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European Urology Today Official newsletter of the European Association of Urology OAB and BPS: Is there any common link?

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Dr. Barabara Padilla-Fernández

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Why does anti-androgen therapy fail? Prof. Norman Maitland

Vol. 27 No.3 - June/July 2015 Expanding the EAU’s reach

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Prof. Chris Chapple

United efforts needed to address Europe-wide topics The EAU Meets National Societies Meeting identifies common goals of European societies By Loek Keizer

already endorsing the EAU Guidelines, in some cases even as the primary urological guidelines within their As every year, the EAU invited Europe’s national country, the Guidelines represent a major contribution urological societies to a two-day meeting to discuss of the EAU to European urology. Recent endorsements collaboration and Europe-wide topics in the field. of the EAU Guidelines came from the British EAU Secretary General Prof. Chris Chapple welcomed Association of Urological Surgeons (BAUS) and the the 50 delegates to “Costa del” Noordwijk (NL), which French Association of Urology (AFU). was in the middle of a rare heat wave on 5-6 June. Of particular interest to the national societies are the Prof. Chapple introduced the meeting, setting out the potential legal implications of the national use of basic aims of the meeting and the EAU in general. European guidelines, and the desire to include “We want to represent urology in Europe, with -and experiences and recommendations from all across through- the national societies. Collaboration is Europe. essential for our field as funding diminishes.” N’Dow: “The biggest way national societies can help Prof. Chapple also commented on the need for the Guidelines office is by encouraging their members longevity of the Association, and the strength of to join the EAU. With more members, we can expect urologists in a multidisciplinary team. “We’ve set up a more financial support for the Guidelines Office. We structured leadership programme to identify new can also use the help of the national societies in leaders across Europe. We are surgeons, in danger of measuring the impact of our Guidelines, and to learn being reduced to robot technicians. The urologist who our readers are. We want to keep improving the knows the patient best, and should be the leader of a transparency of the Guidelines, with increased patient multidisciplinary team.” Prof. Chapple and all other involvement and disclosure of conflicts of interest.” speakers made clear the need for critical input from the national societies. “Tell us what we can do.” Other topics that would be of particular interest to urological societies across Europe are the scholarships that the EAU offers through its European Urological Scholarship Programme (EUSP) and the various initiatives that fall under the wings of the European School of Urology (ESU). A large variety of scholarships are available through the EUSP, from short visits to prepare for a year-long stay at a facility, to having a leading academic urologist visit hospitals and give lectures, courses and seminars. “The acceptance rate for scholarships is high, and there is a significant budget,” Prof. Maria Ribal (Barcelona, ES) stressed. Please visit uroweb.org/education/careerdevelopment/scholarship for more details on how and when to apply!

Prof. Hein Van Poppel takes the microphone into the crowd: Prof. Patrick Coloby on behalf of AFU, adds to the discussion

EAU Initiatives Members of the EAU’s board spoke in turn, highlighting the Association’s many initiatives and emphasising the possibilities for collaboration between the EAU and individual national societies. Prof. Luis Martínez-Piñeiro (Madrid, ES), chairman of the EAU Section Office mentioned the possibility for interested EAU members to become affiliates, also citing the need for new blood. The Young Urologists Office is another way for less-experienced urologists to interact with the EAU and the field in general. Affiliates can become associate members, eventually taking a position on the board of a particular section. The Young Urologists Office (YUO) is another opportunity for young urologists who do not yet have any abstracts or publications to their name. “The national societies should play an important role in communicating these possibilities that the EAU offers to their members,” Prof. Martinez-Pineiro explained.

Beside the vast amount of courses offered at the EAU’s own meetings, the European School of Urology can help national societies offer courses or state-ofthe-art lectures at their own national meetings. Hands-on training or E-BLUS courses are also available on demand. Topics for a European approach Particular emphasis was given in Noordwijk to European-level issues facing Europe’s urologists, and how the EAU can facilitate solutions on a continental basis. With increased legislation coming from the European Union, the EAU is expanding its presence in Brussels, putting urology on the agenda of the European Parliament. Informing members of the European parliament on the medical issues that they are voting on (smoking and bladder cancer is a recent example) can affect EU-wide legislation. Other issues include the release of funding for research and treatment, matters of data protection, and the establishment of a European Reference network on Urology.

The EAU Board members (foreground) and the assembled representatives of Europe’s national societies

Currently, none of the national societies have direct ties to the European Union, so the EAU finds itself in the unique position to lobby for European urologists’ interests in Brussels. Promotion of Urology as a distinct field, establishing standardised practice and influencing legislation, for example on working time directives are all issues that need to be addressed on a European level. National societies are encouraged to share with the EAU their experiences with said legislation, in order to build a case for change. Feedback from the societies On June 6th, feedback was collected from the national societies through lively break-out sessions. Topics that were of particular interest for the societies were the identity of the urologist in an increasingly multidisciplinary landscape, EU-level working time directives, and the need for the EAU to better inform urologists of its opportunities.

was that these directives had a negative impact on staff training, and these should be amended. Prof. Chapple urged the national societies to share their experiences in order to help the EAU build a case for change on a European level. Other concerns that were vocalized concerned the need (or rather, the lack of) for separate national urological Guidelines. A duplication of efforts was perceived as a waste of time by some attendees. Communication with and through national societies can be improved: awareness of the EAU’s scholarships, courses and publications is low in some countries. National societies could distribute this information to their members, translated or otherwise. Similarly, national societies can do more to speak on behalf of all of their country’s urologists. In some cases, the percentage of urologists participating with their respective national society is very low, and this makes it difficult for the EAU to engage with them as a whole.

With the treatment of urological cancers taking a lot of the spotlight, urologists are in danger of losing their specific role, certain society representatives indicated. There are problems in establishing the field, with increased cooperation with (radiation) oncologists. The EAU has always expressed the opinion that the urologist should coordinate appropriate patient care, being the closest to the patient. Meetings like the European Multidisciplinary Meeting on Urological Cancers (EMUC, in Barcelona on 12-15 November) bring all parties together and increase the collaboration in a multidisciplinary approach. There was also discussion about the working time directives. Consensus in one of the break-out sessions

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Prof. Manfred Wirth outlines the EAU’s initiatives in communications while other Executives look on

#EAU16

Prof. N’Dow (Aberdeen, GB) addressed the assembled national societies’ delegates on behalf of the EAU Guidelines Office. With many national societies

Representatives from Armenia and Belarus enjoy some fresh air on an unseasonably hot day in Holland

June/July 2015

Abstract submission opens 1 July 2015 European Urology Today

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Update from the Guidelines Office SoMe Award, Workshops and Chairmen Meeting Aside from recently picking up its SoMe Innovation Award from the BJUI, Guideline Office (GO) members were also busy with training workshops and the Chairmen Meeting. Below are some of the GO highlights in the last few months: Innovation Award to #eauguidelines We were delighted to announce that #eauguidelines was presented the innovation award by the British Journal of Urology International (BJUI) at the American Urological Association (AUA) Annual Meeting in May 2015 (see photos 1 and 1a). We are most grateful to all Guidelines Panels who have submitted their content from the Guidelines in tweet format and we look forward to this project expanding and developing further in the coming months.

Photo 2: The Chronic Pelvic Pain Panel enthusiastically developing their PICOs last May in Amsterdam

The training involves presentations from the Aberdeen faculty in the morning and practical sessions in the afternoon. The Associates specifically work on their Panel’s PICOs. Depending on what stage the systematic review is at, this could involve development of the search strategy, abstract and full text screening, data abstraction, risk of bias Photo 4: Guidelines Panel associates training in May in assessment, data analysis and interpretation Amsterdam (see photos 3 and 4). Guidelines Office Chairmen Meeting The Guidelines Panel Chairs met with the Guidelines Office Board in June, in conjunction with the National Societies Meeting, in Noordwijk, the Netherlands (see photo 5). The meeting, chaired by Prof. James N’Dow, discussed the status of systematic review activities within the panels, patient involvement in the Guidelines and peer review.

Photo 1 and 1a: #eauguidelines receives the innovation award by the BJUI at the AUA annual congress

European Urology Today 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)

Presentations were given by Prof. Steven Canfield on the role of evidence summaries and unifying the phrasing of recommendations, and by Prof. Maria Ribal on the Guidelines and new media activities. The meeting provided an opportunity for the Panel Chairs to ask questions to the Board, discuss plans for their Panels and to look into potential collaborative efforts between the Panels.

The Guidelines Board and Panel Chairs will meet in October in Prague.

Photo 3: Birthday celebrations at the Guidelines Panel associates training in May in Amsterdam

Panel workshops and Associate trainings In April and May this year, the Guidelines Office and the Academic Urology Unit, University of Aberdeen coordinated two Panel workshops and two Associate trainings. Panel workshops were held for the Paediatric Urology, Male Sexual Dysfunction, Male Infertility, Male Hypogonadism and Chronic Pelvic Pain Panels (see photo 2). The 1.5 day panel training sessions include presentations on guidelines development methods, as well as dedicate time to prioritising panel research questions. Guided by the workshop faculty, detailed PICOs (Population, Intervention, Comparison, Outcome) are developed with the Panel as a whole to set up systematic reviews. The Guidelines Panel Associates training looks into the systematic review methodology in greater detail.

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.

Guidelines Office

Photo 5: Guidelines Panel Chairs meet with the Guidelines Board

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

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Help urologists collect CME credits and register your activity today! (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.

www.eu-acme.org June/July 2015


Highlight sessions: Prostate cancer Studies on abiraterone acetate in mCRPC patients Dr. Robert Van Soest Dept of Urology Erasmus University Medical Center and Cancer Institute Rotterdam (NL) r.vansoest@ erasmusmc.nl At the EAU Annual Congress 2015 in Madrid, many scientific sessions dedicated to prostate cancer research were presented. Two specific abstracts were selected for further discussion in the prostate cancer highlights session. Abstract 556: Mulders et al. Abiraterone acetate improves overall survival in chemotherapy-naïve metastatic castration-resistant prostate cancer: Impact of crossover and baseline prognostic factors in the COU-AA-302 final analysis The COU-AA-302 study included patients with asymptomatic or mildly symptomatic, chemotherapynaïve, metastatic-castration resistant prostate cancer (mCRPC), who were randomized to abiraterone plus prednisone or prednisone alone. The coprimary endpoints were overall survival (OS) and radiographic progression-free survival (rPFS). In the interim analyses conducted throughout this study, the rPFS endpoint was met with statistical significance1.

Abstract 668 addressed the clinically relevant question blind, placebo-controlled phase 3 study. Lancet Oncol. of docetaxel efficacy after prior treatment with 2015;16:152-60. abiraterone acetate in mCRPC. This is especially of 3. Mezynski J, Pezaro C, Bianchini D, et al. Antitumour interest since several retrospective studies have activity of docetaxel following treatment with the CYP17A1 shown reduced antitumor activity of docetaxel when inhibitor abiraterone: clinical evidence for crossused after abiraterone, suggesting clinical crossresistance? Ann Oncol. 2012;23:2943-7. resistance3-5. Furthermore, preclinical work has 4. Schweizer MT, Zhou XC, Wang H, et al. The Influence of shown that the androgen receptor (AR) is able to Prior Abiraterone Treatment on the Clinical Activity of confer cross-resistance between docetaxel and novel Docetaxel in Men with Metastatic Castration-resistant AR targeted agents both in vitro and in vivo6,7. Prostate Cancer. Eur Urol. 2014;66:646-52. Cross-resistance might be induced since docetaxel 5. Suzman DL, Luber B, Schweizer MT, Nadal R, and AR-targeted drugs share an overlapping Antonarakis ES. Clinical activity of enzalutamide versus mechanism of action by inhibiting AR-nuclear docetaxel in men with castration-resistant prostate translocation, a well-known pathway of antitumor cancer progressing after abiraterone. Prostate. activity in mCRPC7. 2014;74:1278-85. In abstract 668 the authors observed a PSA response rate (≥50%) in 47% of patients treated with docetaxel after abiraterone in COU-AA-302. This is slightly higher as compared to previous reports of docetaxel after abiraterone with PSA response rates ranging from 26-40%3-5. However, the response is still inferior as compared to a contemporary cohort of docetaxel treated patients who were abiraterone-naïve (PSA response rate ≥50%: 64%), which might confirm the hypothesis of cross-resistance between abiraterone and docetaxel8. In conclusion, encouraging antitumor activity of docetaxel after abiraterone was observed, which might still be impaired by cross-resistance resulting from prior abiraterone treatment. As a limitation, it should be noted that unconfirmed PSA response rates were used in this post-hoc analysis, which generally appear favorable as compared to the established confirmed PSA response rates that are required according to PCWG2 criteria9. Also, no conclusions regarding cabazitaxel could be drawn, since only 4 patients treated with cabazitaxel were included, and previous studies suggested that cabazitaxel has differential AR related properties, with superior anitproliferative effects as compared to docetaxel6,10.

However, the OS endpoint was not met during the interim analyses which may be related to a low number of events and that time. It was only in the final analysis of COU-AA-302 that the OS endpoint was met with statistical significance (HR: 0.81 (0.70-0.93, p=0.003))2. At interim analysis number 2, the study had been unblinded by the IDMC based on a statistical significant benefit in rPFS, which allowed patients in the control arm to subsequently receive abiraterone acetate. This resulted in a significant number of References patients in the control arm of COU-AA-302 that received 1. Ryan CJ, Smith MR, de abiraterone acetate (44%), which could potentially Bono JS, et al. mask the OS benefit obtained by abiraterone. Abiraterone in metastatic In abstract 556 the authors aimed to correct for crossover in the study using multivariate analysis. When correcting for crossover, the HR for the risk reduction of death became even stronger with a HR of 0.74 (0.60-0.88, p<0.0001). In conclusion, despite the prevalent administration of abiraterone in the control arm of the study, a statistically significant OS benefit was reached, which was even more pronounced when correcting for crossover in the control arm, confirming the efficacy of this agent. Abstract 668: Saad et al. Response to taxane chemotherapy as first subsequent therapy after abiraterone acetate in patients with mCRPC: Post-hoc analysis of COU-AA-302.

prostate cancer without previous chemotherapy. N Engl J Med. 2013;368:138-48. 2. Ryan CJ, Smith MR, Fizazi K, et al. Abiraterone acetate plus prednisone versus placebo plus prednisone in chemotherapy-naive men with metastatic castration-resistant prostate cancer (COU-AA-302): final overall survival analysis of a randomised, double-

6. van Soest RJ, de Morree ES, Kweldam CF, et al. Targeting the Androgen Receptor Confers In Vivo Cross-resistance Between Enzalutamide and Docetaxel, But Not Cabazitaxel, in Castration-resistant Prostate Cancer. Eur Urol 2014. in press. doi: 10.1016/j. eururo.2014.11.033. 7. van Soest RJ, van Royen ME, de Morree ES, et al. Cross-resistance between taxanes and new hormonal agents abiraterone and enzalutamide may affect drug sequence choices in metastatic castration-resistant prostate cancer. Eur J Cancer. 2013;49:3821-30. 8. Tannock IF, Fizazi K, Ivanov S, et al. Aflibercept versus placebo in combination with docetaxel and prednisone for treatment of men with metastatic castration-resistant prostate cancer (VENICE): a phase 3, double-blind randomised trial. Lancet Oncol. Lancet Oncol. 2013 ;14(8):760-8 9. Scher HI, Halabi S, Tannock I, et al. Design and end points of clinical trials for patients with progressive prostate cancer and castrate levels of testosterone: Recommendations of the prostate cancer clinical trials working group. J Clin Oncol. 2008;26:1148-59. 10. Azarenko O, Smiyun G, Mah J, Wilson L, Jordan MA. Antiproliferative Mechanism of Action of the Novel Taxane Cabazitaxel as Compared with the Parent Compound Docetaxel in MCF7 Breast Cancer Cells. Mol Cancer Ther. 2014;13:2092-103.

United efforts needed to address Europe-wide topics . . . . . . . . . . . . . . . . . . . . 1 Update from the Guidelines Office . . . . . . . . . 2 Highlight sessions: Prostate cancer. . . . . . . . . 3 Ten questions: Laurent Boccon-Gibod. . . . . . . 4 ESFFU section: OAB and BPS: Is there any common link?. . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 EBU Oral Examination 2015: A success story! . . . . . . . . . . . . . . . . . . . . . 8-9 Why does anti-androgen therapy fail? . . . 10-11 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . 12-14 ESU section: The importance of teaching oncourology . . . 16 Who’s Who in the Board of the European School of Urology. . . . . . . . . . . . . 17 EUSP: Combining research and surgery . . . . 18 International Relations Office: Expanding the EAU’s reach. . . . . . . . . . . . . . 23 ESUT: Future trends in ureteroscopy. . . . . . . 24 EULIS participates in panel on interdisciplinary communication. . . . . . . . . . 24 American Tour 2015 Academic Exchange Programme . . . . . . . . . . . . . . . . . . . . . . . . . 25

The author speaks during the Highlight Session in Madrid

2nd EAU Baltic Meeting: Showcasing young urology talents. . . . . . . . . . . . . . . . . . 26

30th Anniversary EAU Congress

Have you moved? Changed name? New employer? Alter your personal data on-line: fast and easy www.eu.acme.org

YUO section: YAU-BPH group wants you! . . . . . . . . . . . . . What do residents expect from urology training? . . . . . . . . . . . . . . . . . . . . . Spanish residents rise up to the challenge. . ESRU joins the Turkish National Andrology Congress. . . . . . . . . . . . . . . . . . . The Veres Needle. . . . . . . . . . . . . . . . . . . . .

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Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 30 Robotic surgery in urology . . . . . . . . . . . . . 30 The future of robotic surgery in urology. . . . 31 High hopes for advances in bladder cancer treatment . . . . . . . . . . . . . . . . . . . . . 33 Brief overview of modern urolithiasis treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 33

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EAUN section: New EAUN guidelines to benefit bladder cancer patients . . . . . . . . . . . . . . . . EAUN intensifies links. . . . . . . . . . . . . . . . . . EAUN offers first ESUN course . . . . . . . . . . . Australian and NZ Urological Nurses Society Annual Meeting . . . . . . . . . . . . . . . .

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European Urology Today

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• What do you think is the biggest challenge in urology? The biggest challenge is the fragmentation of urology in various subspecialties. Urology is no longer comprehensive. Many young urologists tend to be sub-specialists focused on few technical procedures. Urology’s global view tends to be blurred. • If you were not a urologist, what would you be? I probably would have been a general surgeon. But I was attracted to urology because I didn’t see myself taking out organs. I was more interested in reconstructive surgery even though I ended up doing a significant number of radical procedures • What is the most important piece of advice you can give to doctors just starting out today? Keep an open mind since urology is an evolving specialty. Sixty-five years ago, urology’s core business was tuberculosis and 40 years back it was open stone surgery. For the last 25 years it has been oncology. Oncology is the sexy thing today, but things change as history often shows. We should focus on our core business: basically, voiding dysfunction and stone disease. • What is the most rewarding aspect of being a doctor? Surgeons have big egos and go for technical achievements. But at the end of the day what stays in my mind is the fantastic rewards of patient-doctor relationship. • What is your advice to other doctors on how to avoid burnout? Medicine is not the only thing in your life. Give enough time to non-medical activities. It’s important to have hobbies- read, travel, go to the cinema and not be entirely focused on medicine. • If you could change something in the healthcare system, what would it be? In some countries, financial incentives dominate. I don’t mean that physicians should not be financially rewarded since they have huge responsibilites and difficult tasks. But one should not look at the patient as a source of income. I am not advocating a puritan form of medicine, but there has to be a limit. • What’s the last wonderful book you have read? “The Children Act” by Ian McEwan and Michel Houellebecq’s ”Submission.” Fantastic books. • What’s the last thing that surprised you? The results of the French departmental elections. I was relieved the extreme right didn’t come first in the race. • What is your favorite hour in the day and why? It depends on the season. The summer’s sunset hours are very pleasant.

TEN QUESTIONS Interview and Photograpy by Joel Vega

Specialty: Uro-Oncology, Reconstructive urology City: Paris, France Specialty: 2015 EAU Willy Gregoir Medal

Join us Down Under for:

• What do you most often wish you could say to patients, but did not? When doing oncologic surgery, you know that you can’t promise cure to the patient. In reconstructive surgery, you’re not certain if the outcome will be positive. Living with these doubts and not sharing them with our patients is necessary and demanding.

Laurent Boccon-Gibod

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OAB and BPS: Is there any common link? Inflammation may be the common link between OAB and BPS that leads to urgency Dr. Barbara Padilla– Fernández University Hospital of the Canary Islands University of La Laguna (ES) padillaf83@ hotmail.com

Prof. David CastroDíaz University Hospital of the Canary Islands University of La Laguna (ES) davidmanuel castrodiaz@ gmail.com

Dr. John Heesakkers ESFFU Chair Radboudumc Dept. of Urology Nijmegen (NL)

john.heesakkers@ radboudumc.nl Many patients go to the outpatient clinic complaining of urgency, a symptom which is difficult for patients to describe, or for physicians to evaluate. Overactive bladder (OAB) and bladder pain syndrome (BPS) are both characterised by urgency, but is there any difference between these two conditions? Or are there any common links? In the 19th century, many physicians were concerned about the simultaneous appearance of supra-pubic pain and urgency in many patients, some of them having stones or ulcers, while others were diagnosed without any macroscopic symptoms. It was thought to be a rare condition in postmenopausal women. In 1878 Skene first described interstitial cystitis (IC) as the chronic evolution of an acute cystitis involving the submucosa and the muscle with ulcerations (Skene, 1887). Following these investigations, Hunner pointed out that it was a symptomatic complex of bladder pain, related to bladder filling, and a peculiar but characteristic cystoscopic appearance with rather typical mucosal lesions or ulcers (Hunner, 1915). Afterwards, many other experts classified this pathology by evolution, phenotypes, areas of affections, etc., but which only led to more confusion.

frequently in BPS patients than in the general population like allergies and sensitivities, celiac disease, chronic fatigue syndrome, chronic prostatitis, endometriosis, fibromyalgia, irritable bowel syndrome, lupus erythematosus, migraine headaches, pelvic floor dysfunction, pudendal neuralgia, Sjögren’s syndrome or vulvodynia (Fletcher & Zimmern, 2009). Overlapping symptoms and anodyne physical findings sometimes require a multidisciplinary approach. OAB What about OAB? The International Continence Society (ICS) defined it as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, and in the absence of urinary tract infection or other obvious pathology. Detrusor overactivity should be used as basis in urodynamic studies. Although pain is not included in this definition, many patients complain of supra-pubic pressure as the trigger symptom during urgency episodes. Is there any difference in the "urgency" that patients feel? To some women, urgency is used to indicate the exacerbated need to go quickly to a toilet to avoid urinary leakage, whereas other women consider urgency as the need to void as a way of avoiding intensifying pain, pressure, or discomfort. The first group is most likely to have OAB, and the latter group can be expected to have BPS, although they all have complaints of a sudden, compelling desire to pass urine which is difficult to defer (van de Merwe et al., 2008). It has been suggested that women with OAB can feel urgency and/or sudden discomfort in peaks which they can inhibit with some intervals of normal desire to void before they have to definitely go to the toilet, while those with BPS have a continuous or increasing pain (Abrams, Hanno, & Wein, 2005). It is also recommended to ask patients to mark the location of their pain on a pain map, since many authors like FitzGerald have found that women with OAB indicated their urgency supra-pubically and sometimes vulvar or urethral, whereas PBS patients have a more complex distribution with a wide range of sensory experience (central, lateral or expanded suprapubic, urethral, low back, upper and lateral buttocks, lower abdomen, upper thighs; Figure 1) (FitzGerald, Kenton, & Brubaker, 2005).

"... urgency in OAB is characterized by fair-to-incontinence and appears suddenly, while in BPS urgency is characterized by fair-to-pain and is continuous"

Can we identify any common steps in the development of these two conditions? It is a difficult This scenario has led to the creation of the European task since none of the pathophysiological pathways Society for the Study of Interstitial Cystitis (ESSIC) and are known. Some studies suggest an environmental the first description of the BPS in 2008 as a chronic influence in the onset of BPS and OAB, while others pelvic pain (which has been present for more than six have found a greater incidence of previous sexual or months), pressure or discomfort perceived to be physical abuse in women with these chronic related to the urinary bladder accompanied by at least conditions. But only weak not-yet-proven hypothesis one other urinary symptom, such as urgency to void have been formulated to explain these findings. or frequency. They also proposed a classification More reliable are the most recent investigations involving the performance of cystoscopy and biopsy of suggesting that chronic inflammation plays a central the bladder to acknowledge differences and to make role in the aetiology, leading to differences in it easier to compare various studies (van de Merwe et morphology in bladder sensory and motor neurons al., 2008). and expression of neurotransmitter receptors and biomarkers. The definition of the American Urological Association (AUA) differs with regards the duration of the Urothelium’s role symptoms (more than six weeks) and included the Urothelial cells are supposed to act similarly to condition that the pain appears in the absence of sensory neurons (nociceptors/mechanoreceptors), infection or other identifiable causes. involving diverse signal-transduction mechanisms to detect physiological stimuli and releasing a number The European Association of Urology’s (EAU) of signalling molecules. The urothelium is likely to definition combined previous concepts and also play an important role by actively communicating highlighted that BPS is often associated with negative with bladder afferent neurons, smooth muscle cells, cognitive, behavioural, sexual or emotional lamina propria interstitial cells and cells belonging to consequences, as well as with symptoms suggestive the immune and inflammatory systems (Birder, 2014). of lower urinary tract and sexual dysfunction. It was also stated that it involves a heterogeneous spectrum Disruption of the integrity of the urothelial barrier may of disorders and that there may be specific types of be mediated by hormonal or neural mechanisms and inflammation as a feature in subsets of patients. can lead to changes in the function of urothelial cells and terminals of visceral afferent neurons within the bladder wall resulting in symptoms of urgency, We also have to take into account that patients can frequency and pain during bladder filling and voiding. have other chronic conditions which appear more EAU Section of Female and Functional Urology (ESFFU)

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Tyagi et al. showed higher levels of urinary cytokines, chemokines, and growth factors in OAB patients than

Asymptomatic controls and patients with stress incontinence indicated they experienced an urge to void in a midline, suprapubic location.

The mayority of patients wih BPS and some patients with OAB indicated they experienced urinary urgency/pain at suprapubic and vulvar/urethral sites.

Patients with BPS frequently indicated expanded or lateralized areas of suprapubic bladder sensation. Adapted m from FitzGerald et. al. (2005)

Some patients with BPS localized their urinary discomfort to other sites including low back, upper and lateral buttocks, lower abdomen and upper thighs.

Fig. 1: Locations of pain and urgency in OAB/BPS/stress incontinence

in control, which can result from complex parasympathetic and peptidergic interaction and may contribute to an altered sensory modulation in the bladder (Tyagi et al., 2010). Chung found that urinary nerve growth factor (NGF) and serum C-reactive protein (CRP) were higher in patients with OAB and BPS than in controls, but no correlation between them was found (Chung, Liu, Lin, & Kuo, 2011). In another study they investigated the relationship between urinary and serum NGF, and suggested that the elevated serum NGF levels in IC/BPS patients may be the results of medical comorbidities rather than cause of IC/BPS, and could not implicate them with more severe IC symptoms. On the other hand, there is the hypothesis that elevated urinary NGF level may predict a chronic inflammation localized to the urinary bladder (Lin & Kuo, 2012). Why are these investigators so interested in NGF? This signalling protein is responsible for the growth and maintenance of sympathetic fibres and sensory neurons. When present in the urine, it is supposed to be produced from the urothelium and bladder smooth muscle, and can activate the degranulation and proliferation of mast cells, working as a chemical mediator of pathology-induced changes in C-fiber afferent nerve excitability and reflex bladder hyperactivity, and finally leading to permanent alterations or central sensitization. Current research Basic science studies also suggested that inflammation induces neuroplasticity resulting in increased sensory nerve density in the bladder, generating the LUTS of IC/BPS. Other biomarkers such as inflammatory molecules and brain-derived neurotrophic factor (BDNF), which may be used alone or in combination with NGF, have shown promising results, but further investigations are still needed (Seth et al., 2013). Interest has also been focused on the detection of increased urinary levels of ATP, which is also supposed to be released from the urothelium and can lead to painful sensations by excitation of purinergic receptors. Inhibition of purinergic P2X3 receptors on afferent neurons suppresses afferent excitation in several animal models and may be effective in clinical conditions associated with pain (Birder, 2014). Botulinum neurotoxin type A (BoNT/A) blocks neuropeptide release from afferent nerves, exocytosis of acetylcholine and purines from efferent nerves, and may probably interfere with the ATP release from the urothelium. It also suppresses the surface expression of nociceptor channels on bladder afferents, being the mechanism addressed for its role in patients with BPS; but it might also contribute to the improvement of urological sensory symptoms (Dolly & Lawrence, 2014). As take-home messages, we can point out that inflammation may be the common link between OAB & BPS leading to urgency. From a clinical

viewpoint, we can accept that urgency in OAB is characterized by fair-to-incontinence and appears suddenly, while in BPS urgency is characterized by fair-to-pain and is continuous. A correct diagnosis of the patient implies an early and satisfactory treatment schedule, with a high impact on the quality of life. And be reminded of what Skene wrote in 1878, "If [...] you do not understand, or neglect the peculiar symptoms of this affection, satisfying yourself by referring all pelvic pain and distress to some disease of the uterus or its appendages, you will neither do justice to yourself nor to your patient." References Abrams, P., Hanno, P., & Wein, A. (2005). Overactive Bladder and Painful Bladder Syndrome: There Need not be Confusion. Neurourology and Urodynamics, 24(2), 149-150. Birder, L. A. (2014). Urinary Bladder, Cystitis and Nerve/ Urothelial Interactions. Auton Neurosci, 182, 89-94. doi: 10.1016/j.autneu.2013.12.005 Chung, S. D., Liu, H. T., Lin, H., & Kuo, H. C. (2011). Elevation of Serum C-Reactive Protein in Patients With OAB and IC/ BPS Implies Chronic Inflammation in the Urinary Bladder. Neurourology and Urodynamics, 30(3), 417-420. doi: 10.1002/nau.20938 Dolly, J. O., & Lawrence, G. W. (2014). Chapter 3: Molecular basis for the therapeutic effectiveness of botulinum neurotoxin type A. Neurourology and Urodynamics, 33(S3), S14-S20. doi: 10.1002/nau.22634 FitzGerald, M. P., Kenton, K. S., & Brubaker, L. (2005). Localization of the Urge to Void in Patients With Painful Bladder Syndrome. Neurourology and Urodynamics, 24(7), 633-637. Fletcher, S. G., & Zimmern, P. (2009). Differential diagnosis of chronic pelvic pain in womenthe urologist's approach. Nat Rev Urol, 6(10), 557-562. Hunner, G. L. (1915). A rare type of bladder ulcer in women: report of cases. Boston Med Surg J, 172, 660-664. Lin, H., & Kuo, H. C. (2012). Increased Urine and Serum Nerve Growth Factor Levels in Interstitial Cystitis Suggest Chronic Inflammation Is Involved in the Pathogenesis of Disease. PLoS One, 7(9), e44687. doi: 10.1371/journal. pone.0044687 Seth, J. H., Sahai, A., Khan, M. S., van der Aa, F., de Ridder, D., Panicker, J. N., . . . Fowler, C. J. (2013). Nerve growth factor (NGF): a potential urinary biomarker for overactive bladder syndrome (OAB)? BJU Int, 111(3), 372-380. doi: 10.1111/j.1464-410X.2012.11672.x Skene, A. J. C. (1887). Diseases of the bladder and urethra in women. New York: Wood & Co. Tyagi, P., Barclay, D., Zamora, R., Yoshimura, N., Peters, K., Vodovotz, Y., & Chancellor, M. (2010). Urine cytokines suggest an inflammatory response in the overactive bladder: a pilot study. Int Urol Nephrol, 42(3), 629-635. doi: 10.1007/s11255-009-9647-5 van de Merwe, J. P., Nordling, J., Bouchelouche, P., Bouchelouche, K., Cervigni, M., Daha, L. K., . . . Wyndaele, J. J. (2008). Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/ interstitial cystitis: an ESSIC proposal. Eur Urol, 53(1), 60-67.

June/July 2015


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. 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 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 study No. 44 This 41 year-old man presented with a large tumour of the right kidney, the CT scan is shown in figure 1 a/b. The diagnosis had been made due to fatigue and weight loss of 10 kg. Radical nephrectomy with adrenalectomy and lymphadenectomy was performed. A large renal vein tumour thrombus was found extending just into the vena cava and infiltration of the liver, requiring local excision and resection of liver parenchyma; the postoperative course was uneventful. The histology reported a poorly differentiated clear cell renal carcinoma with a sarcomatoid appearance in parts of the tumour, an adrenal metastasis and infiltration of the liver. Surgical margins were negative, resulting in the pathology classification of pT4 pN0 (0/5) V1 R0 pM1. One year later the patient presents with a new lesion on follow-up CT which is situated behind the liver and close to the vena cava on the right side (fig.2a/b). The patient is completely asymptomatic.

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

An adrenal tumour is a definite possibility Comments by Morgan Rouprêt, Paris (FR)

1. What is the likelihood of this patient having cancer? Obviously we are dealing here with a simple cyst. If the cystic lesion belongs to the kidney itself then the indolent variant of clear cell RCC (ccRCC) is multilocular cystic and accounts for approximately 4% of all ccRCC. A cystic degenerative change (acquired cystic kidney disease [ACKD]) is not an option in this female patient. Compared with sporadic RCCs, cysts of ACKDs are generally, multiple, multicentric and bilateral, found in younger patients and are less aggressive. According to the Bosniak classification, we are dealing with a cyst from category I or II that should not be considered as a potential RCC. If the cystic lesion belongs to the adrenal, this is another story. From the CT images available the contact angle of the cyst with the kidney suggests that a tumour of the adrenal gland is a solid

hypothesis in this particular case. However, the past medical history of the patient is intriguing as she has suffered from recurrent headache. We should consider this as very important information. Thus we cannot exclude that this patient indeed has a tumour of the adrenal gland, especially a pheochromocytoma. Tumours of the adrenal gland are a heterogeneous group of lesions that arise from either the adrenal cortex or the medulla. These tumours are extremely rare and exhibit an average annual age-adjusted incidence of 0.29 cases per 100,000 individuals. They include several subtypes of lesions that can be either benign or malignant. Among patients with incidental adrenal masses, approximately 5% are found to have a pheochromocytoma. Malignancy is rare in the sporadic cases of adrenal pheochromocytoma (up to 5%). Malignant lesions are more likely to exhibit elevated dopamine levels and tend to be larger (> 5 cm). Female patients have significantly increased numbers of self-reported signs and symptoms of pheochromocytoma (particularly headaches) than male patients, irrespective of the biochemical phenotype and tumour presentation. We should also exclude the possibility of other adrenal tumours (i.e. incidentaloma, adrenal carcinoma, oncocytoma, adrenal cysts). Adrenocortical carcinoma is a rare

malignancy that accounts for 0.02% of all cancers reported annually but remains an option. 2. Are there any further useful investigations? Yes! Regarding imaging, an additional abdominal MRI would be mandatory to search for a pathognomonic increased T2 signal and also for possible other locations thinking of extra-adrenal paragangliomas. Laboratory investigations for excessive levels of catecholamines, cortisol and plasma free metanephrines appear to be mandatory. She should undergo measurement of plasma fractionated metanephrines and normetanephrines or 24-hour total urinary metanephrines and fractionated catecholamines (or both plasma and urine studies together).

Fig. 1a/b: Abdominal CT scan before radical nephrectomy

3. What management options are advisable? The adrenalectomy after hormonal evaluation appears to be the only option in this clinical case as the mass is larger than 4 cm on the CT scan. The surgery can be achieved either with an open or a laparoscopic approach with a dedicated team of anaesthesiologists!

A Bosniak II cyst requiring follow-up Comments by Susanne Krege, Essen (DE)

than is characteristic for a simple cyst but less than characteristic of a malignant tumour. The most probable differential diagnosis is a haemorrhagic cyst.

The patient asks if further investigations are useful? For better differentiation of the cyst`s content an This patient has a large cystic lesion at the upper MRI could be done. But as all criteria seen on the pole of the kidney, which was detected incidentally. CT-scan do not favour a malignancy it can be The finding might be completely independent of recommended to the patient only to have follow-up the patient’s headache but perhaps it causes by ultrasound controls. Only in case of enlargement intermittent compression of the renal artery would another CT scan be indicated to look for depending on movement. This could result in renal changes of the cyst in structure or further hypertension which could be the reason for the calcifications. Such findings would then be headache. suspicious of a malignant transformation and would require further measures. The patient worries about the possibility of cancer? Now the patient asks about advisable options for management. The Bosniak classification of renal cysts can be used (see below). The CT- scan shows a cystic lesion with a smooth wall which is not Though the patient has no direct symptoms there thickened. There is one small calcification might be a relationship with the recurrent which classifies the lesion as a Bosniak II cyst. headaches as mentioned above. The most simple The lesion does not show uptake of contrast procedure for treatment would be to puncture the material. All these characteristics are not typical cystic lesion and put a drain in. After one or two of a malignant tumour. But the lesion has a days the cyst can then be sclerosed. An alternative density of 20-30 Hounsfield units. This is more approach can be laparoscopic fenestration.

Bosniak classification of renal cysts I All criteria of a simple cyst II Thin septa with a thickness ≤ 1 mm, few calcifications, homogenous content of the cyst II F Criteria as type II, but multiple septa, discrete contrast material uptake within the septa, short, not contrast-enhanced thickening of the wall III Irregular septa or thickness of the septa > 1mm or multiple contrast-enhanced septa, irregular and broad calcifications IV Irregular thickened wall of the cyst, solid contrast-enhanced lesion within the cyst

Case Study No. 43 continued This patient underwent open surgery for resection of the cyst which was uneventful. The content of the cyst was old haemorrhagic fluid like that of a ‘chocolate cyst’. The histology was that of an adrenal cyst with old haemorrhages. Postoperative recovery was uneventful. Interestingly, the patient reported that she now seems to be relieved of her headaches.

Fig. 2a/b: Abdominal CT scan one year after radical nephrectomy

Discussion points: 1. What is the likely diagnosis? 2. Should other investigations be done? 3. What treatment options are there and what is recommended? Case provided by Oliver Hakenberg, Department of Urology, Rostock University Hospital, Germany. Readers are encouraged to provide interesting and challenging cases for discussion.

Readers are encouraged to provide interesting and challenging cases for discussion. June/July 2015

European Urology Today

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EBU Oral Examination 2015: A success story! FEBU Diploma as an added qualification and an asset to the individual’s CV and portfolio The EBU Examination Committee organises the EBU Oral Examination with the objective to test the candidate’s ability to evaluate and manage common cases in every day practice. With a pass rate of 96%, this year 305 urologists received the FEBU Diploma. The EBU Oral Examination is a one-day examination. The examination is offered in 11 languages; Danish, Dutch, English, French, German, Greek, Hungarian, Italian, Polish, Portuguese and Spanish. The examinations are conducted by an examiner and an observer. The examination session is an interactive exchange between the examiner and examinee. The candidate is presented with three clinical cases which are each scored on Diagnostic Acumen, Clinical Judgement and Therapy. The results are announced at the end of the day and successful candidates are presented the FEBU Diploma. The EBU Examination Committee acknowledges the tremendous efforts of the urologists who voluntarily dedicate their expertise and time to this unique event.

European Board of Urology (EBU)

One of the pre-requisites for sitting the EBU Oral Examination is successful participation in the EBU (Online) Written Examination. The European Board Examinations have become increasingly popular and important as a hallmark of quality standards. We consider this not only an indication of the growing importance of the EBU exams, but also a reflection of our objective to ensure professional standards. The FEBU Diploma is an added qualification and an asset to the individual’s CV and portfolio. The FEBU diploma has no legal value; it does not grant any rights to the beneficiary. It qualifies for 50 CME credit points (category 3). The Oral Examination was held in three different cities: Brussels, Budapest and Warsaw. The exam was organized perfectly and helped create a calm atmosphere for the upcoming FEBUs,” said Miriam Hegemann (DE) when asked for her comments. “Now that I have passed the exam, I have the necessary knowledge and confidence in making decisions in my daily routine.  The written exam was the toughest part of becoming a FEBU.  My personal  tip in preparing for the exam is to try to review the lectures and the slides provided by the EUREP faculty in Prague. The photos on these pages were taken at the FEBU Diploma ceremony in Brussels.

Statistics EBU Oral Examinations 2015 Country Average Score Armenia 7 Austria 8 Belgium 7 Croatia 9 Czech Republic 5 Finland 7 France 8 Georgia 6 Germany 8 Greece 8 Hungary 8

Country Average Score Italy 7 Netherlands, The 8 Poland 8 Portugal 8 Romania 8 Slovenia 7 Spain 8 Sweden 8 Switzerland 8 Turkey 6 United Kingdom 7

IMPORTANT DATES EBU Online Written Examination: 20 November 2015 Visit www.ebu.com for more information

Examination Brussel: Examiners, Trustees and support staff

Examiners & Trustees Brussels K. Ackaert I. Adamakis L. Alvarez Castelo J. Angulo Morales A.A. Antoniewicz J. Bellringer F. Birkhäuser E. Boevé G. Bogaert J. Cabrita Carneiro L. Campos Pinheiro M. Çek C. Conde Redondo N. Coull C. Cracco M. Creta

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European Urology Today

B. da Costa Parada H.J. Danuser T. de Reijke I. Dickinson J. Dominguez-Escrig A. Feyaerts A. Figueiredo S. Giannakopoulos F. González-Chamorro M. Gunst O. Haillot E. Heinrich M. Heuser W. Hochreiter J. Hofbauer K. Jensen J. Jepsen

S. Kraus E. Lledo C. Mamoulakis M. Marszalek J. Martinez Salamanca S. Mattocks L. Monteiro J. Nawrocki P. Nunes E.K. Ong A. Papatsoris P. Pietrzak E. Plas A. Pycha C. Radmayr M. Rauchenwald A. Reissigl

C. Rentsch C. Rioja Sanz J. Robles García J. Rubio Briones J. Santos Dias C. Saussine S. Siracusano A. Skolarikos R. Stein A. Strauss S. Tekgül C. Terrone D. Tilki V. Tzortzis J. van Moorselaar K. Van Renterghem I. Varkarakis

J. Varregoso N. von Ostau S. Walter T. Zellweger Budapest L. Farkas P. Nyirády Warsaw P. Chłosta B. Darewicz T. Demkow P. Dobronski J. Dobruch Z. Jabłonowski A. Kołodziej

P. Kryst M. Lipinski J. Matych W. Pypno P. Radziszewski W. Rózanski A. Sikorski M. Sosnowski T. Szopinski P. Szostek T. Szydełko Z. Wolski H. Zielinski

June/July 2015


FEBU Urologist Exam Brussels Samvel Nikoghosyan, Armenia Clemens Heßler, Austria Reinhard Kastenberger, Austria Thomas Kunit, Austria Roman Neuner, Austria Mehmet Özsoy, Austria Stephan Andreas Seklehner, Austria Emin Mammadov, Azerbaijan Wouter Everaerts, Belgium Gregory Lefebvre, Belgium Olivier Rahier, Belgium Duje Rako, Croatia František Chmelík, Czech Jirí Janu, Czech

Jori Pesonen, Finland Dimitri Pogodin-Hannolainen, Finland Heikki Seikkula, Finland Catalin Marian Ciuta, France Nordine Deffar, France Ed-Dine Fadli Saâd, France Dan George Ungureanu, France Givi Koberidze, Georgia Wael Al Saydali, Germany Christian Baldauf, Germany Judit Bonkovic-Öszi, Germany Blanca Magdalena Brandes, Germany Edlira Duraj, Germany Mohamed Elmahmudi, Germany

Sebastian Elsner, Germany Alexander Engbert, Germany Robin Benjamin Epplen, Germany Philipp Ganßmann, Germany Björn Georgi, Germany Kathrin Haberecht, Germany Martin Janssen, Germany Jens-Holger Jessen, Germany Luis Alex Kluth, Germany Nils Kröger, Germany Jana Lackaja, Germany Sherif Mehralivand, Germany Saskia Carmen Morgenstern, Germany Helaluddin Naser, Germany Ladislau Neagoe, Germany Christopher Netsch, Germany Philipp Nuhn, Germany Timothy Oedekoven, Germany Alexander Passon, Germany Michael Peter Plangger, Germany Lena Rößing, Germany Dennis Schaab, Germany Claudia Schneider, Germany Philipp Schriefer, Germany Andriy Shaleva, Germany Lars Sokolowsky, Germany Regina Johanna Franziska Stredele, Germany Burkhard Ubrig, Germany Wolfgang Unkhür, Germany Carola Wotzka, Germany Friedemann Zengerling, Germany Panagiotis Anastasopoulos, Greece Georgios Dimakis, Greece Konstantinos Gkagkalidis, Greece Chrysovalantis Gkekas, Greece Spyridon Kampantais, Greece Efstratios Kapetanellis, Greece Markos Karavitakis, Greece Martsella Konomi, Greece Charilaos Kostopoulos, Greece Iason Kyriazis, Greece Christos Moiragias, Greece Ioannis Sokolakis, Greece Vasileios Spapis, Greece

June/July 2015

Athanasios Marios Voulgaris, Greece Ardit Tafa, Italy Francesco Ziglioli, Italy Pedro Alexandre Álvares Bargão Dos Santos, Portugal Filipe Alpoim Recasens de Almeida Lopes, Portugal Peter Kronenberg, Portugal Renato Miguel Lains Dos Santos Mota, Portugal José João Mendes Marques, Portugal Pedro Alexandre Mocho Galego, Portugal Pedro Samuel Pereira Dias, Portugal Petre Adrian Turcanu, Romania Andrej Grajn, Slovenia Sara Alvarez Rodríguez, Spain Enrique Artozqui Morrás, Spain Roberto Ballestero Diego, Spain

Stefan Aufderklamm, Germany Atiqullah Aziz, Germany Zentia Bütow, Germany Maximilian Fritzlar, Germany Matthias Heck, Germany Miriam Lena Hegemann, Germany Stephan Hill, Germany Jan Peter Jessen, Germany Melanie Kaufmann, Germany Judith Knapp, Germany Michaela Knieß, Germany Stefan Krieger, Germany Timur Hasan Kuru, Germany Julia Peter, Germany Joachim Reichle, Germany

Beatriz Bañuelos Marco, Spain Manuel Carballo Quintá, Spain Maria De Los Angeles Conca Baena, Spain Gema Del Pozo Jiménez, Spain Francisco Javier Díaz Goizueta, Spain Victor Díez Nicolás, Spain Fernando Estrada Dominguez, Spain José Francisco Flores Martín, Spain Carmen Garau Perelló, Spain Esteban Gómez Correa, Spain Juan Gómez Rivas, Spain David Hernández Hernández, Spain Bernardo Herrera Imbroda, Spain Estíbaliz Jiménez Alcaide, Spain Larissa Geobanina Lara Peña, Spain Ione Linazasoro Fernández, Spain Irene Losada Alvarez, Spain Saturnino Luján Marco, Spain Jorge Alberto Mora Christian, Spain Gabriel Ogaya Pinies, Spain Domingo de Guzmán Ordaz Jurado, Spain Alejandro Lorenzo Puerto Puerto, Spain Felipe Sáez Barranquero, Spain María Tapia García, Spain Antonio Tienza Fernández, Spain Lauro Sebastián Valverde Martínez, Spain José Julián Vázquez Escuderos, Spain Dario Vazquez-Martul Pazos, Spain Katarina Hallén Grufman, Sweden Anne Sörenby, Sweden Laura Boxler, Switzerland Jan Frédéric Brachlow, Switzerland Arachk De Gorski, Switzerland Isabelle Sonja Keller, Switzerland Michaela Mack, Switzerland Livio Mordasini, Switzerland Karsten Reinhardt, Switzerland Malte Rieken, Switzerland Jens Roleff, Switzerland Hildo Ananias, The Netherlands Aida Beganovic, The Netherlands Jikke Bootsma, The Netherlands Benjamin Doornweerd, The Netherlands Filippus Jansen, The Netherlands Joost Leijte, The Netherlands Bart Nieuwkamer, The Netherlands Raoul Richardson, The Netherlands Bart Van der Heij, The Netherlands Gerard Van der Wielen, The Netherlands Ugur Taylan Bilgilisoy, Turkey Deniz Bolat, Turkey Fetullah Gevher, Turkey Murat Gül, Turkey Tayyar Alp Özkan, Turkey Azad Hawizy, United Kingdom Dimitrios Karagiannis, United Kingdom Marco Puglisi, United Kingdom

Markus Riedl, Germany René Benjamin Ritter, Germany Florian Roghmann, Germany Laila Schneidewind, Germany Philipp Fabian Siegel, Germany Danijel Sikic, Germany Kathrin Simonis, Germany Armin Soave, Germany Matthias Stastny, Germany Andreas Streitbörger, Germany Michael Wenders, Germany Felix Wezel, Germany David Martin Zimmermann, Germany Achillefs Drogosis, Greece

FEBU Residents Exam Brussels (status 6-6-2015) Mirco Holz, Austria Tobias Schätz, Austria Martin Schmudermaier, Austria Stephan Schwarz, Austria Christian Johannes Wöhrer, Austria Jan Gysen, Belgium Vlad-Andrei Nechifor, Belgium Maija Kanerva Lahdensuo, Finland Teemu Murtola, Finland Alexandra Masson-Lecomte, France Mhd Wasim Abdul Samad, Germany Adib Al Attar, Germany

Christos Pournaras, Greece Serena Corti, Italy Marco Ennas, Italy Vikiela Galica, Italy Francesco Marson, Italy Francesca Mazzucato, Italy Anna Palazzetti, Italy Vasileios Petrainas, Italy Alessandro Terrin, Italy Valerio Vagnoni, Italy Luca Villa, Italy Osvaldo Vivaldi, Italy Álvaro João Antunes Loureiro Nunes, Portugal Rodrigo Nuno Brito Ramos, Portugal Luís Da Cunha Pacheco Figueiredo, Portugal Pedro De Almeida Melo Da Rocha, Portugal Ricardo Dias Cruz, Portugal Vânia Filipa Magalhães Grenha, Portugal Rodrigo Miguel Marques Garcia, Portugal Andrea Morais Furtado, Portugal Miguel Nunes Almeida, Portugal Lorenzo Serra De Oliveira Marconi, Portugal Nuno Jorge Silva Figueira, Portugal Juan Aragón Chamizo, Spain Jon Belloso Loidi, Spain Xavier Bonet Puntí, Spain Roque Cano Castiñeira, Spain Juan Andrés Cantero Mellado, Spain Albert Carrión Puig, Spain Roberto Castañeda Argáiz, Spain Ana Castelló Porcar, Spain Fredy Hernán Covaria Acuña, Spain Esteban Emiliani Sanz, Spain Lucía García González, Spain Pavel Gavrilov, Spain Alejandro González Alfaro, Spain Natalia González Ávila, Spain Christian Isalt Lemonche, Spain Borja López López, Spain Alejandra Mira Moreno, Spain Rosa Maria Novoa Martín, Spain Juan Camilo Pereira Barrios, Spain Miguel Ángel Rodríguez Cabello, Spain Amaia Sotil Arrieta, Spain

José Valero Rosa, Spain Helena Vila Reyes, Spain Augusto Wong Gutiérrez, Spain Bashar Al-Amiri, Sweden Bartosz Cierzniak, Sweden Andreas Forsvall, Sweden Paul Hannah, Sweden Rafael Lantz, Sweden

Hjalmar Björn Daniel Svensson, Sweden Philipp Baumeister, Switzerland Silvan Boxler, Switzerland Simon Bütikofer, Switzerland Mirjam Bywater, Switzerland Daniel Disteldorf, Switzerland Marianne Flury, Switzerland Armin Halla, Switzerland Stephan Kiss, Switzerland Jacques Pierre Klein, Switzerland Julien Renard, Switzerland Martin Nils Schmidtpeter, Switzerland Geerte de Graaf, The Netherlands Niels van Casteren, The Netherlands Roderick van den Bergh, The Netherlands Willemijn Windt, The Netherlands Ilker Akarken, Turkey Seyfettin Çiftçi, Turkey Fatih Gökalp, Turkey Ibrahim Kartal, Turkey Burhan Özdemir, Turkey Senol Tonyali, Turkey Ufuk Yavuz, Turkey Imran Ahmad, United Kingdom Vishwanath Hanchanale, United Kingdom Derek Hennessey, United Kingdom Rajesh Nair, United Kingdom Ayman Younis, United Kingdom

FEBUs Exam Poland Jakub Biedrzycki Waldemar Bonczar Piotr Bryniarski Wojciech Cichon Michał Dybala Patrik Forszt Łukasz Futyma Piotr Gajniak Tomasz Golabek Agnieszka Ida Maciej Jarosz Adam Kaluzny Adam Kruczek Dariusz Krzemien Jakub Kwapisz Grzegorz Ledniowski Marek Luczak Marcin Majek Magdalena Olszewska Maciej Pawlik Marcin Pietraszun Paweł Pilch Sebastian Piotrowicz Tomasz Piskozub Jacek Politanski Grzegorz Prokopowicz Adam Rychcik Marta Sochaj Jowita Stepniewska Waldemar Szablonski Krzysztof Twardosz Karol Wieczorek Paweł Wieczorek Wojciech Zachalski Tomasz Zajac Szymon Zieba

FEBUs Exam Hungary Alexandra Gulácsi Áron András Bécsi Bálint Horváth Lilla Tóth

European Urology Today

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Why does anti-androgen therapy fail? Drug resistance poses challenge to develop individualised PCa treatment Norman Maitland Professor of Molecular Biology University of York York (UK)

n.j.maitland@ york.ac.uk â&#x20AC;?Why does anti-androgen therapy fail?â&#x20AC;? This is probably one of the most common questions asked by prostate cancer patients, especially those for whom anti-androgen therapy has reduced serum PSA and other indicators of tumour growth and bulk to (below) zero. The obvious follow up questions are â&#x20AC;&#x2DC;Why me?â&#x20AC;&#x2122; â&#x20AC;&#x201C; when the therapy fails rapidly, and â&#x20AC;&#x2DC;Whatâ&#x20AC;&#x2122;s next?â&#x20AC;&#x2122; â&#x20AC;&#x201C; or how will you treat my relapsing tumour? There is of course a simple answer to the original question: Anti-androgen therapy fails as a result of the treatment and the biology of the cancers. No treatment, no resistance! Perhaps a better question would be to ask â&#x20AC;&#x2DC;HOW anti-androgen therapy fails?â&#x20AC;&#x2122; This is a harder question, and one which is difficult to explain to patients, beyond â&#x20AC;&#x2DC;Itâ&#x20AC;&#x2122;s complicated!â&#x20AC;&#x2122; Androgens are not just active in the prostate To try to answer these questions we need to understand both the biology and the biochemistry of cellsâ&#x20AC;&#x2122; responses to male sex hormones. Of course prostate epithelial cells (and the malignant carcinoma form) are not the only cells in the body, or indeed the prostate which can respond to male sex hormones. I have illustrated this in Figure 1. This may explain some or all of the observed side effects of anti-androgen therapy: they are not off-target effects, but are the effect of potent inhibitors on the correct target, but in the wrong cell types! Based on more modern targeted drugs, itâ&#x20AC;&#x2122;s unlikely that an anti-androgen (receptor) therapy would be acceptable if discovered today. There is more to the prostate androgen response than PSA In normal prostate, and indeed prostate adenocarcinoma cells, it is the luminal cells which express the receptor for androgens (AR) and respond to the hormone. This results in the potent upregulation of a variety of â&#x20AC;&#x2DC;prostate-specificâ&#x20AC;&#x2122; proteins such as prostate-specific antigen (PSA), a variety of other proteolytic enzymes and polyamines, which fulfil the primary role of prostatic secretions, the maintenance of human sperm, in the hostile acidic environment of the female reproductive tract.

However, as we have seen, AR is expressed in a variety of other human tissues, but perhaps more strikingly in a proportion of the mesenchymal/stromal cells in the prostate itself. In prostate stroma, when treated with androgens, multiple proteins are secreted (andromedins) which can influence the behaviour of the epithelial component of both normal and malignant prostate.

After combination of two AR-DHT molecules to form a dimer, the structure then translocates into the nucleus of the cell, where it binds to multiple recognition sites (the structure of which is sufficiently loose for them to be known as â&#x20AC;&#x2DC;consensus binding sitesâ&#x20AC;&#x2122;). Other steroid hormone receptors can also bind to these sites on DNA. What defines specificity is often the presence in the complex on DNA of co-activator (or co-repressor) proteins (shown in orange in Figure 2). The immediate effect of complex formation (within a few hours) is an increase in the expression of ARregulated genes, which affect cell survival, secretions (such as PAP and PSA) and (in cancers) of cell replication proteins. Some androgen regulated genes take more than 16 hours to be activated. It is likely that these are indirect effects of the AR-regulated genes, but nevertheless have important consequences for cancer treatment. Castration: a miracle cure for AR-positive tumours After treatment with anti-androgens, whose point of action is illustrated in Figure 3 (a simplified version of Figure 2) and listed in Table 1, there is an almost instant cessation in the expression of AR-regulated

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Androgen signalling is complex but vital to our understanding of resistance Within a prostate cancer, the response to circulating androgens in the luminal-like cancer cells is similar to that in normal luminal cells, with the added effects on androgen-stimulated cell replication in the tumours. Whereas the luminal cell in normal prostate is terminally differentiated and programmed to die, the same cell in a cancer is long-lived and is capable of multiple cell divisions. The signalling process from adrenally synthesized androgens within normal and indeed cancer cells is now better understood, and is summarized in Figure 2. In essence, information flows from the outside of the cell and the supply of testosterone, through the cell cytoplasm, where the androgen is modified by 5Îą reductase to a more potent form (dihydrotestosterone or DHT), followed by binding to the androgen receptor (AR) protein (which releases chaperone proteins from the AR such as heat shock proteins).

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genes â&#x20AC;&#x201C; normally monitored in patientsâ&#x20AC;&#x2122; serum by measuring PSA levels, accompanied (in hormonenaĂŻve patients) by the loss of both luminal cancer and normal prostate cells by natural cell death (apoptosis) mechanisms. Such drug treatments, an aesthetic improvement on the surgical castration practised by Charles Huggins, for which he won the Nobel Prize in 1966, are normally only applied when there is evidence of escape of cancer cells from within the prostate, where surgery and/or radiotherapy is least effective. There is however new evidence (from the CHAARTED Trial) to show that a combination of anti-androgens plus radiotherapy provides longer survival times in these patients, although neoadjuvant anti-androgens to shrink tumours before surgery may reduce survival (more of which later). A small proportion of the primary prostate cancers, treated by anti-androgen therapy do fail to respond from day one.

â&#x20AC;&#x153;All patients have different solutions to the resistance problem. The next generation of prostate cancer treatments should be decided on a truly individual, patient-specific basis.â&#x20AC;? Castration-resistant tumours remain dependent on androgens However, it is important to realise that even the resistant tumours to a first-line androgen therapy are still dependent on androgens for the expansion of secondary tumours. How do they achieve this? Molecular studies of resistant tumours have indicated multiple mechanisms, which can retain androgen responsiveness, even in castration-resistant cancer patients.

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Is this unexpected? Probably not, as we use a strongly androgen-regulated prostate protein (i.e. PSA) to monitor tumour growth. However, far from overexpressing tumour markers such as PSA, the cancer cells express lower levels, and it is access to the bloodstream from metastases and â&#x20AC;&#x2DC;leakyâ&#x20AC;&#x2122; vascularisation of the tumour mass which results in increased serum PSA concentrations. This is despite the higher levels and hyperactive nature of the AR in the tumour cells. There are many routes to castration resistance The number of biochemical mechanisms which the cancer cells can exploit to achieve resistance to anti-androgens is also surprising. These are summarised in Table 1 for convenience, but include endogenous synthesis of androgens within the tumour to replace adrenal androgens blocked by Zoladex, for example, mutation of the androgen receptor to enable it to utilise other steroid hormones such as oestrogen and progestogen, and even amplification of the androgen receptor gene on the X chromosome, resulting in more receptors which can bind the reduced amount of androgens from the bloodstream. Combination blockade of the androgen signalling axis The sequential use of different anti-androgens after failure on first-line castration therapy, results in significant life extensions: for example abiraterone or enzalutamide treatment in patients whose cancers have relapsed after successful Zoladex/Casodex treatments. Despite the molecular information on androgen signalling and resistance, we are still not able to judge either (i) the longevity of the secondary androgen control or (ii) to identify the 40% of patients for whom it will work. The central role of the androgen signalling axis is not in dispute here, since the various antiandrogens of increasing potency result in tumour shrinkage and relief of symptoms such as bone pain from metastases.

Mechanisms of Therapy Resistance to Prostate Cancer Drug Treatments

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European Urology Today

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Table 1: Mechanisms of Therapy Resistance to Prostate Cancer Drug Treatments

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Figure 2: Schematic outline of the androgen response in prostate epithelial cells. The diagram illustrates the flow of signals from serum androgen (pink circles) outside the cells via dihydrotestosterone (red diamonds) into the cell nucleus, where hormone induced changes are stimulated.

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Figure 1: Androgens do not only act in the male reproductive system. A number of different tissues, notably the brain and the spleen/bone marrow, express high levels of nuclear androgen receptor. The level of expression and its significance is reflected in the font size and intensity. Data principally from Dart et al (2013) PLOS One.

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Drug Target Supply of androgens to the PCa cells (1) From Adrenal Gland (e.g. Zoladex) (2) Endogenous synthesis in the tumour via Cyp17 (Abiraterone) Activation of testosterone to dihydrotestosterone via 5Îą reductase (e.g. Finasteride and Dutasteride) Binding of DHT substrate to monomeric androgen receptor (1) Steroidal (estrogen/cyproterone acetate) and (2) non-steroidal (Casodex/ Enzalutamide) Dimerisation and modification (phosphorylation) of androgen receptor Nuclear translocation of androgen receptor Binding or nuclear androgen receptor to (1) Recognition sites on DNA (2) Co-activator molecules Downstream effects of AR-stimulated effector molecules Heat Shock Protein inhibition and Androgen receptor degradation

Resistance Mechanism Switch to intratumoral androgen synthesis Amplification of the androgen receptor gene to maximise the use of low androgen concentrations. Not established Switch in 5aR isotype or use of testosterone/adrenal androgens Gain of function mutations in the androgen receptor gene to enable it to use other steroid hormones. Bypassing of the AR by ligand independent activation of androgen responsive genes

Mutation of the AR gene and expression of ligand-independent splice variants Expression of AR splice variants which translocate to the nucleus in the absence of androgen. Changes in balance between AR co-activator and co-repressor molecules and relative affinity of the receptor by mutation of AR. Activation of alternative salvage pathways which stimulate the signalling molecules downstream from AR activation. Redundancy in the Heat-shock Chaperone system, inhibition of AR proteolysis

June/July 2015


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Figure 3: Intervention points for therapy in the androgen response pathway. Potential and actual drug targets are indicated by the numbers in black boxes, described in more detail in Table 1.

However, attempts to achieve total blockade, either of exogenous and endogenous androgen supply, or simultaneous blockade of AR by enzalutamide plus androgen synthesis with abiraterone, do not seem to have achieved a better patient outcome than the single agents. Androgen biochemistry in a multicellular context To explain the latter results, in a more scientific manner than simply restating the fact that prostate cancers show considerable heterogeneity between patients, we should perhaps consider the cellular content of the tumours: another form of heterogeneity. Firstly, as discussed previously, the key AR target is widely expressed in a number of relevant cell types, apart from the luminal-like prostate cancer cells. â&#x20AC;&#x2DC;Off-targetâ&#x20AC;&#x2122; effects on the bone marrow, spleen and perhaps most importantly the tumour-associated stromal cells can also account for the spectrum of patient responses observed.

survival. In fact, stem cells, whose aim is to survive in an unaltered form throughout the life of the patient, appear to have evolved a hierarchy of gene inactivation, which allows them to be flexible in their responses to changing environments.

â&#x20AC;&#x153;It is the treatment which induces the most variability, propelling the cancer mass towards a fatal and heterogeneous mixture of phenotypes, which more readily resist even the most radical of chemotherapies.â&#x20AC;? They achieve this (i) by folding their chromosomes to turn off unwanted genes in a highly reversible manner, (ii) when a gene is not required for a long time period the cytosine bases are heavily modified (by methyl groups) which is also reversible, but less so than (i) and only when there is a strong selective or mutagenic pressure (iii) a gene is lost, transposed or inactivated/changed by an irreversible point mutation. Progression from (i) to (iii) destroys the SCâ&#x20AC;&#x2122;s flexibility.

Thus, many â&#x20AC;&#x2DC;prostate cancer-specificâ&#x20AC;&#x2122; genes are actually those which represent the absence of the basal cells and luminal cells which can now actively divide. This is illustrated in Figure 4a.

As I have illustrated in Figure 4b (a schematic illustration of multiple dynamic changes) it is highly likely that there will be at least five different cell populations to be treated after a patient has failed first-line castration. Is it therefore possible to ever Within this changing population of cells there is a achieve tumour control in CRPC, especially using minor population (about 1% in normal prostate and targeted agents (which will normally be directed <0.1% in malignant tumours), which is highly invasive against the most common tumour target â&#x20AC;&#x201C; but not but relatively quiescent, even within the dividing mass necessarily against the population of cells which of cells in a tumour. defines malignancy)? This population, which expresses little or no AR in humans, contains the tumour-inducing or cancer stem cell population. Impervious from the start to anti-androgen therapies, it is capable of regenerating the tumour mass, after further adaptation to the chemotherapy-rich environment resulting, by differentiation and expansion in a secondary tumour, sharing the â&#x20AC;&#x2DC;founder mutationsâ&#x20AC;&#x2122; of the original tumour, and the therapy-induced adaptation of the androgen response.

As quantified with other tumour types, and best understood (but not solved) in a number of leukaemias, highly targeted agents have only a limited potency with profound side effects. It is our therapies which select for and define the resistant multiclonal cancers - which kill patients.

All subsequent mutations and the gene rearrangements (found more commonly in prostate cancers) are an enhancement of the original suite of founder changes, which enable the tumour to prosper (and be clinically detectable and relevant) in the tumour microenvironment, both before, during and after treatment. It is the treatment which induces the most variability, propelling the cancer mass towards a fatal and heterogeneous mixture of phenotypes, which more readily resist even the most radical of chemotherapies. What strategies can we evolve to combat the treatment resistant phenotype? It is clear that our increasingly sophisticated oncology drug cocktails are simply getting better at doing what their predecessors could do 40 years ago: killing dividing cells â&#x20AC;&#x201C; but with more acceptable side effects, and at a much higher cost. Studies with antibiotics provide some of the clues to the way forward: as do some of the very first chemotherapy studies (from the 1980s). (i) For example, to select a resistant cell in the laboratory, one treats a population (a large population) of cells with low levels of the drug under study for a long period of time. This is how drug-resistant LNCaP prostate cancer cells were derived. In a patientâ&#x20AC;&#x2122;s tumour, the structure and vascularisation means that the blood levels of a drug are rarely uniform across the cancer mass, and many cells are deprived of a toxic dose: especially within the therapeutic window of docetaxel for example. Whilst there remains uncertainty about the merits of intermittent androgen therapy (IAT) as discussed recently in Lisbon at EUMC 2014, drug resistance kinetics argues strongly that cycles of high-dose treatment should minimise the generation of variants. Any prolongation of sub-toxic treatment simply adds to the tumour complexities. (ii) Combination therapies should be designed with complementary and â&#x20AC;&#x2DC;salvageâ&#x20AC;&#x2122; cell-signalling pathways in mind, now that we can map their existence in vitro and in vivo.

(iii) The ordering and timings of such combinations If we are treating not one but many cancers in one has not been well developed: for example, does one patient, can we ever achieve cure or even control? anticipate resistance by blocking the resistance It may seem from the preceding discussion that strategy, or should the secondary treatment be cancer cures are impossible or at best unlikely, in a delayed? Just because androgen therapy achieves Whether all the AR-modifying mutations (from Table heterogeneous stem cell-based model of cancer. control, it is perhaps important to supplement it Do cancer stem cells exist in prostate cancer: and 1) will be found in the stem cell component remains The current mean survival time of CRPC patients before resistance occurs. how do they influence the outcome of anti-androgen to be established. argues strongly that this is currently true! It is clear therapies? that early surgery and radiotherapy can be curative, (iv) Combination therapies should probably include There is another potential confounding element, Castration resistant prostate cancer: a moving target but nevertheless there are more frequent relapses targeting of multiple cell types including the stem-like which my own research has highlighted over the last As can be seen in Figure 4b, the tumour cell than expected, probably because of early cells (if possible or feasible) in addition to pathway 10 years, since my laboratory first identified a populations in prostate cancer are constantly evolving. metastasis. targeting. tumour-initiating cell population from hormone-naĂŻve New populations arise by random mutation - and not prostate cancers. Within each tumour there are two always in the SCs. This will result in new dominant My current model of prostate cancer implies that the (v) As seen by the number of mechanisms in Table 1, important cellular hierarchies. cell populations (if the mutation is advantageous) or a founder cells of each cancer (of which there can be all patients have different solutions to the resistance series of â&#x20AC;&#x2DC;failed cancersâ&#x20AC;&#x2122; of limited size and survival several in a single patient) are defined in their problem. The next generation of prostate cancer The first is a differentiation hierarchy. In a prostate characteristics (as seen on sectioning of whole mount malignant potential when the cancer emerges from treatments should be decided on a truly individual, acinus there is a balance between basal and luminal prostates from cancer patients and indeed healthy â&#x20AC;&#x2DC;pre-tumour progression.â&#x20AC;&#x2122; patient-specific basis. cells, limited by strict cell adhesion criteria, and individuals over 50). bounded by a basement membrane. In addition, the presence of a mutation in a single As elegantly described by Gleason, almost 50 years copy of the two genes (apart from androgen receptor ago, the basement membrane progressively disappears which is present in one copy on the X chromosome), with increasing tumour grade, and most prostate can frequently be silenced or is subject to an allelic   cancers are virtually devoid of basal cells: reduced from switch if the tumour microenvironment (and   a 40-50% content in normal prostate acini. treatment) demands the normal gene allele for cell          

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June/July 2015

Figure 4b: Fluctuations in clonal cell populations during the development of prostate cancer, and after anti-androgen treatments. The triangles indicate a bulk of proliferating cancer cells, including the multiple cell types in the lower part of figure 4a. Stem and tumour initiating cells are shown by coloured circles: there are multiple stem-like cells in a single tumour (0.1% of total cell number)

European Urology Today

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Key articles from international medical journals Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

Is human urine sterile? Until recently the generally accepted paradigm implied that urine of healthy people is sterile. The authors of the present study investigated urine of healthy subjects by extended bacteriological methods. Three midstream urine samples from 52 healthy subjects each (24 females, 28 males; 18-25 years of age) were investigated by an extended set of culture media for identification of facultative aerobic (FAB) and non-clostridial anaerobic bacteria (NCAB). Ward's method (Euclidean distance) was used for similarity analysis.

As also shown by other investigators, urine of healthy people is normally not sterile The bacterial count of FAB in urine was usually low (≤ 102 colony-forming units/ml) in both groups. In contrast, the bacterial count of NCAB was higher (≥ 103 colony-forming units/ml), at least in some species, with significant differences between genders. The average number of bacterial species found was 5.8 in female and 7.1 in male urine. Half of the females were assigned to a specific 'female' microbial spectrum, different from that of males. In the mixed-gender clusters, the males showed a greater similarity among themselves. As also shown by other investigators, urine of healthy people is normally not sterile. The role of the routinely not cultivated bacteria in healthy and diseased subjects needs to be established. It may alter the diagnostics of infectious and inflammatory diseases of the urogenital tract.

Source: Human urine is not sterile - shift of paradigm. Kogan MI, Naboka YL, Ibishev KS, Gudima IA, Naber KG. Urol Int. 2015 Mar 7. [Epub ahead of print]

were associated with post-biopsy infection (6.6% vs 1.6%, p < 0.001) and hospitalization (4.4% vs 0.9%, p < 0.001). Fluoroquinolone resistant positive rectal culture increased the risk of infection (OR 3.98, 95% CI 2.37-6.71, p < 0.001) and subsequent hospital admission (OR 4.77, 95% CI 2.50-9.10, p < 0.001). If men only received fluoroquinolone prophylaxis, the infection and hospitalization proportion increased to 8.2% (28 of 343) and 6.1% (21 of 343), with OR 4.77 (95% CI 2.50-9.10, p < 0.001) and 5.67 (95% CI 3.00-10.90, p < 0.001), respectively. The most common fluoroquinolone resistant bacteria isolates were Escherichia coli (83.7%). Limitations include the retrospective study design, non-standardized culture and interpretation of resistance methods. The authors concluded that colonization of fluoroquinolone resistant organisms in the rectum identifies men at high-risk for infection and subsequent hospitalization from prostate biopsy, especially in those with fluoroquinolone prophylaxis only.

Source: Fluoroquinolone resistant rectal colonization predicts risk of infectious complications following transrectal prostate biopsy. Liss MA, Taylor SA, Deepak Batura D, Steensels D, Chayakulkeeree M, Soenens C. The Journal of Urology 06/2014; 192(6). DOI: 10.1016/j. juro.2014.06.005

Febrile UTI after prostate biopsy and quinolone resistance Complications after prostate biopsy have increased and various causes have been reported. Growing evidence of increasing quinolone resistance is of particular concern. In the current retrospective study, the authors evaluated the incidence of infectious complications after prostate biopsy and identified the risk factors. The study population included 1,195 patients who underwent a prostate biopsy between January 2007 and December 2012 at Chung-Ang University Hospital. Cases of febrile UTI that occurred within seven days were investigated. Clinical information included age, prostate-specific antigen, prostate volume, hypertension, diabetes, body mass index, and biopsy done in the quinolone-resistance era. Patients received quinolone (250 mg intravenously) before and after the procedure, and quinolone (250 mg) was orally administered twice daily for three days. Univariate and multivariate analysis were used to investigate the predictive factors for febrile UTI.

Fluoroquinolone resistant rectal colonisation predicts …quinolone resistance is the main risk of infectious complications cause of post-biopsy infections in after transrectal prostate their center and suggested that biopsy further evaluation is required to Infection after transrectal prostate biopsy has become validate similar trends an increasing concern due to fluoroquinolone resistant bacteria. The authors determined whether colonization identified by rectal culture can identify men at high risk for post-transrectal prostate biopsy infection.

Febrile UTI developed in 39 cases (3.1%). Core numbers increased from 2007 (8 cores) to 2012 (12 cores) and quinolone-resistant bacteria began to appear in 2010 (quinolone-resistance era). In the Six institutions provided retrospective data through a univariate analysis, core number ≥ 12 (p = 0.024), standardized, web-based data entry form on patients body mass index (BMI) > 25 kg/m2 (p = 0.004), and undergoing transrectal prostate biopsy who had rectal biopsy done in the quinolone-resistance era (p = culture performed. The primary outcome was any 0.014) were significant factors. However, in the post-transrectal prostate biopsy infection and the multivariate analysis adjusted for core number, the secondary outcome was hospital admission 30 days results were not significant, with the exception of BMI after transrectal prostate biopsy. Chi-square and > 25 kg/m2 (p = 0.011) and biopsy during the logistic regression statistical analysis were used. quinolone-resistance era (p = 0.035), which were significantly associated with febrile UTI.

…colonization of fluoroquinolone resistant organisms in the rectum identifies men at high risk for infection and subsequent hospitalization from prostate biopsy A total of 2,673 men underwent rectal culture before transrectal prostate biopsy from January 1, 2007 to September 12, 2013. The prevalence of fluoroquinolone resistance was 20.5% (549 of 2,673). Fluoroquinolone resistant positive rectal cultures Key articles

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The authors concluded that quinolone resistance is the main cause of post-biopsy infections in their center and suggested that further evaluation is required to validate similar trends. Novel strategies to find alternative prophylactic agents are also necessary.

Source: Febrile urinary tract infection after prostate biopsy and quinolone resistance. Choi JW, Kim TH, Chang IH, Kim KD, Moon YT, Myung SC. Korean J Urol 10/2014; 55(10):660-4. DOI: 10.4111/ kju.2014.55.10.660

*Reviewer's Comment: The prophylactic regimen used in this paper deviated from the recommendations in the EAU Guidelines

Anti-androgens benefit men with high risk non-metastatic prostate cancer? The development of novel drugs to disrupt the androgen pathway in prostate cancer has shown an increase in overall survival in patients with chemonaïve metastatic castration resistant prostate cancer. Although endocrine manipulation is not first-line therapy in non-metastatic prostate cancer this has revived the old controversy about what constitutes the optimal timing of endocrine manipulation in the management of prostate cancer, and in particular since the release on the data from the phase II STRIVE study. SPCG-6 evaluated 1,218 men recruited between October 1995 and July 1998 with either localized (T1-2, N0/NX) or locally advanced (T3-4, any N; or any T, N+) hormone-naïve prostate cancer with no evidence of distant metastases. Patients were randomised to receive either bicalutamide 150 mg or placebo until disease progression. However when in 2004 the second analysis showed a significant reduction in progression-free survival the steering committee suggested the treatment code should be broken. This paper discussed the long-term survival with a median follow-up of patients alive of 14.6 years. At this point 866 (71.1%) men have died, 198 (16.2%) men are known to be alive and 154 (12.6%) men were alive at the last data lock 30th August 2008 but could not be chased and so have been censured on that date. In addition to previous analyses this also assessed the effect of bicalutamide according to a modification of the NCCN risk classification. Low-risk: T1, PSA < 10 ng/mL, and well differentiated WHO; intermediate-risk: T2 and/or PSA 10–20 ng/mL and/or moderately differentiated WHO; and high-risk: T3 and/or, PSA > 20 ng/mL and/or poorly differentiated WHO. Patients with T4 or lymph node metastasis were excluded from these analyses.

The median time to initiation of ADT or open-label bicalutamide in the placebo arm was 3.8 years. It suggests that men with locally advanced disease will benefit from immediate androgen deprivation In patients with localised disease survival favoured placebo 11.8 years versus bicalutamide 10.1 years (HR 1.19 (95% CI: 1.00-1.43) p = 0.56). A difference driven by death from other causes and apparent after the first year. In contrast bicalutamide significantly improved OS in patients with locally advanced disease 9.1 years versus 7.3 years (HR 0.77 [CI 0.63-0.94] p = 0.01). As might be expected when stratified by the modified NCCN risk categories, survival nonsignificantly favoured randomisation to placebo in patients with low- (HR 1.53 (95% CI: 0.81 – 2.90)) and intermediate-risk prostate cancer (HR 1.07 (95% CI: 0.83–1.38)). In patients with high-risk prostate cancer there was a non-significant survival benefit of bicalutamide (HR 0.87 (95% CI: 0.73–1.04)). Interestingly, in a multivariate Cox proportional hazard model in the 991 men managed by watchful waiting as their standard of care, all patients with locally advanced prostate cancer gained a survival advantage from bicalutamide as did those men with apparently localised disease and a PSA of > 28 ng/ml. In essence, the SPCG-6 is a study of early androgen receptor inhibitor monotherapy versus delayed endocrine treatment. More than 80% of the study participants were managed on watchful waiting as their standard care and the majority of all included patients required subsequent endocrine therapy following allocated therapy. The median time to initiation of ADT or open-label bicalutamide in the placebo arm was 3.8 years. It suggests that men with locally advanced disease will benefit from immediate androgen deprivation. The question is how this data will be used to inform the debate about the optimal

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikummuenchen.de timing of more powerful anti-androgens in nonmetastatic prostate cancer patients. Source: Survival benefit of early androgen receptor inhibitor therapy in locally advanced prostate cancer: long term follow-up of the SPCG-6 study. Thomsen FB, Brasso K, Christensen IJ, Johansson J-E, Angelsen A, Tammela TLJ, Iversen P on behalf of the Scandinavian Prostate Cancer Group. European Journal of Cancer (2015) http://dx.doi. org/10.1016/j.ejca.2015.03.021.

Development of individual risk assessment in renal cancer The only curative therapy for patients with stage I-III renal clear cell carcinoma is surgery or ablation but approximately 30% of patients will suffer a relapse. The ability to predict who is at risk is increasingly important as anti-angiogenic targeted therapies, which have been shown to have clinical activity in the metastatic setting, are now being assessed as possible adjuvant therapy. Current recurrence risk is calculated using TNM stage with clinical and pathological feature, however many of these can be subject to inter-observer variability. This group looked to develop and validate a prognostic multi-gene signature to give a personalised risk of recurrence. The gene signature was developed using reverse transcription (RT)-PCR from RNA obtained from archived fixed paraffin-embedded tumour tissue from 942 patients treated by nephrectomy at the Cleveland Clinic and validated from an independent cohort of 626 patients treated by nephrectomy at Hôpital Foch and Hôpital Necker Enfants Malades in France. In the development cohort most had Stage I disease. Median follow-up was 6.2 years with 221 recurrences (23%). According to the Leibovich classification, 93% of 540 low-risk patients, 78% of 263 intermediate-risk patients and 36% of 128 high-risk patients were recurrence-free at five years. In the validation study median follow-up was 5.5 years with 99 (16%) recurrences. The association between expression of 732 genes and clinical outcomes were studied. 516 genes were associated with recurrence-free interval in univariate analysis. Analysis identified several major biological pathways, including vascular, cell growth or division, immune response, and inflammation pathways. Higher expression of genes in the vascular and immune response groups was associated with a lower recurrence risk, whereas higher expression of genes in the cell growth or cell division and inflammation groups was associated with increased risk of recurrence.

The strongest prognostic genes identified are members of biological pathways known to be crucial to the biology of clear cell renal cell carcinoma The list of gene candidates was narrowed down by the use of several considerations, including the strength of the associations with recurrence in both univariate and multivariate analyses, consistency of performance across patient subgroups and alternative endpoints (renal cancer-specific survival and overall survival), and analytical performance. Eleven of these genes were selected by further statistical analyses, and were combined with five reference genes, from which a recurrence score algorithm was developed. The association between the recurrence score and the risk of recurrence and cancer-specific survival in the first five years after surgery was assessed using Cox proportional hazard regression, stratified by tumour stage (stage I vs stage II vs III).

EAU EU-ACME Office

European Urology Today

June/July 2015


Prof. Truls Erik Bjerklund Johansen Section editor Oslo (NO)

tebj@medicin.uio.no In the primary univariate analysis, the continuous recurrence score (median 37, IQR 31–45) was significantly associated with recurrence-free interval (HR 3·91 [ CI 2·63–5·79] for a 25-unit increase in score, p < 0·0001). The association between the recurrence score and the recurrence-free interval was similar for patients with stage I and those with stage II–III disease. In multivariable analyses, the recurrence score was significantly associated with the risk of tumour recurrence (HR per 25-unit increase in the score 3·37 [ CI 2·23–5·08], p < 0·0001) after stratification by stage and adjustment for tumour size, grade, or Leibovich score. Consequently the recurrence score was able to identify a clinically significant number of both high-risk stage I and low-risk stage II–III patients. The recurrence score was able to differentiate risk within both stage I and stage II–III disease, and within Leibovich score subgroups, identifying patient subgroups with very low and high risk of recurrence. The strongest prognostic genes identified are members of biological pathways known to be crucial to the biology of clear cell renal cell carcinoma. The score was also predictive of renal cancer-specific, disease-free, and overall survival. This multigene assay may provide individual risk assessment beyond existing clinical and pathological parameters. Ultimately, the recurrence score result could help physicians to make more informed treatment decisions about whether or not to treat patients when adjuvant therapies become available and would need to be assessed for this purpose in ongoing or prospective randomised clinical trials.

Source: A 16-gene assay to predict recurrence after surgery in localised renal cell carcinoma: development and validation studies. Rini B, Goddard A, Knezevic D, Maddala T, Zhou M, et al. Lancet Oncol 2015;16:678-85.

Chemotherapy for high-risk localised prostate cancer? There is strong evidence that combining androgen deprivation therapy (ADT) with radiotherapy improves outcomes including survival in patients with high-risk localised prostate cancer. Interestingly this does not appear to be the case when radical prostatectomy and ADT are combined and there is only weak evidence for the use of long-term ADT in men with lymph node metastasis. For other cancers chemotherapy regimens that are active against metastatic disease have yielded a benefit when used as adjuvant therapy for apparently localised disease presumable by eradicating micro-metastasis. This study evaluated men with histologically proven adenocarcinoma of the prostate with at least one of the following high-risk features: Gleason score of 8 or greater, stage T3 or T4 disease, serum PSA concentration of 20 ng/mL or more, or pathological node-positive disease. Patients had to have no evidence of metastases on bone scan and abdominopelvic CT scan (or MRI) within the past six months.

factor. Local treatment was given three months after the start of systemic treatment. In patients with pathological node-negative disease, it could consist of radiotherapy or prostatectomy. In patients with node-positive disease, it could consist of radiotherapy or no local treatment. 413 men were enrolled median age 63 years. For local treatment 25 (6%) men had a prostatectomy whilst 358 (87%) had radiotherapy with a median dose of 74Gy and the use of a pelvic field in 208 of these equally split between the two groups. The overall median duration of ADT was 36 months. In the chemotherapy group 195 (94%) of 207 patients received the planned for cycles of docetaxel and 187 (90%) of 207 the planned four cycles of Estramustine. With a median follow-up of 8.8 years54% of men in the ADT only group had suffered an event (relapse or death) versus 43% in the ADT plus chemotherapy group (HR 0.71 (CI 0.54-0.94; p = 0.017)). Slightly surprisingly all of the benefit was seen in men with a Gleason score less than 8. This is an interesting study showing significant improvement in relapse-free survival with docetaxel based chemotherapy. This was mainly biochemical failure and longer follow-up will be required to assess if this translates into improved metastasis-free survival and overall survival.

Source: Androgen deprivation therapy plus docetaxel and estramustine versus androgen deprivation therapy alone for high-risk localised prostate cancer (GETUG 12): a phase 3 randomised controlled trial. Fizazi K, Faivre L, Lesaunier F, Delva R, Gravis G, Rolland F, Priou F, Ferrero J-M, et al. Lancet Oncol 2015 http://dx.doi.org/10.1016/S14702045(15)00011-X.

Different patterns of brain reaction to bladder predict response to pelvic floor muscle training for urge urinary incontinence Urge urinary incontinence (UUI) is related to an urodynamic definition of detrusor overactivity. Nevertheless, the underlying causes remain uncertain. The behavioural treatment using biofeedback-assisted pelvic floor muscle training (PFMT) is a recommended therapy option. Nevertheless, strong predictors of response to this treatment are not available, but could improve the patient management. In the present study, the authors assessed the brain reaction to rapid bladder filling with urgency in order to distinguish specific brain areas between patients responders, or not, to PFMT. Sixty-two communitydwelling females with UUI were included and underwent comprehensive clinical and bladder-diary evaluation, urodynamic testing and brain functional MRI before and after PFMT. Inclusion criteria were urge-predominant incontinence including > 5 UUI episodes/week for at least three months and demonstrable detrusor overactivity on urodynamic testing. A > 50% reduction in incontinence episodes was used to define responders to PFMT that lasted two to three months. Mean age was 72 years. Overall, 28 patients responded to PFMT (45%). The mean frequency of UUI episodes decreased from 3.5 to 1.9/24 hours. At the end of the study, 15% were dry. Urodynamic measurements showed few significant differences between responders and non-responders. Maximum detrusor pressure was higher in non-responders.

This is an interesting study showing significant improvement in relapse- There are two different patterns of free survival with docetaxel-based brain response to bladder filling that could predict the success of chemotherapy behavioural treatment of urge urinary incontinence A staging pelvic lymph node dissection was done within 12 weeks before enrolment. Patients were randomly assigned (1:1) to either androgen deprivation therapy (ADT; goserelin 10·8 mg every three months for three years) plus four cycles of docetaxel on Day 2 at a dose of 70 mg/m2 and estramustine 10 mg/kg per day on Days 1–5, every three weeks, or ADT only. They were stratified for high-risk features, with an equal weight for each Key articles

June/July 2015

responders or non-responders to PFMT. After PFMT, MRI assessment in responders (but not nonresponders) showed significant changes in the intensity of brain reaction, suggesting a link between brain reaction modulation and clinical response. There are two different patterns of brain response to bladder filling that could predict the success of behavioural treatment of urge urinary incontinence. The response to PFMT could also be illustrated by modulation in brain reactions in responders. Such findings may guide our treatment decision-making in women suffering from UUI.

Source: Brain mechanisms underlying urge incontinence and its response to pelvic floormuscle training. Griffiths D, Clarkson B, Tadic SD, Resnick NM. J Urol. 2015 Mar 28. doi: 10.1016/j.juro.2015.03.10

Genetic variants and risk for urge urinary incontinence Recent reviews reported moderate epidemiological credibility for genetic correlations with overactive bladder condition. In that study, authors showed the results from the first GWAS to identify genetic variants that could be associated with urge urinary incontinence (UUI) in postmenopausal women. The authors used a large cohort of genotyped post-reproductive white women. Controls reported no UUI at enrolment and follow-up. UUI was defined by incontinence episodes more than once a month leading to leak sufficient to wet or soak underpants or clothes. For primary association analyses, subjects were randomly assigned to discovery and replication samples.

…storage symptoms in white postmenopausal women could be influenced by observed heritability Excluding women with neurological disorders, the prevalence rate of UUI was 52%. Overall, eligible women were randomized to the discovery set (1,513) or the validation data set (1,504). No clinical characteristics differ significantly between discovery and replication sets. In both discovery and replication sets, UUI cases were significantly more likely to be obese than controls. Age and level of education were comparable. Logistic regression models were run independently in the discovery and replication cohorts to identify genetic variants associated with UUI.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com In that study, authors retrospectively reviewed charts from patients undergoing salvage procedures after initial sling failure. Among 330 patients receiving a sling for post-prostatectomy incontinence, 61 men have been included for a second surgery, three surgeons were involved. Post-operative success was defined by the use of 0-1 pad, negative stress test and pad test < 8g/day. Thirty-two patients received an AUS, 29 men a secondary transobturator sling. The AUS cuff was placed around the bulbar urethra.

This study ….reinforced the role of AUS as reference treatment option in persistent urinary incontinence after initial sling placement In all cases, the initial sling was left in-situ. It is worthy to note that 47% of AUS patients have previously undergone external beam radiation therapy compared with 17% of sling patients (p = 0.01). Moreover, level of incontinence was higher among patients receiving AUS when assessing daily pad use, 24-hour pad weight and Valsava leak point pressure. Secondary surgery was performed at a median of 12 months from primary surgery. Median follow-up was short (four months). One hundred percent of AUS patients were continent as compared with 79% of sling patients. Moreover, only 35% of sling patients remained continent after 10 months. The relative risk of treatment failure was six-fold superior in sling patients compared with AUS patients. These analyses were confirmed by KaplanMeier curves.

Although transobturator male sling offers an interesting and effective approach for the treatment of post-prostatectomy incontinence, ideal candidates are mainly those with a low preoperative pad test and no prior radiation therapy. In case of sling failure and persistent urinary leakage, secondary sling placement is feasible; however the risk of success is significantly lower than that reported after salvage AUS. This study has several limitations including its retrospective nature and the absence of validated questionnaires to The 17 variants most strongly associated with UUI represented six genomic loci on chromosomes 5p, assess patient-reported satisfaction. Nevertheless, the 10p, 11q, 12p, 12q, and 18q. Genes located on these worse pre-operative continence characteristics of patients implanted with an AUS reinforced the role of chromosomal bands were the zinc finger protein 521 gene (ZFP521), the ADAM metallopeptidase with AUS as reference treatment option in persistent thrombospondin type 1 motif 16 gene (ADAMTS16), the urinary incontinence after initial sling placement. citron gene (CIT). These genes are involved in regulation of neural stem cell proliferation and central Source: The artificial urinary sphincter is nervous system development. The other three loci superior to a secondary transobturator male were intergenic. sling in cases of a primary sling failure. Ajay D,

Zhang H, Gupta S, et al.

This large genome-wide association study demonstrated a link between genetic variants in the ZFP521, CIT, and ADAMTS16 genes and UUI. This suggested that storage symptoms in white postmenopausal women could be influenced by observed heritability.

J Urol 2015 May doi: 10.1016/j.juro.2015.04.106

Rezum System Water Vapor Treatment for LUTS/BPH

Source: Genetic contributions to urgency urinary The aim of this trial was to evaluate by magnetic incontinence in women. Richter HE, Whitehead resonance imaging the physical effects of convective N, Arya L, et al. Pelvic Floor Disorders Network. thermal energy transfer with water vapour as a J Urol 2015;193:2020-7.

means of treating lower urinary tract symptoms due to benign prostatic hyperplasia.

Artificial urinary sphincter vs secondary sling after initial sling failure in postprostatectomy incontinence

…this imaging study confirms the delivery of convective water vapour technology to create thermal lesions in the prostate tissue

The use of transobturator sling has gained acceptance for the treatment of post-prostatectomy incontinence, mainly in patients suffering from moderate urinary Functional MRI findings revealed that rapid bladder leaks. Reported success rates range from 70% to 90% filling provoked weak brain reaction in normal after mid-term follow-up. In case of sling failure, controls. However, in the study cohort of UUI women, various options are still available including ProACT, some spherical brain regions of interest were new sling placement, and artificial urinary sphincter activated or deactivated (insula, midcingulate, (AUS). Nevertheless, to date, no head-to-head supplementary motor area). Interestingly, different comparison is able to help our treatment decisionpatterns of activation/deactivation were seen between making.

Sixty-five men with lower urinary tract symptoms were treated with the Rezum System by transurethral intraprostatic injection of water vapour. A group of 45 of these men consented to undergo a series of gadolinium-enhanced magnetic resonance imaging of the prostate after treatment to monitor the size and location of ablative lesions, their time course of resolution, and the corresponding change in prostate tissue volume.

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Dr. Francesco Sanguedolce Section editor London (UK)

fsangue@ hotmail.com Visualisation was conducted at one week, one, three, and six months after treatment. Outcomes were available for 44 patients. Convective thermal lesions were limited to the transition zone and correlated with targeted treatment locations. At one week after treatment, the mean volume of ablative lesions was 8.2 cm3 (0.5-24.0 cm3). At six months, whole prostate volume was reduced by a mean of 28.9% and transition zone volume by 38.0% as compared with baseline one-week images. At three and six months after treatment, the lesion volumes were reduced by 91.5% and 95.1%, respectively. Lesions remained within the targeted treatment zone without compromising integrity of the bladder, rectum, or striated urinary sphincter. The authors concluded that this imaging study confirms the delivery of convective water vapour technology to create thermal lesions in the prostate tissue. Lesions generated underwent near complete resolution by three and six months after treatment with a concomitant one-third reduction in overall prostate and transition zone volumes.

Source: Rezum System Water Vapor Treatment for lower urinary tract symptoms/benign prostatic hyperplasia: Validation of convective thermal energy transfer and characterization with magnetic resonance imaging and 3-dimensional renderings. Mynderse LA, Hanson D, Robb RA, Pacik D, Vit V, Varga G, Wagrell L, Tornblom M, Cedano ER, Woodrum DA, Dixon CM, Larson TR. Urology. 2015 May 15. pii: S0090-4295(15)00309-X. doi:10.1016/j.urology.2015.03.021. [Epub ahead of print]

Multinational study of prostatic urethral lift versus TURP Transurethral resection of the prostate (TURP) is considered the gold standard for male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). However, TURP may lead to sexual dysfunction and incontinence, and has a long recovery period. Prostatic urethral lift (PUL) is a treatment option that may overcome these limitations. The authors compared PUL to TURP with regard to LUTS improvement, recovery, worsening of erectile and ejaculatory function, continence and safety (BPH6).

…participants who underwent prostatic urethral lift responded significantly better than those who underwent transurethral resection of the prostate as therapy for benign prostatic hyperplasia Prospective, randomised, controlled trial at 10 European centres involving 80 men with BPH LUTS was conducted. The BPH6 responder endpoint assesses symptom relief, quality of recovery, erectile function preservation, ejaculatory function preservation, continence preservation, and safety. Non-inferiority was evaluated using a one-sided lower 95% confidence limit for the difference between PUL and TURP performance. Preservation of ejaculation and quality of recovery were superior with PUL (p<0.01). Significant symptom relief was achieved in both treatment arms. The study demonstrated not only non-inferiority but also superiority of PUL over TURP on the BPH6 endpoint. Study limitations were the small sample size and the inability to blind participants to enrolment arm. Assessment of individual BPH6 elements revealed that PUL was superior to TURP with respect to quality of recovery and preservation of ejaculatory function. PUL was superior to TURP according to the novel BPH6 Key articles

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responder endpoint, which needs to be validated in future studies. In this study, participants who underwent prostatic urethral lift responded significantly better than those who underwent transurethral resection of the prostate as therapy for benign prostatic hyperplasia with regard to important aspects of quality of life.

(anti-HBsAb) titer of 10 IU/L is admitted to be protective, however, the optimal threshold, at and after KT, is unknown. In addition, the natural evolution of anti-HBsAb titers after KT is so far not known.

The aim of this study was to analyse rates of protective immunity to HBV at time of KT (baseline) and evolution of anti-HBsAb titers during the Source: Prospective, Randomized , Multinational following year. For this a retrospective analysis of HBV Study of Prostatic Urethral Lift Versus serology at baseline, 15 days as well as 4 and 12 Transurethral Resection of the Prostate: months post-KT was done. No patient received 12-month Results from the BPH6 Study. vaccination during the study period, but information Sønksen J, Barber NJ, Speakman MJ, Berges R, about previous vaccination was unavailable.

Wetterauer U, Greene D, Sievert KD, Chapple CR, Montorsi F, Patterson JM, Fahrenkrug L, Schoenthaler M, Gratzke C.

Eur Urol. 2015 Apr 30. pii: S0302-2838(15)00326-7. doi: 10.1016/j.eururo.2015.04.024. [Epub ahead of print]

Comparing 180 W GreenLight XPS laser vaporisation and TURP in treating BPO

Despite a high prevalence of protective anti-HBsAb titer at KT, the loss of protective immunity during the following year was considerable

At baseline, 80% of 141 recipients had anti-HBsAb titer ≥ 10 IU/L. Among these 113 patients, 84 had subsequent HBV serologies at day 15 and month 4, The authors presented the one-year results of the and 67 had also serology at month 12. At month 12, GOLIATH prospective randomised controlled trial 25% of patients had lost protective anti-HBsAb titers comparing transurethral resection of the prostate to (p < 0.001). The duration of protective anti-HBsAb GreenLight XPS for the treatment of men with titers was significantly longer when the initial titer non-neurogenic lower urinary tract symptoms due to was ≥ 100 IU/L versus < 100 IU/L (log-rank test p < prostate enlargement. The updated results at one year 0.0001). Protective titers at month 12 persisted in 93% show that transurethral resection of the prostate and of patients with initial titer ≥ 100 IU/L compared to GreenLight XPS remain equivalent, and confirm the 33% with 10-100IU/L titer (p < 0.0001). In contrast, therapeutic durability of both procedures. They also duration of protective titers did not differ according to reported one-year follow-up data from several the anti-HBV core antigen antibody status at baseline. functional questionnaires (OABq-SF, ICIQ-SF and IIEF-5) and objective assessments. Despite a high prevalence of protective anti-HBsAb titer at KT, the loss of protective immunity during the A total of 291 patients were enrolled at 29 sites in following year was considerable. This study illustrates nine European countries. Patients were randomised one of the mechanisms of post-transplant infections 1:1 to undergo GreenLight XPS or transurethral and this should be taken into account when looking resection of the prostate. The trial was designed to after post-transplant patients. evaluate the hypothesis that GreenLight XPS is non-inferior to transurethral resection of the prostate Source: Considerable decrease in antibodies on the International Prostate Symptom Score at six against hepatitis B surface antigen following months. Several objective parameters were assessed, kidney transplantation. Moal V, Motte A, including maximum urinary flow rate, post-void Vacher-Coponat H, Tamalet C, Berland Y, residual urine volume, prostate volume and prostate Colson P. specific antigen, in addition to functional J Clin Virol. 2015 Jul;68:32-6. Epub 2015 Apr 15. questionnaires and adverse events at each follow-up.

...transurethral resection of the prostate and GreenLight XPS remain equivalent, and confirm the therapeutic durability of both procedures

Predictors of graft recurrence of IgA nephropathy identified

The results showed that of the 291 enrolled patients 281 were randomised and 269 received treatment. Noninferiority of GreenLight XPS was maintained at 12 months. Maximum urinary flow rate, post-void residual urine volume, prostate volume and prostate specific antigen were not statistically different between the treatment arms at 12 months. The complication-free rate at one year was 84.6% after GreenLight XPS vs 80.5% after transurethral resection of the prostate. At 12 months four patients treated with GreenLight XPS and four who underwent transurethral resection of the prostate had unresolved urinary incontinence.

In this study the predictive value of three markers for IgAN recurrence were evaluated: the presence of galactose-deficient IgA1, IgG anti-IgA autoantibodies and IgA-soluble (s) CD89 complexes. These were analysed in 38 kidney transplant recipients with graft recurrence of IgA nephropathy and compared with 22 patients transplanted for IgAN but without recurrence and with 17 healthy controls.

The authors concluded that follow-up at one year demonstrated that photoselective vaporization of the prostate produced efficacy outcomes similar to those of transurethral resection of the prostate. The complication-free rates and overall re-intervention rates were comparable between the treatment groups.

Source: A European multicenter randomized noninferiority trial comparing 180 W GreenLight XPS laser vaporization and transurethral resection of the prostate for the treatment of benign prostatic obstruction: 12-month results of the GOLIATH study. Bachmann A, Tubaro A, Barber N, et al. J Urol. 2015 Feb;193(2):570-8. doi: 10.1016/j. juro.2014.09.001. Epub 2014 Sep 16.

Post transplantation loss of antibody immunity Immunisation against hepatitis B virus (HBV) in kidney transplantation (KT) candidates and recipients is recommended. If anti-HBV surface antigen antibody

IgA nephropathy (IgAN) is the most common primary glomerulonephritis and frequently leads to end-stage renal disease. However, disease recurrence after transplantation in the graft is a major risk.

Pre-transplantation galactose-deficient IgA1 serum levels were significantly higher in the recurrence compared with the no-recurrence or control groups. IgA-IgG complexes were significantly elevated in the recurrence group. Both the recurrence and norecurrence groups had increased values of IgA-sCD89 complexes compared with healthy controls, but values were significantly lower in patients with recurrence compared with no recurrence.

...this study suggests that galactosedeficient-IgA1, IgG autoantibodies, and IgA-sCD89 complexes are valuable biomarkers to predict disease recurrence, highlighting major pathogenic mechanisms in IgAN Areas under the receiver operating curve of the markers in pre-transplantation sera were 0.86 for galactose-deficient-IgA, 0.82 for IgA-IgG, and 0.78 for sCD89-IgA; all significant. Disease recurrence was associated with decreased serum galactose-deficient IgA1 and appearance of mesangial-galactosedeficient IgA1 deposits, whereas increased serum IgA-sCD89 complexes were associated with mesangial sCD89 deposits.

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk Thus, this study suggests that galactose-deficientIgA1, IgG autoantibodies, and IgA-sCD89 complexes are valuable biomarkers to predict disease recurrence, highlighting major pathogenic mechanisms in IgAN. This could be extremely useful in patients with IgA nephropathy under consideration for renal transplantation, especially live-donor transplantation.

Source: Recurrent IgA nephropathy is predicted by altered glycosylated IgA, autoantibodies and soluble CD89 complexes. Berthelot L, Robert T, Vuiblet V, Tabary T, Braconnier A, Dramé M, Toupance O, Rieu P, Monteiro RC, Touré F. Kidney Int. 2015 Jun 10 [Epub ahead of print]

Sobering results of renal autotransplantation Renal autotransplantation is an infrequently performed procedure but is suggested in every textbook as a measure of last resort in several clinical scenarios. It can be used for the management of complex ureteral disease, vascular anomalies, and chronic kidney pain. This paper reports the 27-year experience with this procedure in two centres (Oregon Health and Science University, Virginia Mason) in a retrospective observational study of 51 consecutive patients between 2007-2012. Demographics, indications, operative details, and follow up data were collected. Early (≤ 30 days) and late (> 30 days) complications were graded according to the Clavien-Dindo system. Factors associated with complications and pain recurrence were evaluated using a logistic regression model.

This series is significant in that it shows the high rate of pain indications for autotransplantation with a limited cure rate for this condition by this procedure 51 patients underwent 54 renal autotransplants, median follow-up 21.5 months. The most common indications were loin pain haematuria syndrome (LPHS)/ chronic kidney pain (31.5%), ureteral stricture (20.4%) and vascular anomalies (18.5%). Autotransplantation of a solitary kidney was performed in 5 patients. Laparoscopic nephrectomy was performed in 23.5% of cases. The median operative time was 402 minutes and the median length of stay was 6 days. No significant difference was found between preoperative and postoperative plasma creatinine (p = 0.74). Early high-grade complications (≥ Grade III-a) occurred in 14.8% of patients and 12.9% of patients experienced late complications of any grade. Two graft losses occurred. Longer cold ischemia time was associated with complications (p = 0.049). 35% of patients who underwent autotransplantation for chronic kidney pain had a recurrence, i.e. 65% of patients who underwent the procedure for pain had resolution of the pain at a median follow up of 13 months. No predictors of pain recurrence were identified. Cold ischemia time was the only predictor of postoperative complications. This series is significant in that it shows the high rate of pain indications for autotransplantation with a limited cure rate for this condition by this procedure. 3.7% of autotransplants are lost.

Source: Renal autotransplantation: 27-year experience at two Institutions. Cowan NG, Banerji JS, Johnston RB, Duty BD, Bakken B, Hedges JC, Kozlowski PM, Hefty TR, Barry JM. J Urol. 2015 Jun 5. [Epub ahead of print]

EAU EU-ACME Office

European Urology Today

June/July 2015


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

#esur-sbur15

Fostering collaboration and innovation in urological research The 11th World Congress on Urological Research will take place on 10-12 September in Nijmegen, the Netherlands. Hosted by the EAU Section of Urological Research (ESUR) and the Society for Basic Urologic Research (SBUR), the meeting presents the latest trends in urological research, including molecular diagnostic tools and predictive biomarkers, and tissue engineering. The prestigious Dominque Chopin Award will be presented for the 8th time during the congress as well. The World Congress seeks to encourage cooperation between younger and more experienced researchers. It is a prime opportunity for students and post-docs to approach possible mentors. It is also an opportunity for both sides of the Atlantic to enhance their ties and cooperate to carry out innovative research.

Technology cross-fertilisation can help progress all fields of urological research..

Prof. Jack Schalken Meeting Chair

The meeting also strives to highlight research contributions to basic, translational or clinical urological research. Since 2008, the Dominique Chopin Distinguished Award is presented to a researcher in the field of urology who has contributed significantly to high level urological research. This award is an example of the collaborative and cross-generation approach of the World Congress; it is awarded not only for the research itself, but the recipient must also contribute to the field by mentoring Ph.D. students and post-docs, securing grants, and establishing research networks.

other consortiums to identify new targets and improve conventional therapies for prostate cancer,” says Culig.

This year’s recipient, Professor Jack Schalken, meets all the requirements, and more. “The work of Professor Schalken in dysregulation of e-cadherin in prostate cancer provided a solid basis for future studies. It may lead to a better understanding of epithelial to mesenchymal transition during prostate cancer progression,” says Zoran Culig, ESUR Chair. Also, Schalken has made great contributions in the field of tumour markers. Particular highlights are his work on PCa3 and TMPRSS:ERG fusion.

Join the ESUR-SBUR World Congress on Urological Research, to take advantage of the extensive scientific programme and the collaborative environment. Nijmegen is easily accessible by train from Schiphol Airport Amsterdam and several other European cities.

PRIMA Schalken’s collaboration with younger urologists is also worth highlighting. As a project leader of PRIMA (Prostate Cancer Integrated Management Approach), he has helped provide a unique research platform for students and post-docs. And the groundwork of PRIMA “has helped

The work of this year’s Dominique Chopin Distinguished Award recipient has greatly contributed to put Nijmegen on the map, at the forefront of translational projects carried out by experienced researchers, urologists and residents. Nijmegen is a world-class centre of urological research, and Jack Schalken’s contribution to the establishment of one of the premier urology research departments in Europe will be highlighted during the meeting.

Prof. Jack Schalken Meeting Chair

Prof. Egbert Oosterwijk Meeting Vice-Chair

Prof. Zoran Culig ESUR Chair

Prof. Jill Macoska SBUR Chair

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

Dear Colleagues, Between 14-18 September, the EAU organises UrologyWeek 2015: A week packed with events and activities to bring urology closer to the general public. Throughout this week doctors, nurses, and patient organisations help raise awareness for urological conditions through lectures, tours and other events related to urology. This is a great opportunity for you and your organisation to bring information to a wider audience. UrologyWeek 2015 focusses on kidney, bladder, and prostate cancer. The week is only as successful as you make it! So we are looking forward to your participation by hosting and sharing events related to urology, engaging with the media, and bringing the conversation online. Share your pictures on Twitter with #urologyweek and show us how you are preparing for UrologyWeek 2015. Also, check the UrologyWeek website at www.urologyweek.org for updates and ideas on how to best plan and share your exciting urological event. The entire EAU team looks forward to seeing your UrologyWeek 2015 event on Twitter!

Step Up, Join the Campaign!

Show us how you promote UrologyWeek 2015! This issue of EUT contains a poster of Urology Week 2015. Use the poster to promote your event, and show the world how you and your team are getting ready for Urology Week 2015. Snap a picture with the poster, and tweet it mentioning

@uroweb and #urologyweek Prof. Christopher Chapple EAU Secretary General

www.urologyweek.org June/July 2015

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The importance of teaching oncourology Supported by the Education Office of the EAU in various educational formats By Prof. Marko Babjuk, Prof. Jeroen Van Moorselaar, Dr. Joan Palou Urological tumours comprise about 1/3 of all solid malignancies in the European adult population. Thanks to its increasing incidence prostate cancer is the most frequent malignancy in men. Also other urological tumours such as renal cancer or bladder cancer have a high incidence and are in the top 10 of solid tumours. There is no doubt that oncourology is one of the most important subspecialities in urology and equally important for several other participating specialists, such as the medical and radiation oncologists.

Thanks to enormous research activities we are facing phenomenal discoveries in diagnostic approaches, surgical and particularly medical treatment strategies. As a logic consequence treatment principles and algorithms are changing. This is a fascinating era in which we live and work, which however holds several dangers. Indeed, we must bring significant effort to learn about all new developments, and to play a leading role in translating them to routine clinical practice and continue with research activities.

• Moreover, selected urological specialists must concentrate on new approaches, their development and implementation in daily practice. To accomplish all these tasks, the EAU Education Office organises a broad spectrum of educational activities in oncourology: • Residents can gain extensive knowledge about oncourology during EUREP

• The Education Office organises masterclasses, which concentrate on specific topics (laser treatment, medical treatment in oncourology, etc.) • To support the surgical skills of urologists, the office offers several HOT (hands-on training) programmes • To bring knowledge to a broad spectrum of participants, the internet e-learning courses (e.g. prostate cancer) are available on the EAU website.

There is no doubt, that teaching is of crucial importance in this process. There are some specific tasks which should be fulfilled:

Urologists have a leading role in the treatment of • It is of critical importance for all practising urological tumours. In contrast to general surgeons, urologists to maintain a general overview of urologists always have been familiar to not only modern diagnostic and treatment options and surgical methods, but also to several diagnostic and algorithms in oncourology. At least theoretical therapeutic approaches, including local chemotherapy, knowledge should also cover general areas such systemic treatments such as androgen deprivation and as systemic treatment or radiation therapy. • Urologists, including young urologists, must be various follow-up strategies. This is of particular well-trained in new, particularly less invasive importance as urological tumours have specific needs methods such as urologic endoscopy, laparoscopy or and their effective diagnosis, treatment and follow-up robotic urology, to be able to gain adequate skills. requires thorough and dedicated knowledge.

European School of Urology Teaching activities 2015 August 28-29 29-30

6th ESU – ASU teaching course at the time of the Annual meeting of the Vietnam UroNephrology Association, Nha Trang (VN) Chinese European Urology Education Programme, Shanghai (CN)

September

Board members of the European School of Urology

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)

October 4

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

November 4-5 7 10-14 Prof. M. Babjuk

Prof. J. Van Moorselaar

12

Dr. J. Palou

26-28

2nd ESU Masterclass on Lasers in urology, in collaboration with the EAU Section of UroTechnology (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)

February 2016 2-5 13-16

www.esulasers15.org

Hands-on training skills programme on Laparoscopy and Endourology, Caceres (ES) European Urology Forum 2015 – Challenge the experts, Davos (CH)

March 2016 11-15

2nd ESU Masterclass on Lasers in urology

ESU Courses, HOT, Education and Innovation at the time of the 31st Annual EAU Congress, Munich (DE)

June/July 2016 26–2 July ESU – Weill Cornell Masterclass in General urology, Salzburg (AT)

In collaboration with the EAU Section of Technology (ESUT)

ESU Organised courses at National Urological Society meetings September

4-5 November 2015, Barcelona, Spain

18 20 EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

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)

October 22 23 23

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

Application deadline: 1 September 2015

2 15-16

ESU organised course on Endourology at the time of the national congress of the Egyptian Association of Urology, Cairo (EG) ESU organised course on Upper urinary tract tumours at the time of the national congress of the Georgian Association of Urology, Tbilisi (GE)

Contact: esu@uroweb.org ESU courses are accredited within the

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programme by the EBU with 1 credit per hour

June/July 2015


Who’s Who in the Board of the European School of Urology Responding to the needs of the EAU members, offering diverse education opportunities By Joel Vega

urology component of the ESU’s many courses: the standalone meetings such as EUREP, courses at national association meetings and the Masterclasses.

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.

Q: What are your goals for the European School of Urology?

In this instalment in the series, we have conducted a Q&A with ESU Board Member Prof. Marcus Drake regarding his opinions and views on (online) education and challenges in urology, in general.

Prof. Marcus Drake, Board Member European School of Urology

Q: Can you tell us a bit more about your background, specialty and experience? I trained in preclinical medicine at the University of Cambridge, and clinical medicine at the University of Oxford. During those happy years, I spent much time on the river doing the sport for which both Universities are famous, rowing, and enjoyed successful racing at university level. I became a resident in Urology in 1996 and quickly went in to research, doing my thesis looking at human bladder in spinal cord injury with Professor Alison Brading at Oxford. I stayed in an academic pathway after submitting my thesis, moving to the University of Newcastle as Clinical Lecturer. I gained experience in functional urology and neuro-urology, and had clinical attachments in Oslo and Lucknow to gain experience in neuromodulation and urethroplasty. I became Consultant Urologist at the Bristol Urological Institute (BUI) in 2005, and Senior Lecturer in Urology at the University of Bristol in 2010.

locations around the world, and also established the BUI Expert Urodynamics course. My academic interests are in functional urology and lower urinary tract physiology. I have set up a multicentre study of urodynamics in men considering prostate surgery, the UPSTREAM study, funded by the UK National Institute of Health Research. With the University of Pittsburgh, I have been awarded a 5 year grant by the US National Institutes of Health to look at the effects of PDE5 inhibitors on the voiding reflex. I am also running an RCT of melatonin for nocturia in multiple sclerosis. I was co-ordinating investigator for the NEPTUNE, BESIDE and EUROPA studies evaluating combination therapies in LUTS.

I participate in the EAU Guidelines panel for Male LUTS, and the Board of the European Society of Female and Functional Urology (ESFFU). I am chairman of the International Continence Society Standardisation Steering Committee, which has recently started to review the classic My interests are in urodynamics, neuro-urology, reconstruction and LUTS. The BUI is famous for its standardisation paper on lower urinary tract function and dysfunction published by Paul Abrams urodynamics course, and I have contributed to the Bristol Certificate in Urodynamics course held in many and colleagues in 2002.

Q: What is your role in the ESU board? I have a particular interest in the online courses and the social media. The online courses aim to deliver up-to-date fundamentals of key areas in urology, in an easy to use and approachable format, giving documented proof of completion to serve as evidence of having understood the content. These are an effective route to increasing knowledge in key areas, which can be done at times to suit the participant, either completing the whole course in one go, or returning at convenient intervals. We are increasing the number of courses steadily, and diverging to cover the guidelines, giving a new way which can really help with learning. They are available on the ESU page, uroweb.org/education. I run the ESU’s Twitter account, @UrowebESU, and delegates at EUREP are used to me going round with a good camera to capture what a wonderful experience it is to spend a sociable week with contemporaries getting intensive training from the expert faculty in the beautiful city of Prague. I also edit the educational platform Male LUTS/BPE (malelutsbpe.com). Finally, I help with the functional

I would love to see participation of more current and future experts in developing the online courses and delivering the teaching. The future experts are sometimes reluctant to think of themselves as teachers, but they will always be welcome and encouraged. I hope to see continuing increase in the community of people engaging with ESU activity through all the modalities we offer, enjoying the courses, completing the online opportunities and following @UrowebESU. Of key interest for me is to see recognition of the importance of functional urology more widely by people working in our profession. Functional urology is a fascinating area to work in, but is often pushed behind other areas of urology, despite the huge importance to patients. Q: How do you see the future of education and urology? We need to anticipate that the progress of therapy will accelerate, requiring increasing responsiveness in content development. This may well extend to non-traditional areas, that are increasingly needed in modern healthcare, including safety, patient protection, technology and data handling. We need to be aware of new introductions of modalities of delivering education. Nonetheless, we need to maintain contact and relevance with our main users, the EAU membership, and responding to their requests in our upcoming initiatives. Surgeons are often late adopters of new methods, so we need to ensure our future delivery of education maintains a focus on quality and content as the topline requirement, offering this with a range of modalities and made as convenient and accessible as possible.

www.esufemale15.org

www.esudavos16.org

8th ESU Masterclass on Female and functional reconstructive urology

European Urology Forum 2016

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

Challenge the experts

26-28 November 2015, Berlin, Germany

13-16 February 2016, Davos, Switzerland 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

Application deadline: 1 October 2015

June/July 2015

European Urology Today

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A review committee will screen all entries and an independent jury will select the best paper based on quality and merits. How to apply Inquiries and correspondence should be addressed to the EAU Central Office, at m.smink@uroweb.org, with “EAU Prostate Cancer Research Award 2016” in the subject line of your e-mail. The award is supported by an unrestricted educational grant of € 5,000 from the FRITZ H. SCHRÖDER FOUNDATION. www.fhsfoundation.eu

tumour

Join this competitive search and help boost the quality of prostate cancer research in Europe!

EAU Prostate Cancer Research Award 2016

seminal vesicles

rectum

Combining research and surgery

bladder

ly p Ap ow! n

Rules and Eligibility • The topic of the paper should deal with clinical or experimental prostate cancer research. • The paper must have been published or accepted for publication in a highranking international journal between 1 July 2014 and 30 June 2015, and submitted in the English language. • Applicants must be a member of the EAU. • The submitting author must be the first author of the paper or, by exception, the corresponding senior last author. • Applicants should only submit one paper. • Deadline for submission by e-mail is 1 November 2015.

Fig. 4: A T4 prostate tumour which has spread to the bladder neck, urinary sphincter, and rectum.

A clinical visit in Paris looks into flexible ureteroscopy practices

dr.emresener@ gmail.com

The influence of Prof. Traxer on the use or role of already-on-the-market and forthcoming devices is indisputable. To be a part of the team of the man who defines the future of endourology is priceless. “To achieve success in an operation, you should have proper equipment,” Prof. Traxer once said during an intervention.

Practically, everything during my practical training starts with the phrase: “Avez-vous une calcul? Montrez-nous les radios.” (“Do you have a stone? Show us the x-ray films.”)

European Urological Scholarship Programme Office

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European Urology Today

Knowing the benefits, disadvantages, and the limitations of different endoscopes from major companies helps in choosing the appropriate endoscope for each patient. It may even direct physicians to the appropriate investment for flexible ureteroscopes. Supportive environment I felt at home at Tenon with the support of Dr. Jonathan Cloutier and Dr. Luca Villa, both fellows of Prof. Traxer. They have been working at Tenon University Hospital for a year, and they have welcomed and helped me adapt to the work environment. One of the key points in success is the ability to keep up with technological developments. In Tenon, I saw and experienced the latest developments in ureteroscopic procedures. The wide usage of Narrow Band Imaging and SPIES technology makes Tenon University Hospital a referral center for the conservative management of upper urinary tract tumor patients from all over Europe.

of the day is generally unforeseen. The long working hours are well spent due to the comaraderie in our “stone team” – as Prof. Traxer calls us. The collaboration and team spirit I shared with many young urologists from various countries were memorable. Comprehensive training The devil is in the detail. I could have never learned from anywhere else all the useful tips and tricks I learned from Prof. Traxer. The surgical table set-up is unique and serves as an extra assistant. I realised that even small details make a huge difference in terms of the operator’s comfort. Prof. Traxer patiently explains why and how things should be arranged, the anatomic and pathophysiologic features of patients, and the specific ureteroscopic maneuvers and device characteristics. During the out-patient clinic hours, I was also fortunate to attend every patient consultation, to discuss and learn the details of metabolic evaluation, surgery indications, and the follow-up protocols. Ureteroscopy workshops take place almost every week at Tenon. Before each workshop, the cases are presented by the “stone team” members and lectures are given by professors, coming from all over the world, whom I am very honored to have met.

I would like to thank to Carole Benkiewicz, Prof. Traxer’s secretary, who helped me a lot with the Moreover, with Tenon’s wide range of new equipment arrangements and provided assistance during my stay such as the newly developed digital ureteroscopes and Jérémie Berg, who is not only responsable for all combined with the expertise of Prof. Traxer’s the technical equipment in the OR, but also ensures experience and skills, makes Tenon one of the most their proper functioning and the smooth running of preferred centers for complex urinary tract stone all OR activities, and who never says “no” to any treatment. request that pushes the limits of medical training.

rectum

The main reason that made these three months a remarkable experience was the friendliness shown by Prof. Traxer, an exemplary doctor who not only pursues innovation but also shares his knowledge and expertise. Learning the key aspects and benefitting from the expertise of a leading author in his field on endourology, and having the opportunity to undergo hands-on training under his surpervision, are priceless.

The basic science laboratory established in Tenon helps to integrate every accepted concept on flexible ureteroscopes and lasers. All the endourological equipment from different companies are tested to find the best combinations and define limitations.

The state-of-the art operating theatre is very well structured and equipped with all the new digital and conventional fiberoptic endoscopes and imaging devices. Prof. Traxer has a wide spectrum of digital and fibrooptic flexible ureteroscopes and all the other consumable materials from different companies such as access sheaths, guidewires etc.

bladder neck

Paris, with its renowned elegance and city lights, eludes description, in the same way that my experience at the Tenon University Hospital under the mentorship of Prof. Olivier Traxer and his team, has made an indelible influence on my professional career. With a grant from the European Urology Scholarship Programme (EUSP) my clinical visit lasted for three months until February 2015.

With great ambition, comes great results. And at the Tenon University Hospital there are many aspects that makes it a unique institution. Here are some:

urinary sphincter

My journey begun in November 2014 from Istanbul, the city where two continents meet, to Paris, the city that never sleeps.

Expert center Tenon University Hospital is a well-known facility for stone disease management and upper urinary tract TCC which earned the hospital international attention. Workshops and courses take place throughout the year, which contributes to knowledge and technical issues and improves our understanding of stone disease.

tumour

Dr. Tarik Emre Sener Marmara University and Research Hospital Urology Dept. Istanbul (TR)

Emre Sener & Prof. Olivier Traxer

The weekly schedule at Tenon consists of at least two days at the operating theatre, a day in the out-patient clinic with Prof. Traxer, with the remaining time usually spent in the basic science laboratory. A usual day at Tenon starts at 8:00 am but acitivities toward the end

Finally, I would like to thank to the European Association of Urology for providing such a great opportunity to access unique medical expertise and train under the mentorship of an inspiring professor. June/July 2015

during a digital rectal examination or seen on a scan.

pubic bone

The award will be handed over at the 31st Annual EAU Congress in Munich, 11-15 March 2016 during the Opening Ceremony.

prostate

Patient Information - Prostate Cancer

Fig. 3: A T3 prostate tumour which has spread to the seminal vesicles.

With the goal to encourage innovative, high-quality research in prostate cancer, the EAU has launched the EAU Prostate Cancer Research Award. Supported by an unrestricted educational grant from the Fritz H. Schröder Foundation, an expert jury will select the best paper dealing with clinical or experimental studies in prostate cancer and published or accepted by a renowned international scientific journal.


Patient Information

bladder

seminal vesicles

rectum

http://patients.uroweb.org

Fig. 2: A T2 prostate tumour is limited to the prostate.

tumour in two prostate lobes

Illustrations of the different stages of prostate cancer

pubic bone

tumour

prostate

Fig. 1: A T1 prostate tumour is too small to be felt

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European Urology Today

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awareness of urological

and patient groups to create

practitioners, urology nurses

urological societies, urology

brings together national

Association of Urology, which

initiative of the European

Urology Week is an

14-18 sEptEmbEr


June/July 2015

European Urology Today

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European Association of Urology

#urologyweek

www.urologyweek.org

For public awareness of urological conditions

Join the Campaign!

Step Up,

general public.

conditions among the


bladder

during a digital rectal examination or seen on a scan.

pubic bone

tumour prostate

Fig. 3: A T3 prostate tumour which has spread to the seminal vesicles.

seminal vesicles

rectum

tumour

bladder neck

urinary sphincter

Fig. 4: A T4 prostate tumour which has spread to the bladder neck, urinary sphincter, and rectum.

Patient Information - Prostate Cancer

rectum

June/July 2015

European Urology Today

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International Relations Office: Expanding the EAU’s reach Direct support boosts ties with Japan, China, Australia, Russia and Eastern Europe By Joel Vega

active involvement of the EAU through the International Relations Office.

Although perhaps not well known to many, the EAU’s International Office has been steadily boosting its alliances and collaborative ties in recent months in many countries not only in Europe but also in other continents.

“Our aim is to provide good examples and expertise, encourage future generations to integrate with international standards and explore new developments,” said the Wu Jieping Medical Foundation, organiser of the three-day 4th This quiet but highly focused diplomacy is shown in International Forum on Frontiers in Urology (IFFU) the International Relations Office’s recent activities in held from April 24 to 26. The foundation is named the past six months with sustained efforts that provide after Prof. Wu Jieping, known as the founding father direct support in countries such as China, Japan, of modern Chinese urology and credited with Russia, Serbia and Romania, to name a few. From establishing the Chinese Urological Association (CUA) expanded partnerships with national urological and the Chinese Journal of Urology. societies in Asia to direct participation in scientific courses and workshops in Eastern European The EAU supported the event with its participation in countries, representatives of the International two masterclasses on functional urology and Relations Office have been pursuing a hectic schedule urolithiasis, both held on April 24. EAU Secretary to fulfil the EAU’s mandate to foster closer alliances. General Prof. Christopher Chapple and Profs. Frans Debruyne and Anup Patel took part by giving lectures Below are summaries of the recent developments in the masterclasses. Chapple co-moderated the involving the EAU and other urological organisations: functional urology masterclass together with Profs. Limin Liao, Dongwen Wang and Yong Yang. Chapple Training opportunities Down Under discussed trends and prospects in continence issues, More collaborative projects and comprehensive while Liao lectured on advances on neuro-urology. exchange training programmes are among the key goals the Urological Society of Australia and New The foundation is also organising the Chinese Zealand (USANZ) and the EAU would pursue in the European Urology Education Programme (CEUEP) coming years in a bid to boost urological expertise. from August 30 to 31, 2015 in Shanghai, with the participation of three European School of Urology The mutual aim to expand and build on current (ESU) faculty members. The CEUEP will take place projects were discussed during a meeting with the before the Asian Congress of Urology (ACU) meeting USANZ board held last April 13 in Adelaide, Australia. from September 3 to 6, 2015 in Shanghai, a joint Present at the meeting were USANZ President David meeting between the CUA and the Urological Winkle, President-Elect Mark Frydenberg, USANZ CEO Association of Asia (UAA). The meeting’s first day will Michael Nugara, and EAU Secretary General include an EAU-CUA Summit meeting with speakers Christopher Chapple. from both organisations. “Both organisations are not only committed to further expanding existing relations but also aim to build on what has been achieved in recent years by providing training to urologists from Australia, New Zealand and to their European counterparts,” both organisations said after the meeting. Winkle and Chapple cited the positive feedback from trainees who participated in the annual residents training events such as the European Urology Residents Education Programme (EUREP), and the counterpart programme organised by USANZ. The EAU Guidelines are also widely appreciated by urologists in Australia and New Zealand, according to Winkle, who added that USANZ intends to formally accept and accredit the EAU Guidelines. Chapple highlighted the EAU’s aim to support educational and training goals during USANZ events and meetings, for instance, by organising an EAU session where best practices in Europe are examined and discussed. He also mentioned that the EAU has boosted its online activities with the new EAU website and the UroSource facility, as well as online-based education. In the future, online-based training on minimally invasive techniques will be expanded to include robot-assisted technology.

Russia: Andrology congress The EAU participated in the 2nd Russian-Asian Uro-Andrology Congress held last May in Sochi, Russia, with a well-attended state-of-the-art lecture on male fertility by Prof. Wolfgang Weidner.

(IT) as faculty members, the course presented lectures and case discussions on functional outcomes, surgical techniques, assessment of tissue damage, managing complications and trouble-shooting strategies.

Weidner, chairman of the EAU Section of Andrological Urology (ESAU) gave a comprehensive lecture on “New concepts of sperm retrieval: State-of-the-Art in 2015.” The congress was held under the auspices of the Professional Association of Andrologists of Russia (PAAR) during its 10th Anniversary Congress from May 27 to 30, with the collaboration of the Russian Society of Urology (RSU). Over 1,000 urologists and specialists took part in the four-day event. Aside from urologists from the host country and former Soviet Union republics, participants came from India, South Korea, China, Mongolia and Egypt.

“The programme was comprehensive, diverse and interactive. The ESU faculty gave remarkable presentations in robotic surgery and reconstructive urology and conveyed clear insights and tips,” said Assoc. Prof. Dragoslav Basic of the Serbian Urological Association.

Weidner, widely recognised for his expertise in male fertility issues, discussed the challenges of sperm retrieval techniques in men with testicular azoospermia, and examined the predictive factors for techniques such as testicular sperm extraction (TESE), which have dramatically evolved in recent years. Young European urologists join their counterparts in Beijing, China

Japan: Stronger academic links The EAU and the Japan Urological Association (JUA) have intensified their collaboration with the recent academic exchange visits of young Japanese urologists and the wider participation of Japanese experts in the recent 30th EAU Anniversary Congress in Madrid. This renewed partnership is reflected in the call for two European urologists to participate in an exchange visit programme that will coincide with the 104th Annual JUA Meeting to be held in Sendai, Japan from April 23 to 26, 2016 During the Madrid congress, JUA is one of the most active Asian participants with 204 Japanese urologists attending the congress and the submission of 362 abstracts. With 121 abstracts making it to the final cut, Japan had a 33% acceptance rate, surpassing the average 30% overall acceptance rate.

Prof. Christopher Chapple and Adjunct SecretaryGeneral Prof. Hein Van Poppel lectured during the 103rd Annual JUA Meeting held in Kanazawa, Japan from April 18 to 21. Chapple gave the EAU Lecture on EAU Sec. Gen. Christopher Chapple gives the EAU Lecture at the the topic of underactive bladder and chaired a session USANZ Congress on functional urology. Van Poppel tackled advanced prostate cancer (PCa) in a session on uro-oncology and also co-chaired another meeting on PCa treatment. USANZ held its 68th Annual Scientific Meeting in Adelaide from April 11 to 14, with Chapple giving the In Madrid, the JUA and EAU also confirmed their EAU Lecture during the session “The Future of Urology 2025: Where Will We Be? ” Chapple discussed commitment to boost the JUA-EAU Academic Exchange Programme. The first Japanese participants, treatment strategies in stress urinary incontinence in his lecture “The management of pelvic organ prolapse Drs. Koji Mitsuzuka and Ario Takeuchi visited two hospitals in Madrid. The doctors ended their visit by and stress urinary incontinence in 2025,” which participating in the EAU Anniversary Congress where provided an overview of medical and reconstructive they had the opportunity to link up with opinion treatment options. leaders in European urology. China: High attendance in masterclasses “The JUA appreciates the opportunity for young Two well-attended masterclasses in functional urologists to attend the residents programme and it is urology were recently held in Beijing, China with the hoped that this will continue in the future. And certainly, the exchange programme is beneficial to EAU International Relations Office our mutual goals,” said one of the JUA members. June/July 2015

Board members of the EAU and Japan Urological Association during the EAU Congress in Madrid

“The congress and the session on male fertility was well received not only by delegates from Russia but also those who came from all over Asia, especially participants from China, South Korea and former countries of the Soviet Union. It was a wonderful opportunity to attend this international meeting and represent the EAU,” said Weidner.

“The discussions were not only very constructive and educational, but we saw the participation of almost all the Serbian urologists. The EAU’s support is crucial for the Congress, not only for our training goals but also for the profiling of our urological society as part of the European urological family,” added Basic as he thanked the EAU and the ESU for successfully organising the course. Romania: New course in BCa management From April 1 to 3, the Department of Urology of the Victor Babes University of Medicine and Pharmacy in Timisoara, Romania held what is considered as the first course in Radical Cystectomy and Urinary Diversion Techniques.

Prof. Peter A. Scheplev, President of PAAR and Vice President of the Russian Society of Urology, welcomed the close collaboration with the EAU and expressed his hopes for similar joint activities in the future. Serbia: ESU course Serbian urologists recently participated in a comprehensive, full-day course on reconstructive urology that tackled innovative surgical techniques, challenging cases, diagnosis and treatment strategies in urethral trauma, female urethra damage and urogenital fistulae, among other topics.

Organisers of the Serbian urology congress in Belgrade

Held on April 18 in Belgrade during the last day of the 1st Congress of the Serbian Association of Urology, the course is part of the continuing efforts of the EAU Education Office to extend training to national urological associations across Europe. Organised with the European School of Urology (ESU), the day-long course was well-attended with participants interacting closely with the ESU faculty. Chaired by Assoc. Prof. George Kasyan (RU) with Prof. Massimo Lazzeri (IT) and Dr. Nicolomaria Buffi

Trainees practise their skills during a laparoscopy course in Timisoara, Romania

“To our knowledge this is the first course of its kind in Europe, and is similar to courses currently offered to our colleagues in Mansoura, Egypt,” said the organisers, who added that the course attracted a lot of participants. The organisers received strong EAU support with EAU Adjunct Secretary General for Education, Prof. Hein Van Poppel’s participation as faculty member. As well as Van Poppel, Department Chairman Prof. Viorel Bucuras and Course Director Dr. Alin Cumpanas invited two other renowned surgeons as faculty members, Dr. Nikolaus Vesa (DE) and Assoc. Prof. Gabriel Gluck (RO). “Our basic aim was to improve theoretical knowledge and for participants to gain practical skills in one of the toughest urological procedures. Moreover, incidence of malignant bladder disease is rising and radical cystectomy offers the best chance to reduce recurrence,” said Cumpanas. Trainees lauded the three-day compact course for its thorough approach and the dedicated supervision of the mentors. The participants also had the chance to interact with the surgeons during and after the live surgeries and benefited from their expertise. European Urology Today

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Future trends in ureteroscopy ESUT Expert Meeting on interventional stone treatment in Davos Prof. Thorsten Bach Department of Urology Asklepios Kliniken Hamburg-Harburg (DE) t.bach@ asklepios.com

Prof. Dr. Thomas Knoll Klinikum SindelfingenBöblingen Dept. of Urology Sindelfingen (DE) t.knoll@klinikverbundsuedwest.de

Intraoperative fluoroscopy plays an important role during URS. Thus, the use of either high-fidelity urological OR tables or C-Arms with the latest generation of flat screen detectors should be the future standard of intraoperative imaging, as stated by Hauke Prenzel from Siemens. Flat-detector X-ray imaging offers up to 25% larger coverage of the urinary tract than standard image intensifiers, providing improved differentiation on anatomical structures and decreases the need for intraoperative movements of the C-arm due to larger field of vision. Technical advances Due to the introduction of digital image processing, flexible URS has made a major step in terms of intraoperative visibility. Providing not only excellent views of the upper urinary tract (Photo 1), but also enabling the surgeon to use digital processing techniques like NBI or SPIES to improve contrasts and enhance detection of flat lesion and urothelial tumours within the collecting system, as clearly shown by Guido Gusti (IT).

Ureteroscopy has become the workhorse in urolithiasis showing a clear trend of replacing SWL as first option. Therefore, future trends in ureteroscopy, including imaging, instrument design and development of tools, facilitating stone extraction and disintegration, took the centre stage during the ESUT Expert Meeting in Davos on interventional stone treatment held last February 7 this year and organised by Prof. Jens Rassweiler (DE).

Regarding stone fragmentation, H.O. Teichmann from Lisa Laser showed stunning videos of high-speed photography of HO:YAG stone fragmentation, proving how Holmium laser radiation is breaking up the stone by photo-thermal effect. This means that the laser radiation is absorbed by residual water within the stone, creating a vapour pressure and breaking up the stone from the inside (Photo 2).

"Due to the introduction of digital image processing, flexible URS has made a major step in terms of intraoperative visibility." Another important aspect of laser stone disintegration has been discussed by S. Piesche (DE). He showed his data on laser stone disintegration and proposed high-power laser disintegration with very high frequency to transport more energy per time slot, if stone dusting is the aspired goal.

“Today, URS is more than just pulling out small stones,” said Rassweiler, ESUT chairman, as he stressed out the need for optimising performance of scopes and tools, to improve surgical outcome of what has become the new first-line treatment in interventional stone treatment in the majority of urological departments. EAU Section of Uro-Technology (ESUT)

Photo 2: Laser effect on stones. Ho:YAG lithotripsy (Courtesy of H. Teichmann)

Photo 1: Renal stone in digital ureteroscopy (Courtesy of G. Gusti)

Durability Durability is still a major issue in the use of flexible ureteroscopes. L. Ostermann (IE) shared a first view on a quasi single-use flexible system. In this system a combination of a flexible, single-use access sheath, with 180° flexibility and a re-sterilisable camera system offers reduced repair and replacement cost and may open the door towards single-use instruments even in uretersocopy. Finally, Remzi Saglam (TR) presented the history of developing a robot-assisted platform for ureteroscopy, introducing the Avicenna RobofleX System (Photo 3), which allows the performance of a console-operated flexible ureteroscopy with improved performance of more than 440° scope rotation, more precise deflection by direct conversion of deflection impulse to the tip. Besides enhanced steering properties, the ergonomic strain on the surgeon can be reduced noticeably, which may lead to improved surgical outcomes in the long run.

Another less expensive method of stone disintegration data on pneumatic lithotripsy was presented by W. Merkle from EMS. Small calibre rigid probes with 2.4 to 9.6 French are available for mechanical stone breakage. This is independent of stone composition and can be operated with high efficacy and safety. Although cost-effective, the push-back of the stone and the diameter of the probe limit usage in rigid Photo 3: RobofleX System, steering console endoscopy. (Courtesy of R. Saglam)

EULIS participates in panel on interdisciplinary communication What does the urologist asks the nephrologist and vice versa? Dr. Noor Buchholz SVMC & U-merge Ltd. Dubai (UAE) & London (UK)

noor.buchholz@ gmail.com

Prof. Giovanni Gambaro Nephrology Division, Columbus-Gemelli University Hospital, Rome (IT) giovanni.gambaro@ rm.unicatt.it Nephrologists and urologists have been working closely for a very long time. Yet, too often there seems to be a rivalry, almost a competition, as can be seen in other settings involving physicians and surgeons. Expectedly, given the different approaches to disease, the views of these distinct specialties of the worldand even their “dialect”- differ. This poses a barrier between the two specialties that often care for the same patients, the same organ, and the same pathophysiologies. This applies also to stone disease, which is often complex and caused by underlying co-morbidities that cannot be tackled by blasting the stone alone. Conveniently though for the urologists, developments EAU Section of Urolithiasis (EULIS)

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European Urology Today

in stone blasting technologies have made treatment very smooth and easy, leading to a neglect of the diagnosis of underlying causes. On the other hand, nephrologists show only a limited interest in stone disease amongst all the other renal pathologies to deal with.

Surveys of all kinds as published on their website is 24.8%. The low response rate may have been confounded by invalid email addresses, but it may also reflect a relatively low interest in complex stone disease although these emails have been targeted at delegates from former stone conferences.

A significant number of EULIS board members participated in the Consensus Conference for the Metabolic Diagnosis and Medical Prevention of Calcium Nephrolithiasis and its Systemic Manifestations held this year from March 26 to 28 in Rome, Italy.

Besides some demographic information, the questionnaire consisted mainly of 20 clinical scenarios from within the overlapping areas mentioned above. The findings of this questionnaire were presented to the full consensus panel and a number of areas of major discrepancies between urologists and

An interdisciplinary consensus working group was formed and chaired by N. Buchholz (urologist) in collaboration with E. Croppi (nephrologist), K. Sarica (urologist), A. Trinchieri (urologist) and C. Vitale (nephrologist). This working group was tasked to address the questions “What does the Urologist ask the Nephrologist?” and “What does the Nephrologist ask the Urologist?” Often, the question is also not “what to ask” but “when to ask.” When should be the right time in the course of a disease to involve the other specialty? Areas of overlap related to stone disease where cooperation may be required could be renal function, urinary findings such as haematuria and proteinuria, kidney scarring, metabolic stone disease, surgery on single or impaired kidneys, treatment of urinary tract infections, obstruction and urinary tract malformations. The working group was not aware of any guidelines for urologists or nephrologists specifically addressing points of each other’s involvement. There are guidelines for General Practitioners with regard to chronic kidney disease. However, the few studies in the literature show a poor implementation, which we may assume to be true for specialists as well.

nephrologists were identified. The detailed results will be published shortly. The working group then developed a consensus statement in closed session which was presented to the full panel and approved. (See box) This statement together with the results from the survey will form the basis for future work into developing guidelines, communication tools and promoting interdisciplinary collaboration.

Consensus Statement I) Often, Nephrology and Urology are alternatives rather than complimentary. There is no clear definition of roles in the nonsurgical stone field. There is a need to expand the overall view of the whole stone field and for cooperation between the two specialities. II) Often, the General Practitioner is the first point of contact for stone patients. The GP has a crucial role in triaging patients to urology or nephrology. The GP has a crucial role in excluding and treating in the follow-up underlying diseases associated with stone disease. III) a. Collaboration can be enhanced on a local level by Multidisciplinary Stone Meetings (MDT) and clear local protocols. b. There is a need for skills development including metabolic stone disease on all levels from joint local workshops to international meetings.

c. There is a need to raise awareness for stone disease in general. This can be promoted by cross-talk sessions in each other’s meetings on all levels. d. Guidelines need to be developed to define areas of combined and complementary stone management. A score system could aid in decision-making. e. Stone cross-talks and MDTs could be the driver for other joint uro-nephrological collaborations (i.e. chronic kidney disease after renal cancer surgery, malformations, UTI). This would promote joint continuity of care to the benefit of the patients. f. It would be useful to adapt and expand the joint guidelines and score tools for the use of GPs. g. Joint research into stone disease will further promote cooperation, enhance the knowledge base and lead to a better understanding of stone disease as such.

Prior to the conference, the organisers sent out an email survey to 523 addresses and got back 14.5% responses. The average response rate to Monkey June/July 2015


American Tour 2015 Academic Exchange Programme Memorable experience during exchange programme in the US Dr. Francois Audenet Hôpital Européen Georges Pompidou Dept. of Urology Paris (FR)

patient, partial nephrectomy of a centrally located tumour, PCNL of a complete staghorn calculi and transurethral resection of the bladder). Simultaneously, we discussed the cases and procedures with the surgeons and discovered similarities as well as differences in urological care between the US and our institutions.

francois.audenet@ gmail.com

Just a few months ago the department of urology moved to the brand new Clements Hospital, thanks to generous donations, as it is often the case in the US. Since medical doctors were involved in the planning one of the major advantages is a well-organized layout and system of pre-op, operation and recovery rooms equipped with the latest technology dedicated to high-class urological care. More surprisingly, we had an art tour in the hospital as a certain amount of the budget had been dedicated to the hospital´s art projects.

Dr. Jakub Dobruch European Health Centre Otwock Dept. of Urology Otwock (PL)

kubadobr@wp.pl

Dr. Tobias Maurer Klinikum rechts der Isar der Technischen Universität München Urologische Klinik und Poliklinik München (DE) t.maurer@lrz.tum.de The EAU/AUA Academic Exchange Programme is one of the many prominent activities provided by the European Association of Urology. We felt honoured and privileged when awarded with this scholarship that incorporates a tour among American institutions accompanied with participation in the 110th AUA annual meeting.

Additionally, several scientific presentations were scheduled during our visit in Dallas with faculty covering different urological topics (e.g. on advances in targeting the androgen receptor, sexual development and vaginoplasty repair, study on the search for septic shock predicting factors in obstructive pyelonephritis or MRI-TRUS fusion biopsy). As part of these lectures we also had the opportunity to present our research and introduce our institutions. We had also the pleasure to be introduced to the “Old Wild West” with a guided tour through the Amon Carter Museum displaying one of the best selections of art paintings depicting the life during the first settlements. A visit to the Winspear Opera House where we enjoyed the musical “Newsies” completed our stay. In general, the faculty at UT Southwestern showed great efforts to make it a memorable and rewarding visit for us.

After this short, but intense stay in Dallas, we moved on to Florida to visit the Urology Division of University of Miami hospital led by Prof. Dipen Parekh and his Three academic centres (namely, UT Southwestern team. In the institution a strong emphasis lays on Medical Center in Dallas, University of Miami Miller robotic surgery with six robotic systems currently in School of Medicine as well as Wake Forest School of use – mainly for prostate and renal cancers. After a Medicine in Winston-Salem) had been selected as hosts lecture on the current role of robotic radical offering an intensive scientific and cultural programme. cystectomy we could observe challenging cases of partial nephrectomies and prostatectomies during The first centre we visited was the UT Southwestern in the next two days as well as discuss differences in treatment concepts when compared to our Dallas, Texas, where we experienced a very warm institutions. Although the major management tenets welcome by chairman Prof. Claus Roehrborn and his faculty. After a long flight from Europe, the hospitality do not differ much and share similar guidelines, we still could notice small differences regarding surgical of Texas was remarkable! It started with a visit at the Morton H. Meyerson Symphony Centre followed by a approaches (more robotic, less laparoscopic or open) and general management of patients (length of reception held by one of the faculty members. hospitalisation, medical treatment or application of imaging studies). We also observed their system of During our stay at UT Southwestern each day was prostate fusion biopsy and were introduced to a filled with webcasts of live surgeries, tours in the prospectively maintained data management system campus, scientific presentations as well as cultural that allows evaluation of this new technique and experiences based on a hectic, but well-balanced correlation with further patient management. After schedule. these exciting and intense days we were able to relax during our free week-end in Miami experiencing the From a conference room we could observe live Miami and Cuban way of life and the beauty of South transmissions of surgeries (robotic assisted Beach. laparoscopic radical prostatectomy on a high-risk

The next destination was the Department of Urology at Wake Forest School of Medicine in WinstonSalem, North Carolina. Here, again, we received a warm welcome by Prof. Gopal Badlani, the current Secretary of the AUA. He invited us to a welcome reception and dinner at his house where we could meet the faculty of the Department of Urology. The next two days were again filled with interesting cases of surgery that covered ureterorenoscopies, PCNL as well as Mini-PERC for renal stones, robotic radical prostatectomy, partial nephrectomy and cryotherapy for prostate cancer. During general rounds we were asked to present our current main research focus. François Audenet held a talk on Lynch-syndrome and its association to upper tract urothelial cell carcinoma, Tobias Maurer presented data on 68Ga-PSMA-PET for diagnosis and staging of prostate cancer followed by Jakub Dobruch who spoke on the importance of adequate pelvic lymph node dissection in prostate cancer. At the end of our stay we got a chance to visit the Wake Forest Institute for Regenerative Medicine – a laboratory devoted to develop biological substitutes for human tissues. The long and difficult way of implementation basic animal experiments achievements into daily, clinical practice was introduced during the tour along the lab. At the end, we travelled on to the AUA Annual Meeting in New Orleans where we attended high-class scientific sessions, the AUA President´s Reception as well as enjoy the amazing city of New Orleans before we left again for Europe. All together, the EAU/AUA Academic Exchange Programme 2015 has significantly broadened our perception and understanding of current practice in urology in the US – experiences that none of us wants to miss anymore! Thus, we would like to encourage urologists from both sides of the Atlantic Ocean to participate in future exchange programmes.

Photos, top to bottom: The programme exchange fellows with their colleagues and hosts during the US tour

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The authors at the AUA annual meeting

June/July 2015

European Urology Today

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2nd EAU Baltic Meeting: Showcasing young urology talents Baltic’s dynamic urology community attracts overseas participants By Joel Vega A relatively ‘young’ meeting annually organised by the Regional Office, the 2nd EAU Baltic Meeting held in Riga, Latvia, last May 29 to 30, drew not only the participation of urologists based in the Baltic region but also from across central Europe and countries such as Ireland, the United Kingdom, Nigeria, and Turkey. “We are proud to organise this meeting and see the impressive work that is being done in the region,”

Djavan also underscored that aside from promoting the synergies among the Baltic associations, the meeting also aims to identify promising talents. “The regional meetings have always emphasised the importance of recruiting urologists, which can only help our community to strengthen the core specialties of urology.” Treatment challenges The meetings scientific programme covered a wide range of issues in prostate, bladder and kidney cancers, male sexual function, medical and surgical

and costs, improving current treatments and the impact of new technologies. He concluded that the endoscopic approach promises higher stone-free rates, and the choice whether to use extracorporeal shock wave lithotripsy (ESWL), ureteroscopic lithotripsy (URS) and flexible ureterorenoscopy (FURS) is made based on the local situation and patient preference.

Prize Winners

The follow-up session tackled prostate cancer issues such as clinically insignificant PCa (Mihhail Žarkovski, EE), histological evaluation (Maris Sperga, LV), active surveillance (Robertas Adomaitis, LT) and focal therapy for PCa (Mark Emberton, GB). Noting that prostate cancers now account for a large number of newly diagnosed PCa cases, Žarkovski said doctors should exercise caution in using radical therapies that may only lead to complications. Regarding the use of nomograms, he noted their use as good prediction tools, but stressed that nomograms should be validated in unscreened populations. “Active surveillance (AS) is the only way to reduce overtreatment associated with PSA screening for prostate cancer,” he added.

First Prizes: Astellas Award: “Autoantibody responses elicited by prostate cancer-possible biomarkers for the aggressiveness of the disease,” Asbtract 34, Melne, V. et al., (Riga, LV)

R. Adomaitis (LT) examined challenges in active surveillance and underlined the importance of doctors carefully discussing the option with their patients. Saying that AS is safe, Adomaitis said using multiparametric-MRI would prove valuable in the selection and follow-up of patients. “When it comes to the issue of AS, urologists should take the initiative to go beyond current guidelines and publish our own data, ” he said.

2015 Baltic Meeting Opening session said Regional Office Chairman Prof. Bob Djavan in his opening remarks. He noted that even in the second year alone the event has already drawn the interest of many urologists from various countries.

treatment of stone disease and functional urology in lectures, workshops, hands-on training and poster sessions. Around 78 posters were presented during the two-day meeting in four sessions, with organisers selecting nine winners for the best abstract “If we look at the quality of the scientific work and the presentations. best practices in urology here, we are impressed with the progress you have already achieved,” added In the first plenary session, EAU Adjunct Sec. General Djavan. He said the increase in attendance since the for Science Prof. Francesco Montorsi (IT) gave the EAU first meeting in 2014 signals the advances made in the Lecture on contemporary management of high-risk region. Around 340 participants, including exhibitors prostate cancer (PCa). He said that 15% to 25% of and faculty members, attended this year’s meeting. today’s PCa patients who had radical prostatectomy for localised disease will suffer biochemical Co-organised with the national urological associations recurrence (BCR). “Patients with BCR have higher risk of Latvia, Lithuania and Estonia, the scientific of clinical progression and cancer-specific mortality,” programme covered a number of issues and topics in Montorsi said. He described his centre’s experience in urology such as onco-urology, stone disease, managing PCa patients and compared the pros and andrology, urological imaging and minimally invasive cons of robot-assisted radical prostatectomy versus procedures, among other topics. open radical prostatectomy. Assoc. Prof. Eglis Vjaters , local organiser and president of the Latvian Urological Association, expressed his appreciation for the EAU’s active support and stressed that collaboration with Estonia and Lithuania was invaluable in ensuring the meeting’s success. Profs. Mindaugas Jievaltas and Toomas Tamm, presidents of the Lithuanian and Estonian urological societies, respectively, also mentioned the vital role of close partnership among their organisations and the EAU’s sustained support.

“In G1-2 NMIBC, multi-marker panel or multiparameter analysis is necessary,” he said while underscoring that urologists should conduct prospective (randomized) trials in G1-2 tumours. Quality studies Several sponsored symposiums were presented with speakers discussing benign prostatatic hyperplasia (BPH), overactive bladder, metastatic castrationresistant prostate cancer (mCRPC) and lower urinary tract symptoms (LUTS). Among the highlighted key messages are: • B. Djavan on LUTS: “Watchful waiting is an option, but patient can profit from prevention of progression.”

“A comprehensive meeting full of insights”

• A. Mehik on mCRPC treatment: “Treatment with enzalutamide significantly reduces the risk of death and delays the progression of metastatic disease. Enzalutamide added to ADT at progression provides meaningful clinical benefit to men with mCPRC. ”

“I attended the meeting because I´d like to know more about the specialities of urology before I go for residency. This meeting is really an eye-opener for me and made me more enthusiastic to go into urology. The lectures were not only practical and comprehensive but also gave insights on daily clinical practice, challenges and issues in treatment. I learned much more than I expected. Given the chance, I will definitely attend another meeting. ”

European Urology Today

Dr. Nauman Nabi, practising urologist, from Galway (IE) “This is my second participation in this meeting and I can say that there is improvement. The lectures were all very informative, although it would have been more useful for me if there were more engaging discussions and direct exchange of views among expert panellists and speakers after the lectures. The abstract presentations were also very informative and gave me ideas what urologists and researchers are doing in other countries. Congratulations to the organisers for doing a good job.”

Berlin Chemie Award: “Lower ureteric stones treated by expulsive medical therapy: Selective a1-adrenergic blockers versus tadalafil plus selective a1-adrenergic blockers,” Abstract 75, Nabi, N. et al., (Galway, IE)

Prof. Bernd Schmitz-Dräger (DE) gave a state-ofthe-art lecture on bladder cancer, discussing the challenges in identifying better markers. In his closing remarks, Schmitz-Dräger pointed out that although better markers are desirable, the performance of current markers is sufficient. He recommended that doctors use markers before ultrasound cystoscopies (UC) in the follow-up of high-grade tumours.

Dr. Linards Redmanis (LV) discussed renal colic and examined both conservative and surgical management of stones in the upper urinary tract. Among the challenges he mentioned were the growing number of patients, treatment availability

Marisa Butnere, medical student, from Riga (LV)

26

In his closing remarks, Montorsi mentioned that in a retrospective series, adjuvant radiotherapy “...showed impact on survival of certain patients with nodepositive prostate cancer.“

Emberton discussed the role of focal therapy in prostate cancer. “Focal therapy has emerged as a new class of therapy which now commands legitimacy,” he said while noting that focal therapy has prompted “an order of precision in terms of risk stratification that was hitherto missing.” Emberton: “Our treatments have, to date, been modifications of existing therapies. The next few years will see the emergence of treatments designed for the task.”

• M. Drake on OAB: “Mirabegron is well-tolerated and reduces frequency and incontinence episodes, regardless of prior drugs. ”

Four poster sessions were also organised covering topics such as functional urology, prostate cancer, kidney/urothelial malignancies and stone disease. The organisers said the quality of the submissions were very good and the jury had a tough time selecting the winners of the nine awards given by Astellas, Berlin Chemie and Karl Storz. The first prize winners tackled issues ranging from PCa biomarkers, lower ureteric stones to partial nephrectomy for small renal masses. Below is the list of winners.

Karl Storz Award: “Outcomes following partial nephrectomy for small renal masses,” Abstract 47, Cekauskas, A. et al., (Vilnius, LT) Second Prizes: Astellas Award: “Luminex detected antibodies are clinically relevant in pretransplant risk assessment,” Abstract 73, Veskimäe, P. et al., (Tartu, EE) Berlin Chemie Award: “Survival rates of hereditary and sporadic prostate cancer patients,” Abstract 28, Miculis, K. et al., (Riga, LV) Karl Storz Award: “Immediate results of surgical treatment of non-muscle invasive bladder cancer using the new en bloc TURBT,” Abstract 42, Masanski, I. et al., (Minsk, Belarus) Third Prizes: Astellas Award: “Is there a difference in number of interstitial cells, nuerons, presence of fibrosis and inflammation in UPL tissues of patients with UPJ obstruction with and without crossing-vessel and normal subjects in humans?” Abstract 16, Canda, A.E. et al., (Sakarya, TR) Berlin Chemie Award: “Evidence of bladder re-innervation following spinal cord injury via vagal nerve- fMRI study,” Abstract 5, Krhut, J. et al., (Prague, CZ) Karl Storz Award: “Renal colic: Emergency department diagnostic workout and treatment,” Abstract 76, Redmanis, L. et al., (Riga, LV)

June/July 2015


The EAU Hans Marberger Award 2016 will be handed out for the best European paper published on Minimally Invasive Surgery in Urology. The award, annually given since 2004, is named after Prof. Hans Marberger to honour his pioneering achievements and contributions to endourology and the development of urologic minimally invasive surgical procedures.

How to apply Please send your paper to the EAU Central Office at m.smink@uroweb.org and mention “EAU Hans Marberger Award 2016” in the subject line of your e-mail.

The award will be handed over at the 31st Annual EAU Congress in Munich, 11-15 March 2016 during the Opening Ceremony.

The EAU Hans Marberger Award is supported by an unrestricted educational grant of h 5,000 from KARL STORZ GMBH & CO.KG.

Rules and Eligibility • All urologists and scientists are invited to send in papers. • The topic of the paper should deal with Minimally Invasive Surgery in Urology. • The paper must have been published or accepted for publication in a European Journal between 1 July 2014 and 30 June 2015. • All papers must be submitted in the English language. • All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • Deadline for submission is 1 November 2015.

Win the EAU Hans Marberger Award 2016 Submit your paper on Minimally Invasive Surgery and you might be awarded the EAU Hans Marberger Award 2016 of € 5,000!

The EAU Crystal Matula Award 2016 is the most prestigious prize given to a young promising European urologist under the age of 40 who has the potential to become one of the future leaders in academic European urology. The award will be presented at the Opening Ceremony of the upcoming 31st Annual EAU Congress in Munich, Germany from 11 to 15 March 2016. The list of previous awardees includes many well-known names: M. Rouprêt (2015), S.F. Shariat (2014), P. Boström (2013), P.J. Bastian (2012), S.G. Joniau (2011), J.W.F. Catto (2010), M.J. Ribal (2009), V. Ficarra (2008), M.S. Michel (2007), A. De La Taille (2006), M.P. Matikainen (2005), P.F.A. Mulders (2004), B. Malavaud (2003), M. Kuczyk (2002), B. Djavan (2001), A. Zlotta (2000), G. Thalmann (1999), F. Montorsi (1998), F.C. Hamdy (1996).

EAU Crystal Matula Award 2016

ur s o d y tion n Se ina y! m a no tod

June/July 2015

A review committee, consisting of members of the EAU Scientific Congress Office, will select the winning paper.

Nomination process National Societies can nominate a candidate by supplying the following documents: • letter of endorsement • motivation letter • complete curriculum vitae • list of publications in the below sequence: 1. Peer reviewed papers (including the impact factors of the journals) • original articles • reviews • case reports

2. Book chapters or editor of books • overview of grants received from (inter-)national institutions or from the industry • list of received Awards • The deadline for nomination is 1 November 2015 Please note that eligible candidates can also apply for this award by contacting their national urological societies directly. The candidate is then expected to supply his/her national society with a CV and the above mentioned documents, requesting a letter of endorsement. How to apply Please send your nominations to the EAU Central Office at m.smink@uroweb.org and mention “EAU Crystal Matula Award 2016” in the subject line of your e-mail. The EAU Crystal Matula Award is supported by an unrestricted educational grant of h 10,000 from LABORIE. LABORIE

European Urology Today

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Young Urologists/Residents Corner YAU-BPH group wants you! Sustained research effort on key BPH issues needed Dr. Cosimo De Nunzio Ospedale Sant’Andrea, University “La Sapienza” Chairman YAU-BPH Group Rome (IT) cosimodenunzio@ virgilio.it The European Association of Urology (EAU) has recently supported the development of expert groups of Young Academic Urologists (YAU) to boost research activity in some critical areas of urology and improve academic collaboration among different centres in Europe. The YAU-Benign Prostatic Hyperplasia (YAU-BPH) group’s initial activity begun four years ago during the YAU’s annual meeting in Baveno (Italy). The group has eight urologists from Italy (Cosimo De Nunzio, Chair; Giacomo Novara), France (Nicolas Delongchamps), Germany (Sascha Ahyai, Claudius Fuellhase), Switzerland (Malte Rieken), Romania (Bogdan Geavlete) and the UK (Nickesh Thiruchelvam) who are interested in clinical and basic research on BPH. To investigate the fields of BPH and Lower Urinary Tract Symptoms, we identified the following academic aspects: • The role of androgens and estrogens in LUTS due to BPH; • The pathophysiology of nocturia; • The prognostic value of BOO for BPH progression; • The prognostic value of detrusor underactivity and overactivity in the outcome of BPH treatment; • The relationship between prostate debulking and outcome/durability of BPH surgery; • The feasibility of developing a BPO/BPH nomogram; • Characterise BPH management in Europe; and • Determine the relationship between bladder stones and BPH.

We are proud that most of these questions have been investigated by our group as we recently published the results of our survey on the current practice and attitudes on the surgical management of BPH in Europe. We also developed and validated a nomogram to predict the presence of benign prostatic obstruction in patients. The remaining topics were also evaluated and discussed in a recent book titled “BPH Made Easy,” edited by C.R.C. Chapple and A. Tubaro. All the book chapters were prepared by YAU-BPH members. We have also prepared the pathway for future studies, namely: to analyse clinical and ultrasound parameters to predict a successful trial without catheter in patients treated with silodosin; to determine the relationship between bladder stones and BPH; to develop a LUTS/BPH screener for general practitioners; and to investigate the relationship between metabolic syndrome and LUTS. Recently, the Steering committee of the Clinical Trial Evolution, coordinated by the EAU Research Foundation and tasked to evaluate a real life registry in the current medical treatment of LUTS/BPH in several European countries, involved our group in evaluating the study results and drafting the main manuscripts from the study. The YAU-BPH group have also engaged in social and congress activities. We are collaborating with the Ralph E. Hopkins Jackson Hole Seminar (coordinated by Dr. Fernando Kim, Denver, USA; http:// jacksonholeseminars.com) and the International Translational Research in Uro-Sciences Team (ITRUST) (coordinated by Dr. Roberto Miano, Rome, IT http://www.itrusturology.com), to organise their annual meetings in Jackson Hole and Rome, respectively. These meetings will present a full programme that includes state-of-the-art lectures and critical discussions by a group of international experts called the Critique Panel. The ITRUST meeting organised yearly in Rome also includes a live surgery session in accordance with the EAU live surgery rules. In both meetings BPH/LUTS management is among the main topics.

In November this year, I and three colleagues (Sascha Ahya, Nikesh Thiruchelvam and Giacomo Novara) will end our term in the YAU-BPH group. But during the four years I have served I was given the unique opportunity to meet young motivated colleagues, share ideas and projects, and collaborate with the EAU. I hope and believe that our work have contributed to a new era of research in LUTS and BPH. We have exerted our best efforts but only time will tell the significance of our contributions. In the last five years, about 800 to 1,000 manuscripts, annually, have been published on LUTS and BPH.

Notwithstanding all these efforts, some of the relevant questions in LUTS/BPH remain unanswered. Due to the lack of economic interest, there is not enough drive to design, initiate, and complete the research needed to address the different issues. We hope that the new, young and motivated urologists who will assume our positions in the YAU-BPH group will persevere. It is important that the YAU-BPH group sustain the motivation to address some of the issues listed above and continue what we have initiated. The new members will find the task simultaneously daunting and exciting as we have experienced it ourselves.

What do residents expect from urology training? Turkish survey shows residents feel inadequate in actual surgical training Dr. Ahmet Urkmez Fatih Sultan Mehmet Research & Training Hospital Dept. of Urology Istanbul (TR) ahmeturkmez@ hotmail.com In Turkey urology residency lasts for five years and in 2014, urology departments of 62 universities and clinics of 31 training and research hospitals were providing urology training to 427 residents. ESRU Turkey conducted a questionnaire survey and tried to evaluate satisfaction levels and expectations of our fellow residents on theoretical and practical training. We presented the results of our survey during the 23rd National Congress. A total of 113 residents participated in our survey. Median age of the participants was 28.2 years with a married/single ratio of 64/69. The participants were in their 1st (n=12), 2nd (n=17), 3rd (n=22), 4th (n=24) and 5th (n=38) years of their residency training. Median monthly income of the residents was 4600 TL (1600 Euro). On an average they work for 11 hours a day and they are on-call duty 12.5 (8-15) times a month at the beginning of their residency. Based on the scores obtained by the participants (0: very bad; 1: bad; 2: moderate: 3: good; 4: excellent), the participants expressed their satisfaction with the theoretical and practical training that they received at the urology clinics as either moderate-worse (1.7 pts) and good-moderate (2.8 pts). 28

European Urology Today

Moreover, they were moderately (1.9 pts) satisfied for the encouragement provided in conducting scientific researches. And based on the results of the survey nearly all of the residents thought they are sufficiently competent for endoscopic stone surgery, TUR-P and TUR-B. However, they stated that most of the time they were assisting urologists rather than primarily performing radical and laparoscopic surgery, areas in which they indicated their incompetency. Inadequate surgical skills Since advanced andrological and reconstructive surgical interventions have been performed in a limited number of centres, residents training in centres lacking these technological facilities expressed their inadequacies on these issues. In Table 1, residents’ levels of proficiency based on their self-assessment scores are presented.

performed in certain centres will considerably overcome these obstacles. Based on the results of this survey, we believe that residents should be encouraged to conduct scientific researches and publications, and that working hours should not be overloaded to enable them to set aside enough hours for research work. Currently, the overwhelming numbers of night shifts and extra hours in the hospital make it difficult for residents to pursue scientific work. Based on the outcomes of the survey, we have planned courses for the residents that will train them

in writing scientific papers and performing statistical analysis. In laparoscopic nephrectomy (LN) courses that we planned, each resident will have at least one chance of performing LN in a live animal model. Moreover, participation in these courses will be free of charge for residents. A Handbook of Practical Urology for urology residents was also published and the EAU Pocket Guideline was translated into Turkish by ESRU Turkey. A Resident Assistant Exchange Programme was planned to enable rotations of residents in centres with proven expertise in specific urological specialties.

 0 (very bad)

Open stone surgery

The residents responded to the questions related to the urology subspecialties they wanted to specialise after their residency training as endourology (n=36; 32%), uro-oncology (n=29; 26%), andrology (n=18; 16 %), paediatric urology (n=12; 10 %), general urology (n=12¸12%) and female urology (n=6; 5%). Interestingly, the respondents either considered (n=41; 36%) or did not consider (n=72; 64%) pursuing an academic career after completion of their residency training.

Endoscopic stone surgery

One of the most striking results from our questionnaire survey is that with increasing prevalence of endoscopic and laparoscopic surgery, many residents worry about their inadequacy in managing complications, which might occur during these endoscopic surgeries, and due to what they perceived as their insufficient competency in open surgical interventions. We are convinced that courses for residents in open surgery on fresh cadavers and

Urological reconstructive surgery Andrological surgery

TUR-P1 TUR-B2 Open prostatectomy Open renal surgery Radical surgery Laparoscopic surgery Robotic surgery Penile surgery

Urogynaecological surgery Theoretical training Scientific publication 

1 (worse)

2 (moderate)

2.9 2.8 2.3 1.8 1.1 0.2 1.1

� �

1.4 1.7 1.9

� � �

� � �

1.6 1.6

4(excellent)

� � �

3.2

1.5

3 (good)

1.4

� � � �



June/July 2015


Young Urologists/Residents Corner Spanish residents rise up to the challenge Establishing the Spanish Association of Urology resident’s and young urologist's workgroup Dr. Andrea Durán Rivera Member of Spain Residents Workgroup Urology Resident Valencia (ES) andreajduran@ gmail.com

Dr. Juan Gómez Rivas ESRU Internal Coordinator Officer Chairman of Spain Residents Workgroup Madrid (ES) juangomezr@ gmail.com Unity and close communication are key factors for an organisation to achieve its goals. To raise the quality and improve the standards of urological education, residents and young urologists from Spain have created the resident and young urologist workgroup,

which is fully supported by the Spanish Urology Association (or AEU in Spanish abbreviation). Today, with globalisation as dominant trend and the benefit of speedy communication through social media, young Spanish urologists and residents have formed, since the start of 2015, an official workgroup within the AEU structure and with the support of the ESRU and YUO. One of the main objectives of our new organisation is to improve and maintain the standardisation of the education of young urologists in our country. We believe that establishing common educational targets and guidelines for all residency programmes will help programme coordinators and faculties provide a state-of-the-art education to residents and help trainees keep their work focused and goal-oriented. The establishment of required minimal goals to be accomplished during the residency period and its extension to all programmes is probably one of the cornerstones needed to achieve this aim. Better communication among residents is also one of our main goals. After creating the workgroup, one of the first tasks of the members was to collect into a database the contact information of all urology residents and recent urology graduates in Spain. And

by using an e-mail account system and channelling information through social media, we linked up all urology residents to inform them about the creation of the workgroup and provide updates on our activities.

participation or exposure to international associations like the EAU. This is one of the reasons we are encouraging young urologists and residents to actively join international groups.

Through streamlined communications, we also aim to inform them about important meetings, congress and courses particularly those who are interested in training opportunities. We also intend to facilitate links among residents and update them about the different programmes around the country to improve or fulfil external rotations in various hospitals, enabling residents to complement their training.

It is also important to note that throughout the initial stages of creating the resident workgroup, we received the AEU’s full approval and support. All AEU board members have shown interest in creating this group and after they were informed about our plans and goals, we received positive feedback and were granted the opportunity to organise an official meeting in the next AEU congress in Salamanca, Spain. We are looking forward to meet many residents, share opinions and hear some ideas and start working on our agenda. For the 2016 AEU congress, we plan to organise educational meetings and activities for young urologists and residents.

Benefits Another important benefit from this workgroup is for residents to have official representation in the Spanish Urology Association, enabling them not only to have a legitimate voice and actively participate in meetings and congresses, but also express their concerns and needs. We also hope to assist the AEU in fine-tuning the efforts to improve resident development in Spain. Moreover, the resident workgroup will improve our communication and participation in organisations such as the EAU, YUO, YAU and ESRU. There are over 400 urology residents in Spain, and only 206 are part of the AEU, which also means that they have marginal

We know that this new endeavour is not an easy task, but as executive committee members of the AEU resident workgroup, we are very excited with the creation of this group. We hope to replicate the achievements of residents in other European countries, not only by boosting our participation in the national association but also by developing dynamic links among Spanish residents and improve the quality of our urological training.

ESRU joins the Turkish National Andrology Congress ESRU Turkey offers training courses and workshops Dr. Selçuk Sarikaya Chairman of ESRU Turkey Chairman-Elect of ESRU (TR)

Dr. Selçuk Sarikaya Chairman of ESRU Turkey Chairman-Elect of ESRU Ankara (TR)

were presentations for challenging cases in andrology. The second ESRU session was held the following day including a lecture on statistics and more presentations of challenging cases, with the discussion panel composed of professors.

The 11th Turkish National Andrology Congress was held in Fethiye from April 30 to May 3 this year and the European Society of Residents in Urology (ESRU) organised three sessions in the scientific programme of the congress.

The third congress day also featured the third and last ESRU session, with the author, as chairman of ESRU Turkey, discussing the plans and goals of the group. The ESRU and ESRU Turkey have previously organised joint sessions at the Turkish National Urology Congress and the Turkish National Andrology Congress. Both meetings offered wonderful opportunities to present the latest achievements and activities of ESRU and ESRU Turkey. Also significant was the chance to get residents more interested and actively involved in ESRU’s projects.

Former ESRU chairman Juan Luis Vasquez talked about ESRU’s goals and activities and presented a lecture on electrochemotherapy for bladder cancer during the first session. Following the lectures, there

There were a lot of activities organised by ESRU Turkey during the last year. The live surgery and cadaveric courses were very useful for residents. Many international participants also attended these

drselcuksarikaya@ hotmail.com

courses. These courses attract a lot of trainees since this type of training provides the chance to improve surgical skills. ESRU Turkey plans to organise in the future regular scientific activities for urology residents, activities that will also be open to overseas participants. A Basic Urodynamics Course programme will be held in September this year with the participation of five qualified clinics. There will also be a female urology symposium to be held at the end of the course programme. A uro-oncology symposium will also be organised in November 2015. The symposium will have a theoretical part and a session for live surgeries. For 2016 we are finalising the details of the Cadaveric Education Programme, a unique and dedicated programme consisting of three main segments covering theoretical and practical aspects. This educational programmes will enable residents to perform basic and complex surgical operations and improve their surgical skills. These courses and

A formal thank you to Former ESRU chairman Juan Luis Vasquez

activities are all supported by ESRU and will be open to international participants. The ESRU Turkey team welcomes urology residents from across Europe to join us in Turkey. Regularly check the ESRU and ESRU Turkey online and Facebook pages for updates and details. See you in Turkey!

The Veres Needle How an inventive Hungarian pulmonologist left a legacy in modern surgery Dr. Mihály Murányi University of Debrecen Dept. of Urology Debrecen (HU)

vezermurmillo@ gmail.com Currently, numerous laparoscopic procedures start with the use of a Veres needle. But only a few urologists know how the needle was named or the person who gave its name. Thus, there is also some confusion concerning the correct usage (orthography) of Veres. When we type “Veress needle” in Google search it will list or return 83,900 results. If you Google-search “Veres needle,” the search will return only 4,050 hits. But if we use the Hungarian terms “Veress-tú” and “Veres-tú”, the results will be 168 and 1,450 hits respectively. June/July 2015

needle in 1936 in a Hungarian publication (Veres J. Új légmellkészítés [New method for performing artificial pneumothorax]. Orv Hetil. 1936; 80:536-537).

English-speaking Internet users use this eponym with two S’s, unlike Hungarians, who use it with one “s.” To clear up the confusion over the correct term, we must get acquainted with the inventor of the needle.

Half a century later, with the advent of laparoscopy, the Veres needle became an indispensable tool in safely administering artificial pneumoperitoneum.

A talented painter János Veres was a Hungarian pulmonologist who invented his needle in the 1930s. Veres was born on 1903 in Kismajtény. He was a talented painter and he planned to pursue formal studies in art school. Eventually, he chose medicine and received his medical degree at the University of Debrecen in 1927. He became the Head of the Department of Internal Medicine, Hospital of Kapuvár in 1932. At that time tuberculosis was widespread in Hungary. Due to lack of antibiotics (the first antituberculotic, streptomycin, was discovered only in 1944), pulmonary tuberculosis was often treated with artificial pneumothorax. To safely perform artificial pneumothorax, Veres invented a double-wall, spring-loaded needle. With the help of this new instrument, a lot of iatrogenic lung injuries were prevented. After 950 successful procedures, Veres reported his experiences with the

With his inventive mind, a Hungarian pulmonologist left a lasting legacy with his invention of an important instrument used by gynaecologists, surgeons and urologists during laparoscopic procedures. The original Veres Needle from the 1930’s. (History of Medicine collection, University of Debrecen; photo by Prof. Csaba Tóth)

He deserves to have his name mentioned in a proper way: Veres.

Any comments, suggestions or articles for the Young Urologist/Residents Corner are welcomed at: eut@uroweb.org S. Sarikaya, Section editor European Urology Today

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Robotic surgery in urology Are we on the brink of a new revolution?

Will you be an EAU Award Winner in Munich? EAU Crystal Matula Award 2016 For a young promising urologist under the age of 40 who has the potential to become one of the future leaders in academic European urology. National Societies can nominate a candidate for this award or eligible candidates can apply by contacting their national urological society directly. EAU Hans Marberger Award 2016 For the Best Paper published on Minimally Invasive Surgery in Urology. This paper must have been published or accepted for publication between 1 July 2014 and 30 June 2015.

Dr. Francesco Sanguedolce King's College Hospital Dept. of Urology London (UK)

EAU Prostate Cancer Research Award 2016 For the Best Paper on Clinical or Experimental Prostate Cancer Research. The paper must have been published or accepted for publication in a high-ranking international journal between 1 July 2014 and 30 June 2015. EAU Best Paper Awards 2016 For the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers must have been published or accepted for publication between 1 July 2014 and 30 June 2015.

fsangue@ hotmail.com Isaac Asimov in the 1950s imagined a futuristic world of robots with feelings and morals, and in the 1970s, after the moon landing, NASA predicted that man would be able to land on Mars by the beginning of the new century. In the 1980s, Robert Zemeckis in the movie “Back to the Future II” predicted a world in 2015 dominated by hyper/cyber-technology and flying cars. None of these futuristic visions came true, and similarly, it is mere speculation to foresee how technology in medicine will actually develop in the next decade.

Apply now and win!

Consequently, much of the attention and expectations from industries and physicians are focused on the evolution of robotic platforms, technologies that are now undergoing a fast rate of development.

“Will increased competition make robotic surgery more affordable without compromising continuing development of technology?”

Deadline: 1 November 2015 For more information, rules and regulations: www.eau16.org/the-congress/awards

www.eau16.org

#EAU16

European Association of Urology

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

Currently, there are dozens of prototypes of robotic systems that are about to enter or flood the market in all the medical subspecialties where extreme precision and minimal invasiveness are required for diagnostic or therapeutic purposes. Some of these platforms are already in the market and,

Authors ISBN E-book Publisher Publication Edition Binding Price Pages Website

: D.L. Streiner, G. R. Norman, J. Cairney : 978-0-19-968521-9 : Available : Oxford University Press : Nov. 2014 : 5th : Paperback : € 45.50 ( £32.99) : 416 : www.oup.com

The 5-Minute Urology Consult The first edition of this outstanding textbook was published 15 years ago and updated in 2010 and 2015. The editor-in-chief of the third edition, Leonard G. Gomella, was assisted by more than 115 associate, consulting and specialty editors and more than 280 contributors.

paul.meria@ sls.aphp.fr

Health Measurement Scales All physicians involved in clinical care must frequently assess various subjective states in their patients, such as quality of life. Researchers need also various scales and scores for evaluating the results of their studies. Reliable and valid measures are consequently required. In the 5th edition of this textbook, editors D. L. Steiner, G.R. Norman and J. Cairney aimed to provide scientists and physicians with an exhaustive guide for developing and validating measurement scales useful in different health sciences. The basic concepts were reviewed after an introductory chapter dedicated to measurement scales. In these chapters the authors focused on the methods required for the development of a new scale of measurement. The conception of the items and their assessment were exhaustively described in the succeeding chapters. Estimation methods were considered and the authors described the different categories of judgment scales. The selection of the items and bias limitation were also considered before developing the transition between items to scale development. The concept of reliability, a key aspect of measurement scales, was Book reviews

30

European Urology Today

developed in a dedicated chapter, followed by two other chapters dealing with generalizability and validity. The measurement of change after treatment was described and the authors focused on some controversies surrounding such assessment. The methods of questionnaire’s administration were considered, including new technologies such as web surveys.

The authors aimed to assemble exhaustive information intended for physicians involved in everyday care of patients presenting with urologic problems. This work, looking like all the books edited in the “5-Minute Consult” series, was based on current data available from various articles published in the literature and focused on topics representing what the editor called “the real-world” clinical questions. Evidence-based medicine references were included in this edition and identified in various chapters.

The authors concluded with ethical considerations and test reporting. An appendix provided the reader with a description of the currently available scales in various fields.

The textbook was divided into seven sections, with the first dedicated to urologic diseases and conditions. More than 300 topics were addressed in this section and classified according to an alphabetic order. Nearly all the pathology was covered, including basic conditions or problems, the diagnosis, treatment and ongoing care. No tables and no figures were included in the two-page chapters and only three to five references were cited.

This book is a very exhaustive tool for all physicians involved in research and who are keen to use or develop subjective measurement scales. Urologists who are frequently faced with clinical assessments in various fields such as BPH, incontinence or erectile dysfunction, will find in this book complete and useful information.

The second section was dedicated to “short topics.” The authors focused on more than 1,300 diseases and conditions requiring a very short presentation. Most of them were described succinctly and only one reference was mentioned, without any figure. The third section assembled more than 90 decisional trees dedicated to clinically relevant topics and frequently

where available, they have considerably revolutionised the clinical practice in various and relevant fields. In urology, there is just one brand that has dominated the market in the last 15 years: the Da Vinci System. As key components and software patents are about to expire by next year, many changes are expected in the short and mid-terms. It is likely that we will assist, to certain and progressive degree, the loss of monopoly of Intuitive and a steady increase of competition in the market. “Robotisation” is also progressing in other fields of urology, such as in the case of a recent introduction in the market of a robotic device to assist flexible ureteroscopy. In this issue, Prof. Jens Rassweiler provides a detailed picture on the devices and developments in the pipeline, and the most likely expanded indications in the future for robotic-assisted urological procedures. However, the key question that many urologists would like to ask is: “Will increased competition make robotic surgery more affordable without compromising continuing development of technology?” The problem is that even if for some countries robotic surgery is the present, for many other countries this high technology remains a chimera. The lingering economic crisis has caused significant cuts in many national healthcare systems, which in turn affected or delayed robotic programmes, either existing or about to be developed. Are we about to assist the invasion of robots as predicted by Asimov? Or will robotic surgery remain a luxury tool for a few privileged countries or health centres? > Prof. Rassweiler's article can be found on the next page (page 31).

encountered problems such as a very short section which addressed urinalysis and urine studies. The last sections were dedicated to alternative therapies and drugs available in urology, with the last part of the book assembling various recommendations, clinical scores and TNM classifications. The ebook version is available and supports enhanced information. This textbook is undoubtedly one of the most useful for urologists, regardless of their career level. Certified or in-training, practicing urologists will find a considerable amount of practical information in this high-quality work. Editors : L.G. Gomella, G.L. Andriole, A.L. Burnett, R.C. Flanigan, T.E. Keane, H.P. Koo, J.W. Moul, R. Thomas ISBN : 978-1-451-18998-8 Publisher : Wolters Kluwer Health E-book : Available Publication : 2014 Edition : 3rd Binding : Hardcover Price : € 89 ($99.00) Pages : 880 Illustrations : 90 algorithms Website : www.lww.com

June/July 2015


The future of robotic surgery in urology 10 years of technical developments in a nutshell Prof. Jens Rassweiler SLK-Kliniken Heilbronn GmbH Dept. of Urology Heilbronn (DE)

jens.rassweiler@ slk-kliniken.de Robotic surgery has been widely introduced mainly to facilitate laparoscopic surgery, however accompanied by monopoly of Intuitive Surgery. Soon some patents will expire promoting the review of actual technical developments and speculation on future patterns of robotic surgery in urology. The da Vinci-System first addressed most ergonomic problems sufficiently, such as depth perception, eye-hand coordination, and limited range of motion. Da Vinci provided a console offering 3D-video-system with in-line view, mechanical wrist-technology with six DOF and handles that can be utilized always in an ergonomic working position due to clutchmechanism. In 2000, Binder performed the first robot-assisted radical prostatectomy. Menon achieved breakthrough establishing a full-working clinical programme including training of urologists. Da Vinci S already provided a better range of motion, longer robotic arms and optional an HD-videosystem respectively fourth arm. Next generation represented the SI-system with integrated HD-videotechnology, finger-based clutch-mechanism and isocyanine-green fluorescence. Da Vinci Si dual console surgical robotics system allows two surgeons to collaborate during surgery and represents an ideal training platform (Fig. 1a). In 2014, Intuitive Surgical launched Da Vinci XI-system (Fig. 1b) enabling the 8mm-camera port to be chosen liberally for all four ports. This might be important for colonic and rectal surgery. The robotic arms have a much finer design to minimize instrument clashing. With this system, the new robotic SP-platform for 7 DOF-robotic LESS-surgery can be used (Fig. 1c). There is no active opponent for Intuitive Surgical, mainly based on the fact, that Intuitive bought Computer Motion in 2002 saving all patents concerning single arm devices mounted to the table. In 2009, Intuitive bought NeoGuide Systems, a company focussing on robot-assisted colonoscopy and NOTES. Console-based devices for robot-assisted laparoscopy MIRO Surge (German Aerospace Centre) consists of three arms mounted to the operating table (Fig. 2a) with instruments driven by micro-motors also providing tactile feedback (via potentiometers). MIRO robot is composed of seven joints with serial kinematics, comparable to human arm. Arms and instruments are light-weighted. The surgeon sits in front of an autofocussing monitor. Until now MIRO Surge has only been tested in-vitro, adequate instruments are missing, and German Aerospace Centre has not yet found an industrial partner.

1c

Fig. 1: Last generations of Da Vinci robots a) Concept of Double console for training and assistance realized with the Da Vinci SI-System. b) Da Vinci XI with finer design of robotic arms to minimize the risk of clashing of instruments. Variable use of robotic arms for the camera. c) SP-platform for LESS with snake-style wrist at site of end-effector and elbow-wrist for triangulation.

June/July 2015

Supported by European Commission TELELAP Alf-X (Sofar) utilizes a remote control station and robotic arms (Fig. 2b). Unique system features include haptic feedback and an eye-tracking system. First targets of TELELAP Alf-X are gynaecology, urology and thoracic surgery procedures. Experimental studies proved safety, however, handling particularly at the console did not reach standards of Da Vinci. Raven Project developed through collaborative effort of several universities (Santa Cruz, Berkeley, Davis) aims to produce an open source system that would allow two surgeons to operate on a single patient simultaneously. The initial system includes two portable surgical robotic arms, each offering seven DOF and a portable surgical console (Fig. 2c). Raven II is a two-armed surgical robot designed with a camera and may utilize 3-D ultrasound imaging to show internal organs in real time. Raven III includes four robotic arms and optionally two cameras. Raven platform is one of the most advanced surgical robotics research platforms. A lot of research is dedicated to battlefield and underwater tele-presence remote surgery. SOFIE (Surgeon's Operating Force-feedback Interface Eindhoven) provides a force-feedback interface with less space for robot consume. Two components (master and slave) are completely separated from each other, however all communication between the two takes place over data cables arranged in an overhead wiring boom. Three different light-weighted robotic arms with maximally 8 DOF can be fixed to operating table (Fig. 2d). Until now no laparoscopic application has been published. Devices for robot-assisted single-port surgery Laparo-endoscopic single site surgery (LESS) further minimizes access trauma of classical laparoscopic or robot-assisted laparoscopic surgery as a potential step toward true natural orifice surgery (NOTES). However, classical LESS-technique is significantly impaired by suboptimal ergonomics with clashing of instruments. Robotic technology may overcome these problems. Spider System (TransEnterix) represents a platform developed for LESS based on tubes in which flexible instruments can be manipulated to perform laparoscopic surgery. The initial device used wire-based manipulation only for 5 mm instruments requiring insertion of on additional trocar for ablative renal surgery. Handling of instruments was difficult particularly concerning endoscopic suturing. Therefore Transenterix improved the system considerably providing the robotic arm SurgiBot (Fig. 3a). Since the original Spider-system has been FDA-approved, TransEnterix expects FDA-approval for SurgiBot in 2015.

University of Nebraska collaborating with Virtual Incision (Nebraska, United States) presented the prototype of a two-armed dexterous miniature robot system controlled by two external handles using interchangeable end-effectors to provide mono-polar cautery, tissue manipulation, and intra-corporeal suturing. Titan Medical stopped development of AMADEUS RSS and focused on SPORT-system as a platform for robot-assisted LESS consisting of a console with 3D-HD-vision and a manipulator at bedside to perform the procedure (Fig. 3e). The basic design of the platform is similar to other solutions including a 3D-flexible telescope with fibre-optic based illumination and two flexible instruments. FDA-approval for the system is expected for 2015. Main applications should be robot-assisted LESS-cholecystectomy. Recently, nephrectomy has been performed in the animal model requiring an additional trocar for retraction and placement of clips. Introducing Da Vinci XI-system, Intuitive Surgical also presented their robotic single-port SP-platform (Fig. 1c) representing a significant progress over previously used Vespa-System. The design of SP-platform includes a 3D/HD flexible telescope and two flexible instruments. Once introduced via umbilical incision, the flexible instruments with a snake style wrist separate to achieve triangulation. The device is controlled by use of EndoWristtechnology at the console. In contrast to all other devices, the SP-platform has been used in a clinical pilot study. Future development of Robotic Surgery in Urology Developments in robotic surgery are limited by the actual clinical monopoly of Intuitive Surgical. Over the years Intuitive Surgical has built barriers to new entry, including superior product offerings, intellectual property protection, multiple regulatory clearances, a large installation base, worldwide training centres, strong customer relationships, and an excellent balance sheet. Expiration of company`s existing key-patents in 2015 and 2016 poses a serious challenge. Once these patents expire, competitors can utilize those technologies, and Intuitive Surgical`s advantages might be lost. Speaking of competitors, TransEnterix and Titan Medical will be soon introducing their own robotic platforms (Fig. 3a,e).

2b

2a

2d

The ARAKNES Project (Array of Robots Augmenting the Kinematics of Endoluminal Surgery) funded by EU-Programme hopes to produce a micro-roboticbased smart operating system for advanced endoluminal surgery. The system is based on the common design of a remote console and two robotic arms with rotating grippers on the end (SPRINT robot) introduced via the umbilicus (Fig. 3b). This device is still experimental. To evaluate potential role of mechatronic platforms 2c for NOTES the ‘‘Highly Versatile Single Port System’’ (HVSPS) was developed at Technical University of Fig. 2: Console-based robotic devices Munich consisting of a two-armed device with two a) MIRO Surge-robot for laparoscopic surgery (German manipulators and a semi-flexible telescope (Fig. 3c). Aerospace Centre, Germany): Three lightweight Both manipulators are partially automated and robotic arms are mounted to the operating table with controlled over a real-time Matlab-Simulik motorized MICA instruments. Console with application. Two joysticks are used as human machine auto-stereoscopic monitor and handles with interfaces using Bowden-wires. The device is mainly force-feedback. applied experimentally for LESS. b) Telelap ALF X (Sofar, Italy): Robotic four arm system

1a

1b

AMADEUS RSS (Titan Medical, Toronto, Canada) also reached only experimental level. The device showed similarities to the Da Vinci-design with a console and 3 robotic arms. This might be the main reason, why in 2013 Titan Medical stopped the development of AMADEUS RSS.

IREP (Insertable Robotic Effectors Platform) is currently developed at Vanderbilt University consisting of a 3D-telecope and two flexible arms with snake segments design providing a passive and active segment (Fig. 3d). Enlargement of working space may be provided based on parallelogram instrument design. The device is operated by two hand-pieces and a 2D-monitor not comparable to a surgical console.

with instruments mounted on 2 carts. Console with 3D-Monitor requiring polarizing glasses like for laparoscopy c) Raven Surgical Robot: 7-DOF cable-actuated surgical manipulator. Software of robot is compatible with open source robotics coding platform. Two handles via standard 2D-videoscreen manipulate robotic arms. d) SOFIE (Surgeon's Operating Force-feedback Interface Eindhoven): Three different robotic arms with maximally 8 DOF can be fixed to the operating table.

3a

3b

3c

3d

3e Fig. 3: Devices for robotic single-port surgery a) SurgiBot (Transenterix, USA): Robotic arms may compensate for most of the deficiencies of Spider platform, such as optimal fixation, handling of instruments, integration of 3D-telescope, and adjustable motion scaling. b) SPRINT-robot developed in the framework of ARAKNES-project: Remote console with 2d-screen and two robotic arms with rotating grippers on the end. Control motors are external thus allowing for a smaller access port of end-effectors. c) Highly Versatile Single Port System (Technical University Munich, Germany: Two-armed device with two manipulators and a semi-flexible telescope. Both manipulators are partially automated and controlled by two joysticks using Bowden-wires. d) Insertable robotic effector platform (IREP; Vanderbilt University, USA): Movements of platform based on parallelogram-design and snake like arms of end-effectors The device is operated by two handpieces and a 2D-monitor actually not comparable to a surgical console (Courtesy of D. Herrel). e) SPORT Titan Medical, Canada: A console offers 3D-HD-vision and a manipulator at the bedside to perform the procedure. 3D-flexible telescope with fibre-optic based illumination and two flexible instruments. Experimental nephrectomy (dissection of renal vein). Note the use of additional instrument/ trocar for retraction of the kidney.

The design of Da Vinci-systems proved to be very ergonomic and efficacious. Beside cost-issues, there are no doubts about applicability of this advanced technology to achieve similar functional and oncologic results compared to open or laparoscopic surgery with proven advantages of better ergonomics and shorter learning curve for the surgeon, less morbidity for the patient, and thus better long-term outcomes for health care systems. All other developments will have to stand the test of time: Most of the developments are focussing on LESS, where ideal indications like cholecystectomy are not frequent in Urology. Using SP-Platform, Kaouk et al. needed additional ports in 4 of 11 robotic LESS-prostatectomies. Reduced working space will also become an issue. One can hardly assume, that such devices will become routine for radical prostatectomy. Likewise, advocates and developers of such devices assume that mechatronic support tools solving currently existing barriers to NOTES remain to be closer to vision than to reality. What about console-based robotic devices. There are several ways to improve the design of robotic arms (i.e. light-weight, smaller size, mounted to OR-table, tactile-feedback of instruments, motorized arms), however, da Vinci-console provides a perfect design. Thus, all proposed solutions have to be assessed critically. However, endourology may really benefit from such developments e.g. when using robotassisted flexible ureteroscopy. This article has been shortened due to space constraints. The full two-page article is available in PDF at EUT@uroweb.org. European Urology Today

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7th European Multidisciplinary Meeting on Urological Cancers 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

Optimising opportunities in multidisciplinary care 12-15 November 2015, Barcelona, Spain

Scientific Programme EMUC2015 is held in conjunction with: Thursday, 12 November

12.25-12.40

Medical psychologist - F. Mols, Tilburg (NL) Update on clinical trials in prostate cancer Chair: P. Ghadjar, Berlin (DE)

08.30-18.00

4th Meeting of the EAU Section of Urological Imaging (ESUI)

12.40-13.55 12.55-13.55

Lunch and poster viewing Industry session Astellas

08.30-17.30

ESO Conference - Personalised approach to prostate cancer management

13.55-14.10

14.00-17.00

European School of Urology

Best of Journals: Medical oncology Chairs: Medical oncologist - A. Necchi, Milan (IT) Medical oncologist - J. Oldenburg, Oslo (NO)

14.10-15.25

Metastatic kidney cancer Chairs: Radiation oncologist - G. De Meerleer, Ghent (BE) Urologist - M. Kuczyk, Hanover (DE) Medical oncologist - S. Osanto, Leiden (NL)

Friday, 13 November

ESU-ERUS Hands-on Training Courses Saturday, 14 November Workshop Falcon ESU-ERUS Hands-on Training Courses Sunday, 15 November Young Academic Urologists Meeting

14.10-14.25 14.25-15.25

Friday, 13 November 08.15-08.25

08.25-10.50

08.25-08.45 08.45-09.05

09.05-09.25 09.25-09.45 09.45-10.20

10.20-10.40

10.40-10.50

What’s new in prostate cancer? From epidemiology to genomics Chairs: Medical oncologist - J. Bellmunt, Boston (US) Radiation oncologist - M. Bolla, Grenoble (FR) Urologist - R. Karnes, Rochester (US) The changing landscape of prostate cancer epidemiology TBC Is Gleason score outdated? The new prognostic grading system Pathologist - R. Montironi, Torette di Ancona (IT) Use of MRI-guided biopsy: A real step forward? TBC Genomics: When and for whom Urologist - J. Catto, Sheffield (UK) Clinical case discussion on “locally advanced” prostate cancer Case presenter: Urologist - G. Giannarini, Udine (IT) Medical oncologist - C. Massard, Villejuif (FR) Radiation oncologist - P. Ost, Ghent (BE) Radiologist - H. Thoeny, Berne (CH) Urologist - K. Touijer, New York (US) State of the art lecture: Next generation pathology: Predicting clinical course and targeting disease causation Chair: Medical oncologist - C.N. Sternberg, Rome (IT) Pathologist - C. Cordon-Cardo, New York (US) RA 223: From clinical to real live practice Oncologist - J. Charles, Barcelona (ES)

10.50-11.10

Coffee break and poster viewing

11.10-12.40

Prostate cancer in the young patient Chairs: Medical oncologist - S. Osanto, Leiden (NL) Radiation oncologist - R. Valdagni, Milan (IT) Urologist - M. Wirth, Dresden (DE)

11.10-11.25 11.25-11.40 11.40-11.55 11.55-12.10 12.10-12.25

32

Welcome and Introduction Medical oncologist C.N. Sternberg (ESMO) Radiation oncologist P. Poortmans (ESTRO) Urologist H. Van Poppel (EAU) Radiologist H. Thoeny (ESUR) Pathologist A. Lopez-Beltran (ESP/ ESUP)

Biomarkers at young age: PSA and beyond Biostatistician- A. Vickers, New York (US) The role of screening in younger patients Urologist - M. Roobol, Rotterdam (NL) Is active surveillance too risky in young men? Urologist - C. Bangma, Rotterdam (NL) The perfect curative treatment at long term: What can we achieve? Urologist - R. Karnes, Rochester (US) Long-term survivorship and quality of life after curative treatment

European Urology Today

Coffee break and poster viewing

16.00-16.40

Update on systemic treatments in bladder cancer Chairs: Medical oncologist - J. Bellmunt, Boston (US) Urologist - H. Van Poppel, Leuven (BE)

16.10-16.20 16.20- 16.30 16.30-16.40 16.40-17.20

10.20-10.35 10.35-10.50 10.50-11.05 11.05- 11.20

Peri-operative chemotherapy Medical oncologist - C.N. Sternberg, Rome (IT) Targeted therapies Medical oncologist - M. De Santis, Vienna (AT) Immune therapy Medical oncologist - T. Powles, London (GB) Discussion Testis cancer session Chairs: Urologist - N. Mottet, Saint-Étienne (FR) Medical oncologist - A. Necchi, Milan (IT)

Coffee break and poster viewing

11.50-12.50

MDT case of patient with muscle invasive bladder cancer with minimal nodal invasion Chairs: Clinical oncologist - R. Huddart, Sutton (GB) Radiation oncologist - B. Jereczek-Fossa, Milan (IT) Urologist - G. Thalmann, Berne (CH) Case presenter YAU: Urologist - E. Xylinas, Paris (FR) Radiation oncologist - A. Kiltie, Oxford (GB) Pathologist - A. Lopez-Beltran, Lisbon (PT) Radiation oncologist - L. Moonen, Amsterdam (NL) Medical oncologist: TBC Urologist - A. Stenzl, Tubbingen (DE)

12.50-13.05

Best of journals: Surgery Chairs: Urologist - F. Montorsi, Milan (IT) Biostatistician - A. Vickers, New York (US)

13.05-14.20 13.20-14.20

Lunch and poster viewing Industry session sanofi

14.20-15.10

Kidney cancer: Novel approaches in advanced renal cancer Chairs: Urologist - A. Minervini, Florence (IT) Urologist - P. Mulders, Nijmegen (NL) Medical oncologist - T. Powles, London (GB)

14.20-14.30 14.30-14.40

17.10-17.20

Optimal imaging for disease recurrence Radiologist: M. Bertolotto, Trieste (IT) Management of residual masses after RPLN Urologist - V. Matveev, Moscow (RU) Report from ICUD Medical oncologist - J. Oldenburg, Oslo (NO) Discussion

17.30-18.30

Industry session Bayer Healthcare

15.00-15.10

16.40-16.50 16.50-17.00 17.00-17.10

14.40-14.50 14.50-15.00

Oral presentations of the 6 best abstracts Chairs: Medical oncologist - M. De Santis, Vienna (AT) Radiotherapist - C. Cozzarini, Milan (IT) Urologist - F. Sanguedolce, London (GB)

09.10-09.20

Announcement 3 best unmoderated posters Chairs: Medical oncologist - T. Powles, London (GB) Urologist - J. Walz, Marseille (FR)

09.20-11.20

Bladder cancer: Management of carcinoma in situ Chairs: Medical oncologist - TBC Urologist - P. Gontero, Turin (IT) Urologist - M. Rouprêt, Paris (FR)

09.20-09.35

Update on the genome cancer atlas Urologist - S. Lerner, Houston (US) Optimal management of carcinoma in situ The role of Hexvix Urologist - F. Witjes, Nijmegen (NL) The optimal conservative management for CIS Urologist - L. Martínez-Piñeiro, Madrid (ES)

09.35-09.50 09.50-10.05

Vaccine therapies TBC Understanding the immunology of advanced RCC: The role of checkpoint inhibitors Medical oncologist - D. McDermott, Boston (US) Tumour response assessment Urologist - J. Bedke, Tübingen (DE) Update on neo-adjuvant and adjuvant therapies Urologist - A. Bex, Amsterdam (NL) Discussion

15.10-16.00

Rare kidney tumour session Chairs: Urologist - U. Capitanio, Milan (IT) Pathologist - E. Compérat, Paris (FR) Urologist - M. Hohenfellner, Heidelberg (DE)

15.10-15.20

Can a radiologist influence treatment approach? TBC Rare tumours Medical oncologist - G. Malouf, Paris (FR) Hereditary cancers Pathologist - G. Martignoni, Verona (IT) Discussion Ongoing clinical trials in kidney cancer Medical oncologist - S. Osanto, Leiden (NL)

Saturday, 14 November 08.30-09.10

Pathology features with prognostic implications Pathologist - E. Compérat, Paris (FR) Biomarkers in non-muscle invasive bladder cancer Urologist - M. Ribal, Barcelona (ES) What can we ask to imaging in non-muscle invasive bladder cancer? Radiologist - V. Panebianco, Rome (IT) Surgical management: Oncological outcomes and follow-up Urologist - C. Stief, Munich (DE) Update on clinical trials in urothelial carcinoma Urologist - S. Shariat, Vienna (AT)

11.20-11.50

Intratumoral heterogeneity in kidney cancer Medical Oncologist - Samra Turaljic, London (GB) Clinical case discussion on metastatic RCC Case presenter: Urologist - A. Volpe, Novara (IT) Radiologist - G. Heinz-Peer, Saint Poelten (AT) Pathologist - F. Algaba, Barcelona (ES) Medical oncologist - L. Albiges, Villejuif (FR) Urologist - V. Matveev, Moscow (RU) Radiotherapist - C. Cozzarini, Milan (IT)

15.25-16.00

16.00-16.10

10.05-10.20

15.20-15.30 15.30-15.40 15.40-15.50 15.50-16.00 16.00-16.20

Coffee break and poster viewing

16.20-16.50

Late breaking news Chairs: Urologist - P-A. Abrahamsson, Malmö (SE) Radiation oncologist - P. Poortmans, Nijmegen (NL)

16.50-17.10

Best of journals: Radiotherapy Chairs: Radiation oncologist - P. Poortmans, Nijmegen (NL) Radiation oncologist - G. De Meerleer, Ghent (BE)

17.10-17.25

State of the art lecture on genomics/ personalised medicine Chair: Urologist - A. Briganti, Milan (IT) Speaker: TBC

17.25-18.05

Management of upper urinary tract transitional cell carcinoma Chairs: Urologist - S. Shariat, Vienna (AT) Urologist - J. Walz, Marseille (FR)

17.25-17.35

17.55- 18.05

When is organ sparing allowed? Urologist - M. Rouprêt, Paris (FR) Role and extent of lymph node dissection during nephroureterectomy Urologist - M. Brausi, Modena (IT) When and how to use chemotherapy Clinical oncologist - R. Huddart, Sutton (GB) Discussion

18.15-19.15

Industry session Janssen

17.35- 17.45 17.45-17.55

Sunday, 15 November 09.15-09.25

Announcement 3 best unmoderated posters Chairs: Radiologist - H. Thoeny, Berne (CH) Urologist - B. Tombal, Brussels (BE)

09.25-11.15

Prostate cancer: Oligo-metastatic disease Chairs: Medical oncologist - TBC Clinical oncologist - TBC Urologist - F. Montorsi, Milan (IT)

09.25-09.40

When science meets the clinics: The rationale beyond cytoreductive approaches in prostate cancer A. Bjartell, Malmo (SE) Management of oligo-metastatic prostate cancer Clinical case presented by Urologist - C. Surcel, Bucharest (RO) Clonal heterogeneity and prostate cancer metastases TBC What can surgery offer? Urologist - S. Joniau, Leuven (BE) Optimal radiotherapy for imaging detected recurrence Radiation oncologist - A. Bossi, Villejuif (FR) Optimizing hormonal manipulation Urologist - B. Tombal, Brussels (BE) Docetaxel: From the start? TBC

09.40-10.00

10.00-10.15 10.15-10.30 10.30-10.45 10.45-11.00 11.00-11.15 11.15-12.05 11.15-11.25 11.25-11.35 11.35-11.45 11.45-11.55 11.55-12.05

Take home messages Radiologist H. Thoeny, Berne (CH) Urologist A. Briganti, Milan (IT) Medical oncologist S. Osanto, Leiden (NL) Radiation oncologist A. Bossi, Villejuif (FR) Pathologist A. Lopez-Beltran, Lisbon (PT)

12.05-12.15

Closing remarks Medical oncologist C.N. Sternberg (ESMO) Radiation oncologist P. Poortmans (ESTRO) Urologist H. Van Poppel (EAU)

New levels of interactivity with the IML Connector • Message the session chairman • Cast your vote

June/July 2015 www.emuc15.org


High hopes for advances in bladder cancer treatment 7th EMUC: Focus on best practices in multidisciplinary care By Joel Vega

that multi-disciplinary collaboration plays in delivering optimal treatment.

Cancer experts have high hopes for advances in bladder cancer treatment despite the widespread perception among medical professionals that studies on the deadly disease are fewer compared with other onco-urological malignancies such as prostate cancer. At the upcoming 7th European Multidisciplinary Meeting on Urological Cancers (EMUC) in Barcelona, Spain from November 12 to 15, onco-urological experts from and outside Europe will again gather to tackle challenging treatment issues in urological malignancies and identify best practices in multidisciplinary care. Organised by three front-line professional organisations- the European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU)- the EMUC provides a platform for various cancer experts where they can share insights and exchange knowledge on how best to deliver optimal care. Bladder cancer (BCa), which in recent years have shown high mortality rates in Europe and elsewhere, is one of the key topics in the four-day meeting, with diagnostics, medical and surgical therapies among the major points in the agenda. In Europe bladder cancer is considered the fifth most common cancer with more than 151,000 new cases diagnosed in 2012, compared to around 60,000 new cases of bladder cancer diagnosed annually in the United States, or approximately 13,000 deaths every year. “I expect much more (developments) in the field of non-muscle invasive bladder cancer (NMIBC) compared to muscle invasive bladder cancer (MIBC). Actually NMIBC is our real challenge in daily practice in the western world,” said Prof. Morgan Roupret (Paris, FR) who will deliver an update lecture on BCa treatment strategies. “With the advent of new technologies combined with endoscopic access to the bladder for easier diagnosis, better treatment becomes a reality.” Currently, the combined use of 5-ALA (Hexvix) and blue light cystoscopy is of great help to depict and detect more flat lesions in daily practice. However, he expects even more advances ahead mentioning technologies

Prof. Morgan Rouprêt

such as in-vivo non-contact and ultraviolet excited autofluorescence measurements that are converted into simple color-coded images-- diagnostics that improve or provide more efficient current detection methods. “It is already a reality. If this is converted from bench-to-beside, this will not only avoid bladder instillation but also depict flat lesion and provide direct endoscopic diagnosis,” he added. But there are tough challenges ahead since bladder tumours have high recurrence rates that are often deadly, prompting doctors to resort to more radical treatment options. “Some of the current challenges in bladder cancer management are to increase the detection of nonmuscle invasive bladder cancer and especially flat lesions, to reduce residual tumours, reduce recurrence rate and to enhance the quality of the follow-up,” Roupret explained.

worldwide,” he said. “The meeting is an opportunity to gain experience, updates and key messages from the best of the best, and from a multidisciplinary perspective on how to deal with difficult cases. In fact, all the cases for which you cannot find a solution with currently available clinical EAU guidelines and which could only lead to a dead end.”

“If we want to provide symptom control whilst respecting patients’ co-morbidities, a ‘tailor-made’ treatment is mandatory,’ said Roupret. “This personalised medicine cannot be fulfilled without the help of other colleagues and clinicians in the field who are likely to bring their own perspective and strategy.” This year, and for the first time, the European School of Oncology (ESO) will also hold during the EMUC the ESO Interdisciplinary Conference to examine insights He is convinced that collaborative links are key to achieve the most efficient way to improve patient care. on personalised approaches to prostate cancer management. Also to be held on the EMUC’s opening “Bottom line is I only see positive aspects in day on November 12 is the 4th EAU Section of multidisciplinary team decisions,” he said while Urological Imaging (ESUI) meeting with “Imaging and underscoring that effective treatment hinges on close Individualised Medicine” as theme. coordination among experts. “It is necessary to establish a coherent strategy, follow the evidence and Courses organised by the European School of Urology consider the experience of other experts which can (ESU) will also complement the Scientific only raise the level of medical care.” Programme’s focus on the medical treatment of metastatic kidney and castrate resistant metastatic Regarding the role of meetings like the EMUC, prostate cancer, future prospects and the impact of Roupret noted the vital role of organising meetings the latest outcomes from research studies. that are focused on specific areas of expert care. For details on the EMUC’s Scientific Programme, visit the meeting website at “EMUC is, in fact, a "super multi-disciplinary team" and expert meeting that involve the best experts www.emuc15.org/scientific-programme

“The detection of carcinoma in-situ (i.e. flat lesion) can be improved due to technological advances and recent discoveries in molecular knowledge of carcinoma in-situ,” he added, noting that the challenge for specialists, such as urologists, is proper diagnostics and assessment of individual cases. “After initial diagnosis of non-muscle invasive bladder cancer (NMIBC), up to 70% of these tumors are likely to recur. Urologists have to understand that the risk stratification is crucial and these tumours are often misclassified. Keep in mind that over 40% of NMIBC are multi-focal at initial diagnosis,” according to Roupret. Crucial role With treatment in the hands of many cancer experts such as medical oncologists, radiotherapists and urologists, Roupret acknowledged the crucial role

Last year’s 6th EMUC in Lisbon, Portugal

Brief overview of modern urolithiasis treatment 3rd EULIS Postgraduate Workshop on Urolithiasis in Budapest Prof. Peter Nyirády Semmelweis University Dept. of Urology Budapest (HU)

diagnosis, prevention and treatment of urolithiasis were conducted in a very comprehensive manner that gave participants an overall knowledge where we are today in managing stone diseases.

The first day started with a presentation on metabolic analysis, prevention and conservative treatment given by Dr. Csaba Horváth (Budapest), focusing mainly on stone disease from the internists’ perspective. Dr. nyirady.peter@med. Klára Agócs (Budapest) discussed anticoagulation, semmelweis-univ.hu supine vs. prone position and general vs. spinal anesthesia from the anesthetists’ point of view. Prof. The Department of Urology of Semmelweis University Péter Tenke (Budapest), chairman of the Hungarian Association of Urology, lectured on infectious collaborated with the Hungarian Association of complications and prevention, followed by Dr. Miklós Urology to hold the 3rd EULIS Postgraduate Workshop on Urolithiasis in Budapest from April 10 to Merksz (Budapest), who discussed paediatric stone disease. 11 this year. The event involved many internationally acclaimed specialists such as EULIS Chairman Prof. Kemal Sarica (TR) and Professors Palle J. Osther (DK), Cesare Marco Scoffone (IT), Cecilia Cracco (IT), Andreas Gross (DE), Christian Seitz (AT), Olivier Traxer (FR) and András Hoznek (FR), together with participants from 12 countries. To organise and present comprehensive updates on urolithiases, the local scientific committee had the benefit of attracting some of the best European specialists. From the welcome remarks by Prof. Péter Nyirády as local organiser, Prof. Péter Tenke as the president of the Hungarian Urological Society and Prof. Kemal Sarica as EULIS chairman, until the very end, the presentations covering the background, EAU Section of Urolithiasis (EULIS)

June/July 2015

Dr. Gergely Bánfi (Budapest) gave an overview on ESWL, followed by the Nightmare Session which tackled some very interesting and challenging cases. After the lunch break Dr. Zsolt Szepesváry (Györ) discussed new technical modalities in the surgical treatment of stone disease, followed by two presentations by Prof. András Hoznek (Paris – Créteil) on the evolution of puncture techniques during PCNL and PCNL

miniaturisation. Prof. Sarica discussed residual fragments and showed an impressive video on the use of robots in treating stone disease. The day ended with Prof. Christian Seitz (Vienna) discussing metabolic analysis and conservative treatment from the urologists’ point of view. Debates The second day opened with a debate on prone vs. supine position during PCNL, with Prof. Andreas Gross (DE), supporting prone and Prof. Cesare Marco Scoffone (IT) arguing for the supine position. Both speakers gave strong arguments. Prof. Traxer discussed the present role of flexible ureteroscopes and the optimisation of lasers during surgical treatment of stone disease. Prof. Osther

Photo 1: Prof. Sarica welcomes the participants of the Postgraduate Workshop on Urolithiasis

presented the pathophysiological aspects of ureterorenoscopy, followed by Prof. Andreas Gross who lectured on treatment options for ureter stones. Dr. Ákos Tordé (Budapest) gave an overview of stone disease in pregnant women, followed by a lecture from Prof. Cecilia Cracco on combined intrarenal surgery. Dr. Pál Bata (Budapest) presented the radiological aspects and the workshop concluded with a debate on lower pole stones: Dr. Attila Szendröi (Budapest) argued for ESWL against Dr. Ákos Tordé who supported endourology.

Photo 2: The faculty of the 3rd EULIS Postgraduate Workshop in Budapest

Finally, Prof. Nyirády, head of the Urologic Department of Semmelweis University and EULIS chairman Prof. Sarica gave their closing remarks in the well-attended concluding session. Participations expressed their appreciation of the expert updates regarding new treatment modalities and the latest developments on operation techniques for stone disease. European Urology Today

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ERUS15

#erus15

12th Meeting of the EAU Robotic Urology Section 15-17 September 2015, Bilbao, Spain Basic and Advanced ESU-ERUS Hands-on Training courses available!

Robotic Urology in Bilbao at ERUS15 An interview with the local organising committee Robotic surgery is a growing area within urology, and the popularity of the EAU Robotic Urology Section’s annual meetings are a clear reflection of this. After a successful 2014 meeting in Amsterdam, ERUS is heading to warmer climes in Bilbao, in Northern Spain’s Basque Country. From 15 to 17 September, attending urologists can expect a comprehensive scientific programme featuring live surgery, hands-on training and a special programme for young urologists. We spoke to the meeting’s local organising committee members, Dr. Ander Astobieta Odriozola (Bilbao, ES) and Dr. José Gregorio Pereira Arias (Bilbao, ES), Head of Urology at Galdakao Hospital. Live Surgery A popular, and indeed major part of the ERUS scientific programme is the live surgery component. Procedures are to be shared between Mottrie, Aalst (BE) The private IMQ Zorrotzaurre Prof. ClinicAlex and Cruces University Hospital. Chairman Astobieta: “Each hospital willERUS perform half of the surgeries to be done during the meeting. We will see radical prostatectomies, with some different modifications, radical cystectomies and the derivations, and a Focal HIFU for localized prostate cancer treatment.” Pereira: “It’s promising to be a very interesting showcase with world robotic surgeons experts in Robotic radical prostatectomy in complex cases, partial robotic nephrectomies with Firefly system, Robotic radical cystectomy, robotic sacrocolpopexy, and special indications. If feasible, this will mark the first time a robotic kidney transplantation will be demonstrated through live surgery.” The meeting is set to

receive EAU approval for live surgery, guaranteeing highest standards of patient safety. Young Urologists Recent research shows that robotic skills are more easily mastered by urologists under forty. The Junior ERUS – Young Academic Urologists meeting, part of ERUS15 highlights their needs. Pereira: “Beginners are interested in how to deal with complications, tips and tricks in complex robotic surgery, how to standardize robotic procedures, and learning curves.” “The Junior ERUS meeting is a vital part of ERUS schedule and of paramount interest. Junior robotic surgeons have their chance to communicate their experience and even create a contact net between them to warrant future cooperation. So robotic surgery is not only here to stay, but it will be developed by this young generation.” Robotic Urology in Spain Pereira: “Robotic surgery in Spain started in July 2005. We’ve been following the lead of the Puigvert Foundation in Barcelona and cooperating with different groups along the country in their beginning. Since then, around 30 Da Vinci Systems have been installed in our country, and robotic surgery interest is increasing in recent years. We have organized local meetings of robotic surgery in our institution, and nowadays we have six Da Vinci systems for two and a half million inhabitants in Basque country. So we felt it was the right moment for the ERUS meeting to come to Spain.”

“Even taking into account the limited financial resources, particularly in the Public Health System, robotic urology surgery in Spain is here to stay. We can observe multiple publications about robotics in our Spanish Urology Association annual congress and through arranging the ERUS meeting in Bilbao we hope to create a starting point for Spanish urologists to participate with and lead in the EAU Robotic Urology Section.” Bilbao Pereira: “When we’ve accomplished our scientific goals with the ERUS meeting, I invite everyone to enjoy our hospitality, gastronomy and architecture. You’ll find that Bilbao’s blending of classical and modern is what makes so special, from the Casco Viejo (old quarter) to Bilbao’s crown jewel: the Guggenheim Museum.” “Don’t miss Bilbao´s gastronomy! The Basque Cuisine is one of the most highly rated in Spain, with more than 20 Michelin stars distributed among several restaurants, including 4 with 3 stars. This is just a selection of everything you can learn, see and do during this year’s ERUS so book your place now! We’ll be waiting for you in Bilbao, eskerrik asko!”

Late fee registration deadline: 31 August 2015

For more information and the preliminary scientific programme, please visit 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

ESUI goes to Barcelona Is PET a game-changer in PCa management? PET scanning is a hot topic in uro-oncology and especially in prostate cancer it is becoming more popular. At the forthcoming 4th EAU Section of Urological Imaging (ESUI) Meeting to be held in Barcelona on November 12, and in conjunction with the 2015 EMUC meeting, the role of PET scanning in prostate cancer therapy will be closely examined. In a joint session of the ESUI with the European Association of Nuclear Medicine (EANM) with “Molecular Imaging in Urology” as theme, a pointand-counterpoint discussion will focus on the value of PET scanning in prostate cancer (PCa) management. Recent studies show that in initial staging the use of PET is limited by the relatively high false negative rate due to the small dimension of neoplastic lesions and the low spatial resolution of PET tracers. However, in the restaging setting for patients with biochemical recurrence, choline PET/ CT may visualize the site of recurrence earlier and with higher accuracy than conventional imaging modalities. Other tracers such as FACBC and Ga-PSMA are emerging in recent literature with preliminary promising results. The information gained with PET/CT in this clinical setting has the potential to change disease management.

effective, especially when it comes to salvage radiotherapy after radical prostatectomy. Moreover, studies that thoroughly used histology to validate PET findings show a high number of false negative and false positive findings. As a result, the value of PET in the clinically relevant PSA ranges has little potential to change the management. A critical discussion on the performance of PET in prostate cancer management is necessary to differentiate hype from scientific evidence. The ESUI has invited two experts who will highlight their point of view on PET and demonstrate why they think this imaging tool really changes PCa management or has no meaningful impact at all. The usefulness of PET/CT in managing prostate cancer is supported by studies demonstrating that choline PET/CT has better accuracy to visualize disease relapse than conventional imaging. Several studies reported a sensitivity and specificity to correctly identify relapse in a range of 60-

There is a caveat. PET/CT often remains negative in the early relapse situations when PSA levels are still very low (<1ng/ml). Unfortunately these levels are the “window” where salvage treatment will be most

Riccardo Schiavina (IT), University of Bologna

Lars Budaeus (DE), Universitätsklinikum Hamburg-Eppendorf

100% and 66-98%, respectively. Choline PET/CT has also opened new therapeutic options such as salvage lymphadenectomy or salvage LN irradiation. Riccardo Schiavina (IT) will argue in favor of PET/CT MRI as a helpful tool in restaging prostate cancer. Arguments against such a capability is backed by studies that show very low rates of lesion detection at early biochemical recurrence in PSA ranges <0.5ng/ml, where only 5-8% of PET/CTs are positive. Even at PSA levels <1ng/ml only 5-20% of PET/CT are positive. Moreover, studies that evaluate PET/CT findings with extended salvage lymph node dissection (an experimental treatment approach), show false positive results of PET/ CT in up 42% of patients, resulting to a large overestimation of disease stage and extent. These studies also show a high rate of false negatives of 61 to 79%. Regarding the role of new tracers, results are by far coming from single-centre experiences and require confirmation. Lars Budäus (DE) will argue against PET/CT as a helpful tool and will present his centre’s experiences with Ga- PSMA PET in high-risk PCa patients. This exciting discussion will open the molecular imaging session that will highlight recent developments. During the EMUC meeting several other topics regarding the role of imaging in managing other urological malignancies will also be discussed in their clinical contexts. Join us in Barcelona for the latest updates and fresh insights!

Early registration deadline: 15 August 2015

For programme information and registration please visit www.esui15.org 34

European Urology Today

June/July 2015


Early fee registration deadline: 22 July 2015

EULIS15

#EULIS15

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

Collaboration is crucial in stone management 3rd EULIS Meeting to boost links with kidney specialists Boosting collaborative work and bringing the latest updates in stone management will top the agenda of the 3rd EAU Section of Urolthiasis (EULIS) Meeting to be held in Alicante, Spain, from 10-12 September. “For the first time we are pushing for a closer collaboration with our nephrologist partners through Prof. Kemal Sarica, a joint session with European Renal AssociationChairman EULIS European Dialysis & Transplant Association (ERAEDTA). This meeting will be the first one to initiate closer collaboration between EULIS and partner societies,” said Prof. Kemal Sarica, EULIS chairman. Sarica stressed that stronger links with specialised societies such as nephrologists across Europe is important since consensus in treatment will ultimately bring benefit to stone patients through optimal care anchored on evidence-based approaches. “A strong collaboration between societies and consensus in shared approaches in the diagnosis, management and follow-up of stone-forming patients will certainly speed up the innovations in pathophysiology, management and medication of stone disease,” Sarica said.

The bi-annual meeting, which followed two editions held in London and Copenhagen in 2011 and 2013, respectively, will also present for the first time unedited video presentations that will highlight innovative surgical approaches. The video sessions will be complemented by state-of-the-art lectures to prompt discussions. One of the featured lectures, a critical look on technology-driven innovations, will be the Endourological Society lecture by As. Prof. Evangelos Liatsikos (GR) titled “Standard, mini, ultra-mini, super-mini, micro PNL: Do we need all this stuff?” The opening session will bring participants the most recent updates and discussions on controversial topics in stones, with expert opinion leaders sharing their insights and findings. Sarica said not only did the organisers re-formatted the programme but have also focused on educational goals such as simulation training in endourology to highlight the role of an integrated and standardized educational training programme for urology residents. From plenary sessions and round-table discussions, workshops, poster and video sessions, and thematic discussions are lined-up for the threeday event, covering key aspects in modern stone management.

For details on registration and the scientific programme, visit the meeting website at: www.eulis15.org

6th International Congress on the

History of Urology In conjunction with EAU16 11 March 2016, Munich, Germany

Prof. F. Debruyne Honorary Congress President

Discover the worldwide roots of urology The EAU History Office, together with a diverse scientific committee is currently compiling a full-day scientific programme for the 6th International Congress on the History of Urology. The Congress will take place on 11 March 2016, on the first day of the 31st Annual EAU Congress in Munich. Attendance is free of charge for all delegates attending the main Annual Congress.

Speakers from around the world are being considered for the programme, which is divided into four topics: • Worldwide roots – international contributions to early urology • Politics – the establishment of societies, standards and regulation • Pioneers – the personalities and stories behind innovators of the field • Sex around the world – attitudes and practices across the globe

The greatest challenge in the history of urology has been to visualise the urinary tract through the natural orifice of the urethra. In this paper we describe early pioneers of endoscopy in the British Isles, how they were influenced by the progressive evolution of endoscopy on the Continent and how they subsequently influenced the progression to modern cystoscopy. We also examine how this new technology was introduced into urological practice in the British Isles.

Registration for EAU16 opens on 1 October 2015. Please keep checking eau16.org for the latest information on the scientific programme of EAU16 and the 6th International Congress on the History of Urology. The adjacent picture of the Bozzini Light Conductor is a sample from this year’s volume of De Historia Urologiae Europaeae, which illustrates the international roots of our field: The Introduction of the Cystoscope into the British Isles By Jonathan Patrick Noël and Jonathan Charles Goddard, University Hospitals of Leicester NHS Trust, Leicester General Hospital

in conjunction with

June/July 2015

The Bozzini Light Conductor from The European Museum of Urology: history.uroweb.org

Light From ancient times healers have been able to access the bladder via the urethra but this was done blindly, the skill was a tactile one; they couldn’t see. The advance of endoscopy was hampered by the lack of illumination in the deep cavities of the body; much of the history of cystoscopy is the story of the manipulation of light. The well-recorded history of cystoscopy has always focused, rightly, on continental Europe and it is usually accepted that the Lichtleiter of the German-Italian Philip Bozzini was the first endoscope. In 1806, Philip Bozzini (1773-1809) of Mainz conceptualised the Lichtleiter that used an in-built beeswax candle with adjustable viewing ports to perform basic endoscopy of body cavities including the urethra. In 1826, Pierre Sègalas (1792–1874) in France attempted to improve on the Lichtleiter, not least by adding a second candle. In America, John Fisher (1798-1850) of Boston also described a candle-powered endoscope. In 1844 John Avery, a surgeon at Charing Cross Hospital London, presented the British attempt at candlelit endoscopy. He increased the illumination of the candle using a modified Palmer’s lamp reflector. This device was used by miners on their hats to reflect and focus light and was adapted by Avery. It consisted of a concave reflector with a perforation, worn by the surgeon to redirect candle light down a Bozzini inspired speculum. This not only allowed visualisation of the urethra but could be used in otolaryngology cases as well. We hope to have piqued your interest! You can read the full article in De Historia Vol. 22, and enjoy similar presentations at the 6th International Congress on the History of Urology in Munich.

www.eau16.org European Urology Today

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Call for applications for Chairman of the EAU Section Office Chairman will serve a four-year term, once renewable, from March 2016 The EAU represents the leading authority within Europe on urological practice, research and education. Over 15,000 medical professionals have joined its ranks and help to create forward-looking solutions for continuous improvement, professional growth and knowledge sharing. The EAU delivers training, stimulates research and broadcasts information. The EAU’s scientific publications encourage discussion and its expert recommendations guide urologists in their every-day practice. The aims and objectives of the Association are: • to act as the representative body for European urologists and facilitate the continued development of urology and all its superspecialities; • to foster the highest standards of urological care throughout Europe; • to encourage urological research and enable the broadcasting of its results; • to promote contributions to the medical and scientific literature by its members; • to promote European urological achievements worldwide; • to establish standards for training and European urological practice; • to contribute to the determination of European urological health care policies;

The EAU Section Office will be composed of 1 Chairman and a minimum of 5 members and ex officio the Adjunct Secretary-General - Science. Any of the Executive Committee members may serve as an ex officio member of this office. • EAU Section Office: consists of the Chairmen of each Superspecialistic Section and is chaired by a Chairman, represented in the EAU Board which is consisting of the Chairmen of all EAU Offices and the EAU Executive • EAU Superspecialistic Section: group of experts with particular expertise and interest in a specific superspecialistic field of urology chaired by one Chairman (represented in the EAU Section Office) and a maximum of 9 Superspecialistic Section Board members. • A Superspecialistic Section may accept Associates on basis of approved application. The Associates choose (vote for) the members of the Superspecialistic Section Board. • Each section has at least one YAU Member as an ex-officio member. If a member of any office or committee fails to attend meetings on a regular basis without the agreement of the Chairman or does not reply within a reasonable period of time to the request of the Chairman, he can be asked to resign after a decision of the Chairman.

Should a Chairman of an office fail to meet the • to disseminate high quality urological information responsibilities which, within reason, are inherent to patients and public. to this chairmanship, the Executive Committee is entitled to request his/her resignation. A member of the Executive Committee can take over the The EAU Section Office is responsible for the chairmanship, temporarily - or until the expiration development of superspecialistic sections of the term of the Chairman in question. covering all superspecialistic fields of urology. The Chairman shall serve a four- (4-)year term, It develops all necessary scientific and clinical once renewable. programmes to develop and strengthen the urological superspecialistic fields and sections For practical programme execution the office will within the EAU. rely upon the EAU Central Office.

Patient Information Essential tool in your practice

• Jargon-free • Evidence-based

Position Description • Convenes and presides over the Section Office Board meetings and sends out the convocations of the Section Office Board meetings (to be organised at least once a year); • The Chairman is responsible for taking minutes of the Section Office Board meetings and maintains contact with the EAU Executive on all topics considered of relevance; • The Chairman is a member of the EAU Board; • The Chairman is ex-officio member of the Education Office; • The Chairman is ex-officio member of the EAU Guidelines Office; • The Chairman is an ex-officio member of the Scientific Congress Office; • Will ensure proper reporting at all EAU Board meetings and to the EAU Central Office/Executive Manager Operational Affairs about the past and future activities; • Will ensure continuous interaction with the reference EAU Executive member (Adjunct Secretary-General – Science);

• Is responsible for the records and archives of the EAU Section Office; • Holds a list of office members; • Compiles an annual budget and report of expenditures of the office; • Is responsible for the coordination and communication of all activities related to his Office with all those involved in EAU programmes and activities (namely the Education Office, the Guidelines Office, the Scientific Congress Office, the Regional Office, publication and promotional platforms such as EUT, websites, etc.) to ensure and facilitate effective collaboration, avoiding duplication and overlap. • The Chairman will nominate the members of the respective office but the nominations will have to be approved by the Executive Committee; • The Chairman represents the EAU on all occasions in national, international and intercontinental organisations and is responsible for the promotion of the association.

Position Qualifications/Requirements • Must be EAU Active Member, active in the practice of urology. • Must be fluent in English (both oral and written) as the official language of the Association is English. • Should have corporate/board governance experience. • Knowledge of EAU History (e.g., prior Board of Directors member, Section Officer, or experience on EAU committees, etc.). • Must be available for frequent communication with members of the Section Office, Executive, Board and staff via e-mail, fax, phone conference (approximately up to 5 hours per week commitment). • Must meet travel requirement for EAU and other international meetings: • EAU Section Office Board meetings (2 per year) • EAU Board meetings (2 per year) • EAU Scientific Congress Office meetings (2 per year) • EAU Education Office meetings (2 per year) • EAU Guidelines Office meetings (2 per year) • EAU Annual Congress • Other EAU meetings or activities

• • •

• •

(approximately 5 per year; represent Section Office during Fall meetings) • EAU Lectures (upon request of national societies) Should have strong operational skills combined with strategic vision, be dynamic, diplomatic, flexible and able to work under pressure, with impressive communication and language skills as he/she will operate in a multi-cultural environment. Must be effective communicator and express enthusiasm/interest in position. Must regularly compose/review correspondence, articles and reports. Must comply with EAU’s Disclosure and Conflict of Interest Policy, thereby divesting himself/herself of any governance role, consultant or advisor, paid lecturer or paid attendee with Pharma/Medical Device companies prior to and throughout the term of office for this EAU policy-making position. May not serve as Expert Witness (for either plaintiff or defendant) in medical liability cases while a member of the Board of Directors. Must understand that all power rests with the full Board, not individual Board members. Must comply with applicable laws, regulations, bylaws, policies and Code of Ethics.

Application Individuals wishing to apply must submit a Curriculum Vitae along with a personal Statement of Interest indicating their understanding of the position and provide a current Disclosure/Conflict of Interest Statement. Please note that a person may not have a significant conflict as determined by the Board and Executive during his/her tenure as Chairman. Deadline These documents should be forwarded to the EAU at snc@uroweb.org to the attention of the Chairman of the Search and Nomination Committee (SNC) – Prof. Christopher Chapple by 1 September 2015. The EAU Search and Nomination Committee will interview finalists for this position in October 2015.

• Clear illustrations

Chairmen of the Offices are to be approved by a raise of hands of a majority of the eligible members present at the General Assembly in Munich 2016 upon proposal by the SNC.

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36

European Urology Today

D13907-EN

June/July 2015


www.cem15.org

www.seem15.org

CEM15

SEEM15

EAU 15th Central European Meeting

EAU 11th South Eastern European Meeting

2-4 October 2015, Budapest, Hungary

6-8 November 2015, Antalya, Turkey 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

Call for Abstracts

Deadline 1 August 2015

Deadline 1 September 2015 European

European

Association

Association

of Urology

of Urology

ESOU16 13th Meeting of the EAU Section of Oncological Urology (ESOU)

#ESOU16

15-17 January 2016, Warsaw, Poland

Early fee registration deadline: 1 November 2015 Online registration deadline: 11 January 2016

Key updates and insights from Europeâ&#x20AC;&#x2122;s leading opinion leaders The annual ESOU Meeting will present the current state of the art in onco-urology, with particular emphasis on the diagnosis and treatment of cancer. The meeting will give you a unique opportunity to meet international experts in the field of onco-urology and to actively participate in lively discussions and debates. A multidisciplinary approach to cases will be maintained together with debates and videos of surgical procedures. The format of the meeting has changed over the years with the implementation of the STEPS programme (Sessions To Evalute

June/July 2015

ProgresS in the management of urological cancers) directed at a selection of young European urologists particularly interested in onco-urology who will have the opportunity to sit with international experts and discuss prostate, bladder, renal and since last year testis cancer. Hands-on training sessions in robotics have also been introduced into the programme. We look forward to seeing you in Warsaw, a wonderful and charming European city full of history and tradition.

For registration or programme information: www.esou16.org

European Urology Today

37


New EAUN guidelines to benefit bladder cancer patients EAUN workshop to launch new guidelines on bladder instillations Giulia Villa, RN EAUN Board member Milan (IT)

g.villa@eaun.org The chance to participate in developing the EAUN Intravesical instillation in non-muscle invasive bladder cancer guidelines has inspired me since being part of an international group of expert colleagues is a once in a lifetime opportunity! The EAUN, among its many important roles, is active in the development, implementation, and revision of the guidelines used by nurses who work in urology. A lot of work has been done in recent years to assist colleagues with guidelines distribution and implementation. Among the published guidelines, of particular interest are those about intermittent urethral catheterisation in adults, continent urinary diversion and transrectal ultrasound guided biopsy of the prostate. The majority of these guidelines has also been translated to other languages and is periodically submitted to a rigorous process of revision and update. The guidelines are also available free of charge via the EAUN’s website. Holistic nursing care The most recent EAUN guidelines tackled intravesical instillation with mitomycin C and bacillus Calmette-Guérin (BCG) in non-muscle invasive bladder cancer, a topic of debate among nurses, particularly with regards to safety during

treatment and patient education. The skills a nurse must possess to manage this procedure extend beyond the clinical setting but also touch on education and social skills since the treatment pathway also includes the guidance of patients during a treatment course that often takes several weeks (with possible repeat procedures). In the European Union, the age-standardised incidence rate for bladder cancer is 27 per 100,000 for men and six per 100,000 for women (Ferlay et al., 2008a). Bladder cancer incidence has dropped in some registries, possibly reflecting the decreased impact of causative agents, mainly smoking and occupational exposure (Bosetti et al., 2011). Mortality from bladder cancer has also decreased, possibly reflecting an increased standard of care (Ferlay et al., 2008b). Approximately 75% of patients with bladder cancer present with a disease confined to the mucosa (stage Ta, CIS) or submucosa (stage T1). These categories are grouped as non-muscle-invasive bladder tumours. Non-muscle invasive bladder cancer (NMIBC) has a high prevalence due to low progression rates and long-term survival in many cases (Burger et al., 2013). From the prognostic viewpoint, NMIBC falls into one of three categories: low-risk, intermediate-risk and high-risk for progression and recurrence according to the European Organization for Research and Treatment of Cancer criteria (Babjuk et al., 2013). Based on tumour risk category, the EAU Guidelines recommend a specific intravesical treatment (Babjuk et al., 2013).

of the professional based on his experience, enabling him to evaluate and personalise the assistance given to the patient, while considering clinical settings and conditions, patient preferences and available resources. Guidelines development The process of guidelines development began in September 2013, with the creation of the team, coordinated by Susanne Vahr (DK), an expert colleague who has worked on guidelines development, and composed of five other nurses, namely, W. De Blok (NL), B. Thoft Jensen (DK), N. Love-Retinger (US), B. Turner (UK), G. Villa (IT) and urologist Jan Hrbácek (CZ). Each panel member developed a part of the guidelines, which was then shared and discussed with the other members. The final version was then subjected to external blinded review. The written guidelines are made up of three parts. The first part is methodological and explicitly described the process used for writing guidelines and the definitions of terms. The second and principal part included chapters regarding indications and contraindications to intravesical instillation, and the alternatives to the use of bacillus Calmette-Guérin and mitomycin C. These are followed by chapters on care pathway and safety.

In these chapters, the European Safety Regulation, risk factors and exposure are presented, which are very important for the safety of nurses, healthcare workers, and patients. The succeeding chapter focused on education prior to instillation, followed by the management principles on nursing The EAUN guidelines aim to provide recommendations interventions, including insightful recommendations on behavioural conduct, evidence-based and shared for treatment management (patient assessment, by experts for an optimal treatment regimen. These preparation of intravesical medication, recommendations must support the clinical decisions administration, and patient education). The next

chapter explained the recommendations regarding complications and side effects of BCG and mitomycin C, how to reduce risk of side effects and manage side effects. The final chapter summarised the literature on patient quality of life. The third part of the guidelines consists of documents, which help the nurse understand what has to be documented. Aside from examples there is a glossary section with abbreviations and an appendix, including many useful recommendations presented in summary tables and lists, such as a checklist of patient information, management options for side effects (associated with intravesical BCG), examples of training documents, and detailed step-by-step documentation of the procedures for BCG and mitomycin C instillation. Digital copies of the new guideline are available at the EAUN website: http://nurses.uroweb.org/nurses/ guidelines/ and paper copies can be ordered at eaun@uroweb.org. Due to space constraints the reference list has been omitted. Interested readers can send a request for the complete list at EUT@uroweb.org.

EAUN intensifies links

EAUN offers first ESUN course

Chair visits CUA Meeting in Ningbo

New nursing perspectives on CAUTI issues

By Lawrence Drudge-Coates Clinical Nurse Specialist, Uro-oncology, EAUN Chair, London (UK)

By Hiske Visser and Paula Mourik Onze Lieve Vrouwe Gasthuis, Dept. of Urology, Amsterdam (NL)

As chair of the EAUN it was my great privilege to be invited to attend this year’s annual Chinese Urology Nursing Meeting in Ningbo, a seaport city in the northeast of Zhejiang province, People's Republic of China.

Under the auspices of the EAUN’s educational activities, the European School of Urology Nursing (ESUN) offered its initial course in Amsterdam in the Netherlands from May 8 to 9 this year, and in this report two participants describe their impressions:

A meeting made possible by the gracious invitation of the chair Ms. H.E. Wei and fellow committee members of the Chinese and Hong Kong Urology Nursing Associations, Mr. Larry Tsang and Mr. Gilbert Lui. Over 200 delegates attended the meeting over the two days, representing only a fraction of the expanse of Chinese urology nursing across such a vast country. The purpose of my visit was to continue and grow the unity and collaboration previously started by fellow colleagues in the EAUN, this unique opportunity providing key insights into urological nursing practice in China and the commonalities in practice and issues faced by urology nursing across different continents. Unlike the previous meeting where overviews of the EAUN were presented, as chair I supported the meeting with a presentation on bone metastases in urology cancer and the role of the urology nurse, as part of our ongoing commitment to share expertise and practice, which was well received. This provided an opportunity to highlight the EAUN bone health course, one of our first online educational initiatives. Members of the CUA & CUAN

CUA President: Prof. Yin-Hao Sun (left), Prof. Li-Ping Xie (third from left) and Ms. H.E. Wei (CUAN chair) right

38

European Urology Today

Committee members of the CUAN

With translators, language did not prove to be of any hindrance although my Mandarin I hope will improve with time. Uniquely for this year the meeting was initially chaired by the key figures in the Chinese Urology Association (CUA), CUA President Prof. Ying-Hao Sun, and the CUA Ex-President Prof. Zhang-Qun Ye, the Chinese Urology Association of Nurses (CUAN) coming under the umbrella of the CUA. In the opening address Ms. Wei (CUAN chair) thanked the EAUN for its continuing engagement with the CUAN and its plans for further collaboration and group membership and outlined the programme of the day. The EAUN’s mission remains and importantly is not only to support and encourage the development of urology nursing within Europe, but also to collaborate with national societies across the globe in support of the development and application of high-quality urology nursing practices. The next and important step in this collaborative chapter I believe, is to welcome the CUAN as group members and these discussions are moving forward. Our continued collaboration offers huge potential for the sharing of clinical practice and education, and with that the opportunity to develop education programmes across two great urology nursing organisations. We have a lot to learn from each other and I look forward to an exciting and successful union. My thanks go to Ms. H.E. Wei (chair) and the CUAN committee for its hospitality and very warm welcome and to Mr. Larry Tsang and Mr. Gilbert Lui for making this all possible.

We are two registered nurses from Amsterdam and we were privileged to be part of this training. The course took up urinary tract infections (UTI) and catheter related urinary infections (CAUTI’s) as the main topic. To prepare for this course we read articles and current guidelines on the topic. The course agenda was made up of eight lessons and the lecturers were given 50 minutes to discuss and present their topics after which a Q&A session followed. Before the use of antibiotics became widespread in the1950s, our bodies used it’s natural immune system to fight infections. But with the growing dependence on antibiotics, this has led to growing resistance to the point that nowadays patients become more vulnerable to the threat of multi-resistant infections. A cause of alarm among experts is that with the growing resistance, a clear solution to this threat has not yet been found, certainly a worrying prospect to everyone. The way we handle this problem requires more attention. Among the most important measures are the following: 1. Prevention of infection; 2. Avoiding overtreatment with antibiotics; and 3. Right time, right dose and the right indication of antibiotics.

number of days using an in-situ catheter will minimise infection risks. It has been noted that in-situ catheter use increases infection risk by 5% on a daily average. Thus, it is advisable to set-up a policy that recommends daily or regular checks of indwelling catheter. UTI is now the second most common infection after pneumonia, and 70% of UTI cases are catheter-related (CAUTIs). Nurses play an important role in educating the patient and healthcare workers. They can highlight and promote the importance of prevention. Moreover, we also have the professional obligation to actively implement the EAUN’s guidelines on catheter use. Some of the content and information in this course were known to us but we also learned new insights and benefited from the exchange of views. Certainly, we can use this knowledge to make an inventory and help in the review of our own protocols. We also valued the opportunity to meet our colleagues from other European countries and the enthusiastic interaction with them helped us gain new perspectives. We thank the EAUN and sponsors for this wonderful course and we look forward to the ESUN’s future activities.

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

A major challenge The main challenge is how to decrease the number of UTI cases. Reducing the use of indwelling catheters and the

 Supported by an educational grant from Wellspect HealthCare

June/July 2015


Share your experience and ambition in Munich

Fellowship Programme

12-14 March 2016, Munich, Germany

European Association of Urology Nurses

Nursing research may bring the most amazing results With the EAUN’s commitment to support innovative work, we invite you to submit a research project proposal for the EAUN Nursing Research Competition. The topics that have to be included in the project plan and examples can be found on our website. During the 17th International EAUN Meeting in Munich (12-14 March 2016), all projects of the nominees will be discussed in a scientific session, enabling all participants to learn through feedback and discussions. A winner, chosen from the final nominees selected by a jury, will receive € 2,500 to (partly) fund the research project. Supported with an educational grant by

Join our search for Nursing Solutions in Difficult Cases If you are among those who encounter atypical cases in daily practice and have found your own solutions, we would like to invite you to take a few photos and write a standard protocol. You can download a form with a list of standard questions. The form should include a description of the problem, the nursing intervention provided, the material you have chosen to help the patient and the final results. Please note: Difficult cases that have not been (completely) solved may also be submitted. The best cases will be rewarded with a free registration for the congress. Detailed submission criteria and rules for both submissions can be found at the congress website. Submission deadline: 1 December 2015 For more information please contact the EAUN at eaun@uroweb.org.

www.eaun16.org

European Association of Urology Nurses

EAU Best Papers published in Urological Literature Awards To be awarded at the 31st Annual EAU Congress in Munich, 11-15 March 2016

ly p Ap ow! n

June/July 2015

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

The two EAU Prizes for Best Paper published in Urological Literature are tools through which the EAU encourages young and promising urological scientists to continue their work and to communicate their achievements to the European urological community. Two awards of € 5,000 each will be made available for the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers have to be published or accepted for publication between 1 July 2014 and 30 June 2015. The awards will be handed out at the 31st Annual EAU Congress in Munich, 11-15 March 2016. Rules and Eligibility • Eligible to apply for the EAU Best Paper published in Urological Literature are urologists, urologists-in-training or urology-related scientists. All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • The paper must be written in the English language (or translated into the English language). • The subject of the paper must be urological or urology related. • The deadline for submission is 1 November 2015.

European Association of Urology Nurses

How to apply • Please send your paper by e-mail to m.smink@uroweb.org, indicating clearly the category in the subject line: “EAU Best Paper on Clinical Research” or “EAU Best Paper on Fundamental Research”. • Include a copy of your curriculum vitae. • Supply a list of all authors who have significantly contributed (if relevant). • Mention any financial support by companies, government or health organisations. • A publisher’s letter of acceptance has to be submitted along with your paper. A review committee consisting of members of the EAU Scientific Congress Office will review all submitted papers and select the winner of the two EAU awards for Best Paper published in Urological Literature.

European Urology Today

39


Australian and NZ Urological Nurses Society Annual Meeting Comprehensive 20th annual meeting tackles wide range of topics in urology nursing Jean Bothwell Clinical Nurse Specialist, Urology Waitemata District Health Board Waitemata (NZ)

In April I had the privilege of attending a full and varied urological conference programme in Adelaide, Australia. The 68th Annual Scientific Meeting was collaboratively organised by the Urological Society of Australia and New Zealand (USANZ) and the Australian and New Zealand Urological Nurses Society (ANZUNS) and held at the Adelaide Convention Centre from April 11-14, 2015. USANZ is the professional body for urological surgeons in Australia and New Zealand, administering the Surgical Education and Training Program in urology through the Royal Australasian College of Surgeons. ANZUNS is a special interest nursing society which aims to promote excellence in urology nursing through research, education, mentoring and the identification of standards of nursing care. The shared annual conference provides a diverse scientific programme and offers updates on urological topics. Adelaide, capital of South Australia, is the continent’s most productive wine state with wine-producing regions such as the Barossa, Adelaide Hills and McLaren Vale. The winemaking tradition stretches back to 1840 with the arrival of British and German settlers and has the longest lineage of winemaking. I managed to sight-see, allowing me to sample the Barossa’s fine wine products away from the European Association of Urology Nurses

conference schedule. It would have been a shame to merely be a passive spectator! The ANZUNS programme ran over two days while my full registration entitled me to attend concurrent medical sessions and additional content through the medical programme. The content was so robust that it led me to dilemma at times when I ended up in two sessions almost at the same time! My conference began prior to the official opening of the meeting when I attended the Advanced Urological Nursing Professional Development (ANZUNS) workshop. This focussed on providing a greater understanding of the selection of different investigations, and interpretation of findings. Yvette Sullivan, nurse practitioner from Queensland, provided a comprehensive description of urological investigations, both pathological and radiological. There was a selection of three workshops for nursing delegates, others being Uro-Oncology (which this year focussed on renal cancer) and General Urology. This workshop aimed to educate on identifying high risk / frail / co morbid patients prior to urological surgery. The keynote speaker for the ANZUNS opening session was Elizabeth English, Senior Credentialed Stomal Therapy Nurse at the Royal Adelaide Hospital. In 2013 she led a team of stomal therapy nurses to Kenya to establish the first Stoma, Wound and Continence Program in Eastern Africa. She returns annually to teach in ongoing programs and to ensure sustainability of this project. Her presentation showed the disparities in care between private and public hospitals, the latter with poor hygiene, hand washing and two patients sharing a single bed – including sharing with a dying patient. Schistosomasis (bilharzia), cloaca and exstrophy are common conditions in Kenya. Elizabeth is obviously passionate about her work and keen to continue (despite funding issues) offering her knowledge and skills in developing nations.

Adelaide Convention Centre

There were 12 podium presentations for the ANZUNS awards. These are ten-minute presentations and all were of a very high standard. There was a wide range of innovative practice and audit outcomes presented, ensuring a good quality of transferable knowledge for delegates to take back to their workplace. I was delighted that the winner of both the most innovative paper and best new presenter awards was Jacinta Townsend, from Counties Manukau District Health Board in Auckland, New Zealand. Her paper titled ‘A little thing called a bladder diary’ was about creating a new diary and format for her organisation which has now been published for wider use in her District Health Board area. The best poster prize was for the study titled “Development of a pathway of care for men undergoing Radical Retropubic Prostatectomy in a private healthcare setting,” won by Kerry Santoro of the Calvary Hospital, North Adelaide. Over the past six years, I have increased both my interest and involvement in the assessment of urinary incontinence as clinical nurse specialist in urology. I was particularly interested in attending the various ‘Female Urology’ sessions in the USANZ part of the conference. Prof. Philip Van Kerrebroek (NL) presented on investigation and management of nocturia. Among the key points were:

12-14 March 2016, Munich, Germany

• Each void is preceded and followed by sleep; • Accurate bladder diary is important – 60% may improve with lifestyle advice; • No evidence of benefit from the use of diuretics; • 85% of elderly population will have nocturnal polyuria; • Desmopressin gives >50% reduction in output but requires close monitoring of sodium levels; and • Sleep apnoea is a major cause of nocturia. He also discussed the role of neuromodulation- in functional pelvic problems – to ‘rebalance’ the problem area; sites for stimulation include anogenital, transcutaneous (TENS), percutaneous nerve and sacral nerve. He mentioned a 50% success rate at five years for sacral nerve stimulation.

Other sessions provided learning on Chronic Pelvic Pain (or Persistent Pelvic Pain), vulval condition/ diseases, stress urinary incontinence and slings. The Female Urology Forum closed with a panel discussion which consisted of case presentations, followed by panel and delegate discussion on stress incontinence, underactive bladder, overactive bladder, pelvic pain and urinary retention. I have had a long association with our society and it was a real pleasure to meet so many familiar faces – ‘networking’ is such a key part of these meetings. The Industry Exhibition area displayed the 170 USANZ posters with topics including endourology/ stones, LUTS/BPH, oncology, uro-oncology and reconstructive urology. There were also three ANZUNS posters. The trade strongly supported the conference with 56 excellent exhibition stands displaying a wide range of urological medication and products. Overall it was a great meeting in a city new to me. It was an excellent opportunity for my husband and me to tick Adelaide off our ‘bucket lists’, while updating my urological knowledge. The next meeting is planned for April 16 to 19 next year at the Gold Coast in Queensland, Australia.

EAUN Board 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

DEADLINES Difficult Case Submission

Apply for your EAUN membership online!

Research Project Plan Submission

1 December 2015

Would you like to receive all the benefits of EAUN membership, but have no time for tedious paperwork? Becoming a member is now fast and easy!

www.eaun.uroweb.org

Abstract Submission

Go to www.eaun.uroweb.org and click EAUN membership to apply online. It will only take you a couple of minutes to submit your application, the rest - is for you to enjoy! in conjunction with

www.eaun16.org

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European Urology Today

European Association of Urology European Nurses Association of Urology June/July 2015 Nurses

European Urology Today - Vol. 27 No.3 - June/July 2015  

European Urology Today - Vol. 27 No.3 - June/July 2015

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