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European Urology Today
EAU19 Congress News 34th Annual Congress of the European Association of Urology Barcelona, 15-19 March 2019
Plenary Session addresses BCa in young female patients Patient case discussions and surgical aspects By Erika de Groot “Bladder cancer (BCa) is generally considered as a disease of the elderly with a median age approximately 65 to 70 years at diagnosis. But approximately, one to two per cent of patients will be under 40 years of age. At Bern University in Switzerland, we have had 39 patients under the age of 50 and 16 patients under 40 from 2007 to 2017. ” So stated Prof. Fiona Burkhard (CH) as she kick-started “Plenary Session 01 Bladder cancer in the young patient: Unique aspects”, chaired by herself and Prof. Morgan Rouprêt (FR). Prof. Burkhard introduced the case of a 34-year-old female presenting with macrohaematuria at a different hospital. The patient had an initial
transurethral resection of the bladder (TURB) with a pT1G3, followed by a re-resection when muscleinvasive disease was found. She is a painter with one child, and has a smoking history of 10 pack-years. Prof. Burkhard shared that “the first question the patient asked me was ‘I would like to have second child. Would that be possible?’” The initial step is preoperative assessment, in which oncological aspects (tumour location) are prioritised over preserving fertility. Following this, specific surgical aspects are considered: nerve-sparing, organ-sparing, and the type of diversion to be offered to the patient. Then, if the patient is pregnant, the focus shifts to care during pregnancy and delivery. The introduction was followed by the lecture, “Fertility in the young female patient with bladder cancer: Surgical aspects” by Dr. Jo Cresswell (GB). She stated that it is not uncommon to see young female patients wanting to have children; however, for a number of young women who have/will undergo radical cystectomy (RC) or have BCa, sexual function and fertility may also be of importance.
Dr. Cresswell emphasises preservation of sexual function
Dr. Cresswell also discussed pelvic organ-sparing cystectomy, which includes uterine-sparing to preserve fertility; ovarian-sparing to avoid early menopause; and vaginal- and nerve-sparing to preserve sexual function.
On Saturday, live surgery got underway at EAU19! The EAU Section of Uro-Technology (ESUT), in cooperation with the EAU Robotic Urology Section (ERUS) and the EAU Section of Urolithiasis (EULIS) held an ambitious, all-day session dedicated to surgical cases. By using live feeds from up to four operating theatres simultaneously, as well as pre-recorded cases and expert moderation, delegates could experience a seamless surgical programme with demonstrations of all the latest tech. Live procedures included 3D laparoscopic partial nephrectomy; en-bloc bipolar bladder tumour resection; 4K laparoscopic radical prostatectomy and Lithovue single-use ureteroscopic lithotripsy.
She also cited the EAU Guidelines (2018): “In women, standard RC includes removal of the bladder, entire urethra and adjacent vagina, uterus, distal ureters and regional lymph nodes... Data regarding pelvic organ-preserving radical cystectomy for female patients remains immature.” One of the current Guidelines recommendations – offering sexualpreserving techniques to preserve sexual function since the majority will benefit – was rated “weak”. However, Dr. Creswell foresees this changing.
“I think it’s time to pay attention to vaginalsparing and ovarian-sparing surgery, and to put more focus on sexual function,” she stated. Careful assessment of the vagina is needed, and bladder-neck urethral biopsies should be considered pre-operatively. For uterine-sparing surgery with the objective of preserving fertility in selected patient cases, improved urinary function should also be taken into account.
Guidelines Session: Omitting biopsy in case of normal MRI mpMRI before biopsy for biopsy-naïve patients recommendation now in EAU Guidelines By Loek Keizer
(FR) offered a “balanced” viewpoint to aid discussion.
The EAU Guidelines Office, led by Prof. James N’Dow (GB) uses the Annual EAU Congress to launch its annually-updated guidelines. The Guidelines Controversies sessions, two of which took place on Saturday at EAU19, are a way to highlight the latest additions and changes.
“Hold fire, not end-fire” Prof. Moore strongly argued that standard biopsy in men with a negative MRI can have unfortunate results. “Side-effects of biopsy are common,” Moore pointed out, “and current treatment rates are much higher than recommended. Even active surveillance has morbidity and cost associated with it.”
The chairs of each Guidelines panel and independent experts explore the evidence base for new recommendations and involve the audience in the decisions through voting and discussion. The Prostate Cancer panel, led by Prof. Nicolas Mottet (FR) wanted to highlight changes in its recommen-dations on MRI imaging and the way it affects the decision to proceed with a biopsy. Prof. Caroline Moore (GB) and Dr. Sigrid Carlsson (USA) debated the pros and cons of foregoing biopsy after MRI, while Dr. Olivier Rouvière
Sunday, 17 March 2019
disease that might impact his life and be happier to forego the biopsy.” “In the UK, the discussion is reasonably well-framed about not detecting all cancer. A drive for maximum diagnosis can be a real problem. I think we will see people being sued for these harms. We can already see the beginnings of a backlash against overdiagnosis.”
“Five-year detection rates of significant cancer in men with negative MRI and no TRUS biopsy are low [5%]. I recommend that we hold fire, rather than end-fire.” Dr. Carlsson voiced her concerns on mpMRI being able to adequately detect all tumours: the technology might have a high enough sensitivity to detect, but there is massive inter-observer variability. The learning curve and the variance in each centre’s MRI capabilities also proved a challenge. Carlsson suggested several possible treatment pathways that could serve urologists and patients in future. Addressing the concerns about MRI quality, Moore later told EUT Congress News that while there is increased confidence in MRI, there is also still a lot of discussion about its quality. “During the session, James N’Dow asked if we had enough long-term data. I think it’s not long-term data we need, it’s quality assurance across the board.”
Prof. Moore at the Guidelines Controversies session
Involving the patient It was emphasised at the session that the patient should also be involved in the decision to perform biopsy if the MRI is negative. Moore: “Discussion with the patient is important and I’m pleased to see that in the 2019 EAU Guidelines. It’s a recognition that this is a preferencesensitive decision. A man might prefer greater certainty at the expense of side-effects and cost. Or he might be very confident in the fact we’re not missing the sort of
“Many good centres can do MRI. What we haven’t shown is that every centre can be a good centre. I think we can get there and that it’s mainly a training issue,” Moore concluded.
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