Mário was a highly regarded and dedicated urologist, head of the Neurourology and Urogyneacology Unit of Hospital Santo Antonio in Porto, Portugal. He was one of the pioneers of functional urology in Portugal and organised several courses and workshops to help develop the skills of local trainees and those coming from abroad. He also founded the Pelvic Floor Department of Hospital Santo Antonio, which includes various medical and surgical specialties. Mário João Gomes served as member of several editorial boards and was very active in a number of international societies. He was a member of the

March/May 2015

EAU Section of Female and Functional Urology (ESFFU), General Secretary of the Mediterranean Incontinence and Pelvic Floor Society, VicePresident of the Ibero-American Society of Neurourology and Urogyneacology and was a member of several committees of the International Continence Society and International Urogyneacology Association. I have known Mário for the last 20 years and enormously enjoyed his friendship. He was a charming person and a man dedicated to his family, friends and patients. We will certainly miss Mário and express our sincere condolences to his beloved family. -By John Heesakkers and David Castro Diaz, on behalf of the ESFFU

Plenary Sessions

Thematic Sessions

Abstract Sessions

31st Annual EAU Congress www.eau16.org

Section Meetings

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Live Surgery Sessions

ESU Courses

Exhibition

European Association of Urology

European Urology Today

17


ADVERTORIAL

BPH: Why? The Real Story …. Report on Berlin-Chemie/Menarini-sponsored satellite symposium 2015 On the occasion of the 30th Anniversary Congress of the EAU in Madrid, March 20 – 24, 2015, Berlin-Chemie (Menarini) organised a very wellattended symposium with the title Pharmacological treatment of BPH symptoms. The readers of this report can ask themselves: Why another symposium on BPH (Benign Prostatic Hyperplasia) in 2015? Indeed, BPH has been the topic of interest for more than twenty years, more particularly with the advent of 5-alpha reductase inhibitors, which were introduced to the urological community in the mid-nineties. Moreover, in the second half of the previous century alpha-blockers became available and over the years, became more and more uro-selective. Shortly afterwards, a combination of 5-alpha reductase inhibitors and alpha-blockers became available. More recently, antimuscarinics were introduced to treat the overactive bladder component of LUTS (Lower Urinary Tract Symptoms) - BPH, as well as the combination of alpha-blockers and antimuscarinics. All these treatments have experienced a great acceptance in the (global) urological community. Hence, the question is understandable whether another scientific (companysponsored) session on BPH is indeed necessary. The chairman and moderator of the symposium, Bob Djavan, Professor of Urology at New York University as well as at the University of Vienna and also Chairman of the Regional Office of the EAU (European Association of Bob Djavan Urology), together with the sponsor of the session (BerlinChemie/Menarini), thought it worthwhile to discuss once more the different aspects of BPH in the year 2015. He managed to compose a most interesting programme on the different current aspects of BPH, including the role of phytotherapy. Phytotherapy has been neglected for a long time and was not globally accepted by the urological community for two reasons. First of all, the mechanism of action of phytotherapy was not completely scientifically elucidated. Moreover, there are very few randomised prospective clinical trials available comparing phytotherapy to placebo or to other forms of medical treatment of BPH, indicating a lack of evidence-based outcomes. This has led to some restrictions with respect to the recommendations of phytotherapy as medical treatment of BPH in national and international (EAU/AUA) guidelines. However, the questions addressed during the symposium are in fact of high relevance.

prostate enlargement. These symptoms consist of voiding difficulties, hesitancy, a weak stream, pollakiuria and nocturia. The symptoms are initially judged more or less acceptable by most men suffering from them until, with ageing the growth of the prostate (although not always directly related) worsens symptoms and induces progression. It is important that this progression is recognised in time by the urologist. When the symptoms are mild (IPSS < 11) the risk of progression is 10%, when they are moderate (IPSS 11 – 13) the risk of progression is 24%, but when they are severe (IPSS > 14) there is a 40% risk of progression, which means acute urinary retention or the development of chronic retention, urinary tract infections and bladder complications. The second suspicious factor is chronic inflammation. Until recently, it was not really recognised that chronic inflammation is associated not only with later development of prostate cancer but more particularly also with the development of BPH. More and more data in this respect are becoming available. This was clearly explained in Prof. Djavan's presentation. First of all, he mentioned that inflammation is detected in a high number of biopsies of BPH prostates. In an evaluation of more than 1,500 patients with BPH biopsies, 43% showed signs of inflammation in the biopsy, indicating a high risk of developing (symptomatic) BPH and even acute urinary retention. So, chronic prostatic inflammation is an important factor in the development of (symptomatic) BPH.

Prof. Djavan: "Cochrane-based analysis for clinical evidence should be taken into consideration with care when dealing with non-cancer issues and symptomatic outcomes."

PDE-5 inhibitors was briefly mentioned, as this therapeutic option was also recently included in the EAU guidelines.

Serenoa repens vs. alpha-blockers 26

24 The role of phytotherapy 22 and more particularly the 20 position of Serenoa repens in the guidelines 18 were also extensively 16 discussed by Prof. Brausi. 14 He pointed out that both 12 the EAU and the AUA 10 stated that there still is a lack of evidence-based -1 0 1,5 3 outcomes in order to generally advise phytotherapy. On the other hand, both the EAU figure 2 and the AUA guidelines acknowledged that those drugs, especially Serenoa repens, can play an important clinical role in the management of BPH. A Cochrane meta-analysis demonstrated an insufficient evidence-based positive outcome for Serenoa repens, but clinical daily practice evidence indicates that an improvement can be expected from these drugs in at least mild and moderately symptomatic patients. Therefore, Prof. Brausi came to the conclusion and the take-home message that Serenoa repens can be used for mild and moderate LUTS. Moreover, Serenoa repens has a major advantage over the other drugs, i.e. it does not affect the sexual function, which is left unimpaired, and has no influence whatsoever on PSA, which is not the case with 5-alpha reductase inhibitors.

severe BPH tamsulosin (n = 65)

Total IPSS

By Frans Debruyne

Prof. Brausi’s conclusions are very important, since as a leading expert he clearly demonstrated how The third factor is the bladder. With ageing, more evidence-based data have to be interpreted with care collagen tissue develops in the bladder wall, changing for daily clinical practice. the muscular activity of the bladder in men and women. This is usually expressed by urgency caused The following speaker was by overactivity of the bladder. This overactivity rapidly Andrey Vinarov, Professor of increases over the age of fifty. In association with Urology at the First Moscow benign prostate enlargement (whether or not induced State Medical University, who by concomitant inflammation), this combination of performed a prospective overactivity of the bladder with prostate enlargement randomised study with Serenoa can cause significant symptoms in many men, repens, more particularly with symptoms that deserve an appropriate, whenever Andrey Vinarov Prostamol® uno. Firstly he possible, conservative treatment. pointed out the different possible modes of action of Serenoa repens, being Prof. Djavan concluded with four statements that are anti-proliferative, anti-congestive, antirepresented in Figure 1. inflammatory and therefore clearly influencing BPH and its symptoms. Prostamol® uno contains a fixed After this excellent and and well-defined dosage of Serenoa repens in a comprehensive introductory stable formulation. In his study, which included 90 The first presentation by Prof. Djavan consisted of a lecture of Prof. Djavan, Maurizio patients, 50 received Prostamol® uno, and 40 general introduction on the different aspects of BPH. Brausi, Prof. of Urology at Modena patients were assigned to a control (watchful In his well-structured presentation, he not only University, Chairman of the ESOU waiting) arm. IPSS, quality of life, residual urine, stressed the increasing incidence of BPH but also (EAU Section of Oncological and Qmax (flow) were positively influenced by the discussed more particularly three possible Urology) and President of the Serenoa repens (Prostamol® uno) treatment. explanations with respect to the origin of LUTS Italian Society of Urology, Maurizio Brausi However, this is not the first study showing associated with BPH. discussed the current EAU superiority over placebo, but the advantages of the guidelines with respect to symptomatic BPH. Vinarov study lie in the long-term follow-up. This is Firstly, he analysed the role of the prostate volume, in contrast with the recent Cochrane meta-analysis, which evidently increases with ageing. Almost all men The first option of watchful waiting was clearly which analysed 13 clinical trials including more than will develop histological benign growth (BPH) of the addressed as an important approach in daily clinical 2,800 patients and could not find, at least not on a prostate. However, just over half of these men will urological practice. Watchful waiting should be significant statistical basis, the outcome as observed experience symptomatic LUTS associated with this accompanied by advice for self-management, which is in the Vinarov study. As could be expected, the study becoming an increasingly important issue in the did not show any changes in prostate volume. management of LUTS problems. Self-management CONCLUSION includes regulating fluid intake, adapting voiding These long-term results demonstrated for the first time schemes and techniques, using bladder training, that after ten years of treatment, the beneficial effects LUTS HAVE A PROFOUND IMPACT ON AGEING MEN avoiding constipation and also avoiding drugs such as of Serenoa repens are still maintained. Although only a AND THEIR SOCIO-ECONOMIC ENVIRONMENT
 decongestants and antihistamines, which can limited number of patients (39) were followed for more influence the symptoms, and finally avoiding caffeine than ten years, Prof. Vinarov could clearly conclude that OUTFLOW OBSTRUCTION FROM PROSTATIC ENLARGEMENT IS A COMMON, BUT NOT THE there is a permanent duration and hence a durable and overconsumption of alcohol. ONLY, CAUSATIVE FACTOR effect of Serenoa repens. If medical treatment becomes necessary, the CHRONIC INFLAMMATION AND OAB ARE ALSO RESPONSIBLE!!! guidelines evidently advise 5-alpha reductase The scientific symposium was concluded by Frans Debruyne, Emeritus Professor of Urology of inhibitors as well as alpha-blockers. More recently, THERAPEUTIC APPROACHES NEED TO ADDRESS ALL the Radboud University Medical Center in muscarinic receptor antagonists, alone or in THREE CULPRITS Nijmegen, and very much involved in the combination, have been included in the medical figure 1 management of men’s health in the ageing male treatment options of BPH. Lastly, also the role of

S. repens (n = 59)

moderate + severe BPH tamsulosin (n = 269) S. repens (n = 273)

6

9

12 months

Debruyne F, Europ. Urol. 41 (5), 497-507, 2002 Debruyne F, Europ. Urol. 45, 773-780, 2004

as Medical Director of the Andros Men’s Health Institutes in The Netherlands. Prof. Debruyne's presentation concentrated on the comparison between Serenoa repens and Frans Debruyne alpha-blockers, more particularly tamsulosin, in the management of LUTS symptoms in men suffering from BPH. Prof. Debruyne was a Principal Investigator in a large study comparing Serenoa repens (in this study Permixon®, 320 mg/once daily) compared to tamsulosin in symptomatic BPH patients. Close to 600 patients (296 in the tamsulosin group and 273 in the Serenoa repens group) were included in the study, and Debruyne indicated that there is a clear noninferiority of Serenoa repens compared to tamsulosin. When analysing all patients, it was found that the curves completely overlapped. Surprisingly however, when looking at severely symptomatic patients, Serenoa repens was statistically superior to tamsulosin in managing BPH symptoms (Figure 2). Those patients had an IPSS of > 15 when they were included in the study. In this respect it is clear that Serenoa repens is comparable to tamsulosin, lacking the side-effects of alpha-blocking therapy. Prof. Debruyne also explained the criticism of the study, which did not have a placebo arm. He also explained that the post hoc subgroup analysis (severe symptomatic patients) also has its limitations. After the four presentations, questions of the audience were addressed and discussed by the faculty. It was interesting to see that many questions related to the aetiology, the symptomatology and the therapeutic management of BPH symptoms could be elucidated and advised. More particularly, in the discussion Prof. Djavan underlined that the Cochranebased analysis for clinical evidence should be taken into consideration with care when dealing with non-cancer issues and symptomatic outcomes. Most of the time, there are too many variables in the different studies to allow real objective metaanalyses.

Prof. Vinarov: "... long-term results demonstrated for the first time that after ten years of treatment the beneficial effects of Serenoa repens are still maintained." At the end of the symposium the conclusions were summarised by the chairman, namely that medical treatment of BPH in 2015 still has a real current value with a shift to therapeutic management initially including self-management, medical management including drugs such as Serenoa repens, with fewer side-effects and as a last resort interventional treatment to manage the many patients with symptomatic BPH seen in daily urological practice.

30th Anniversary EAU Congress 18

European Urology Today

March/May 2015


Thulium laser: New kid on the block Is thulium just another laser for prostatectomy or a new tool with potentials? Dr. Iason D. Kyriazis Dept of Urology University of Patras Rio-Patras (GR)

jkyriazis@gmail.com

Prof. Thomas RW Herrmann Dept of Urology and Urooncology, Hanover Medical School [MHH], Hanover (DE) Herrmann.thomas@ mh-hannover.de

Prof. Evangelos N. Liatsikos Dept of Urology University of Patras Rio-Patras (GR)

liatsikos@yahoo.com Since 1995 when the first clinical report on surgical management of benign prostatic obstruction with the use of laser was published by Gilling et al and after significant advances taking place in medical laser technology, laser prostatectomy has become a very popular treatment option among urologists worldwide1. This popularity is boosted by the favourable perioperative outcomes of laser prostatectomy in terms of less morbidity, the excellent haemostatic properties of laser ablation and the ability for surgeons to offer treatment under active anticoagulation.

the prostate (ThuVEP) and transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP)4,5. Thulium:YAG Vaporisation, Vaporesection and Vapoenucleation of the prostate All three techniques are based on the excellent efficacy of Tm laser to vaporise tissue. ThuVAP employs vaporisation solely in an effect similar to Greenlight laser prostatectomy6 [Figure 1A]. Yet, Tm laser is considered superior than Greenlight laser given that its vaporising efficacy remains stable throughout the operation in contrast to Greenlight laser where as its target chromomphore oxyhaemoglobin in the superficial layers of tissue is being altered by energy application, the efficacy of laser to vaporise is being reduced7. ThuVARP employs both vaporisation and tissue resection. It imitates conventional TURP relieving the prostatic obstruction by cutting adenoma into small pieces [Figure 1B]. Still, it is characterised by improved perioperative vision and safety, being an almost bloodless approach throughout the operation. The approach is boosted by the familiarity of surgeons with the TURP principles and hence has a limited learning curve8. Finally, ThuVEP follows the principles of HoLEP approach and enucleates the adenoma, vaporising a layer of tissue between the adenoma and prostatic capsule9 [Figure 1C]. The efficacy of all three approaches has been well documented in the literature. Tm:YAG supported transurethral anatomical enucleation of the prostate Retrograde anatomical enucleation of the prostate is a relative novel approach in the management of BPO. It was introduced by Herrmann et al in 2010 and is characterised by the blunt retrograde enucleation of the adenoma over its surgical capsule using blunt dissection with the use of the tip of the transurethral instrument10 [Figure 1D]. The approach is similar to the finger enucleation during open adenomectomy.

Briefly, after a transverse incision of the adenoma at the level of verum montanum which is deepened down to surgical capsule, the transurethral instrument is used to dissect blindly without energy the adenoma Currently, Holmium and Greenlight laser prostatectomy are the most commonly employed laser and push it into the bladder. At the level of bladder neck, the adenoma can be separated by the capsule treatments to relieve benign prostatic obstruction. Their efficacy is well documented in the literature and with the use of energy. Prostatic lobes can then be either morcelated in the bladder, resected in pieces or is comparable with the gold standard transurethral vaporised. and open prostatectomy approaches2. Still both energy sources have their limitations. Holmium laser The technique possesses several advantages over compared to the other lasers demonstrate inferior haemostatic properties requiring focused coagulation energy-based enucleating techniques. First of all, the plane over prostatic capsule ensures a complete of bleeding vessels; it is not suitable for tissue adenoma removal and excellent postoperative vaporisation and in addition it provides a less clean outcomes. In addition, prostatic capsule being visible cutting of tissue due to its pulse nature. Greenlight laser demonstrates brilliant haemostatic efficiency but throughout the operation serves as an anatomical landmark of orientation which is particularly its treatment is relative slow, offering excellent important in very large adenomas [Figure 2]. Finally, outcomes only in small to medium prostate sizes. the energy- free blunt enucleation ensures a low risk High power 180W Greenlight laser has partially for capsular perforation in addition to the fact that addressed this problem but still treatment of very minimises the energy scattering to peripheral tissues, large adenomas with this laser is questionable. In addition, due to the single-use side fibers Greenlight improving surgical safety. prostatectomy disposables might be considered more expensive than those used in the rest of laser treatment options. Thulium laser was introduced in urological practice in 20053. It emits energy at a wavelength of 2013nm which is strongly absorbed by water providing a shallow penetration depth similar to holmium laser and, hence, improved safety. However, in contrast to the pulsed Holmium laser, Thulium delivers energy in a continuous wave fashion producing a clean and fast tissue cutting. Depending on the energy used thulium laser can produce different tissue ablating effects. It can both cut and ablate tissue similar to holmium laser but it can also vaporise tissue very effectively, similar to Greenlight laser. The above variations in ablative characteristics allow surgeon to employ a variety of different techniques on the prostate with the use of this energy. Accordingly, currently accepted international consensus nomenclature subdivides all Tm:YAG assisted techniques into Thulium:YAG Vaporisation of the prostate (ThuVAP), Thulium:YAG Vaporesection of the prostate (ThuVARP), Thulium:YAG Vapoenucleation of EAU Section of Uro-Technology (ESUT)

March/May 2015

Thulium laser appears as the ideal energy for retrograde anatomical enucleation. It provides a clear and bloodless incision to the prostate necessary for the proper identification of prostatic capsule. In addition, it has excellent haemostatic properties necessary in punctual coagulation of bleeding capsular vessels during enucleation. Finally, it provides vaporisation to treat remaining tissue or even evaporate the whole lobes after enucleation. We have recently reviewed ThuLEP outcome. Literature on this treatment modality is still very limited and further investigation is required to establish its exact role in the treatment of BPH. Nevertheless, available data from randomised controlled trials comparing ThuLEP with transurethral prostatectomy (TURP) and HoLEP reveals promising and comparable outcomes11. 200W Thulium laser: New kid on the block Following the continuous evolution of Thulium equipment and the successful implementation of 150W Thulium laser, recently, a 200W laser became available. The application of this powerful laser is still under clinical investigation, yet our personal initial experience reveals that increasing the power of the laser improves laser’s efficacy (mainly in vaporisation speed) without any adverse effects such as increasing postoperative irritative symptoms (unpublished data). Further documentation of safety and efficacy of this new laser should be awaited. Conclusions Thulium prostatectomy has already gained widespread acceptance among urologists mainly due to the favourable properties of Thulium energy source. Thulium laser combines the advantages of all alternative lasers for prostatic tissue ablation into a single unit and should be expected to play a major role in laser prostatectomy in the future. References 1. Gilling PJ, Cass CB, Malcolm AR, Fraundorfer MR. Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience. J Endourol 1995;9(2):151-53 2. Rieken M, Bachmann A. Laser treatment of benign prostate enlargement-which laser for which prostate? Nat Rev Urol. 2014;11(3):142-52. 3. Fried NM, Murray KE. High-power thulium fiber laser ablation of urinary tissues at 1.94 microm. J Endourol 2005;19(1):25–31

Figure 2: Endoscopic view during retrograde anatomical enucleation of the prostate. Prostatic capsule remains visible throughout the operation ensuring a complete adenoma removal

4. Herrmann TR, Liatsikos EN, Nagele U, et al. EAU Guidelines on Laser Technologies. Eur Urol 2012;61(4):783-95 5. Bach T1, Xia SJ, Yang Y, et al. Thulium: YAG 2 mum cw laser prostatectomy: where do we stand? World J Urol 2010;28(2):163-168 6. Vargas C, García-Larrosa A, Capdevila S, Laborda A. Vaporization of the prostate with 150-w thulium laser: complications with 6-month follow-up. J Endourol. 2014;28(7):841-5 7. Teichmann HO, Herrmann TR, Bach T. Technical aspects of lasers in urology. World J Urol 2007;25:221–225. 8. Bach T, Herrmann TR, Ganzer R, et al. RevoLix vaporesection of the prostate: initial results of 54 patients with a 1-year follow-up. World J Urol. 2007;25(3):257-62. 9. Xia SJ, Zhuo J, Sun XW, et al. Thulium laser versus standard transurethral resection of the prostate: a randomized prospective trial. Eur Urol. 2008 Feb;53(2):382-89. 10. Herrmann TR, Bach T, Imkamp F, et al. Thulium laser enucleation of the prostate (ThuLEP): transurethral anatomical prostatectomy with laser support. Introduction of a novel technique for the treatment of benign prostatic obstruction. World J Urol 2010;28(1):45-51 11. Kyriazis I, Swiniarski PP, Jutzi S, et al. Transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP): review of the literature on a novel surgical approach in the management of benign prostatic enlargement. World J Urol. 2015;33(4):525-30.

Make sure we have your up-to-date address details! Log in to your My-EAU account on uroweb.org to update your e-mail and correspondence addresses. www.uroweb.org/My-EAU

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Figure 1: Thulium laser-assisted transurethral approaches for the management of benign prostatic obstruction. ThuVAP: Thulium:YAG Vaporisation of the prostate, ThuVARP: Thulium:YAG Vaporesection of the prostate, ThuVEP: Thulium:YAG Vapoenucleation of the prostate, ThuLEP: transurethral anatomical enucleation of the prostate with Tm: YAG support

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European Urology Today

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• What do you think is the biggest challenge in oncology? That would be keeping abreast of all the research that is being conducted and being published in the field of genito-uro-oncology. Another challenge is translating this research into usable feasible clinical practice. • If you were not an oncologist, what would you be? I can’t imagine doing anything else; but I do love the arts and, in particular, music. So if I had had any talent I might have followed that road. But I really love the challenge of my work. • What is your most important piece of advice for doctors just starting out today? I always tell my students that to become a physician they need to have a passion for what they do. That’s the only way to experience the stress and the work load positively and it will help in developing stamina. Sometimes you have to make sacrifices with your work-life balance, but it’s worth it if you have a passion for your work. • What is the most rewarding aspect of being a doctor? Building a relationship with my patients and the gratitude and empathy that comes back from them. In addition, the interaction and engagement with interesting and intelligent people who have exciting and important ideas and the capability of translating them into studies and research programmes. • What is your advice to other physicians on how to avoid burnout? As I have already said having a passion for what you do helps a lot. I also agree with psychologists who say it is important to look after yourself to be able to look after others. • If you could change something in the healthcare system, what would it be? I would ensure that everyone has access to free health care. To me this is a human right. I would also like to see more opportunities for research to also be implemented in general practice and not only in the academic environment. • What’s the last wonderful book you have read? I am reading “A History of the World in 100 Objects,” which is a fascinating piece of work by Neil MacGregor, the director of the British Museum and former director of the National Gallery in London. • What’s the last thing that surprised you? The courage and resilience of my patients never fails to surprise me. And I am delighted and surprised by how many young female researchers are at this meeting (ed. EAU Congress, Madrid) and I hope to see more of them on the stage in the future. • What’s your favourite hour in a day and why? I enjoy the early morning hours most because this is the quietest time of the day, no telephone calls and no emails coming in.

TEN QUESTIONS Interview by Joel Vega Photography by Nancy Horowitz

Specialty: Oncology City: Vienna, Austria On-Going Project: Translational project on urothelial cancer

• What do you most often wish you could say to patients, but didn’t? I wish I could tell more patients that they are cured but this is rarely possible.

Maria De Santis

Outstanding opportunity for development Thalmann in Budapest as EUSP visiting professor For many decades the Department of Urology at Semmelweis University in Budapest has invited highly skilled urology experts for them to share their knowledge and help younger colleagues develop operating technique skills. In November 2014 the department welcomed Prof. George Thalmann as the European Urological Scholarship Programme (ESUP) visiting professor. Thalmann is Head of the Urologic Department of the University Inselspitals in Berne, Switzerland. Through the EUSP Visiting Professor Programme, Thalmann visited the Semmelweis University, Department of Urology and Centre for Uro-oncology from November 23 to 26 last year. The relationship between the two institutions begun in 2009 when former Head of the Inselspitals University, Prof. Urs Studer visited Prof. Imre Romics, former Director of the Department in Budapest. Similar to what his

predecessor has done, Thalmann carried out several operations and held presentations to the department staff, and also to German-speaking medical students.

"The relationship between the two institutions begun in 2009 when former Head of the Inselspitals University, Prof. Urs Studer visited Prof. Imre Romics, former Director of the Department in Budapest." During the scientific programme, Thalmann held a presentation on seminal vesical sparing cystectomy and shared his unique method which aims to provide good quality of life for patients with equally acceptable oncological outcomes.

way it was done at their department. The radical prostatectomy with extended lymphadenectomy, however, was performed in a different manner. Super extended lymphadenectomy is not a common practice at the Department and by performing this procedure Thalmann has showed the super extended lymphadenecetomy can be a safe method in trained hands. Prof. Peter Nyirády

Prof. George Thalman

Finally, Prof. Péter Nyirády, Head of Urologic Department of Semmelweis University, expressed his Prof. Thalmann operated on muscle invasive bladder appreciation and acknowledged the fruitful cancer patients, and also performed surgery on men discussions and technical demonstrations during with locally advanced prostate cancer. Staff urologists Thalmann’s visit. He gave Thalmann the Illyés – of the department noted that the radical cystectomy, Babics certificate, which honours visiting professors considered to be a challenging operation, was who have contributed significantly to the development performed by the very skilled urologist in a very similar of the institution.

European Urological Scholarship Programme (EUSP) Do not forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme, before the next deadline of 1 September 2015! Handing over the Ilyés Babics certificate to honour visiting professor Thalmann

For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website http://www.uroweb.org/education/scholarship/

European Urological Scholarship Programme Office

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European Urology Today

March/May 2015


Laparoscopy and endourology training ESU organises skills programme at JUMISC in Cáceres, Spain Mr. Bhaskar K. Somani University Hospital Southampton Dept. of Urology Southampton (GB) bhaskarsomani@ yahoo.com

Assoc. Prof. Evangelos Liatsikos General University Hospital of Patras Dept. of Urology Patras (GR)

The course was held over five days and the trainees were divided into two groups of 10 each. While the first group did endourology (over two days), the other group did laparoscopy (spread over 2.5 days) and both groups crossed over during the week. During the workshop, the participants trained in both bench and porcine animal models to acquire or improved their laparoscopic and endourological skills. A total of 48 porcine animal models were used for the course (over five days), including 28 animal models for endourology session (14 for each group) and 20 animal models for the laparoscopy session (10 for each group). Apart from the ESU nominated tutors, under the supervision of Dr. Federico Soria, the local faculty included six veterinary anesthetists, four nurse assistants, two porters, three endourology nurse assistants and five laparoscopic nurse assistants.

The exercises during the laparoscopy workshop were: laparoscopic nephrectomy (radical and partial) and liatsikos@yahoo.com radical prostatectomy in animal model; with the previous performance in bench models and ex-vivo The Minimally Invasive Surgery Centre Jesús Usón models of basic maneuvers, tissue cutting and (JUMISC) in Cáceres, Spain and the European School dissection, laparoscopic intra-corporeal suturing and of Urology (ESU) organised the ESU Hands-on training vesico-urethral anastomosis. skills programme on Laparoscopy and Endourology from February 2 to 6 this year. The activities performed in the endourology workshop included ureteroscopy in bench and porcine models, JUMISC is a multi-disciplinary institution devoted to laser ureteral lithotripsy in ex-vivo and porcine model, research, training and innovation in health sciences, handling of stone anti-migration devices, retrograde with over 20 years of experience in urologic intrarenal surgery lithotripsy in ex-vivo simulator and laparoscopy training and 14 years in endourology. in renal stone porcine model, and ureteral access Besides urology, they also have hands-on training in sheath placement under fluoroscopy control. endoscopy, microsurgery and other advanced laparoscopic surgical skills. The course started at nine in the morning every day with two 20-minute coffee breaks and a lunch break, Twenty urologists from 14 different European and ended by six in the evening. The accommodation countries attended the course. The tutors included facilities were on-site with the Caceres town center Prof. Evangelos Liatsikos (GR) and Dr. Ben Van only a five-minute taxi ride. Since this was the first Cleynenbreugel (BE) for the Laparoscopy Workshop, ESU course co-organised by the centre, there was Mr. Bhaskar Somani (GB) and Dr. Achilles Ploumidis immense enthusiasm from the trainees, the local (GR) for the Endourology Workshop, as well as the trainers and the ESU. Furthermore, the evaluation of endoscopy and laparoscopy staff of the JUMISC. these activities by the participants makes evident the

success of the course (9.93 over 10 points), the high degree of satisfaction with the training activity and its definite application to daily urological practice.

Dr. Achilles Ploumidis O.L.V. Aalst Dept. of Urology Aalst (BE)

Hands-on training For the Endourology Course (held over two days), the animal models were prepared with the insertion of a double J stent four to seven days prior to the course. The stones (a mixture of artificial and real renal stones) were inserted by open PUJ incision and then sutured for anatomical continuity. There were five stations, with two trainees in each station sharing one pig model.

aploumidis@ yahoo.gr

Dr. Ben Van Cleynenbreugel UZ Leuven Dept. of Urology Leuven (BE)

Over a two-day period the participants were given 30-minute presentations on topics such as: 1. Introduction, knowledge of material and equipment for the course 2. Porcine model in Endourology training: Comparative anatomy 3. Technique, indications and complications of Ureteroscopy, and 4. Tips and tricks of Rigid and Flexible Ureteroscopy

Ben. Vancleynenbreugel@ uzleuven.be

European School of Urology Teaching activities 2015 May 30

ESU course on Imaging in urological cancer at the time of the EAU Baltic Meeting, Riga (LV)

5-11

ESU – Weill Cornell Masterclass in General urology, Salzburg (AT)

28-29

6th ESU – ASU teaching course at the time of the Annual meeting of the Vietnam UroNephrology Association, (VN)

July August

September 4-9 15

13th European Urology Residents Education Programme (EUREP), Prague (CZ) ESU-ERUS courses at the 12th Meeting of the EAU Robotic Urology Section (ERUS), Bilbao (ES)

4

ESU course on Infections at the time of the EAU 15th Central European Meeting, Budapest (HU)

4-5

2nd ESU Masterclass on Lasers in urology, in collaboration with the EAU Section of Uro-Technology (ESUT), Barcelona (ES) ESU course at the time of the EAU 11th South Eastern European Meeting, Antalya (TR) 2nd Confederación Americana de Urologia Residents Education Programme (CAUREP), Cancun (MX) ESU courses on Medical treatment of metastatic renal cancer and Castrate resistant prostate cancer at the occasion of the 7th European Multidisciplinary Meeting in Urological Cancers (EMUC), Barcelona (ES) 8th ESU Masterclass on Female and functional reconstructive urology, in collaboration with the EAU Section of Female and Functional Urology (ESFFU), Berlin (DE)

October

November 7 10-14

Konstantinos Gkagkalidis: “The beautiful city of Caceres, the modern training center, good trainers and the ideal number of trainees have made this programme one of the best courses in endourology and laparoscopy. Thank you for this unique experience!”

Ricoardo Godino: “This is one of the best hands-on training courses I have ever participated in. The acquisition of new knowledge in laparoscopy and endourology supported by excellent facilities increased my knowledge. I thank all the mentors, the local organisers and the European School of Urology.”

Deyan Anakievski: “Thanks to the ESU for the opportunity to take part in this course. This one-week high-level programme on laparoscopic and endourology hands-on training was an invaluable opportunity for me to learn much more. The professional organization and helpfulness of colleagues in the centre were impressive. I am very thankful to our tutors for sharing and showing some tips and tricks. This was the best course I have ever attended.”

Chrysovalantis Toutziaris: “This course is unique. Every participant had sufficient time to learn and apply practical tips and tricks and to raise his confidence with regards difficult endourological and laparoscopic procedures. The tutors and the staff members of the institute were very helpful and with their patience they helped in explaining and solving the problems. I hope this programme will continue and that I get another chance to participate in other meetings in the near future.”

ESU Organised courses at National Urological Society meetings

Timur Kuru: “I thank the European School of Urology and especially my tutors for this great course in Caceres, Spain. Everything was perfectly organised and I learned a lot at this impressive institute.”

19

“We had a nice five days of hands-on training in Caceres! It was a unique opportunity to improve our surgery skills and to make new friends from all over Europe. Thanks EAU for this beautiful experience.”

12

26-28

May 9

June 11 13 19

Jan Breza: “The hands-on course held in Caceres, Spain is by far the most intense urological skill-improving experience I ever had. We spent eight hours per day operating under the supervision of leading experts in different fields of urology, and were given the chance to practise, improve, and progress our surgical abilities. I honestly believe this course made us better Janis Auzins: “Courses are very important urologists.” for young urologists. The week in Caceres gave me skills and knowledge which will Andrey Bolotov: “Doctors are said to be useful in the operating theater.” have a cemetery of patients behind their back. This training course will provide physicians with the necessary knowledge Arnas Bakavicius: “Thanks to everybody. The course was extremely good!” to make this cemetery much smaller!”

18

October 22 22 23

ESU organised course on Management of the lower urinary tract with benign urological problems at the time of the national congress of the Polish Urological Association, Warsaw (PL) ESU organised course on What’s new in male infertility and (locally) advanced prostate cancer at the time of the national congress of the Russian Society of Urology, St. Petersburg (RU) ESU organised course on Urinary infections at the time of the national congress of the Czech Urological Society, Olomouc (CZ) ESU organised course on Paediatric urology for the adult urologist: A practical update, at the time of the national congress of Tunisian Urological Society, Sousse (TN) ESU organised course on Any progress in prostate and kidney cancer treatment? And Update on modern stone treatment at the time of the national congress of the Moldavian Urological Society, Chisinau (MD)

November 2 7

ESU organised course on Male LUTS, urinary incontinence and fistula at the time of the national congress of the Scientific Society of Urologists of Uzbekistan, Tashkent (UZ) ESU organised course on Bladder cancer at the time of the biannual congress of the Urological Association of Northern Greece, Thessaloniki (GR)

December 2

March/May 2015

ESU organised course on Kidney cancer at the time of the national congress of the Slovak Urological Association, Presov (SK) ESU organised course on Modern management of upper tract urothelial carcinoma (UTUC) at the time of the Uro-Oncology meeting of the Hellenic Urological Association, Thessaloniki (GR) ESU organised course on Prostate cancer at the time of the national congress of the Ukrainian Urological Association, Kiev (UA) ESU organised course on Locally advanced prostate cancer and non-muscle invasive bladder cancer at the time of the national congress of the Romanian Association of Urology, Bucharest (RO)

September 20

Simone Albisinni: “This has been an extraordinary hands-on training course. Over seven hours a day trying complex endoscopic and laparoscopic procedures and using state-of-art animal and ex-vivo models. A mind-blowing center, great tutors and a strong group, this is truly ‘a must’ experience.”

ESU organised course on Diagnosis of prostate cancer and non-muscle invasive bladder cancer at the time of the national congress of the Moroccan Urological Association, Rabat (MA)

ESU organised course on Endourology at the time of the national congress of the Egyptian Association of Urology, Cairo (EG)

European Urology Today

21


ESU Course impressions from Madrid Enthusiastic participants and suggestions from lecturers The ESU and HOT Courses offered in Madrid during the annual congress not only attracted a high number of participants but also elicited positive responses. Below are selected remarks and suggestions from some of the lecturers:

The course on surgical anatomy for renal and pelvic robotic and laparoscopic surgery attracted a large number of participants, certainly more than what we had expected. It was fully booked and participants showed great enthusiasm. We tried to be interactive and encouraged active learning as much as possible within the time constraint of two hours. We recommend that this course be offered again next year, perhaps over a period of two days.

The ESU course on infectious diseases was held for the first time at the 30th EAU Anniversary Congress in Madrid and provided a broad, up-to-date coverage of the most important and recent issues in infectious urological diseases. It provided definitions and classifications of urogenital tract infections and tackled topics such as diagnosis, treatment and prophylaxis. Since urogenital tract infections range from benign infections (such as uncomplicated and recurrent cystitis) to lifethreatening infections (e.g. urosepsis) often encountered in daily clinical practice, the course was well attended. The management of infections and of urogenital tract infections, in particular, was closely examined since their management has been compromised by the rapid and sustained occurrence of antimicrobial resistance. Basic biologic principles and strategies to counter antibiotic resistance were extensively discussed during this workshop.

ESU course 31 Infection diseases Chair: F. Wagenlehner, Giessen (DE) Nr participants: 27 By: F. Wagenlehner, Giessen (DE)

ESU Course 5 Comorbidity in urology Chair: N. Mottet, Saint-Étienne (FR) Nr participants: 26 By: N. Mottet, Saint-Étienne (FR)

ESU course 18 Surgical Anatomy Chair: J-U. Stolzenburg, Leipzig (DE) Nr participants: 106 By: G. Nabi, Dundee (GB)

The highlighted key messages were: • Age per se plays a minimal role, if any, in the treatment decision-making process; • Senior adults suffering from GU cancers are undertreated; • Co-morbid condition is the key driver for survival; • For patients, there are tools to clarify the individual expected life expectancy. Some tools such as the gate speed are easy to use and should probably become more systematic; • There are available tools to evaluate this condition, and if improvement is feasible, this might lead to a real change in the treatment proposal; • The geriatrician has probably the best position to consider and, when possible, correct all the factors impacting the senior adult’s comorbid conditions, as well as social circumstance. The latter has a major impact on the treatment itself; and • Based on the number of potential patients, it is not possible to refer all of them to a geriatrician. A validated screening tool called the G8 is the way to go, and should be considered mandatory when dealing with senior adults. Modular training session in robot-assisted techniques

The new ESU course on Comorbidity in Oncology took place on March 21 in Madrid. The course intended to clarify the impact of co-morbidities on treatment decisions in uro-oncology. It was my pleasure to work with Maria De Santis, a medical oncologist and Muriel Ranfray, a geriatrician.

Tips and tricks in basic and advance laparascopy

Co-morbidities are seen as among the key drivers for survival. But their evaluation and the ways to deal with co-morbidities represent a new facet in treatment decision-making, particularly in senior adults. This population, defined as those older than 70 years, represents a growing group of patients, as 65% of all GU cancers occur beyond 70 years of age.

Proper handling and positioning of instruments are given in a step-by-step manner

The session was really interactive. Based on the discussions and comments from participants, we believe we provided useful information. Of course improvements are still welcome based on the detailed feedback. See you next year in Munich!

www.esufemale15.org

www.esulasers15.org

8th ESU Masterclass on Female and functional reconstructive urology

2nd ESU Masterclass on Lasers in urology

In collaboration with the EAU Section of Female and Functional Urology (ESFFU)

4-5 November 2015, Barcelona, Spain

In collaboration with the EAU Section of Technology (ESUT)

26-28 November 2015, Berlin, Germany EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

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All these points were highlighted in the discussion of prostate and muscle invasive bladder cancers, leading to insights on how co-morbidities can impact screening, surgery and systemic treatments.

European Urology Today

EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

March/May 2015


European Urology Forum in Davos First prize winner gets the ‘nerves’ in Challenge the Experts sessions Dr. Hashim Hashim Consultant Urological Surgeon Director, Urodynamics Unit Bristol Urological Institute Bristol (GB) hashim@gmail.com The European Urology Forum (EUF) is held every February at the ski resort of Davos, Switzerland, and is the same city venue of the World Economic Forum. The urology forum is one of the EAU's longest-running and most established scientific and educational activities and this year marked the 24th anniversary. The programme included state-of-the art lectures by eminent urologists from Europe providing evidencebased practice updates and the latest developments in urology, complex case presentations, "Challenge the Experts" sessions and, of course, skiing!

The urological challenge is the main highlight and most stimulating part of the programme and involves five consultant urological surgeons from different European countries. Each challenger has to submit five 'thought-provoking' topics to the EUF 'board.’ The board then choose three topics for each challenger to present. These topics usually relate to ‘high-impact’ research projects the challengers have performed in the past or are currently involved in and have the potential of changing clinical practice. Each challenger presents for 20 minutes and then gets 'grilled' for another 20 minutes on their subject by five judges who are professors of urology from various European countries. The atmosphere is friendly but professional and debates are often very stimulating. Besides the author, the five challengers this year were Stavros Tyritzis (GR), Jakub Dobruch (PL), Stephan Hruby (AT) and Oscar Rodrigues (ES). The varied topics included oncology, endo-urology and functional urology and the jury members are specialised in various urological fields, which led to

comprehensive discussions. The topics I presented were 1) Antidiuresis in overactive bladder syndrome, 2) Urodynamics before stress incontinence surgery in women and 3) Artificial urinary sphincter versus sling in men with post-prostatectomy incontinence. The challengers had daily dinners with the expert faculty and judges which helped in 'breaking the ice' for a more relaxed atmosphere during the presentations. On the day of the presentations, however, I still experienced moments of nervousness. As challengers we also shared experiences and make friendships. In one of the social activities, we even rode horse carriages further up the mountain to have dinner-- an experience in itself-- and were we had Swiss fondue. On the last night, following three days of excellent presentations, the dinner featured live music

performed by Prof. Jens Rassweiler and his band, a tradition which have been quite popular in previous years and was a great performance. Certificates and prizes were also presented to the challengers (Photo). Until that point we had no idea who the winner was since all presentations were of very high quality. I was very delighted and proud to have won the first prize. During the extended lunch breaks, there were opportunities to go up the mountains and ski. Although I do not ski, I hiked to the mountain and was rewarded with breath-taking views of the Davos peaks on a sunny day. Overall, it was a very delightful and educational experience that allowed me to make new friendships. I would certainly recommend the meeting both as a delegate and a challenger.

Dynamic days in wintry Davos Challenging the experts was tough as nails Dr. Jakub Dobruch Assistant Professor Centre of Postgraduate Medical Education Warsaw (PL) kubadobr@ amwaw.edu.pl The Winter Forum in Davos is one of the oldest scientific and educational programmes run by European Association of Urology. This year, which marks the 24th edition, one of the remarkable sessions is “What’s new in urology” which reviews novel management strategies. I also had the pleasure to take part in the “Challenge the Experts” sessions where invited European speakers deliver three lectures. Each presentation runs for 20 minutes and the lecturers are then challenged by a panel of judges from various countries. The four other participants or challengers were Dr. Stephan Hruby (AT), Dr. Hashim Hashim (GB), Dr. Stavros Tyritzis (GR) and Dr. Oscar Rodríguez Faba (ES).

Unique meeting

Dr. Stavros Tyritzis, University of Athens Medical School 'Laiko' Hospital Athens (GR)

Davos has been a traditional and popular spot for winter sports. But in the urological community Davos is the venue for the EAU’s Winter Forum, a unique scientific meeting that covers all aspects of our discipline, with state-of-the-art presentations, debates and the Challenge the Experts sessions. My experience this year, however, has shown me that the challenge is on the Challengers themselves and not the experts. The Davos meeting is no playground, no time for fun and skiing (at least not a lot…), but demands from the Challenge participants to be as prepared as possible. At the same time, the “stress” of the contest is also its real beauty and it was a privilege to be part of this event. To push ourselves to the limit and take on the challenge and the expectations was certainly worth it.

March/May 2015

We were asked to propose five topics including three that the organizing committee has deemed the most important and worthy of discussion. Each jury in the panel has to query the presenter, and believe me, the questions were tough with some of the queries actually an inspiration or trigger for future studies. Despite the anxiety of the challenge sessions, the beautiful Alpine weather and lovely winter landscape The five challengers of 2015 from left: Hashim Hashim (GB), Oscar Rodrigues (ES), Stephan Hruby (AT), Stavros Tyritzis (GR) and Jakub Dobruch (PL) surrounding the Congress Centre had a positive influence on our nerves. But the feeling similar to that of being screened when we’re graduating from our medical universities remained; strangely the challengers seem to have bonded, a group that is united on the face of severe critique from the expert panel.

www.esudavos16.org

Besides the challenge sessions, all participants have the chance to get acquainted and after the sessions we spent the evenings sharing our professional experience and insights on urological issues. Hashim Hashim won the first prize and we all celebrated during the elegant dinner. My gratitude to Professors Frans Debruyne, Chris Chapple and Jean Palou for their mentorship, and my special congratulations to Prof. Debruyne for his unique and dynamic way of presiding the sessions.

An excellent opportunity

European Urology Forum 2016 Challenge the experts 13-16 February 2016, Davos, Switzerland EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

Dr. Oscar Rodriguez Faba, Fundació Puigvert, Barcelona (ES)

“The “Challenge the Experts” represents an excellent opportunity for urologists who wish to develop an academic profile during their career. It comprises three intensive days during which participants present three lectures on their own research, and are then evaluated by a panel of experts. Besides the scientific content, guidance is given by the panel on presentations skills, the ability to respond to questions, and language skills for non-native speakers of English. Moreover, it gives participants the chance to meet many wellknown urologists in Europe. I would highly recommended taking this challenge to academic urologists.”

European Association of Urology

European Urology Today

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Who’s Who in the ESU Board Future education will increasingly shift to the virtual sphere By Joel Vega

Another goal is to stimulate and collaborate in the improvement of online education; this is the future of education and many efforts are dedicated in creating a good structure for future online initiatives. One of my key tasks is also to facilitate or boost the links of the ESU to the rest of the world by creating a network with urological associations and by participating in educational exchanges or organising activities such as ESU expert lectures, specialised courses, workshops and Hands-on-Training courses all over the world. Q: In your field of (urological) interest, what do you think are the biggest educational challenges?

As part of the European School of Urology’s (ESU) efforts to improve training and deliver educational opportunities to young urologists and support the exchanges among urology professionals in Europe, we are running a series of Who’s Who to introduce members of the ESU Board. For the first instalment in the series, we have conducted a Q&A with ESU Chairman Prof. Joan Palou regarding his opinions and views on education and challenges in urology, in general. Q: Can you tell us a bit more about your background, specialty and experience? Palou: My expertise is on bladder cancer and I am an Associate Professor of Urology at the Universitat Autònoma de Barcelona and Chief of the Urological Oncology Department at the Fundació Puigvert in Barcelona. In 2012 I was appointed as ESU Chairman. I graduated at the Medical School of the Universitat Autònoma de Barcelona (Spain) and became an urologist at the Hospital Vall d’Hebrón, also in Barcelona. During my residency training I stayed for short periods in different urology centres in the US. I am an expert in laparoscopy and robotic surgery and have collaborated with the International Consultation on Bladder Cancer, Upper tract tumours and Penile Cancer, sponsored by the WHO and SIU. I have also been involved in writing the EAU Guidelines for non-muscle invasive bladder cancer and upper urinary tract tumours. My publications include many chapters in medical and urology books and more than 200 articles in peer-reviewed journals. The most recent publication I have authored focused mainly on bladder cancer, examining the different aspects such as prognostic factors, BCG, T1G2 tumours, T1G3 tumours, guidelines, risk stratification and robotic

Prof. Joan Palou

surgery. A new protein marker of aggressiveness and prognosis of progression in patients with T1G3 tumours of the bladder has been developed with the CNIO (National Center for Oncologic Investigations) with encouraging results. I have participated as lecturer in several national and international meetings and as a visiting professor in university hospitals in various countries. My unit has received several awards for publications, videos, oral and poster presentations at different meetings. One of these awards is the Hans Marberger Prize from the EAU in 2004. Q: What is your role in the ESU board? Palou: As ESU director I closely collaborate with all ESU board members to create, develop and improve the ESU’s educational activities. We also work on promoting interaction among the different sections of the EAU by creating new courses, lectures, masterclasses, and by collaborating with other EAU partners such as the Guidelines Office.

Palou: As I am mainly focused on oncology, and as Chief of the Urological Oncology section in Fundació Puigvert, I am fully dedicated to working in urological cancers. Regarding challenges in uro-oncology, there are two main aspects-- medical and surgical treatment. Urologists are more focused on surgical aspects and in response we promote courses and master-classes to provide training on aspects related to anatomy, skills, tips and tricks, etc… At the same time, we also emphasise the multi-disciplinary approach to these diseases, and that the medical treatment approach has to be shared with medical oncologists. The ESU is promoting and teaching all these aspects that are very important in daily practice. Q: What are your goals for the European School of Urology Palou: For the ESU to become a reference and a credible school for teaching and learning to all urologists regardless of the stage of their career. We aim to deliver top-quality, clinically oriented, unbiased information. Quality, not quantity, is the yardstick. Another goal is to bring European urology residents into the EAU community by providing them with educational tools that will improve their knowledge

and refine their skills. We also work on improving urologists’ outcomes and boost the influence of our faculty by way of providing efficient and in-depth educational activities. A key objective is to facilitate the apprenticeship process for all urologists. We have to carefully consider the training needs not only of residents, but also of young and established urologists, taking into account their interests. It is not always easy to combine the different perspectives and needs of each group. This is clearly reflected in the attendance during the ESU courses at the annual congress. Depending on the topic (review, tips and tricks, medical, surgical, etc.), you see a different kind of audience profile. Q: How do you see the future of education and urology? Palou: Education is a complex process that we have to simplify in order to reach our goals. Teachers are central to this process or to any methodology used for education, and they have a key role in the “invention” or “re-invention” of the schools of the future. I see the future of education as a combination of classroom, studio and virtual learning activities. The classroom as the paradigm of a single teacher addressing uni-directional information in a physical setting (to interact directly). The studio as a peer-to-peer learning environment with group discussion, learning and tackling problems. And finally the virtual, as a disembodied environment where learning, discussion and assessment still occur regardless of physicality or geography. The latter is the real future and with a lot of new tools or technologies to help develop it and combined with other standard methods. Certainly, the ESU aims to address these challenges for us to move forward.

EUREP15 13th European Urology Residents Education Programme

www.eurep15.org

4-9 September 2015, Prague, Czech Republic www.eurep15.org

New faculty for EUREP 2015 The European Urology Residents Education Programme (EUREP) is now in its 13th year and continues to be an extremely popular and a “must-do” course for final-year residents. The EUREP format provides a comprehensive update and overview of modern urological practice presented by a distinguished European faculty. The full six-day course includes sessions that feature state-of-the-art lectures complemented by interactive case discussions, videos, and test your knowledge segments. EUREP has a tradition of rotating faculty in order to introduce new academic and teaching talent. Continuing that tradition, we are pleased to announce that the following new faculty members will join EUREP in 2015: Module 1 - Urological Cancer Prof. Milan Hora, Plzen (CZ) Head of the Urology Department, University Hospital, Faculty of Medicine in Pilsen, Charles University Module 2 - Prostate cancer & BPH Prof. Alberto Briganti, Milan (IT) University Vita-Salute San Raffaele in Milan

Module 3 – Andrology, stones and upper tract endourology Ass Prof. Evangelos Liatsikos, Patras (GR) Head of the Endourology-Laparoscopic Unit at the University of Patras Module 4 – Functional Urology Ass Prof. George Kasyan, Moscow (RU) Head of Functional Urology and Urodynamics Unit at Moscow State University of Medicine and Dentistry (MSMSU) Moscow

EUREP15 13th European Urology Residents Education Programme 4-9 September 2015 Prague, Czech Republic

Module 5 - Paediatric urology, trauma & infection Prof. Florian Wagenlehner, Giessen (DE) Head of Urology at University Hospital Giessen EUREP faculty members are joining a thriving community of outstanding teachers-scholars as EUREP continues to grow as a unique training programme. The faculty at EUREP is well-known for its dedication to interactive and engaged teaching to achieve maximum impact in the five day intensive course. We are confident that our new faculty will help us make this great teaching course even stronger. We wish them well and look forward to seeing you in Prague! The quality of our faculty represents the heart of our academic mission!

European Association Milan Hora Module 1

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Alberto Briganti Module 2

European Urology Today

Evangelos Liatsikos Module 3

George Kasyan Module 4

Florian Wagenlehner Module 5

of Urology

March/May 2015


ADVERTORIAL

Towards individualized care in prostate cancer A report of the Ipsen-sponsored satellite symposium at the 30th EAU Anniversary Congress 2015 Chair: Speakers:

Noel Clarke, The Christie and Salford Hospitals, Manchester, UK Maria Ribal, Hospital Clinic University, Barcelona, Spain Yohann Loriot, Gustave Roussy Institute, Villejuif, France

The PCA3 urine assay, which measures prostatederived RNA to generate a PCA3 score,9,10 is relatively well established as an aid to improving diagnostic accuracy on repeat biopsies (biopsy-negative but elevated PSA levels) when used alongside clinical assessments and PSA measurements. However, there are conflicting data on the value of PCA3 measurement as a predictor of prostate cancer Summary Today, optimising the application of biomarkers and aggressiveness.11,12 Despite this uncertainty, the imaging, and incorporating them into multivariable risk addition of the PCA3 score to existing risk calculators calculators, will improve diagnosis of prostate cancer and nomograms may enhance prostate cancer and identification of men with high-risk disease. This is detection in the ‘grey area’ of PSA levels between 2 an essential step to reducing unnecessary biopsies and and 10 ng/ml.13 Another method to potentially for directing treatment more appropriately. We have enhance the clinical utility of PCA3 score is to use it in also made progress in our knowledge of mechanisms combination with the measurement of TMPRSS2-ERG of castrate resistance in prostate cancer. In late stages, gene fusions in urine.14 prostate cancer consists of a large number of ‘subdiseases’ defined by targetable genomic alterations. A promising marker for initial screening and to Identifying the optimal drug for each of these subreduce unnecessary biopsies is the four-kallikrein (4K) diseases is the key to individualising treatments. In the score, which combines blood measurement of free immediate future, earlier combination treatment to PSA, total PSA, intact PSA and kallikrein-related avoid emergence of resistance (rather than the current peptidase 2.15 practice of sequential treatment) and targeting the tumour microenvironment may be achievable steps to Although the non-invasive nature of such improve the care we offer to men with prostate cancer. biomarkers is an advantage, there is a risk of contamination of these samples, and measuring markers in biopsy samples can also play a role in Diagnosis and assessing risk in prostate cancer – beyond PSA prostate cancer – especially for more precise risk stratification in patients already biopsied. Such The imperfections of prostate-specific antigen (PSA) genotyping-based methods are in their infancy in measurement in the diagnosis and assessment of prostate cancer,16 but we hope that future prostate cancer have been extensively discussed.1-3 Continued reliance on serum PSA measures increases developments in prostate cancer will mimic those the risk of unnecessary biopsies and treatment of men that have taken place in other diseases such as with indolent disease. There is therefore a need for breast cancer and colorectal cancer. improved prostate cancer-specific biomarkers that are minimally invasive, reproducible, sensitive and The future use of biomarkers? specific, and cost-effective, that can enhance risk Improved genetic information on patients and stratification and thus guide more individualised prostate tumours will drive the future management. individualisation of prostate cancer management.

“In our experience we can avoid 13-19% of prostate biopsies using the phi test.” Dr. Maria Ribal, Barcelona, Spain

International guidelines conclude that there are no adequate replacement biomarkers for PSA at present4,5. More research is clearly needed! Improving what we have An ideal source of a biomarker is urine or blood as these samples are obtained through relatively non-invasive processes. While novel biomarkers will undoubtedly emerge in prostate cancer, we should also consider how serum PSA measures can be optimised. For example, the prostate health index (phi) test takes advantage of the various forms of PSA that can readily be measured, to enhance the diagnostic accuracy of this biomarker. By combining information on free PSA levels, total PSA levels and levels of the PSA precursor [-2]pro-PSA, the phi test could help reduce unnecessary biopsies in men with PSA levels of 2-10 ng/ml (the ‘grey area’ for diagnosis).6 The main limitation of the phi test is that a  precise cut-off, below which biopsies can be  avoided, is not yet defined.7,8 

However, while we await such developments it is important that multivariable models are used – these should include conventional and novel non-invasive biomarkers combined with the latest multiparametric imaging techniques to improve prostate cancer diagnosis and risk stratification.

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  March/May 2015

Dr. Yohann Loriot, Villejuif, France

Understanding resistance Resistance to abiraterone and enzalutamide can be acquired, and a number of different mechanisms may account for this. However, specific clinical trials to understand these mechanisms in humans are needed because preclinical models do not accurately reflect the clinical situation, and assessing response versus non-response in clinical trials does not take into account acquired resistance. Tumour heterogeneity also plays a part in loss of response to agents targeting the AR axis. Both intra-patient and inter-patient heterogeneity occur in prostate cancer. Within individual patients, it is likely that different tumour cell populations exist, and those cell populations may vary depending on the source of the sample. As well as this spatial heterogeneity, temporal heterogeneity appears to exist – markers measured in metastatic tumours may only be detectable in a very small area of the primary tumour, which suggests clonal selection of specific cell subtypes that subsequently predominate in metastases.20 Furthermore, changes have been measured in the levels of different sub-populations of tumour cells when abiraterone therapy is initiated, and these temporal changes do not occur in the same manner at different sites.21 This complexity means that different mechanisms may drive resistance at different sites within an individual patient. The current strategy of managing CRPC with sequential therapies simply increases the risk of multi-drug resistance. This is evident in clinical studies showing cross-resistance between abiraterone and enzalutamide.22-24 Instead, starting treatment early with a combination of drugs, with non-overlapping mechanisms of resistance, may help prevent emergence of resistance. Possible combination treatments are being assessed in studies such as the CHAARTED study (ADT + docetaxel)25 and PEACE-126 (combinations of ADT, radiotherapy and abiraterone).

Inter-patient heterogeneity is also present in prostate cancer.27 This highlights the need to identify and treat the mechanisms of cancer progression at the level of the individual. In CRPC, Therapeutic approaches beyond the androgen we have a good understanding of the multiple receptor genetic alterations, which include deletions and Castration with androgen deprivation therapy (ADT) is mutations in many genes, alterations in AR, and an effective approach for prostate cancer, but most rare but important events such as BRCA patients develop castrate-resistant prostate cancer deficiencies. This information combined with the (CRPC) within 2-3 years. In CRPC, despite castration, growing number of available drugs with different mechanisms of action mean that precision the androgen receptor (AR) signalling pathway medicine in prostate cancer is feasible.28 remains active, and so newer agents that target the AR axis (abiraterone and enzalutamide) are Incorporating genetic screening into the biopsy analysis of patients with metastatic CRPC may effective.17-19 Other newer agents include bonetargeted agents (radium 223), chemotherapeutic therefore help identify the individual tumour signature and select the most appropriate agents (cabazitaxel) and immune therapies (sipuleucel-T). One of our challenges today is to treatment for each patient.29,30 However, as outlined  optimise the sequencing or combination of these above, the temporal evolution of biomarker status various agents. and discrepancies between the primary tumour and metastases mean that more than a single molecular screen at diagnosis will be needed.

Table: Overview of the most promising markers. 

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“How do we target tumour heterogeneity? Maybe by using therapies earlier and together.”



Epigenetic factors also have to be considered in prostate cancer. BET-containing proteins that act as co-activators or co-repressors of gene transcription are active in prostate cancer. In preclinical models, BET inhibitors have been shown to have antineoplastic effects, possibly through ablation of AR signalling and by inhibiting the expression and oncogenic activity of TMPRSS2-ETS gene fusions.31 Treating the prostate tumour as an ecosystem There are complex interactions between different cell types of the immune system and tumour cells, and enhancing antitumour immunity with monoclonal antibodies could reduce metastasis in selected patients.32 Indeed, if we can better understand the

molecular basis of response to immunotherapies, we should be able to select patients who are most likely to receive benefit – for example, neoepitope signatures in tumours have been described that predict long term benefit of immunotherapies.33 Three mechanisms of immune escape are known: loss of antigenicity; loss of immunogenicity; and the development of an immunosuppressive microenvironment. Loss of immunogenicity may be tackled with combination of agents such as the combination of anti-CTLA4 and anti-PD-L1 that has been tested in melanoma cells.34 Targeting the tumour microenvironment with novel agents to reverse the immunosuppressive environment35,36 is a promising area for new developments. It appears that the role of the tumour ecosystem has been underestimated in prostate cancer. A better understanding of this microenvironment and treatments that target this, along with earlier and individualised combination treatments, may extend the future possibilities of managing CRPC. Acknowledgements This report summarises the content of an Ipsen supported satellite symposium at the Anniversary EAU Congress 2015. Editorial assistance was provided by Martin Gilmour ESP Bioscience, Crowthorne, UK funded by Ipsen. References 1. Schroder FH. PSA screening-a review of recent studies. Eur J Cancer 2009;45 Suppl 1:402-4. 2. Barry MJ. Evaluation of symptoms and quality of life in men with benign prostatic hyperplasia. Urology 2001;58:25-32; discussion. 3. Andriole GL, Jr. PSA screening and prostate cancer risk reduction. Urol Oncol 2012;30:936-7. 4. Heidenreich A, Bastian PJ, Bellmunt J, et al. EAU guidelines on prostate cancer part II: Treatment of advanced, relapsing, and castration resistant prostate cancer. Eur Urol 2014;65:467-79. 5. NCCN. NCCN Clinical Practice Guidelines in Oncology. Prostate Cancer 2014. 6. Catalona WJ, Partin AW, Sanda MG, et al. A multicenter study of [-2]pro-prostate specific antigen combined with prostate specific antigen and free prostate specific antigen for prostate cancer detection in the 2.0 to 10.0 ng/ml prostate specific antigen range. J Urol 2011;185:1650-5. 7. Bruzzese D, Mazzarella C, Ferro M, et al. Prostate health index vs percent free prostate-specific antigen for prostate cancer detection in men with “gray” prostatespecific antigen levels at first biopsy: systematic review and meta-analysis. Transl Res 2014;164:444-51. 8. Filella X, Gimenez N. Evaluation of [-2] proPSA and Prostate Health Index (phi) for the detection of prostate cancer: a systematic review and meta-analysis. Clin Chem Lab Med 2013;51:729-39. 9. Haese A, de la Taille A, van Poppel H, et al. Clinical utility of the PCA3 urine assay in European men scheduled for repeat biopsy. Eur Urol 2008;54:1081-8. 10. Deras IL, Aubin SM, Blase A, et al. PCA3: a molecular urine assay for predicting prostate biopsy outcome. J Urol 2008;179:1587-92. 11. Nakanishi H, Groskopf J, Fritsche HA, et al. PCA3 molecular urine assay correlates with prostate cancer tumor volume: implication in selecting candidates for active surveillance. J Urol 2008;179:1804-9; discussion 9-10. 12. Hessels D, van Gils MP, van Hooij O, et al. Predictive value of PCA3 in urinary sediments in determining clinicopathological characteristics of prostate cancer. Prostate 2010;70:10-6.

References 13-36 of this article are available from Ipsen by sending an e-mail to: patrick.cabri@ipsen.com with reference to the article “Towards individualized care in prostate cancer”, EUT, March/May issue 2015. European Urology Today

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Young Urologists/Residents Corner Survey insights on labour issues among young urologists Unemployment among young urologists perceive to rise in many countries residency and working conditions; two questions were about other specialties taking over the tasks of a urologist. Answers to some questions were not included in this article.

Dr. Markiian Stepanchenko Bukovinian State Medical University Clinic Chernivtsi (UA)

Results The questionnaire was sent to 40 countries in Europe. Thirty-four countries responded (85%). We did not have any or have lost contact with the NCO’s from Iceland, Ireland, Latvia, Luxemburg, Malta and Moldova.

stepanchenko. mark@gmail.com European residents in urology have united to achieve mutual understanding, define cross-border problems in training, and gather opinions for them to respond to and influence developments in medical education.

Unemployment Representatives of 10 countries reported unemployment (29.4%, in 2013 – 25.7%) (Table 1). Countries such as the Netherlands, Spain and the United Kingdom mentioned temporary job European trainees in urology are consolidated within opportunities for young urologists, or duty contracts the European Society of Residents of Urology (ESRU) and other unattractive positions. Greece, Italy, which closely cooperates with the European Board of Netherlands and Spain mentioned the economic crisis Urology (EBU) and the European Association of as a reason for a decrease in the number of available Urology (EAU). Being an independent organisation, positions. In Austria, Lithuania an Uzbekistan, there ESRU raises issues in urological training. were responses that reported urologic tasks taken over by surgeons who are not urologists. Some One of the ESRU’s projects – ‘Unemployment among countries reported unemployment of young urologists residents in Europe’ – has been conducted and is now due to the reluctance of young specialists to move out on its second year following a 2013 ESRU Board from capital or big cities (Greece, Romania and Meeting in Prague where the issue was first discussed. Ukraine). Others anticipate a growing unemployment The project aims to raise awareness regarding problem due to the big number of residents vis-a-vis unemployment among young urologists in Europe. fewer job opportunities based on local healthcare Among the controversies identified was the perception system peculiarities (Belgium, Finland, Netherlands that many countries have a lack of urologists, while and United Kingdom). others face an oversupply. In a 2014 survey, new questions were added to examine the varying working Fourteen (41.2%) countries stated that residents were conditions among residents in different countries. With employed even before completing their training (Table globalisation trends in labour, it was hoped that 1), whereas four countries (11.8%) reported survey results might provide insights to residents from employment less than a month after finishing countries with high unemployment rates in case they residency; five countries (14.7%) reported employment consider the option to find work elsewhere. one to three months after finishing residency; six countries (17.6%) up to six months after finishing The answers were collected from the National residency; three countries (8.8%) up to one year; and Communication Officers (NCO) of European countries. two countries (8.8%) reported employment more than Since the data was not sourced from official agencies, one year after finishing residency. the relevance of each particular quantitative score may differ per country. Thus, in the 2014 survey any indexes 21% of respondents mentioned that other (para-) that could represent ‘by-country’ healthcare system medical specialists (e.g. nurse-practitioner, physicianfunctioning was not calculated. Conversely, the survey assistant, etc.) are taking over the tasks of the was primarily designed to reflect trainees’ opinion urologist, of which 24% believed this trend might also regarding unemployment among young urologists in affect or reduce the demand for urologists in their Europe. countries. In Finland, France and Norway, oncologists may treat some urological cases; in Poland and Methods Norway interventional radiologists may perform select Responses were collected per country using the online procedures; in France and the Netherlands nurse survey service “Survey Monkey.” Participation in the practitioners could take over certain procedures, while survey was offered to all current NCO’s of countries in Sweden those same practitioners may even perform represented within the ESRU (maximum of two follow-up cystoscopy or transurethral microwave respondents per country). Each reporter had to therapy in rare cases. answer 28 questions, out of which seven requested the contact details and statistical data; another two Getting employed were about resident’s involvement in the National Out of the NCO’s who responded to the survey, 64.7% Urological Associations (NUA); six questions were said there is regulation in the number of residents, out about actual unemployment rates and employment of which 86.4% reported that it is the government process in the EAU member countries; four questions which determines the number of residents in urology were about the selection procedure to become a who are to be trained in their countries, 13.6% resident in urology; seven questions were about responded that the quantity of trainees is based on Table 2

What is your country of training?

Residents unemployment?

Main reasons for unemployment?

Unemployed - lose license?

Greece

Yes

Lack of urology jobs in the National Health System

No

Italy

Yes

Lack of work opportunity

No

Lithuania

Yes

Not every hospital has a urology department. There are too many urologists in training

No

Macedonia

Yes

Changes in the structure of healthcare

No

Netherlands

Yes

Experienced urologists tend to work longer because of the crisis. Too many urologists in training

No

Residents are not interested in leaving the capital. Limited number of jobs offered by the Health Care System

No

Romania

Yes

Spain

Yes

Economical crisis. Lack of budget in some hospitals

No

Ukraine

Yes

Number of residents in training exceeds the needs in specialists of urology

1 year unemployment: study 2 months to keep license. 3 years unemployment: study 3 months and pass exam

United Kingdom Yes

Lack of urology jobs in the National Health System

No

Uzbekistan

Not every hospital has a urology department. there are too many urologists in training. Surgeons overtake urological care. Too many residents.

1 year unemployment: study 2 months to keep license. 3 years unemployment: study 3 months and pass exam

Yes

Table 1 26

European Urology Today

Figure 1

single hospital decisions. Only the Netherlands and month; 55.3% of the respondents stated it does not United Kingdom have mentioned the NUA’s role in this exceed 3,000 euros; more than 3,000 euro per month regulatory process. was indicated by 33.3% of the respondents. For the above-mentioned salary rankings, young specialists To be hired for urological training, 45.5% of fresh have to work less than 45 hours per week in 20% of medical faculty graduates face national selection the cases; no more than 55 hours in 46.7%; and more procedure before being accepted for training in than 55 hours/week in 33.3% of the respondents. urology, 42.4% - selection for a single hospital and only 12.1% indicated regional selection (in cluster or Unemployment trends Residents from European countries that took part in provincial). our 2014 Unemployment Survey had difficulties answering quantitative questions particularly those Regarding job prospects following residency, referring to human resources. Depending on the respondents were asked about the factors that may country, its size and involvement of residents in the help a young urologist get a job offer (Figure 1). 65% NUA, relevance of some issues might differ. But we of the respondents stated scientific (academic) have achieved our main purpose, having collected background, 61% mentioned the importance of a residents’ opinions that might help shed some recommendation from a respected urologist, 57% insights on problems encountered in different indicated the role of having a PhD, 48% have countries or individuals and by raising awareness indicated the quality of a completed residency (e.g. among specialists. residents from city "A" university are always good). Having a FEBU title constituted 26%, while “corruption” was mentioned in 13% of the responses. Unemployment among young urologists in Europe exists. Ten countries out of 34 (29.4%) have reported Nowadays, the FEBU exam is mandatory in Poland it. A superficial analysis and comparison among and Hungary only; in other countries urologists may countries have been made in terms of the reasons for take the FEBU voluntarily. However, positive perception of the FEBU in Europe is growing currently, unemployment and the different regulations affecting the employment process. The new data requested as this response was also given by NCO’s of Czech from residents in the 2014 survey – factors easing Republic, Denmark, Germany, Slovenia and employment – showed the convincing dominance of Switzerland. scientific background, recommendation from respected professional and gained PhD. Evaluation of Working conditions working conditions showed that 80% of young In the 2014 survey we expanded the questionnaire to urologists work more than 45 hours per week which is include a comparison of working conditions of young urologists from select countries (Table 2). The duration considered to be overtime in many countries. Salary levels, which vary widely among countries, do not of residency is six years in 40% of the interviewed indicate something definite since costs of living widely respondents; five years in 46.7%; and four years by differ across the region. 13.3% of the respondents. After completing their residency, 60% of respondents are free to find Evaluating the factors influencing the urological job employment anywhere in the world, 6.7% are linked market in Europe might help elucidate the labour to their country, 33.3% of young specialists have to problem. The current globalisation in labour that stay and work in their (specified) clinic. The monthly salary indicated by the interviewed respondents varies affect the urological community and other medical international associations may later have a bigger much: in 33.3% cases it is lower than 500 euros per impact on countries’ regulations and on the use or implementation of human resource tools in Europe to Are residents linked to Salary Hours/ Defined # of night Overtime/more help promote labour mobility, which in the end might your country / specific week duties/month money clinic after finishing ease unemployment and eventually raise the quality of residency? urological care across European borders.

What is your country of training?

Length of training in urology?

Belarus

5 years

Linked to specific clinic

<500

45-55

4 duties

additional night duties

Belgium

6 years

Free to get employed anywhere in the world

5000

60

No

Yes

Denmark

6 years

Free to get employed anywhere in the world

>3000

35-45

3 to 5 per month

Yes

Georgia

4 years

Linked to specific clinic

500-1000

45-55

5-6 month

Yes

Germany

5 years

Free to get employed anywhere in the world

2500-3000 45-55

Depends on the Hospital Yes and the number of staff. Usually 5-9

Hungary

5 years

Linked to specific clinic

500-1000

3

Yes

Italy

5 years

Free to get employed anywhere in the world

2000-2500 45-55

No/depends on hospital

Yes

Netherlands

6 years

Free to get employed anywhere in the world

>3000

45-55

No/depends on hospital

No

Portugal

6 years

Free to get employed anywhere in the world

1200

40-52

3 duties 12h

yes

Slovenia

6 years

Linked to specific clinic

1300-2000 40-70

5-7 24h duties

yes

Spain

5 years

Free to get employed anywhere in the world

1500-2000 >55

Not specified. All duties 24h

No

Sweden

5 years

Free to get employed anywhere in the world

4000

3-4 duties

Switzerland

6 years

Free to get employed anywhere in the world

4500-5500 50-62

No, official regulation. Mostly 1-2 weekends a month and 4-8 night shifts.

No

Any comments, suggestions or articles for the Young Urologist/ Residents Corner are welcomed at: eut@uroweb.org

Turkey

5 years

Linked to the country

2000-2500 45-55

No

Yes

S. Sarikaya, Section editor

Ukraine

4 years

Linked to specific clinic

<500

No/depends on hospital

No

>55

40

40

Table 2 March/May 2015


Young Urologists/Residents Corner Complications after laparoscopic radical prostatectomy Pudendal artery embolisation as management of massive haematuria Dr. Daniel Tueti Silva La Paz University Hospital Madrid (ES)

dtueti@gmail.com

Dr. Juan Gómez Rivas ESRU Internal Coordinator Officer NCO Spain La Paz University Hospital Madrid (ES)

minimally invasive procedures such as laparoscopic surgery have the advantages of less bleeding, faster patient recovery, less use of analgesics and shorter hospital stays. However, complications of laparoscopic procedures seem under-reported. The reasons for this may include variable opinions as to 1) what constitutes a complication in each department, 2) different degrees of technical difficulty between laparoscopic procedures, 3) complications usually depends on other variables such as comorbidities and 4) lack of standardised reporting. Massive hematuria after LRP is an uncommon complication that may compromise the patient’s life

juangomezr@ gmail.com The advent in the last decade of laparoscopic techniques in urology demands that their complications might be solved also by minimally invasive procedures. Laparoscopic radical prostatectomy (LRP) is the standard treatment in our department for prostate cancer (PCa) since 2002. It is well-known that

Figure 1: Embolisation of pudendal artery

and represents a serious issue to deal with. To our knowledge, there are few related cases reported on the literature of hematuria after LRP. The prostatic arterial supply have been well described using pelvic CT angiography and digital subtraction angiography (DSA), allowing the use of supraselective embolisation of pudendal artery as a strategy to treat the benign prostate hyperplasia and the hemorrhage after prostate and bladder transurethral resection. In a revision performed by Delgal et al, of 20 patients with bladder and/or prostate bleeding treated with transcatheter arterial embolisation after failed conservative treatment, the success rate was 90% (18/20 cases) (8). Based on this experience, in our department we have performed this technique with success in patients using supraseletive embolisation of pudendal artery as a minimally invasive procedure to control massive bleeding after LRP when conservative therapies have failed or when the clinical situation of the patient contraindicates surgery (Figure 1 and 2). Efforts should be made to use standard grade systems to report complications such as the Clavien-Dindo. High quality analysis of complications in different urology departments and their management are important to reduce complication rates and for quality management at the respective institution; also this may be relevant for other centres, offering possibilities to report the experience especially in rare complications.

Figure 2: CT scan after the procedure

The YAU Urothelial Cancer Working Group Networking among multi-disciplinary experts Dr. Evanguelos Xylinas Chairman YAU Urothelial Cancer Working Group Paris (FR) evanguelosxylinas@ hotmail.com The European Association of Urology (EAU) has recently supported the development of expert groups of the Young Academic Urologists (YAU) to boost research activity in some critical areas of urology and improve academic collaboration among different centres in Europe. The expert groups aim at scientific cooperation, study design or other scientific output. The Urothelial Cancer Working Group is open to European non-urologists with an interest in the management of urothelial carcinoma of the upper and lower tract in order to fully cover the disease in a multi-disciplinary fashion. What are the aims of our Urothelial Cancer Working Group? Urothelial carcinoma of the upper and lower tract is still associated with adverse outcomes after surgery. Treatment of this disease challenges national health systems with high costs. In order to change the natural history of the disease, a fundamental and translational researches as well as clinical outcomes research are warranted. Our goal as a group is to merge already existing retrospective multiinstitutional databases and create prospective multi-institutional databases and registry studies. Within the EAU, our group wishes to actively participate in the revision process of the EAU Guidelines on non muscle-invasive, muscle-invasive and upper tract urothelial carcinoma. Moreover, we are involved in the EAU Section of Onco-Urology (ESOU) where we participate in the annual meeting as lecturers for the ESOU Journal Club of the Year, and as members of the ESOU Bladder Cancer subcommittee. Generating ideas to international multi-centre projects: current and future studies Prospective projects of the Urothelial Carcinoma Working Group include the evaluation of the impact of smoking exposure at the time of diagnosis in patients with muscle-invasive bladder cancer treated March/May 2015

Dr. Luis Kluth YAU Urothelial Cancer Working Group Hamburg (DE)

Dr. Atiqullah Aziz YAU Urothelial Cancer Working Group Hamburg (DE)

l.kluth@uke.de

a.aziz@uke.de

with radical cystectomy and pelvic lymphadenectomy, as well as patients with upper tract urothelial carcinoma treated with radical nephroureterectomy. In addition, we performed a prospective evaluation of the quality of life in patients after radical cystectomy for muscle-invasive bladder cancer using translated validated questionnaires. Our retrospective studies include a multi-institutional validation of the T1 substaging (micro/extended) in patients with non-muscle invasive bladder cancer treated with TUR and adjuvant intravesical instillations of BCG. Furthermore, we analysed prognostic factors and risk groups in a multi-institutional cohort of 2451 patients with T1G3 non-muscle invasive bladder cancer patients that were initially treated with BCG.

“One major strength of our fruitful collaboration is that we do not consider ourselves as colleagues only, but friends.” For patients with clinical node-positive metastatic bladder cancer, we conducted a study, which aimed to assess the impact of postchemotherapy lymphadenectomy on survival. Furthermore, we are evaluating the perioperative complication rates and clinical outcomes of patients with muscle-invasive bladder cancer that were treated with radical cystectomy and having a previous history of abdominal radiation therapy. Within a systematic review article, we are investigating on perioperative chemotherapy in patients who undergo radical nephroureterectomy for upper tract urothelial carcinoma. Finally, we conducted two surveys, which aim to assess the urologist’s role in smoking cessation, and secondly, practice patterns among European urologists of immediate post-operative instillation of

to communicate and exchange ideas. Our goal is to bring together young academic urologists practicing in Europe with a major interest in managing urothelial carcinoma and promote active collaboration. The YAU Urothelial Cancer group welcomes not only urologists from academic institutions, but also urologists who are dedicated in doing research in urothelial carcinoma and participating in collaborative scientific projects. Our group also wishes to include young academic non-urologists (i.e. radiologists, radiation oncologists and medical oncologists) practicing in Europe with a major interest in the management of urothelial carcinoma. We believe that networking, as exemplified by the YAU group, may facilitate and improve the way research can be done in the future to approach disease management from various professional perspectives.

chemotherapy after radical nephroureterectomy for upper tract urothelial carcinoma. Boosting research through networking Our group is an ideal platform for exchanging data, clinical experience and planning new projects. The semi-annual meetings of our group are a great way





Evanguelos Xylinas (Chairman)

Paris (France)

Atiqullah Aziz

Hamburg (Germany)

Felix Chun

Hamburg (Germany)

Jakub Dobruch

Warsaw (Poland)

Paolo Gontero

Turin (Italy)

Andrea Necchi

Milan (Italy)

Aidan Noon

Sheffield (UK)

Michael Rink

Hamburg (Germany)

Morgan Rouprêt

Paris (France)

Bas Van Rhijn

骢睘붔 珢睞珢睞

Amsterdam (Netherlands)

Roland Seiler

Bern (Switzerland)

Shahrokh Shariat

Vienna (Austria)

Roman Sosnowski

Warsaw (Poland)

European Urology Today

27


Young Urologists/Residents Corner EAU Congress: A resident’s viewpoint Congress participation provides insightful feedback and networking Dr. Mónica Vega Robalino Resident La Paz University Hospital Madrid (ES) monik.verob88@ gmail.com

Dr. Juan Gómez Rivas ESRU Internal Coordinator Officer NCO Spain La Paz University Hospital Madrid (ES)

pleasure to attend this scientific event right in Madrid. For urology residents, this is a great opportunity to get updates on innovative research studies, new trends in technology and surgical techniques. It is interesting how the plenary, thematic and special sessions held during the five-day congress have inspired us to investigate and research, considering that in our hectic work routine we barely have time for research work. And to those who participated in the poster and oral presentations, the congress offered the opportunity for us to share with our colleagues from other countries our clinical or basic research experience, enabling us to get feedback from experts in the subject.

Regarding the courses organised by the European School of Urology (ESU), these are wonderful opportunities for us to learn new insights on many urology topics that would help our daily practice. Moreover, the ESU courses were led by renowned juangomezr@ professors, certainly a remarkable, not-to-miss gmail.com opportunity that allow us to ask about their surgical techniques, medical management and Each year urologists from Europe and all over the world research findings, among other issues. The direct interaction with an expert during these courses is gather to discuss state-of-the-art topics in urology at really motivating to a young or novice urologist. the annual EAU congress, and this year we had the

Another important benefit of the annual congress is the chance to meet residents from other Europe countries to exchange hospital and training experiences. It is fascinating to talk with other residents about daily practice and to learn about the differences among countries regarding training programmes, duration of residency, mentorship, surgical approaches, management of pathologies and residency final exams, to name a few.

The Challenge the Expert(s) session at the Residents and Young Urologists Day

We believe this annual event have given us a wonderful experience in terms of learning and exchange of professional experience that would

certainly help in our growth as urologist. We encourage urology residents to participate in these events. We hope to see you in future meetings!

Residents’ Day in Madrid High attendance at successful annual residents’ event Dr. Giulio Patruno ESRU Chairman Rome (IT)

introduced their new portfolio service MedBook, which is available for residents and is also offered as an smartphone app.

g.patruno@ gmail.com

The YAU morning session saw some passionate young speakers discussing the scientific work of their groups: kidney cancer, men’s health and BPH. Besides presenting the results of their studies, they showed how one can be inspired by or come up with a good idea-- in the operating theatre, between cases, at a lunch conference and during a social gathering. A speaker mentioned that scientific ideas can even be written first on a piece of paper napkin, which can later become a standard in daily practice.

The success of Residents’ Day was again evident during the 30th EAU Anniversary Congress held in Madrid. 2015. Officially, the meeting is called “Residents and Young Urologists Day,” organised by the Young Urologists Office (YUO) in collaboration with the European Society of Residents in Urology (ESRU) and the Young Academic Urologists Working Parties (YAU). A rather long name which shows how much effort goes into the careful planning of such an event. More than 500 residents, 30% of the total, attended the meeting which began early in the morning with a warm welcome and introductory remark by YUO Chairman Michiel Sedelaar and ESRU Chairman Juan Vasquez. A lot of changes occurred including a new logo, a new website and an even closer collaboration between the ESRU and EAU, all mentioned by Juan Vasquez during his remarks. Useful information on the European School of Urology, the EAU Regional Offices, European Board of Urology, and the new EAU Patient Information project and the EAU Research Foundation were also presented, highlighting the benefits for residents and young urologists from these offices and organisations. The EBU, in particular,

Fig. 1: Prof. Chapple joining the Residents during dinner

28

European Urology Today

The YUO/EUSP joint session showed not only the benefits of applying for a scholarship, it also introduced to the residents a brilliant speaker, Dr Maria Ribal, who gave an inspiring talk on the wonderful opportunities offered by the EUSP to young urologists and residents. Stephane Larré noted that good projects are often granted a scholarship. Currently, almost all applicants who meet the requirements are awarded with a grant. Francesco Sanguedolce, YAU coordinator, showed how the tuition of young committed academics can be of help while Prof. Peter Mulders reiterated the strong links between the EUSP and EAU-RF. Prof Chris Chapple, EAU Secretary General, confirmed his support to the EUSP. In fact, one of the EUSP centres is the Sheffield Urology Department.

Fig. 3A: Group picture of the residents

The survey results also aided the ESRU what subjects to feature during the tips and tricks session. The ESRU will continue the project and keep a close eye on European residents training to help tailor the training to the real needs of residents. The subject quickly became a trending topic on Twitter, thanks to the comments of residents who are attending and are following online the hashtags #EAU2015 and #YUORday15 (official hashtag).

The popular Campbell Team Challenge Quiz tested the audience’s knowledge on various urological topics, followed by an interesting panel discussion. Prof. Oliver Hakenberg shared expert knowledge and commented on every question with a touch of sharp wit. Danish resident Marie-Louise Vrang won this year’s quiz and received the latest edition of Campbell’s Urology. Surgical session The afternoon session featured the second edition of a special surgical session offered to residents and urologists, especially those with less experience. Repeating its previous success, the session featured tips and tricks on surgical procedures such as TURBT, pelvic lymphadenectomy, circumcision, robotic setup and URS. The speakers, renowned opinion leaders and great communicators, gave useful advice on how to improve one’s surgical technique to achieve better clinical outcomes. The procedures chosen were classic operative procedures which with the necessary discipline and expertise can lead to great results. The session on education opened with the annual results of ESRU’s flagship survey project regarding resident training in Europe. The results confirmed what was shown last year: the inconsistencies among countries regarding surgical training.

a surprise visit to toast and chat with the residents, conveying his support to the ESRU and the younger urologists. The dinner was also an opportunity for residents to get to know each other. This year’s programme was prepared with the needs of residents in our minds as reflected in the ESRU’s survey. The programme intended to highlight training opportunities offered by the EAU and how residents can improve their daily clinical and surgical practices through tips and tricks. We are already planning next year’s programme and it is important for us to have your feedback so we can introduce further improvements. Let us know what you would like to discuss or be taken up in next year’s programme by contacting the author at g.patruno@gmail.com.

Fig. 2: Dr. Marie-Louise Vrang, the Campbell quiz winner

We look forward to your comments and suggestions and are very excited for next year’s programme. With your active support we hope to organise an even better programme in Munich next year!

Following a second YAU session, the programme ended with the Challenge the Expert, a joint ESRU/ YAU session on everyday ‘nightmares’’ or vexing clinical questions such as: What to do with patients with a negative prostate biopsy and rising PSA? What to do with an infected stone in a pregnant woman? Lymph nodes in penile cancer: To dissect or not to dissect? All cases were very informative, well presented and prompted a good discussion regarding diagnosis, treatment and potential complications led by a YAU expert and a non-YAU opinion leader. Social programme The social programme included a dinner and party which attracted many participants. Prof Chapple made Fig. 4: Full room for surgical tips & tricks March/May 2015


Young Urologists/Residents Corner Elaut Prize 2015 Day-long event showcases Belgium’s young urology talents Dr. Barbara Hermans NCO Belgium Leuven (BE)

barbarahermans@ hotmail.com

Dr. Vincent De Coninck NCO Belgium President-elect ESRU Belgium Brussels (BE) vincent.deconinck@ uzbrussel.be

The Professor Elaut Prize is an annual scientific and social event organised by the Flemish section of the Belgium Society in Urology (BVU www.bvu.be). The prize is named after Professor Léon Elaut (1897-1978), born in Ghent and widely known as Belgium’s first urology professor.

The ceremonial conferment of the prize is preceded by day-long activities when science is celebrated among like-minded friends. Every year urology residents are given the opportunity to submit their abstracts from which the jury selects nine clinical and three scientific subjects and 12 posters. Participating residents present their work to an audience of urologists and professors. By the day’s end the BVU members will vote for three laureates for clinical presentation, one for scientific work, and one winner from the poster sessions.

that the latter leads to a shorter operation time, less positive surgical margins for pT3 tumours and superior potency rates.

Co-organised by members of a local hospital and AZ Delta Roeselare, this year’s event was held at a congress centre. Residents and urologists participate in the scientific programme while their partners are offered a memorable social programme which highlighted culture, art and history. The social itinerary included a visit to Dr. Lieven Declerck’s art gallery whose collection includes paintings, fine arts and photos of famous artists, a visit to a World War I German military cemetery, and to the studio of Nick Ervinck, a talented young local artist known for his architectural sculptures.

Dr. Maes analysed in a retrospective trial independent predictors (grade of hypospadias, surgical technique, suture material, age at operation) that lead to re-intervention following primary hypospadias repair. She concluded that proximal hypospadias is the only independent predictor for re-intervention, a factor that cannot be modified. In a prospective trial following urethroplasty for anterior strictures, Dr. d'Hulst found a significant decline in erectile dysfunction in patients with mild or no baseline erectile dysfunction. After nine months, there was no full restoration of erectile function.

Scientific programme The sessions consisted of 10-minute presentations of recent projects by the participants and followed by a five-minute Q&A by the jury. Dr. Verbrugghe analysed data in a retrospective single-surgeon trial the comparative outcomes of conventional laparoscopic versus robot-assisted prostatectomies. She concluded

Dr. Weyne won the scientific price with his study on galanin as an important component in the early endogenous neurogenerative response to cavernous nerve injury.

Dr. Hermans studied the measurability of quality indicators in testicular cancer. The need for quality measurement to reduce treatment and diagnostic variability is becoming more important, and not only for improving quality of care, but also in reducing financial costs. Moreover, her study has shown that high-volume centres don’t always means high quality.

The podium presentations were followed by short poster presentations. Dr. De Coninck studied the

incidence of bladder neck sclerosis after monopolar and bipolar transurethral resection of the prostate. He found no difference in stricture incidence between both techniques. Dr. Claeys won the poster prize with his study evaluating the effect of cytoreductive nephrectomy in patients with metastatic renal cell carcinoma. In half of the patients, the disease stabilized and resulted to a two-year overall survival of 93 % (versus 19 % in non-responders). Evening programme Before the awards ceremony, trend watcher Adjiedj Bakas took the audience to the future which he expects to become more digital- a future where IT meets medicine. He showed new trends in healthcare, and what future doctors should undertake to be up to date. He predicted fewer developments in medical specialties, but more advances in IT and new technologies (additional information can be found at Bakas’s website at http://www.bakas.nl). The awards ceremony was complemented by a wonderful reception and dinner. Science is like food for the brains, but after a long interesting day, participants enjoyed the dinner prepared by Chef Tim Boury, whose superb culinary skills have earned him a Michelin star. Topping the remarkable evening was a live performance by singer-songwriter Flip Kowlier.

The best for practising minimal invasive surgical skills JUMISC in Cáceres attracts young urology trainees It has been said that experience is the way to know oneself and that we always grow with experience. The same can be said on practical experience and its role in honing surgical skills. Every surgeon would like to know where and how to practise before taking real risks. I am a third–year resident, specialising in urology at the Henares Hospital in eastern Madrid, Spain, and this article concerns my experience at the Jesús Usón Minimally Invasive Surgery Centre (JUMISC). JUMISC is a multidisciplinary institution in Cáceres province, some three hours from Madrid by car, and this centre focuses on pre-clinical investigation and surgery training. The centre offers extensive expertise in several areas of specialised investigation, such as laparoscopy, endoscopy, microsurgery, endoluminal therapy and diagnosis, anaesthesiology, pharmacology, bioengineering and medical devices, stem cell therapy and assisted reproduction. Regarding urology, it offers a range of courses: endourology, treatment of obstructive uropathy; laparoscopy, NOTES and single-incision laparoscopy surgery.

On the basis of my experience, JUMISC is an excellent centre where the trainee is offered the chance to learn how to manage several techniques such as laparoscopy, since in many instances it is not possible to practise with real patients. In this case, simulation cannot take the place of direct experience with real patients and assessments are often used formatively to provide feedback on developing surgical knowledge, skill and attitudes.

I assisted under the Basic Level Course of Laparoscopy, practising radical and partial nephrectomies in experimental animals such as live porcine models. I started the course as a second-year resident, and I am now working to pass for the Advanced Level Course specialised in Laparoscopy. JUMISC facilities The centre has superb facilities, qualified staff members and perfect conditions for experimental animal maintenance. There are personal trainers for each group and all participants, who provide crucial support and helpful tips on an individual basis while taking into consideration the trainee’s skills level and abilities.

"The centre has superb facilities, qualified staff members and perfect conditions for experimental animal maintenance." In addition, there are ten well-appointed hotel rooms for those who prefer to stay without moving to

Dr. Laura Martínez Third-year Resident Hospital del Henares Madrid (ES)

lmartinezb@ salud.madrid.org Cáceres centre. Convenient facilities are easily available such as WiFi network, programme information and the line-up of offered courses. A Cáceres tourist guidebook is also provided for those who want to discover the cultural and tourist destinations of this wonderful city. With these facilities and superb training programme to help me in honing my surgical skills, I am confident that I am on the right track. And to those who are interested I look forward to meeting you at the Scientific Centre. Detailed information can be accessed at www.ccmijesususon.com/

Spain retains lead in organ donation and transplant Effective donation programme relies on collective effort Dr. Juan Gómez Rivas ESRU Internal Coordinator Officer NCO Spain La Paz University Hospital Madrid (ES) juangomezr@ gmail.com Spain has been the world leader in organ transplants since 1992 and in 2014 the country remains the global leader in the number of organ transplants conducted. The National Transplants Organization (ONT) reported that in 2014 Spain once again broke its own record after carrying out a total of 4,360 transplants. The March/May 2015

data presented by the ONT shows that there was a The living kidney donation and donation after cardiac donation rate of 36 donors per one million inhabitants death are the two clearest ways to improve the last year. number of kidney transplants and on this subject, the ONT showed that living kidney donation accounted for 15.8% of all kidney transplants in 2014, raising the During a news conference at the Health Ministry, officials said Spain also broke records last year in number to 423 donors; this represented a huge relation to the number of kidney and heart transplants. improvement in recent years, especially when compared with the year 2004 when 61 transplants A total of 2,678 kidney transplants were carried out in 2014, up by 5% from the previous year, and 265 from living donors were performed. Of these, 43 have patients received new hearts, up by 6% from 2013. been part of the kidney crossed transplant programme, a mode which is consolidated in our Kidney transplantation is the treatment of choice for country, reaching the first 100 kidney crossed patients with end-stage renal disease. Living donor transplants. renal transplantation has shown superiority over cadaveric donor renal transplantation through the The intense transplant activity in Spain was also years. The advantages of live-donor renal reflected in another data-- the number of transplants transplantation are countless, including: shorter cold carried out in one 24-hour period: on February 20, a ischemia time, better graft and recipient survival and record of 45 transplants took place in 22 hospitals in 11 regions across Spain. no waiting time for transplantation to the recipient.

By regions, the northern regions have the best donation rates, with the ranking as follows: La Rioja, Cantabria, Castilla y Leon, Asturias, Baleares and Navarra. By hospitals, the hospitals who registered the top global transplantation activity was the 12th of October University Hospital at Madrid, and regarding kidney transplants the 12th of October University Hospital also led, followed by the Regional University Hospital in Malaga. These excellent results would not be possible without the invaluable assistance of judges, forensic, law enforcement and numerous groups of non-health professionals involved in the donation and transplantation activity, and also without the generosity of families who approve organ donations. These factors combined are the mainstay of hope for many patients waiting for a transplant, a means to improve their quality of life or even save it. European Urology Today

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Rolf Ackermann Respected urologist and scientist 1941-2015

with Frans Debruyne to transform the EAU into an innovative organisation.

On 11 February 2015 Prof. Rolf Ackermann passed away very suddenly and unexpectedly due to a cerebral hemorrhage. An esteemed colleague who played an active part in urological science, he was a good friend to many urologists worldwide. Discussions with him were always very interesting and insightful. We all miss him. He was born in 1941 in Ulm where he also went to school. He studied medicine at the University of Wuerzburg and Vienna, and graduated in 1968 at the University of Wuerzburg, Medical School, obtaining his degree as doctor of medicine. He trained as resident in Scuol, Switzerland, at the University of Ulm and in Glueckstadt/Elbe. In 1970 he began his urological training at the Department of Urology, University of Wuerzburg under the guidance of Hubert Frohmueller. In 1973 he received a NIH scholarship and did research work at the Department of Surgery, University of California in Los Angeles, USA. He completed his residency in 1975 and a year later he was promoted as Oberarzt (staff member) at the Department of Urology, University of Wuerzburg where he became Assistant Professor in 1977 and later appointed as full professor of urology in 1980. From 1983 to 2007 Rolf Ackermann served as Chairman of the Department of Urology, University of Duesseldorf, Medical School. He set up a modern urology department with excellent clinical

and scientific facilities. He trained many urologists, several of whom became heads of departments of university and city hospitals. He also helped in administering the local Heinrich-Heine University as Prorector from 1993 to 1995. From 1995 to 2003 he was appointed as Medical Director (CEO) of the University Hospital Duesseldorf. Due to his veteran experience and outstanding skills he was instrumental in creating a modern University Department in Duesseldorf. With his focus on urological cancers, Rolf worked on the mechanisms of prostate and bladder tumours, micro-analysis and DNA-modulation and growth signaling pathways. One of his specialties is to look for new techniques to better classify tumours and discover new prognostic factors. He was one of the pioneers in using microarray analysis and DNAmethylation techniques, and was in the forefront with regards to applying new techniques in tumour

treatment, particularly immunotherapy of kidney and prostate cancers by dendritic cells and target therapies. He was active in the German Association of Urology where he served as board member from 1985 to 1996. He was General Secretary for six years and was president from 1995 to 1996, a period where he helped transform the German Society of Urology into a modern organisation which served as an example to other German medical societies.

In 1996 Rolf ended his term as board member and became a member of the EAU Academy, which he led as chairman from 2010 to 2012. In all these different and very important roles, Rolf remained a hard worker, always enthusiastic in reaching goals and well-known for his perceptive, critical views. With his warm and charming character, Rolf was an engaging friend who can converse on diverse subjects from fine arts, music to politics. For his outstanding work he received significant awards such as the 2005 Frans Debruyne Lifetime Achievement Award, the 2008 Maximilian Nitze Medal from the German Society of Urology, and several Honorary Member accolades from various societies such as The German Society, The European Society and the American Urological Association, to name a few.

Rolf always had an international outlook. He was elected in 1989 as a member of the very prestigious American Association of Genitourinary Surgeons. He also played an important role in developing the EAU. In 1992 he was a member of the organising committee of the 11th EAU Congress, and in the same year served as chairman of the EAU’s Statutes and Bylaws Committee. In that period he worked closely

Rolf is survived by his wonderful wife Christel. Married since 1972, Christel and Rolf were known to many of their friends as a generous, warmhearted couple. To Christel and the Ackermann family we convey our deepest sympathy.

Binding Price Pages Illustrations Website

anaesthesiologists, the knowledge of such techniques can be useful. For these reasons this textbook, although intended for anaesthesiologists, will be of interest to various surgeons, including urologists.

-By Professors Manfred Wirth, Marc-Oliver Grimm and Hubert Frohmueller

Book reviews Prof. Paul Meria Section Editor Paris (FR)

Authors ISBN E-book Regional Anesthesia, Publisher Stimulation and Ultrasound Publication Edition Techniques Binding Price Currently, the development of ambulatory surgery is Pages partially based on various advances in the field of anaesthesia. The development of regional anaesthesia Illustrations during the last 10 years was based on some important Website factors such as nerve location under ultrasound guidance, improved knowledge of drugs for local anaesthesia and better understanding of the role of local drug injection, either preoperatively or postoperatively as an analgesic protocol.

paul.meria@ sls.aphp.fr

Mini Oxford Handbook of Clinical Medicine The first edition of the Oxford Handbook of Medicine was published 30 years ago. The ninth edition of this textbook is now available in a mini format, described by the editor as a “small size and massive content textbook.” Editors M. Longmore, I.B. Wilkinson, A. Baldwin and E. Wallin aimed to collect information from all fields of medicine. They updated the previous edition with the help of reader’s comments and suggestions. This remarkably designed textbook is clearly not written for specialised practitioners, but for all of them, urologists included. The book can serve as an exceptional compilation of the basic principles which govern daily medical practice. All aspects of practical medicine were considered in this survey with the initial chapters focusing on various aspects of clinical care, such as patient’s approach and questioning, drug prescription, the elderly, death, ethics and many other issues. Functional enquiry and exhaustive physical examination were considered in the second chapter, before the various aspects of the specialised branches of medicine were addressed. The succeeding chapters were dedicated to all specialties, including nephrology, urology, surgery Book reviews

30

European Urology Today

: Flexicover : £ 29.99 : 920 : 411 colour photographs and line drawings : www.oup.com

and emergencies. All of them were richly illustrated and included various decisional trees, tables and figures. Undoubtedly, all urologists who purchased this remarkable pocketbook will have a wealth of medical references in a handy format which is very useful in actual daily practice. They will also find the answers to frequently asked questions for certain topics which are not in their specialty. Authors ISBN E-book Publisher Publication Edition

: M. Longmore, I.B. Wilkinson, A. Baldwin and E. Wallin : 978-0-19-872254-0 : Available : Oxford University Press : Nov. 2014 : 9th

: P. Warman, D. Conn, B. Nicholls and D. Wilkinson : 978-0-19-955984-8 : Available : Oxford University Press : Nov. 2014 : 1st : Paperback : £ 44.99 : 576 : Over 200 : www.oup.com

Editors P. Warman, D. Conn, B. Nicholls and D. Wilkinson aimed to gather in this handy pocket-sized book all the current aspects of regional anaesthetic techniques. The book’s first part was dedicated to general considerations and addressed various topics including physiology of pain, pharmacology of analgesics, toxicity, basic physics of ultrasounds, and anatomy. Risks and complications of local anaesthesia were also addressed. The five succeeding parts were dedicated to head and neck, upper and lower limb, trunk and neuraxial blocks. All regional anaesthetic techniques were exhaustively described. For each block a step-by-step description was made, including indications, contraindications, risks and complications. In the daily practice of urologists some trunk blocks are of interest such as paravertebral, intercostal, transversus abdominis, rectus sheath and penile block. Although we can currently rely on high-level March/May 2015


Long-term strategies to boost reconstructive urology ESGURS takes steps to consolidate gains Dr. Rados Djinovic Chairman ESGURS Sava Perovic Foundation Belgrade (RS)

djinovic@gmail.com The EAU Section of Genitourinary Reconstructive Surgeons (ESGURS) has its roots back in the 1980’s and begun as a group of specialists from across Europe with the goal to meet and exchange experiences with like-minded colleagues. The section was formally established in 2001 following the merger of the European Society of Male Genital Surgery (group of Prof. Edoardo Austoni) and the European Society for Reconstructive Urology (group of Prof. Tony Mundy) with Prof. Friedhelm Schreiter as the first chairman. Particular to reconstructive surgery is the need to correct affected organ/system and re-establish function using surgical techniques. Uro-genital reconstructive surgery involves urological and genital problems, which are usually not life-threatening diseases, but conditions that can significantly decrease quality of life.

Up to this day, the field of genito-urinary reconstructive surgery is not established as a distant subspecialty, and there is no single centre in the world which offers a standardised training programme. The specialty is usually practised by interested individuals at certain centres, mainly by urologists, but also other specialists. In any case, the majority of urological centres in many countries have no experience with challenging cases and many patients suffer from complications due to bad outcomes. A growing interest The latest development in other urological surgical procedures and with the introduction of modern endoscopy, laparoscopy and robotics and improving standards of care are probably among the main reasons for the growing interest of many urologists to our field. And there is a significant increase of interest in recent years. The number of participants at the ESGURS meetings has progressively increased in the last decade - from less than 100 participants five years ago to more than 800 at the last Annual EAU Congress in Madrid. This is a clear indicator of the growing need to provide state-of-the-art standards of care, to recognise appropriate specialised centres with a high-level of expertise and to organise educational activities for interested urologists. These are among the main goals of our society.

The recent changes in EAU regulations governing the EAU’s super-specialist sections give us more flexibility and encourage further development through the creation of Working Groups which will present real expert opinions. Our groups will work on the following areas: urethral, transgender surgery, penile, male incontinence as well as bladder and ureteral reconstruction.

Reconstructive surgery is a demanding task and requires great knowledge, experience as well as creativity to provide good results and avoid complications, which are basic requirements in surgery. Since there is a wide range of aberrations for every condition, individualised approach and combination of different techniques are often required. For this reason training for this surgical field Of particular interest is the establishment of the should be extensive and requires basic experience in Congenital Lifelong Urology (CLU) Working Group in classical urology. ESGURS, with the goal to unify various specialists who

are, up to now, separately working in the treatment of patients with congenital anomalies (both childhood and adulthood). For instance, there are a certain number of patients born with congenital anomalies and treated in early life who continue to have problems into adulthood. They usually seek help from urologists specialised in adult conditions but who are not usually trained for this kind of surgery. On the other hand, paediatric urologists do not have experience with adults, so these patients are mostly not getting the care they need. For this reason the CLU Working Group will attempt to better identify their problems and to organise appropriate medical services throughout Europe. ESGURS membership Our goal is also to increase the number of ESGURS members – an issue which was also clarified by the EAU; any EAU Member can become an affiliated

Help urologists collect CME credits and register your activity today!

member to one or several EAU Sections. The criteria to elect associate members are as follows: • Must be an EAU Member; • Must be involved in the subspecialty area; • Must have at least 3 manuscripts published in that given area plus at least 7 more PubMed articles; and • Must be approved by the Section Board. We encourage young urologists to join us and further strengthen the platform wherein we can promote uro-genital reconstructive surgery through a wide variety of teaching activities. These activities include hands-on-training sessions, EAU Meeting courses, symposia, masterclasses, live surgery, and courses organised at third party congresses. We hope to achieve our goals and provide better care to all patients.

Have you moved? Changed name? New employer?

(Inter)National Urological Associations and the CME providers (organisers of CME activities) are invited and encouraged to send in requests to register nationally accredited CME activities or requests for European accreditation.

Alter your personal data on-line: fast and easy -

www.eu-acme.org

www.eu.acme.org

EAU Section of Genito-Urinary Reconstructive Surgeons (ESGURS)

15th Russian Society of Urology Congress Three-day event organised in collaboration with the EAU and ESU St. Petersburg will host the 15th Russian Society of Urology (RSU) Congress from September 18th to 20th, a three-day event that will present a comprehensive scientific programme tackling major issues in urology, controversial topics in treatment and the latest updates in technology. Below is an interview with Dr. Y. Alyaev, RSU chairman and head of the organising committee regarding the congress: Q: What is the Congress dedicated to? Alyaev: The theme of the 15th Congress of the RSU - in collaboration with the EAU - is Urology in the 21st Century: Present and Future, covering new technologies but also current long-proven methods of treatment and new approaches and technologies.

We also invite to join young professionals and head of departments, such as proctologists, oncologists, radiologists, endocrinologists, nephrologists, diagnosticians, internists, and paediatricians. In modern medicine it is necessary to be an expert in related fields.

Prof. Yuriy Alyaev, RSU Chairman

Q: What is special about the congress? Alyaev: The scientific programme of the 15th Congress is remarkable as it has been prepared in collaboration with the European Association of Urology, making it a significant event. Over the years many Russian urologists have been actively involved in the EAU’s committees and sections and with the European School of Urology. Understanding the need for mutual exchange of experience and educational resources has led to this collaborative meeting.

Q: What can an expert from overseas gain from the Congress? Alyaev: Courses are offered on nine major topics (two to three-hour duration) with interactive discussions. The faculty consists of Russian, European and American lecturers. The programme includes several modules consisting of lectures, seminars with discussions, practical courses and an exam at the end.

We have also active explored 3D-modeling experience. Achievements of 3D-technology are increasingly applied. We have published the book "3D-Technology in Operations of the Kidney: From Virtual to Real Surgery" issued at the 14th RSU Congress, including a digital version. Additionally, we organised this year a large number of conferences, video presentations and webinars.

Q: Why was Saint Petersburg chosen as the congress venue? Q: What is offered specifically for young doctors and Alyaev: The history of the RSU began in this city. The medical scientists? professor of the St. Petersburg Military Medical Alyaev: There is a competition for young scientists Academy, S. Fedorov founded our society in 1907. He Q: What are some of these new technologies? and the best one will be selected in the oral was a well-known surgeon and urologist and the Alyaev: The rapidly evolving 3D-technology, for presentations. We also encourage the most interesting society’s first president. St. Petersburg is Russia’s example, provides valuable information that work done in fellowships abroad. Young professionals second largest political, industrial and scientific centre. allows diagnosis and determining the type of can participate in satellite symposia, submit posters, With its cultural legacy, the city is called the "Venice of treatment (operative, conservative), its nature Q: Since when and in what areas do you cooperate attend the different courses, etc... the North" and is a popular travel destination. The (organ-preserving, correcting and organcongress venue will be at the EXPOFORUM, a new and with the EAU? resecting) as well as the option to plan technical Alyaev: In 2013, at the Annual EAU Congress in Milan, Q: What are the RSU’s achievements that you‘d modern congress and exhibition centre. operative details, virtually "rehearsing" the surgery consider as most important? there was a meeting between the RSU and the EAU in various ways. leadership. The question of joint activities in Moscow Alyaev: Today the Russian Society of Urology is the Q: What other benefits will participants gain from the in 2015 was discussed. We are working on key issues largest professional medical organisation with over Congress? The introduction of concepts in the internal anatomy to improve the postgraduate training programme for 5,000 Russian urologists. With the direct Alyaev: Section meetings of the congress are focused of the kidney, internal topographic anatomy, computer urologists. The RSU participates in European and involvement of the RSU’s Executive Director, Prof. M. on major urology issues such as urolithiasis, benign simulation of the pathological process and virtual international clinical and research projects. One Gazimiev, virtual platforms were created-- website prostatic hyperplasia, prostate cancer, kidney and operations all have great practical impact and may example of cooperation was the joint translation work and mobile application for relevant news, job tasks bladder cancer, neurourology, men's health and lead to the probability of 3D-printing of kidneys. In and adaption of the EAU Guidelines within the Russian solution, and exchange of experience, contacts and paediatric urology and andrology, among others. We the 14th RSU Congress the issue of integration in context. An important step towards the creation of a communication among its members. A new system have prepared a comprehensive scientific programme urology was considered to be very relevant. An unified approach to the diagnosis and treatment of for modular education for urologists is introduced with key opinion leaders from both RSU and EAU, an integrated approach to diagnosis and treatment is not patients with urological diseases are also planned. for the first time in Russia. The programme‘s goal is exhibit with the latest developments in urology, the a fashionable trend but an urgent necessity to the independent distance training of Russian possibility to share professional knowledge and improve delivery of efficient urological care. But Q: What medical fields do you expect to be doctors. Departments of urology and by leading experience, peer networking, the participation of integrating the most significant innovations is not an represented during the congress? Russian urologists created the nine modules which equipment manufacturers and medical suppliers, and participants can join courses and participate in a easy task. For instance, data from the basic research is Alyaev: We expect to have delegates from various fields: included, to name a few, Haematuria, Chronic andrology, uro-gynaecology, phthisiourology, oncoInflammatory Diseases of the Lower Urinary Tract, social programme that will give them the chance to extremely important for daily practice and for assessing treatment results. urology, paediatrics, geriatric, emergency urology, etc. Acute Urinary Retention, Pyuria, Anuria, etc... see and experience this beautiful city. March/May 2015

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www.baltic15.org

www.cem15.org

BALTIC15

CEM15

2nd EAU Baltic Meeting

EAU 15th Central European Meeting

29-30 May 2015, Riga, Latvia

2-4 October 2015, Budapest, Hungary EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

Call for Abstracts Deadline 1 August 2015 European

European

Association

Association

of Urology

of Urology

www.seem15.org

www.esou16.org

SEEM15

ESOU16

EAU 11th South Eastern European Meeting

13th Meeting of the EAU Section of Oncological Urology

6-8 November 2015, Antalya, Turkey

15-17 January 2016, Warsaw, Poland EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

European

European

Association

Association

of Urology

of Urology

Call for Abstracts Deadline 1 September 2015

32

European Urology Today

March/May 2015


Personalized Cure and Care in Urology Anniversary congress 11 September 2015 Nijmegen, The Netherlands 50 Years of Academic Urology in Nijmegen

Live Surgery of Functional Urological Disorders 10 September 2015 Nijmegen, the Netherlands

Wim Moonen 1965 - 1979

Frans Debruyne 1979 - 2004

State-of-the-art functional procedures sling surgery in women sphincter prosthesis in men and women neuromodulation systems botulinum toxin A injections.

Peter Mulders Since 2004

Top of the bill urological surgeons Accreditation The organisation has applied for European CME credits (ECMEC). Information and registration www.paoheyendael.nl/ urologylive15

It is our pleasure to invite you to the Radboudumc Department of Urology Anniversary Congress. In a dynamic, interactive and inspiring setting, Urology staff members of the Radboud university medical center highlight the scientific achievements of the past 50 years, as well as its future perspectives. Here, highly-qualified international faculty members discuss their views, while a number of patients reflect on these different topics.

www.radboudumc.nl/urologycongress2015

With support from the European Section of Female and Functional Urology. Endorsed by the Live Surgery Committee of the EAU.

#PCCU15

A request for European accreditation is submitted to the UEMS/EACCME

ESUR-SBUR15 11th World Congress on Urological Research 10-12 September 2015 Nijmegen, The Netherlands

#esur-sbur15

ESUR-SBUR15 offers state-of-the-art scientific programme for an international audience On 10-12 September, the EAU Section of Urological Research (ESUR) and the Society for Basic Urologic Research (SBUR) will organise the 11th World Congress on Urological Research in Nijmegen, The Netherlands. Meeting Chair of ESUR-SBUR15, Prof. Jack Schalken, highlights the unique opportunities this meeting offers. The programme of the 11th World Congress addresses the latest trends in urological research, including molecular diagnostic tools and predictive biomarkers in oncology, advances in fertility research, and tissue engineering. The

ESUR-SBUR15 addresses the latest trends in urological research, don’t miss it

March/May 2015

Prof. Jack Schalken Meeting Chair

aims of the World Congress are to improve interaction between highly active researchers on both sides of the Atlantic and to enable students and post-docs to approach their future mentors. ESUR-SBUR15 focuses on a variety of oncological and non-oncological research areas. “Interestingly,” says Schalken, “the delegates will experience that ‘technology cross-fertilisation’ can help to progress all fields of urological research.” The programme includes, among other things, a spectacular real-time video of cancer cell imaging which paves the way to perioperative imaging of cancer cells. Nijmegen is a world-class centre of urological research which is easily accessible by train from Schiphol Airport Amsterdam and several other European cities. The meeting coincides with the celebration of the 50th anniversary of the urology department at Nijmegen’s Radboud University. Schalken: “We cordially invite you to join this premier urological event and enjoy the state-ofthe-art programme, the cross-continental network

opportunities, and the celebration of 5 decades of urological research in Nijmegen. If that all doesn’t convince you to come to ESUR-SBUR15, one more argument: Nijmegen has the highest pub-density of The Netherlands.” Prof. Jack Schalken Meeting Chair

Prof. Egbert Oosterwijk Meeting Vice-Chair

Prof. Zoran Culig ESUR Chair

Prof. Jill Macoska SBUR Chair

Abstract submission deadline: 1 June 2015 Early bird registration deadline: 13 July 2015

Check out the full programme at: www.esur-sbur15.org

European Urology Today

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ERUS15

#erus15

12th Meeting of the EAU Robotic Urology Section 15-17 September 2015, Bilbao, Spain Three-day scientific programme, including: • 6 Live Surgery Sessions • Hands-on Training Courses • 5 Different ESU Courses • Special Junior ERUS - Young Academic Urologists Programme

Prof. Alex Mottrie, Aalst (BE) ERUS Chairman

A selection of topics at ERUS15 • Robotic urologic surgery in Europe. What’s happening in each country and why? • Robotic surgery and guidelines: Where is the evidence? • Neuronavigation in RARP • Fluorescence guided robotic surgery • Robotic prostatectomy – Why train surgeons to do a surgery they won’t or shouldn’t do? • Lessons learned from open radical cystectomy • Robot-assisted LESS inguinal lymphadenectomy Prof. Alex Mottrie, ERUS Chairman: “As the ERUS audience is evolving from mostly beginners in the field to robotic users as a majority, this year’s edition focuses more on complex cases and novel indications for robotic surgery as well as live surgery. We will also have roundtable discussions on novel tools and techniques as well as up-to-date results, both oncological and functional.”

Robotic Live Surgery Send your abstracts now!

Live Surgery

Prof. Mottrie: “You will be joining the largest robotic congress in urology worldwide, with close to 1,000 attendants. In three days, you will get an extensive, detailed update on urological robotics from with live surgery, state-of-the-art lectures, round table discussions, ESU Courses and Hands-on Training Courses.”

Prof. Mottrie: “Live surgery has traditionally been an important part of ERUS meetings. Over the past few years, we have been approved by the EAU Live Surgery Committee to ensure the highest standards of care. At the beginning of each ERUS meeting, we give an overview of how the

“You will also have ample opportunity to meet your colleagues from around the world in an informal setting. Bilbao is a splendid city with lots of things to visit, including the famous Guggenheim museum.”

Keep checking erus15.org as the full scientific programme becomes available!

Abstract Submission Deadline: 1 June 2015 Early Registration Deadline: 15 June 2015

patients at the last meeting fared over the past year.” “This year, if the appropriate patients are available, we want to show special indications like salvage prostatectomy, renal transplantation, and retroperitoneal prostatectomy.”

For more information please visit www.erus15.org

ESUI15

#ESUI15

4th Meeting of the EAU Section of Urological Imaging

Imaging and Individualised Medicine

In conjunction with the 7th European Multidisciplinary Meeting on Urological Cancers

12 November 2015, Barcelona, Spain During the upcoming 4th EAU Section of Urological Imaging (ESUI) meeting to be held on November 12 in Barcelona, in conjunction with the EMUC2015, the topic of multiparametric MRI (mpMRI) and prostate cancer will be extensively addressed. In the session entitled “How can imaging individualise and optimise prostate cancer management?” a point-counterpoint discussion will focus on mpMRI in prostate cancer diagnosis. Recent studies and reviews using mpMRI for lesion targeting show an increase in prostate cancer detection over randomised biopsies in the repeat biopsy setting. In addition to this laudable improvement in prostate cancer management, some authors suggest that mpMRI has additional capabilities. The most appealing being the capability to detect especially significant prostate cancer while ruling out significant disease when mpMRI is negative. If this would be the case, a major problem in the management of prostate cancer would be solved: the problem of over detection. Other authors do not support those statements. The ESUI felt that a critical discussion on the performance of mpMRI in the diagnosis of prostate cancer is necessary to differentiate hype and enthusiasm from scientific evidence. The discussion will involve two experts in prostate cancer imaging. Both will highlight their point of view on mpMRI and demonstrate why they think the detection of especially significant disease is a myth or a truth. The side favouring the capability of MRI to detect significant disease is supported by studies providing high negative predictive values (NPV: 95%) for detection of high-volume cancer lesions (>0.5cc) either verified by whole mount sections or by template biopsies. Moreover, this point of view is supported by biopsy studies showing MRI-targeted cores to provide a higher cancer involvement per core as well as higher rates of Gleason 4 or 5 patterns relative

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European Urology Today

to randomised biopsies, suggesting that cancers found with mpMRI targeting are more significant than those found with randomised biopsies. Hashim Udin Ahmed (GB) is a supports this viewpoint and will discuss in favor of MRI as a reliable tool to diagnose significant prostate cancer while ruling out significant disease when MRI is negative. The position against such a capability is backed up by whole mount section studies comparing cancers detected with mpMRI with those

Dr. Jochen Walz, ESUI Chairman

Dr. Hashim Ahmed, ESUI Associate Member

cancers not detected with mpMRI. These studies show that up to 40% of cancers undetected by mpMRI are of high-grade (Gleason 4 or 5) and up to 30% are of high-volume (>0.5cc), therefore suggesting that a nonnegligible rate of significant disease is missed by mpMRI. When it comes to biopsy studies, the definition of significant cancer is the key point to support or refute the capabilities of mpMRI to detect significant cancers. In fact, the most frequently applied Epstein criteria were developed for randomised biopsies and not for targeted biopsies. The use of the Epstein criteria for targeted biopsies represent a major methodological flaw, with a risk to overestimate the significance of cancers detected with targeted biopsies (lesion centred core = high core involvement) and to underestimate the significance of cancers detected with randomised biopsies (peripheral core = low core involvement). Both events would artificially inflate the rate of “significant” disease found with mpMRI-targeted biopsies relative to randomised biopsies. Jochen Walz (FR) is a supporter of this point of view and will discuss against MRI being a reliable tool to rule out significant prostate cancer. This discussion is the introduction to the prostate cancer imaging session that will highlight the most recent developments in prostate cancer imaging and its use in different clinical scenarios. Moreover, during the EMUC meeting several other topics regarding imaging in the management of urological malignancies will be discussed in their clinical context. For programme information and registration please visit www.esui15.org

Abstract deadline: 1 July 2015 Early registration deadline: 15 August 2015

March/May 2015


EULIS15

#eulis15

3rd Meeting of the EAU Section of Urolithiasis 10-12 September 2015, Alicante, Spain www.eulis15.org

EULIS: “Boosting collaborative links is crucial” 3rd EULIS Meeting in Alicante to strengthen educational goals Effective collaboration and the delivery of skills training underpin the goals and current activities of the EAU Section of Urolthiasis (EULIS), and for its bi-annual meeting in Alicante, Spain, organisers will present a programme that aims to fulfil some of its educational and collaborative initiatives. Following its previous meetings in London and Copenhagen, the 3rd EULIS Meeting in Alicante will offer a scientific programme that not only highlights recent gains, developments and challenges in stone management, but also brings to the fore the crucial role effective collaboration with other kidney specialists plays in modern stone treatment.

“For instance, Dr. K. Ahmad from London will present simulation training in endourology, a topic that is now widely considered as an important phase at the start of endourology training,” according to Sarica. By harnessing the experience of expert stone specialists affiliated with EULIS, Sarica said they hope to support the skills training of younger urologists. “By working actively with specialists, we aim to implement “standardized endourology training steps” for residents beginning with simulator training, followed by hands-on workshops and live surgery practice to complete the process,” he said, while underscoring that EULIS will strongly work to achieve standardized training systems across Euorpe.

On top of this is the renewed focus of EULIS to achieve its educational targets. EULIS chairman Prof. Kemal Sarica spoke on these initiatives, and stressed that training of young urologists in stone management remains a key item in the society’s agenda.

Prof. Kemal Sarica, Chairman EULIS

Dr. Juan A. Galan, Local organiser

Collaborative work In Alicante the colllaborative aims of EULIS are showcased in a joint session with the European Renal Assocation-European Dialysis & Transplant Association (ERA-EDTA), a first in the bi-annual event which aims to initiate closer collaboration between EULIS and partner organisations. He stressed the need for effective partnerships with nephrologists, saying that optimal stone management can only be realised if various specialists rely on a multi-disciplinary approach. The basis, Sarica noted, is a consensus among these specialists to enable physicians and medical professionals to deliver optimal care. “A strong collaboration between two societies and the consensus resulting in shared approaches in the diagnosis, management and follow-up of stone forming patients will certainly speed up the innovations in the pathophysiology, management and medication of stone disease,” he said. From plenary sessions, round-table discussions, state-of-the-art lectures to workshops, video presentations and poster sessions, the meeting will cover the most urgent topics in stone disease and management, providing the insights, opinions and the sharing of best practices.

“In this year’s meeting we again prioritized educational programmes like simulation training in endourology to stress the importance of an integrated and standardized educational training programme for residents in urology,” Sarica said.

EULIS activities in the coming months will also address the challenges brought about changes in technology which has a big impact on stone treatment. Besides its aim to deliver focused training, EULIS would also encourage its members to develop or contribute to innovative work.

A main feature this year are the unedited video presentations, which aims to trigger discussions and the sharing of knowledge and insights with participants. Sarica cited specific sessions that will particularly tackle simulation training.

Early Registation Deadline: 21 July 2015

6th International Congress on the

History of Urology

Optimising opportunities in multidisciplinary care

Urology on Six Continents

12-15 November 2015, Barcelona, Spain

11 March 2016, Munich, Germany

Abstract submission deadline

1 July 2015 Early registration deadline

14 August 2015

7th European Multidisciplinary Meeting on Urological Cancers Pioneers, politics and the worldwide roots of urology

International Speakers

• Urology and Culture

In conjunction with • ESU courses on Medical treatment of metastatic renal cancer and Castrate resistant prostate cancer • European School of Oncology: Personalised approach to prostate cancer management • 4th Meeting of the EAU Section of Urological Imaging (ESUI) • Young Academic Urologists meeting

in conjunction with

www.eau16.org

March/May 2015

European Association of Urology

www.emuc15.org European Association of Urology

European Urology Today

35


4th ESUT Expert Meeting on interventional stone treatment A collaborative project with EULIS and the German Shock Wave Lithotripsy Society -Part 1 Prof. Thorsten Bach Department of Urology Asklepios Kliniken Hamburg-Harburg (DE) t.bach@ asklepios.com

Prof. Jens Rassweiler Department of Urology SLK Klinken Heilbronn Heilbronn (DE)

damage outside of the focus zone. On the other hand, he pointed out the relevance of careful targeting, when working with a precise focus.

 Table 1: Summary of existing theories for stone fragmentation 

 

Subsequently the issue of stone localization and navigation of the shock wave energy to the desired target was emphasized (Table 2). Werner Schwarze from AST (DE) demonstrated easy application of acoustic tracking for either fluoroscopic or ultrasoundguided stone localization. Othmar Wess (Storz-Medical) and Virginie Homel (EDAP-TMS, Lyon, FR) emphasized the advantages of different optical navigation systems (Figure 3), while Sinan Kabakci, (ELMED, Ankara, TR) presented his experience of automatic ultrasound localization of stones, using an articulated robotic arm, demonstrating the potential of this system.

 

 

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 

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 

    

  

     

    

  

  

   

 

   

   

  

 

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  

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  

  

 

    

   

    

jens.rassweiler@ slk-kliniken.de

Table 2: Factors influencing the success of extracorporeal shock wave lithotripsy  

Happy Birthday, Shock Wave Lithotripsy!

    

– ESUT Expert Meeting on stone treatment, 35 years after the first impact Perfect timing is a matter of planning and sometimes of coincidence. However, this time it could not be better. The 4th ESUT Meeting on interventional stone treatment took place in conjunction with the ESU Forum “Challenge the Experts” in Davos on February 7 in Davos, Switzerland.

  



Almost 60 international experts from urology, engineering as well as instrument and supplier manufacturers meet exactly 35 years after Prof. Christian Chaussy and his co-workers (Figure 1) treated the first patient with extracorporeal shock wave lithotripsy (ESWL) in Munich, Germany on February 7, 1980 using the Dornier HM1 lithotripter.

 

Figure 2: Modification of design of electromagnetic lens (Siemens, Erlangen Germany) results in considerable enlargement of focal zone. The annular ring cut (a) causes the modified pulse profile via in situ pulse superposition with a second delayed wave originating from the same EM pulse (b).

Figure 1: ESUT and EULIS celebrate the 35th anniversary of first ESWL treatment by Prof. Christian Chaussy

 

Christian Bohris (Dornier MedTech, Germering, Germany) focused on the importance of adequate coupling for effective ESWL proposing the superiority of a new system of optical controlled coupling by use of an in-built video camera system. Geert Tailly (BE) could demonstrate a 43% reduction of accumulated energy (i.e. 25% less shock waves) when using the system in clinical trials (Figure 4).



 

Jens Rassweiler (DE) started the meeting with his presentation about the mechanisms of stone disintegration during ESWL, explaining the effects of tear and shear forces and a detailed insight into the theories behind spallation, quasi-static squeezing, cavitation and dynamic squeezing (Table 1). There is a trend in the literature to prefer a large focal size like in the original Dornier HM3. This allows fragmentation with lower peak pressures and, therefore, with less energy density. Less energy density minimizes the acute side effects such as shock wave induced renal trauma.

 

 

 

 









 



 

  

 

 

  

 









 



 



  

 

 

   

   

        

      

 

 





     

 



 



 

 

  

   

    



  

 

 



 

 



New developments The latest developments of SWL machines include the improvement of localization, implementation of different focal sizes, multi-functional work stations versus low-cost devices. Interestingly, Siemens will no longer support the production of the Lithoskop being one of the most advanced multi-functional lithotripters.

Paying tribute to the impact of that day, ESWL played a major role during the meeting, featuring 14 international experts and covering all aspects of shock wave lithotripsy.

 

Hans-Goran Tiselius (SE) and Hans-Martin Fritsche (DE) discussed the importance of an optimized treatment protocol and outlook on future directions to achieve further improvement of ESWL. Both pointed

out that ESWL still represents the only non-invasive method of active stone removal and is effective if used appropriately. It is related to a low incidence of complications and can be done without anaesthesia. Optimized coupling, stone tracking and fixation (kidney-belt to reduce respiratory movement) are relevant factors, influencing the treatment results. Postoperative percussion, inversion and diuresis have the potential to improve stone passage. Nevertheless, the most important variable behind every lithotriptor is the person who operates it.

Accordingly, Andreas Neisius (DE) presented his work, and in cooperation with Duke University, when he showed data about recent lens modifications for electromagnetic lithotripters which provide enlargement of the acoustic and geometric focus that lead to better stone comminution and improved stone fragmentation (Figure 2). Opposing view An opposing view was given by Othmar Wess, physicist from Storz-Medical (CH) who challenged the dogma of the large focus size and proposed that a large focus size may not be necessary since most of the energy passes the stone laterally. Thus, a more precise smaller focus can be used to achieve efficient disintegration reducing the risk of collateral tissue EAU Section of Uro-Technology (ESUT)

36

European Urology Today

Figure 3: Application of optical tracking in combination with in-line ultrasound (a) at Modulith (Storz Medical, Kreuzlingen, Switzerland) and lateral ultrasound at Modulith (b) and Sonolith (c) using the VisionTrack System (EDAP-TMS, Lyon, France)

Figure 4: Optical control of coupling quality using an in-built video-camera (Dornier Gemini, Germering, Germany)

March/May 2015


EAU-JUA Academic Exchange Programme Japanese visitors observe urology experts in Madrid Dr. Koji Mitsuzuka Tohoku University School of Medicine Dept of Urology Sendai (JP)

mitsuzuka@uro.med. tohoku.ac.jp

Dr. Ario Takeuchi Graduate School of Medical Sciences Dept of Urology Kyushu University Fukuoka (JP) ario@uro.med. kyushu-u.ac.jp We were selected to join the 2015 EAU-JUA Academic Exchange Programme which involved visiting two hospitals in the suburbs of Madrid and participating in the 30th EAU Anniversary Congress. We have participated in the EAU annual meeting on several occasions in the past, but this was the first time for us to professionally visit a hospital outside Japan. Our first visit was to the Hospital Universitario Fundación Alcorcón. They performed an extremely wide variety of surgical operations, such as HoLEP, TUL, PVP by Greenlight laser, urethroplasty using buccal mucosa, and laparoscopic total cystectomy, among others, enabling us to observe and see for ourselves the sophisticated techniques of our urological colleagues in Spain.

In the afternoon meetings, we discussed the EAU presentations given by the staff. One of the topics was active surveillance for localised prostate cancer. In the evening, we had dinner with Prof. C. Llorente Abarca, his wife, and the hospital staff. They took us to not only an elegant restaurant, but also a popular bar, adding to our social experience. We had a particularly wonderful time that evening, experiencing a bar unique to Spain and where the seafood and wine were especially remarkable. Hospital Universitario Infanta Sofia Our second visit was at the Hospital Universitario Infanta Sofia and the procedure we saw there was, by chance, also urethroplasty. Prof. L. Martínez-Piñeiro is extremely experienced in performing urethroplasties and gives a course on urethroplasty in the EAU congress. In addition to surgery, we also attended his detailed lecture. In the afternoon, we visited the nearby research institution where he carries out collaborative research.

doctors in their tuxedos, but then we were called to the podium and introduced to the audience, and given a wonderful plaque. That evening we met a lot of people who welcomed and congratulated us and took souvenir photos with us—certainly an evening to remember! The rainy weather was very uncharacteristic of Spain during our visit, but the excellent organisation of the EAU-JUA academic exchange programme made us forget the gloomy weather. Instead we had a great experience and truly enjoyed our time in Madrid. Finally, we express our sincere gratitude to the EAU and JUA staff who planned and carried out the

programme, and to Professors C. Llorente Abarca and L. Martínez-Piñeiro, and all the hospital staff who gave us a warm welcome.

Prof. Martínez-Piñeiro also has vast experience in BCG injection treatment for bladder cancer and is also actively interested in basic research on this topic. We were impressed by the lively discussions he led with the researchers. In the evening, he took us to a much-anticipated tour of Santiago Bernabéu Stadium, home base of Real Madrid. Although we didn’t see a Real Madrid game, it was still very exciting as the tour showed the glorious moments of Real Madrid including the fascinating games of football superstars. In both hospitals, the professors and the hospital staff actively interacted with us, and we participated in the programme and discussions. On Sunday night during the annual congress, we were invited to a friendship dinner. We felt very out of place and awkward at first in the midst of all renowned

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16th EAUN Meeting in Madrid Practical suggestions help enhance patient care throughout Europe By Alba Leon Urology nurses from Europe and around the world gathered in Madrid to learn about the latest in patient treatment in a programme that featured practical workshops, courses, as well as state-of-the-art lectures on cancer detection and follow-up, sexual rehabilitation and treatment for incontinence, among other topics. The following is an overview of the varied and wide-ranging programme that took place from March 21 to 23: The three-day event acknowledged the importance of a common knowledge and training framework for urology nurses across Europe. The treatment of urological diseases is a multi-professional effort, in which nurses play a key role. However, the level of education and practical training varies widely among countries. Having a urological nursing standard is therefore crucial to improve the quality of urological care throughout Europe.

can be offered. The plan is to offer these online courses later this year, as part of the EAUN’s educational commitments.” The courses, workshops, and state-of-the-art lectures gave ample opportunity for the nurses to engage in practical discussions on some of the most challenging situations they encounter in their daily interaction with patients. The sharing of best practices provided not only food for thought, but also a re-examination of current nursing approaches. Solutions generally highlight a more active patient involvement. Nursing guidance On the third and last day of the 16th EAUN Meeting presentations included topics such as pelvic floor exercises, diagnostic tools for prostate cancer, and sexual rehabilitation.

In a workshop on pelvic floor rehabilitation, Aoibhin McGreal (IE) shared practical tips on teaching pelvic floor muscle exercise and techniques to patients who have undergone radical prostatectomy. Her recommendations focused particularly on the Mr. Drudge-Coates, EAUN Chair: “Underpinning this so-called ‘difficult patient.’ She mentioned that in goal are common education standards or a many cases instructions on how to correctly carry out framework which must be created across Europe if the exercises are difficult for the patient to follow, if consistent and quality nursing care is to be achieved. they are given at all. In her view, the quality of the exercise would benefit from clearer prompts, and During the plenary presentations it became clear that from encouragement and guidance to check whether the level of education and practical training in urology patients are performing the pelvic floor muscle nursing differs widely among European countries exercises correctly. and, as such, significantly impacts the role and responsibilities of nursing professionals in the region. More importantly, the exercise programme should be as personalised, functional, and progressive as Moreover, it was highlighted how the EAUN is possible to promote not only compliance but also supporting the idea of a common training framework physical comfort. “Maybe it is not that they are for Specialised Urological Nurses in cooperation with difficult patients, maybe it is that we are not teaching the European Specialist Nurses Organisation (ESNO). them the right way,” McGreal concluded. The focus on fostering and addressing standards of care underscored the need for urology nurses to Wendy Naish (GB) presented data from a small study conduct studies and actively disseminate research carried out in Croydon, England. Naish looked at 47 findings in a bid to strengthen evidence-based men, who had radical prostatectomy, over a period of nursing practices. three years. The study asked about the information they had received on pelvic floor muscle exercises The session ended with a discussion on the benefits related to post-radical prostatectomy incontinence. of providing core educational programmes to urology nurses and how this could be used to create a Based on self-reported incontinence established common ground in Europe. An example cited was the through questionnaires at four to six weeks after the use of online urology nursing courses, where operation, and then after three and six months, her convenient access to structured training and skills team established that pelvic floor muscle exercises evaluation are expected to provide benefits. actually did help reduce incontinence episodes, and the number of incontinence products used. “The key The discussion reflected the current need for the is to start early, review how patients are doing, and EAUN to further boost its initiative in developing an figure out how often patients need to be seen,” online channel where core urology nursing courses according to Naish.

A full meeting room in Madrid at the EAUN Guidelines workshop

In two state-of-the-art lectures Steven Joniau (BE) and Timur Hasan Kuru (DE) discussed the role of prostate specific antigen (PSA) and imaging, respectively, to diagnose and follow-up on prostate cancer patients. While both are non-invasive, the PSA method remains controversial and not in small measure because it detects slow-growing, non-life-threatening cancers which do not benefit from treatment. PSA results may cause stress in patients and may even lead to patients feeling like they are not getting the appropriate treatment. Regarding Magnetic Resonance Imaging (MRI), the procedure is slowly becoming a guidelineapproved way, as PET scanning, to facilitate active surveillance. According to Kuru, however, possible treatment pathways, rather than just observation, can also be done with MRI. Research results are promising, although not conclusive yet, but technology is developing quickly. Female sexual assessment and rehabilitation is an often neglected topic, but it was extensively examined during a European School of Urology

(ESU) Course, where the importance and best practices regarding patient questionnaires were shared, particularly in terms of how to apply a questionnaire with a sound methodology. Although medical personnel are not always free in their choice of questionnaire, nurses were encouraged to understand the needs of the patient not only in terms of questions but also in the administration of the questionnaire, to improve patient care. The session ended with nurses sharing case studies on various problems they faced when attempting to start a programme of sexual assessment and rehabilitation with trauma patients. Lack of communication, shame and embarrassment, and trust issues are chronic issues in the daily work of a nurse, and overcoming these remain a challenge. However, as the case studies illustrated, nurses can get through to patients and help them improve their sex life and their life in general. To do this, nurses must seek to obtain as much information as possible, be diligent and respectful of the choices made by those in their care.

Call for Papers The International Journal of Urological Nursing - The Official Journal of the BAUN

Introducing the new EAUN Guidelines

Interesting discussions at the Poster Viewing sessions

The International Journal of Urological Nursing is clinically focused and evidence-based and welcomes contributions in the following clinical and nonclinical areas: • General urology • Clinical audit • Continence care • Clinical governance • Oncology • Nurse-led services • Andrology • Reflective analysis • Stoma care • Education • Paediatric urology • Management • Men’s health • Research There are many benefits to publishing in IJUN, including:

Mr. D.J. Ralph speaking on sexual dysfunction at the Men's Health Workshop

Mr. Drudge-Coates, EAUN Chair, opens the first Plenary Session

• Broad readership of papers—all published papers will be available in print and online to institutional subscribers and all members of the British Association of Urological Nurses • Fast and convenient online submission— articles can be submitted online at http://mc.manuscriptcentral.com/ijun

16th International EAUN Meeting 38

European Urology Today

• Fast turnaround—papers will be reviewed and published quickly and efficiently by the editorial team • Quality feedback from Reviewers and Editors—double-blind peer review process with detailed feedback • Citation tracking—authors can request an alert whenever their article is cited • Listed by the Science Citation Index Expanded™ (Thomson ISI)

For further information and a free sample copy go to: www.wileyonlinelibrary.com/journal/ijun

16th International

EAUN Meeting 21-23 March 2015, Madrid, Spain

March/May 2015


EAUN Workshop at Madrid Congress Indwelling catheterisation: Trouble shooting and quality of life issues Ms. Veronika Geng, RN, MNSc, ICP Workshop Chair Manfred-SauerStiftung Lobbach (DE) veronika.geng@ msstiftung.de On Sunday morning, March 22, around 120 nurses attended in Madrid the workshop “Troubleshooting and quality of life in indwelling catheterisation,” which aims to give participants insights into the management and care of patients with indwelling catheters as well as managing complications, troubleshooting and quality of life (QoL) aspects. Susanne Ohlhorst, educated as a Master in Nursing science from the University Hospital in Zürich, Switzerland, gave an excellent overview on the problems encountered with the use of an indwelling catheter. One of her main messages in case of indications for indwelling catheters was to use intermittent catheterisation, postoperative, instead of indwelling catheterisation, whenever possible! She underscored the complications of catheterisation and said that around 30% of all patients with short-term catheters have urinary tract infections (UTI). UTIs account for 30% of all hospital-acquired infections. Leakage occurs in 11% and urethral strictures and erosions between 3% and 17% (Hollingsworth, 2013). The complications of long-term catheterisation are described as follows: One UTI per 100 catheter days.

Patients with indwelling catheters are three times more likely to die, to be hospitalised or to require antibiotics. Urosepsis often follows on a traumatic manipulation of the indwelling catheter and the risk of bladder stones and bladder carcinoma is elevated (Drinka 2006).

• To the question regarding use of evidence-based guidelines in daily practice, about 20 nurses responded in the affirmative; • To the query whether nurses use the EAUN guidelines as a guide for their hospital’s standards, only five nurses responded in the affirmative. Since the EAUN Guideline was launched in 2013, or two years ago, good compliance or a high rate of actual adaption has not been achieved.

To avoid leakage or catheter bypassing, nurses have to find out the reasons for the leakage. These may include kinks in the tube, UTI, blockage, hyperactive detrusor or hypersensitivity to latex. Aspects to consider and avoid leakage could include an increase in fluid intake, lemon-based drinks, the use of a valve instead of a continuous flow, or by changing the material – silicone instead of latex-- and bladder instillation with mild acid solution. These options are not evidence-based but experienced-based.

An important message we can learn here is the need for the EAUN to take two steps backward and discuss how we can close the gap between theoretical evidence and nursing practice.

Mrs. Mirjam Kappert, Nurse Practioner (NL)

Ohlhorst’s take-home message was that avoiding complications caused by indwelling catheters is one of the most important nursing tasks. To find alternatives for indwelling catheters and a thorough education of patients are two main factors on how to avoid complications.

For the next conference we will have to consider how to implement guidelines into actual nursing care or in general hospital practices, and how we integrate theoretical findings in nursing care education. Obviously, there is still a lot of work for us to do.

preferences” (Elwyn, 2010). Kappert described how to achieve this in actual practice and her take-home message emphasised the importance of always See you next year when we will present to you the helping patients make decisions based on their new EAUN guidelines on male external catheters. wishes and the goals they have set out for themselves. The second part was a presentation from Mirjam For nursing teams this implies they have to act Kappert, advanced nurse practitioner (Doetinchem, consistently and use the nursing process as a basic Netherlands). She discussed “Living with a catheter; tool. The sessions ended with a short discussion with what patients, caregivers and nurses should know.” She the audience. cited a quote from Roger Dawson who said: “It is not how long life is but the quality of our life that is Below are summaries of some of the highlights and important.” issues discussed during the workshop: Kappert focused on shared decision-making, an approach “…where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options and achieve informed

EAUN Award Winners

• 28% of physicians are not aware whether their patient has a catheter or not (Toughill 2005) and it has been established that a daily assessment whether the catheter is still necessary will reduce the risk of UTI; • In response to a query, posed to the workshop audience, asking if their hospitals has a rule requiring a daily assessment to find out if catheter use is needed, only four people in the audience Mrs. Susanne Ohlhorst, Master in Nursing Science (CH) raised their hands;

First Prize for the Best EAUN Poster Presentation C. Paterson, A. Robertson, A. Smith, G. Nabi (Dundee, United Kingdom) For the poster: "A systematic review of the empirical evidence identifying the unmet supportive care needs of men living with and beyond prostate cancer: Are we there yet?" Supported by an unrestricted educational grant from AMGEN (Europe) Second Prize for the Best EAUN Poster Presentation L. Lydom, T. Thomsen (Copenhagen, Denmark) For the poster: "Beyond one’s depth – he experience of postoperative complications following radical cystectomy" Supported by an unrestricted educational grant from AMGEN (Europe)

The latest EAUN guidelines publication is now online!

Third Prize for the Best EAUN Poster Presentation E. La Cognata, B. Necchi, L. Caiazza, A. Crescenti, M. Boarin, G. Villa (Milan, Italy) For the poster: "Nutritional status and postoperative functional outcomes in patient undergoing radical cystectomy: A prospective observational study" Supported by an unrestricted educational grant from AMGEN (Europe)

Visit www.eaun.uroweb.org/nursing-guidelines for a free download or to order a printed copy

Prize for the Best EAUN Nursing Research Project H. Syhler (Copenhagen, Denmark) For the Project Plan: “Improving male patients coping with urinary incontinence after prostatectomy.”

ide lines for Evide nce-based Gu gical Health Care Best Practice in Urolo European Association of Urology Nurses PO Box 30016 6803 AA Arnhem The Netherlands

Apply for your EAUN membership online! Would you like to receive all the benefits of EAUN membership, but have no time for tedious paperwork?

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Applying guidelines in actual clinical nursing practice Prudent antibiotic use in men who had prostate biopsies Sue Osborne Urology Nurse Practitioner Waitemata District Health Board Dept. of Urology Auckland (NZ) Sue.osborne@ waitematadhb.govt.nz Kia Ora from your urological New Zealand nursing colleagues. We hope you had a highly successful congress in Madrid. It has been four years since I joined in Vienna, yet my memories of a very worthwhile, stimulating meeting are still vivid. I hope to join another EAUN annual meeting but it can be challenging to get release time and funding to attend even local meetings, let alone meetings held on the other side of the world! My EAUN membership remains important to me, as does my membership to our national organisation the New Zealand Urological Nurses Society. Both organisations regularly publish a newsletter to provide a vehicle for networking with colleagues, as well as new information on urological topics, case studies and literature reviews. You can be very proud of the comprehensive EAU and EAUN guidelines which are excellent evidencebased resources available for consultation when planning care for urological patients and when preparing teaching sessions. I recently delivered a case review to a group of non-urological nursing colleagues, evaluating the care delivered to an elderly lady with recurrent urinary tract infections. When critiquing the care delivered I used the recently updated EAU Urological Infections guideline as a reference. European Association of Urology Nurses

While New Zealand local microbial environment and resistance patterns vary somewhat from those of the Northern Hemisphere, the evidence-based principles for treatment of urological infections certainly apply. As outlined in the Urological Infections Guideline, prescribing decisions should be guided by a prudent use of available antibiotics, based on local pathogen and susceptibility profiles. These principles apply not only for treatment of urological infections but also in the area of prophylaxes. EAU Urological Infections guidelines note the high risk of infection associated with transrectal prostate biopsy and strongly recommend antimicrobial prophylaxis. The document stresses the need to carefully assess risk factors for sepsis including an individual’s risk of carrying resistant bacterial strains (i.e. fluoroquinolone (FQ) resistance). As detection of FQ resistant E.coli and ESBL E.coli or Klebsiella sp in our setting is relatively common, the Waitemata District Health Boards Urology and Infectious Diseases Departments implemented regional guidelines whereby all men undergoing transrectal prostate biopsy have rectal swabs taken prior to the procedure. A targeted single dose of prophylactic antibiotic is then prescribed in response to the rectal swab culture result. At present the oral antibiotic regimes in use are Ciprofloxacin monotherapy, Ciprofloxacin with Cotrimoxazole or Fosfomycin.

"The document stresses the need to carefully assess risk factors for sepsis including an individual’s risk of carrying resistant bacterial strains" At Waitemata District Health Board, the urology clinic nurses prospectively collect data on every patient who undergoes a transrectal ultrasound-guided prostate biopsy, including recent travel history and antibiotic use. When men present for their prostate biopsy

results (10-14 days post-procedure) data is again collected, this time recording any uncomplicated urinary tract infections or urosepsis events (positive blood cultures) that occurred post-biopsy. Data is also captured on men who experienced clinical symptoms of infection without positive cultures. Results from the first 300 patients were recently presented in a poster presentation at the Australasian Society of The poster with the infection data on men who undergo prostate biopsy presented at the Infectious Diseases Australasian Society of Infectious Diseases Annual Scientific Meeting in Auckland last March Annual Scientific Meeting (March 18 to 22) held in Auckland. Data analysis revealed our population’s I sincerely hope those of you who were at the meeting ESBL prevalence rate to be 8.3% (60% ESBL also FQ have benefited from the lectures. And who knows resistant). One in 11 men required prophylactic maybe I can join next year! antibiotics other than ciprofloxacin monotherapy. Through the use of targeted antibiotics no ESBL infections occurred post-transrectal prostate biopsy. EAUN Board Such audits enable our team to contribute to the national and international evidence-based that will inform future prophylaxis guidelines. The data collection process requires diligence, enthusiasm and the collective will of many. Analysis of the data requires similar characteristics, as well as thorough and close scrutiny to ensure the data is ‘brought to life’ and contributes to patient care decisions moving forward. Excellence in patient care drives the content of our organisations newsletters. It is the main goal of the EAU/EAUN guidelines and has been the focus of most, if not all, of the 2015 EAUN congress sessions.

Chair Chair Elect Past Chair Board member Board member Board member Board member Board member Board member

Lawrence DrudgeCoates (UK) Stefano Terzoni (IT) Kate Fitzpatrick (IE) Paula Allchorne (UK) Simon Borg (MT) Erica Grainger (DK) Corinne Tillier (NL) Susanne Vahr (DK) Giulia Villa (IT)

www.eaun.uroweb.org

Fellowship Programme 12-14 March 2016, Munich, Germany

European Association of Urology Nurses

DEADLINES Abstract Submission Difficult Case Submission

Visit a hospital abroad! 1 or 2 weeks - expenses paid

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1 December 2015

Application deadline: 31 August 2015 • Only EAUN members can apply, limited places available • Host hospitals in Belgium, Denmark, the Netherlands, Sweden, Switzerland and the United Kingdom • A great way of widening your horizon

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For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

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European Urology Today - Vol. 27 No.2 - March/May 2015  

European Urology Today - Vol. 27 No.2 - March/May 2015

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