EUT Congress News - Monday 18 March

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European Urology Today

EAU19 Congress News

T on hird da Ed y 1 iti 8 on M ar ch

34th Annual Congress of the European Association of Urology Barcelona, 15-19 March 2019

Breaking News: New PCa drugs and imaging

Is MRI-targeted biopsy enough?

By Loek Keizer

Opposing views on the efficacy and significance of MRI-targeted biopsy were presented during the first debate in Plenary Session 3: Imaging in prostate cancer: Is it time to change paradigms?, chaired by Dr. Jochen Walz (FR) and Prof. Dr. Francesco Montorsi (IT).

The results of two new studies were announced on the third day of EAU19: the eagerly awaited and possibly paradigm-changing ARAMIS study and new research into fast bi-parametric MRI. Delegates braved the early hours of Sunday morning to attend the Breaking News Session that was part of Plenary Session 3, on imaging in PCa. Prof. Teuvo Tammela (FI) presented the latest results of the ARAMIS study, which tested the effects of darolutamide on the PSA levels of men with non-metastatic castration-resistant prostate cancer (nmCRPC). “The latest results indicate that darolutamide significantly improves metastasis-free survival in men with nmCRPC. It elicits strong PSA declines and significantly delays PSA progression compared to placebo. Because it also has a favourable safety profile, we think darolutamide could be an attractive option for treating nmCRPC.” Prof. Peter Albers (DE) was on hand to place these findings in a wider context, first pointing out that the selection criteria were limited to patients with very short and aggressive doubling times.

Albers: “The overall survival curves separate after about 18 months, so we have to wait longer. The study has a surrogate endpoint of metastatic-free survival.”

“Darolutamide is a new and effective nextgeneration androgen receptor inhibitor,” Albers concluded. It has a better safety profile compared to enzalutamide and apalutamide, and will change practice if the advantage in metastasis-free survival leads to an overall survival advantage. It does however need strong selection criteria to prevent overtreatment.”

Plenary Session tackles the benefits and drawbacks

By Erika de Groot

Prior to the deliberations, moderator Dr. Arnout Alberts (NL) asked the audience “Which biopsy strategy would you use in men with a clinical suspicion of PCa?”. The audience keyed in their answers via the EAU Events App. About 55% of the audience chose MRI (+targeted biopsy in case of positive MRI), always combined with TRUS biopsy; and 30% chose MRI (+targeted biopsy in case of positive MRI), TRUS biopsy depending on risk-stratification.

The debate then commenced.

In the presence of a positive MRI, Dr. Veeru Kasivisvanathan (GB) shared his insights on the advantages of MRI-targeted biopsy without TRUS biopsy. For example, patient burden and risk of (infectious) complications decrease when there are fewer biopsy cores per procedure. The detection rate of Grade Group (GG) 1 (Gleason 3+3) prostate cancer (PCa) is lower, and patients with a false negative MRI-targeted biopsy are not lost to follow up.

In summary, the counter-arguments of Dr. Guillaume

Fast MRI Prof. Jelle Baretsz (NL) presented the latest results from a multi-centre study on 626 biopsy-naïve patients, hoping to convince the audience that a “fast” prostate MRI without contrast is cheap, non-invasive and can double prostate MRI capacity.

The study compared contrast-enhanced multiparametric full MRI protocol (mpMRI, 16 minutes) to an unenhanced, bi-parametric MRI (bpMRI, 13 minutes) and a fast bpMRI protocol (8 minutes).

The latest data showed that non-invasive fast bpMRI without contrast agent can accurately detect and rule-out csPCa. Additionally, bpMRI-fast can be performed at significantly lower (55%) costs. The full results will be published soon in European Urology.

Prof. Briganti (IT) pointed out that the results depend largely on the availability of the highest quality MRI and most experienced radiologists, warning that fast bpMRI is possibly ready to replace mpMRI in all patients, but only at selected centres.

Monday, 18 March 2019

Ploussard (FR) included the significant learning curve associated with multi-parametric MRI (mpMRI) reading and MRI-targeted biopsy, the possible registration errors in MRI-targeted biopsy, and the 10 to 20% of GG ≥ 2 (Gleason ≥ 3+4) tumours that are missed. Tumour evaluation (e.g. multifocality, heterogeneity) can be suboptimal if MRI-targeted biopsy is performed without TRUS biopsy.

Negative MRI, no TRUS biopsy needed Prof. Francesco Porpiglia (IT) agreed that in the presence of a negative MRI or native MRI-targeted biopsy, no TRUS-biopsy is needed due to the high negative predictive value (NPV) of up to 95% of MRI for GG ≥ 2 (Gleason ≥ 3+4) PCa. There is a 30% reduction

in biopsies, which means a decrease in patient burden and costs, with fewer complications. Additionally, the detection rate of GG1 (Gleason 3+3) PCa is lower.

Dr. Christian Arsov (DE) raised opposing points such as the significant learning curve associated with mpMRI reading; a lack of mpMRI quality control; and 10 to 20% missed GG ≥ 2 (Gleason GG ≥ 3 + 4) tumours. Dr. Alberts considered the pros and cons discussed, and concluded that there is no single right answer to the question of whether MRI-targeted biopsy is enough.

He stated that the way forward seems to be an individual strategy with upfront risk-stratification and the combination of MRI-targeted biopsy and TRUS biopsy in case of elevated risk.

Renal Cell Carcinoma: Controversies in care Debates on robotic approaches and treatment modalities

By Jen Tidman “The only thing that is permanent in surgery is change,” remarked Prof. Alexandre Mottrie (BE), launching the first debate in Sunday morning’s packed plenary on renal cell carcinoma (RCC).

He was arguing that the benefits of new technologies, including robotic-assisted partial nephrectomy (RAPN), are unlimited compared to classical surgery, which he said results in too many complications. In his view, RAPN spares more healthy tissue, avoids large painful incisions, and gives good oncological and functional outcomes.

Prof. Barentsz presenting new results

Experts deliberate on efficacy of MRI-targeted biopsy

However, Mottrie admitted that although robots do not cause problems, the people behind them can. He therefore emphasised the need for proficiency-based, standardised, and quality-assured education, and congratulated the EAU on certifying the first training programme in robotics, by ERUS. In counter-argument, Prof. Markus Kuczyk (DE) said RAPN results in decreased patient satisfaction, and in low-volume centres often leads to transfusions, positive margins, and conversions to open surgery. In these centres, doctors experienced in open surgery should stick with this or send patients to expert centres.

In the second debate, moderator Prof. Peter Mulders (NL) presented the case of a small renal mass in a 42-year-old woman with a BMI of 31. Three experts then discussed her treatment.

Prof. Charles Karim Bensalah (FR) felt PN was the primary option, with fewer complications and a comparable survival rate. PN can actually improve outcomes in obese patients and the only potential obstacle would be toxic fat, which can be surmounted with good training and ultrasound identification of the

tumour margin. He noted support from the EAU Guidelines (2019), which recommend offering PN to patients with P1 tumours (strong level of evidence).

Dr. Umberto Capitanio (IT) favoured local tumour ablation (cryoablation, radiofrequency, microwaves, or irreversible electroporation), especially in a patient at high risk of PN complications. However, in view of the weaker evidence, more research is needed.

Dr. Antonio Finelli (CA) suggested active surveillance (AS) rather than potentially unnecessary surgery. He noted that 80-90% of <4cm masses grow at only 0.22cm per year on average and that it is not

uncommon for <1cm tumours to disappear. In addition, as obesity is a risk for RCC, de novo tumours might develop after initial surgery. He therefore advocated AS (except in young and healthy patients with >4cm tumours) intervening only when the opportunity for cure exists and the risk of progression has been appreciated.

In conclusion, the experts agreed that in this particular case, all modalities were valid, depending on biopsy results and discussion with the patient. As Mulders said, any treatment decision must be based on all factors known about the patient, the physician, the facility and new research.

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A success for patients and stakeholders Patient Information Session: Updates on PCa, BCa and RCC

By Patricia Chang Prof. Hein Van Poppel (BE) and Dr. Antonella Cardone (BE), chaired the EAU Patient Information (EAU PI) Session on Sunday afternoon. Prof. Van Poppel warmly welcomed the attendants to this Specialty Session.

Congress News . . . . . . . . . . . . . . . . . . . . . . 1 Congress highlights . . . . . . . . . . . . . . . . . 2-3 Fertility-sparing surgery . . . . . . . . . . . . . . . 4 ERN and eUROGEN . . . . . . . . . . . . . . . . . . . 5 Social media in office urology . . . . . . . . . . . 7 Antimicrobial treatment . . . . . . . . . . . . . . . . 8 Spotlights on office urology . . . . . . . . . . . . 10 Interview: New ESOU chairman . . . . . . . . . 12 SCO: Interview with Prof. Briganti . . . . . . . 14 Implications of GDPR . . . . . . . . . . . . . . . . . 15 Nursing and ERAS . . . . . . . . . . . . . . . . . . . 17 EAUN19: QoL and cancer . . . . . . . . . . . . . . 18 Sexual side effects of prostatectomy . . . . . 19 Tumours in transplant and native kidney . . 20 EAU Guidelines group on men’s health . . . 23

EAU Patient Information’s former Chairman, Prof.

Thorsten Bach (DE), and its current Chairman, Dr. Mark Behrendt (DE), delivered the highlights from the past and present activities of this patient-centered office.

With the support of, and academic contributions from the EAU PI’s dedicated Working Group Members, EAU PI has grown into a successful urological platform for patients and stakeholders. “EAU PI aims to become a key resource for medical professionals, patients and policymakers both across the EU and beyond,” Dr. Behrendt explained.

On behalf of the European Cancer Patient Coalition (ECPC), Dr. Antonella Cardone (BE) introduced the coalition’s multi-annual strategy and its growing activities in the field of patient advocacy. Prof. Hein Van Poppel (BE) explained the need for reconsideration of structured population-based PSA screening for prostate cancer in Europe. Mr. John Dowling (IE), representing Europa Uomo on behalf of Mr. André Deschamps (BE), emphasised that it is time for a new strategy to re-introduce prostate cancer

Editor-in-Chief Prof. M. Wirth, Dresden (DE)

Co-speaker on behalf of Europa Uomo, Mr. ErnstGünther Carl (DE), pointed out that rare diseases, such as penile and testicular cancer, do not get as much attention as other urological disease. It is therefore necessary to provide better information and material for patients for early education and detection.

Dr. Lorenzo Serra De Oliveira Marconi (IT), member of the RCC Guidelines Panel shared their 2019 key updates and concluded that guidelines increasingly benefit from patient involvement. On behalf of the International Kidney Cancer Coalition (IKCC), Dr. Rachel Giles (NL) highlighted the IKCC’s activities and its 2019 strategy.

She reported that the IKCC has put in place an InfoHub in order to share information.

EAU Guidelines On behalf of the EAU Guidelines Office, its PCa Panel Chairman, Prof. Nicolas Mottet (FR), emphasised the importance of early detection of prostate cancer and the choice of detection methods following the recommendations of the EAU Guidelines. Dr. Fred Witjes (NL), Chairman of the Muscle-invasive and Metastatic Bladder Cancer Guidelines panel focussed on the importance of attention for BCa. The future of early detection of BCa includes better imaging and the use of biomarkers.

Fight Bladder Cancer, the UK-based bladder cancer charity, was represented by Dr. Lydia Makaroff (GB) and Mr. Andrew Winterbottom (GB) who spoke about the newly-established World Bladder Cancer Patient Coalition. The Coalition will officially be launched at EAU19 on Monday, 18 March 2019 (16:00, Red Area).

Dr. Makaroff also presented the results of the Bladder Cancer Patient Experience Survey, a global survey of

Mrs. Michelle Battye (GB), Centre Manager for the European Reference Network (ERN) on rare uro-rectalgenital diseases, eUROGEN, demonstrated the abilities of the ERN Clinical Patient Management System (CPMS), which facilitates virtual multi-disciplinary team meetings in order to improve the diagnosis and treatment of rare or low-prevalence complex diseases and conditions.

Prof. Van Poppel at the Patient Information session

Thematic Session 6 addresses medical management of OAB A panel of OAB experts convened in Barcelona on Sunday, presiding over a series of state-of-the-art lectures and case presentations. The case presentations served to illustrate the variety of treatment options for overactive bladder.

The priority for OAB research should be to identify and understand subsets of patients with specific pathophysiology and biomarkers. We also need to identify suitable treatment options that address the ‘master switches’ of such pathophysiology.” Michel noted that OAB was a symptom complex, not a disease entity that can be treated with a single miracle drug. Multiple diseases may be at play in a patient’s OAB, each requiring specific treatment.

additive and synergistic effects). Each drug can have an optimal dose, leading to dose reduction and better tolerability.

Prof. Van Der Aa summarised the results of the SYNERGY, SYNERGY II and BESIDE trials. The combination of antimuscarinics and Beta3 adrenoceptor agonists led to either clinically insignificant results, or statistically significant results that only offered a very small benefit to patients.

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, Paris (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Dr. F. Sanguedolce, London (GB) Dr. Z. Zotter, Budapest (HU)

Prof. Martin Michel (DE) was invited to discuss the latest developments in OAB drugs, but regrettably had to conclude that the pipeline was empty for the foreseeable future.

“Room for improvement is limited for tolerability of oral OAB treatments. The greatest medical need in OAB efficacy exists for urgency and nocturia (which both have major adverse impacts on QoL),” Michel pointed out.

Potential for combination therapy?

A similarly cautious talk about the potential of combination therapy followed from Prof. Frank Van Der Aa (BE). “What is the current problem with medical treatment for OAB? Patients typically stop taking antimuscarinics after about one year, because they are found to be ineffective, expensive and perhaps cause side-effects.”

Founding Editor Prof. F. Debruyne, Nijmegen (NL)

“Major efficacy gains may not come from new drug classes if the OAB population is targeted as a whole.

The potential advantages of combination therapy for OAB can be found in the increased efficacy (due to

Onsite Reporting and Editing E. de Groot L. Keizer J. Tidman P. Chang

Focal therapy: Promising or insufficient?

By Erika de Groot

Advertising M. van der Krieke F. Strating

Focal therapy is a general term for a variety of non-invasive techniques aimed at destroying small tumours inside the prostate, leaving the remaining gland intact and sparing most of its normal tissue.

The efficacy of focal therapy was examined in the point-counterpoint session “Focal therapy in which setting?” during “Thematic Session 02: Focal Therapy”, chaired by Prof. Chris Bangma (NL) and Prof. Arnauld Villers (FR).

Disclaimer No part of European Urology Today (EUT) may be reproduced without written permission from the Communication Office of the European Association of Urology (EAU). The comments of the reviewers are their own and not necessarily endorsed by the EAU or the Editorial Board. The EAU does not accept liability for the consequences of inaccurate statements or data. Despite of utmost care the EAU and their Communication Office cannot accept responsibility for errors or omissions.

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He stated, “During this timeframe, 553 patients out of 695 (80%) of the patients have died. The absolute benefit associated with radical prostatectomy increased by a factor of more than two, between years 10 and 23. A Gleason Score (GS) > 7 was associated with 10 times higher risk of PCa death compared to GS 6.”

According to Prof. Yossepowitch, focal therapy for unilateral International Society of Urological Pathology (ISUP) grade 2/3 lesions is a plausible

“I do think focal therapy will play a role in the future. However, active surveillance remains the preferable option for low-risk PCa,” stated Prof. Ofer Yossepowitch (IL) in his presentation “Focal therapy ready for which recommendations in the guidelines?”.

“In the end, combination therapy is not a game changer,” Van Der Aa concluded. “The combined effects add up to a small improvement, and it does not have synergistic side-effects.”

alternative in intermediate to high-risk disease.

However, he advises informing patients about follow-up data, which is currently inadequate to ascertain its curability potential. He added that patients also need to know that there is a 20 to 30% local failure rate, and that focal therapy is best considered for relatively older male patients. Prof.

Yossepowitch stated that the optimal salvage strategy is still unknown.

Dr. Hashim Uddin Ahmed (GB) counter-argued that focal therapy is advantageous for patients. In his lecture Dr. Ahmed stated, “The new targeted biopsy paradigm inevitably requires us to match our treatment to the biology of the disease. Focal therapy has shown a low side-effect profile.”

Adverse effects of focal therapy on functional outcomes include no long-term bowel problems; 1 to 2% urinary incontinence; 5 to 20% erectile dysfunction; and 50% dry orgasm (men can remain naturally fertile). Complications included 0.1% rectourethral fistula, 1% urethral stricture and 5% infection.

He agreed that in terms of functional outcomes, focal therapy is “unequivocally superior” to whole gland therapy (risking urinary and erectile dysfunction), but inquired, “With oncologic outcomes, can focal therapy cure those who need to be cured?”

Prof. Yossepowitch cited the results of the Prostate Cancer Intervention versus Observation Trial (PIVOT) study wherein the median follow-up was 23 years.

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The EAU Guidelines only make cautious recommendations on combination therapy, and mainly suggest the addition of mirabegron if initial solifenacin proves ineffective, rather than immediately starting with a combination of drugs.

Thematic Session 2 explores risks and advantages

Marketing Communication J. Bloemberg M. van Gurp L. Stuart-Young

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1,615 bladder cancer patients and their carers from 39 countries.

OAB: Current options and future challenges

By Loek Keizer

European Urology Today

screening via three pillars: awareness, PSA-led screening and cancer centres.

Dr. Ahmed: “Focal therapy has shown a low side-effect profile”

Focal therapy in men who have clinically significant prostate cancer has good medium-term cancer control. Long-term comparative data are awaited but patients should be counselled about focal therapy.

Monday, 18 March 2019

Expertise is crucial for testis cancer treatment Uncertainties and controversies discussed in thematic session

By Jen Tidman The controversial issue of primary retroperitoneal lymph node dissection (RPLND) for the staging and treatment of patients with high-risk clinical stage I non-seminomatous germ cell tumour (NSGCT) was debated at Saturday’s Thematic Session “Testis Cancer: Surgery is Back Again”.

Dr. Siamak Daneshmand (US) said that with a 99% overall survival rate for stage I NSGCT, he tells his patients, “You can survive this, but how we get there is important”. He presented the case in favour of primary RPLND, particularly using a midline extraperitoneal approach that has negligible morbidities, shorter hospital stays, and an excellent cure rate.

He argued that surveillance works only when you have patient acceptance, patient compliance (which is hard to predict or ensure), and the availability of crosssectional imaging (CT scan). However, 37% of patients have been shown to have significant anxieties around scanning, which may negatively affect their quality of life.

Chemotherapy obviously plays a role in cancer treatment, but for Daneshmand it carries the

unnecessary long-term risks of significant toxicity, morbidities, and secondary malignancy, which surgery does not.

Presenting the case against surgery, Prof. David Nicol (GB) warned that a significant correlation between case volume and both surgical complications and recurrence risk has been shown in multicenter studies: “We need to look at what happens in practice rather than in centres of excellence.” He therefore recommended adjuvant single-cycle BEP chemotherapy rather than surgery as the preferred management of high-risk stage 1 NSGCT. Testicular Dysgenesis Syndrome Unfortunately Prof. Daniel Nettersheim (DE) could not be present, so session co-chair Prof. Peter Albers (DE) presented Nettersheim’s slides on the potential pathogenesis of Testicular Dysgenesis Syndrome (TDS).

TDS originates in the embryonic period, at approximately four weeks gestation. The condition predisposes men to hypospadias, cryptorchidism, poor semen quality, and testicular germ cell tumours (although all may have other causes).

The specific pathogenesis of TDS still unknown, but as the incidence is higher in industrialised countries, interplay of environmental and genomic factors is

suspected as the cause, rather than mutations. Indeed, a solid body of evidence suggests the mother’s exposure to environmental chemicals and endocrine disruptors is responsible. “Unfortunately the exact mechanisms of these on DNA is still unclear, and until confirmed we cannot derive recommendations,” Albers concluded.

In his lecture “Surgical management for Somatic Malignant Transformed Teratoma”, Prof. Noel Clarke (GB) presented six cases of one of the most dangerous histological transformations. He said in assessing patients, there are three key questions to ask: “What is the distribution? What is the cell type? Can it be removed completely and safely?”

is possible, and so far the patient has been stabilized with radiation and chemotherapy.

In his take home messages, Clarke emphasized the need to accept that not everyone is suitable for surgery and not everyone is curable even with surgery. He reiterated the importance of involving experts. “If you can’t get complete resection, then you really shouldn’t be trying this from the outset,” he said. “Don’t try this surgery at home if you don’t have friends.”

In four of the cases, he was able to answer the questions and positive outcomes were successful, albeit challenging. In a fifth, late-presenting case, the cell type was unclear and unfortunately the patient died six months after surgery from widespread metastases.

In a sixth case with a spinal lesion, Clarke was unsure about attempting surgery and contacted other experts across Europe. These colleagues counseled him that the tumour was impossible to completely resect and therefore unfortunately incurable. However, palliation

Prof. Albers spoke on Testicular Dysgenesis Syndrome

Day 3 Award Gallery

First Prize Best Abstract by a Resident: S. Khadhouri (London, United Kingdom) Sponsored by BOSTON SCIENTIFIC

Second Prize Best Abstract by a Resident: D. Thurtle (Cambridge, United Kingdom)

Third Prize Best Abstract by a Resident: J. Whitburn (Oxford, United Kingdom)

Best Scholar Award Basic Research: M. Vartolomei (Targu Mures, Romania)

Best Scholar Award Clinical Research: V. De Coninck (Paris, France)

First Video Prize: F. Porpiglia (Turin, Italy)

Second Video Prize: R. Martos Calvo (Barcelona, Spain)

Third Video Prize: K. Black (Ann Arbor, United States of America)

European Urology Resident’s Corner Award: K. Pang (Sheffield, United Kingdom)

European Urology Resident’s Corner Award: A. Soave (Hamburg, Germany)

Ronny Pieters Award: R. Pieters (Ghent, Belgium)

ESUI Vision Award 2019: G. Gandaglia (Milan, Italy) Sponsored by INVIVO, a Philips Company

ESTU Research Grant: R. Boissier (Marseille, France) Sponsored by ORGAN RECOVERY SYSTEMS

ESTU Rene Kuss Prize: M. Wettstein (Zurich, Switzerland)

Guidelines Cup winners

UROlympics winner day 1: M. Elsayed Elbadwy

Monday, 18 March 2019

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Fertility-sparing surgery Window of opportunity in azoospermic testicular cancer patients to optimise treatment Dr. Marij DinkelmanSmit Erasmus MC University Medical Centre Rotterdam (NL)

Patients who are diagnosed with testicular cancer find themselves exposed to risk factors that may have a severe negative impact on their quality of life. Both the diagnosis and the sequelae of surgical and adjuvant treatment are associated with subfertility, reduced body image, hypogonadism and sexual dysfunction.

Urologists who take both the oncological as well as the andrological aspects of the disease into account will be able to prevent issues that negatively influence quality of life as much as possible. However, the reduction of loss of quality of life is greatest when treatment options are adapted at the beginning of the diagnostic process, when patients present with a testicular mass. In addition, timely patient counselling and education will aid the shared decision-making process and empower patients to adjust their lives and future perspectives.

Identify who benefits from fertility-sparing surgery The sequence of sperm banking and radical orchiectomy is crucial to identify patients who will benefit from fertility-sparing surgery. One of the first studies that reported on the feasibility of testicular sperm extraction (TESE) as an alternative to sperm banking in azoospermic cancer patients prior to gonadotoxic treatment was published in 20031.

Despite 15 years of experience with TESE in cancer patients and 40 years of sperm banking, fertility preservation in men with testicular cancer is still underutilised. The objective of this article is to create awareness for the timing of fertility preservation strategies in patients with testicular cancer.

According to the EAU testicular cancer guidelines, fertility assessment should be performed in patients in the reproductive age group. It is recommended to discuss fertility preservation at the time of diagnosis, preferably prior to the first line of treatment, radical orchiectomy. But at least prior to chemotherapy or radiotherapy. First-line chemotherapy regimens and radiotherapy have a temporary, dose-cumulative dependent impact on the quality of spermatogenesis.

We are still unable to predict fertilising potential in men exposed to adjuvant testicular cancer treatment.

“Timely patient counselling and education will aid the shared decision-making process and empower patients to adjust their lives and future perspectives.”

Impact on fertility In general practice, not all patients have an interest in fertility preservation. For example, the median referral rate for sperm banking in Dutch patients with testicular cancer is 30%. In a recent systematic review of questionnaire studies among cancer patients and survivors, 30-87% of patients recall that the impact of

Figure 1: ultrasound stage 1 non-seminoma testis, with adjacent normal testicular parenchyma

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the cancer diagnosis and treatment on fertility and sperm banking was discussed2.

overall probability of pregnancy in couples who banked sperm was higher9.

An important aspect of fertility assessment and counselling in men with testicular cancer is that 50% of patients will be confronted with abnormal sperm parameters during a sperm cryopreservation attempt.

This pre-existent risk of subfertility can be explained by well-known overlapping confounders for both testicular cancer and subfertility: testicular dysgenesis and a history of cryptorchidism. In 4-26% of men diagnosed with testicular mass, suspected for testicular cancer, sperm banking will not be feasible due to azoospermia at the time of diagnosis3.

Treatment for those who benefit most In summary, the sequence of fertility preservation strategies is essential to identify testicular cancer patients with azoospermia. Fertility sparing surgery is indicated in these patients as a second line treatment option for fertility preservation (see image 3). Urologists who rearrange their fertility preservation and oncological networks can make use of the window of opportunity in azoospermic testicular cancer patients to optimise counselling and treatment in those patients who will benefit most.

The diagnosis of oligo- or azoospermia shortly after the diagnosis of testicular cancer is an obvious double shock for patients in their reproductive age. It is essential for the understanding of patients to address that the azoospermia is not caused by the testicular cancer. The only exception is the rare HCG producing Leydig cell or testicular germ cell tumour that leads to endocrine suppression of the spermatogenesis. In the majority of patients, the lead time towards the diagnosis of oligozoospermia or non-obstructive azoospermia (NOA) is simply fast forwarded by the diagnosis of testicular cancer. Assessment of the testicular function will indicate decreased testicular volume, increased FSH and decreased inhibin B; the hallmarks of testicular insufficiency. The reverse course of action, diagnosis of testicular cancer during the work up of NOA, is more rare and occurs in 3-5% of cases. In comparison, the prevalence of azoospermia in couples attending fertility clinics because of subfertility is 10%4. In the general population, azoospermia is diagnosed in 1% of men5.

“Radical orchiectomy offers a unique window of opportunity to perform simultaneous oncological testicular sperm extraction (oncoTESE).”

Earlier diagnosis Nowadays, partly because of increased awareness among patients, most testicular cancers are diagnosed as stage I, small palpable testicular lesions. Whenever normal testicular parenchyma adjacent to the tumour is observed on testicular ultrasound, TESE is a feasible treatment option to obtain and cryopreserve testicular sperm for later use in assisted reproduction (see image 1). In patients with testicular cancer and concomitant NOA, radical orchiectomy offers a unique window of opportunity to perform simultaneous oncological testicular sperm extraction (oncoTESE) as an alternative means to preserve fertility from tissue that would have otherwise been discarded.

The success rate of oncoTESE is comparable to conventional TESE with reported sperm retrieval rates (SRR) up to 68% (abstract 251, poster session 18, Male infertility and reproductive health: translating new techniques into clinical application). Histological studies have confirmed the obvious correlation between the quality of spermatogenesis and the vicinity and size of the testicular tumour. Spermatozoa have been successfully identified retrospectively in pathological sections in 58% of patients with azoospermia6.

Differential diagnosis The surgical technique of oncoTESE comprises conventional radical orchiectomy, with on the bench equatorial or longitudinal incision of the tunica albuginea and subsequent (micro)TESE in the testicular parenchyma as far away from the testicular tumour as possible (see image 2). Whenever the differential diagnosis is a benign lesion, and tumour diameter is less than one centimetre, testicular sparing surgery with perioperative frozen section examination can be attempted.

Bilateral oncoTESE increases the SRR. Not only does contralateral TESE provide an additional opportunity to bank testicular sperm, it also identifies patients with the precursor lesion of testicular cancer: Germ Cell Neoplasia In Situ (GCNIS). Based on an observational study, 70% of patients with GCNIS will progress to invasive TGCT within 7 years7.

Extrapolation of these data has led to the assumption that all patients with GCNIS will eventually develop TGCT. Treatment of GCNIS with 16-20 Gy local radiotherapy or orchiectomy may prevent the

Figure 2: oncoTESE: longitudinal incision of the tunica albuginea to expose normal testiscular parenchyma for testicular sperm extraction

development of a metachronous bilateral tumour.

However, the lead time to a second tumour is unclear.

Patients will develop azoospermia following local radiotherapy and will increase their risk of hypogonadism.

Contralateral biopsy recommended Both the extrapolation of available data, the comorbidity of treatment and the low incidence of GCNIS make it controversial to routinely perform systematic contralateral testicular biopsies. The EAU testicular cancer guidelines recommend a contralateral biopsy in cases with risk factors for testicular cancer, e.g. history of cryptorchidism, testicular volume < 12 ml and poor spermatogenesis (Johnsenscore 1-3). The reported prevalence of GCNIS in NOA patients is 1-2%, compared to up to 9% of patients with a medical history of testicular cancer.

The incidence of GCNIS on routine contralateral biopsies in patients with azoospermia in our hands is 24%. Azoospermia per se remains a controversial risk factor for GCNIS. Opposing views of bilateral oncoTESE or biopsies are fuelled by medicolegal issues and cost efficiency debates. Urologists may be reluctant to perform surgery on a seemingly healthy contralateral testis, with the risk of introducing hypogonadism. A recent systematic review and meta-analysis concluded that induction of hypogonadism following TESE is transient and will resolve spontaneously within 18 months post-surgery8.

The costs for (micro)TESE, cryopreservation and TESE-ICSI are high. Based on current knowledge, one might even suggest that sperm banking via oncoTESE in azoospermic males is more cost effective than sperm banking in all patients with testicular cancer, since most patients with normal fertility status at the time of diagnosis will recover from gonadotoxic treatment to their pre-treatment status. The low use rate of banked sperm for assisted reproduction provides circumstantial evidence for this opinion. As can be expected, sperm banking prior to gonadotoxic treatment for testicular cancer is more cost efficient than assisted reproduction with (micro)TESE, and the

“The overall probability of pregnancy in couples who banked sperm was higher.”

References 1. Schrader, M., M. Muller, N. Sofikitis, B. Straub, H. Krause, and K. Miller, “Onco-tese”: testicular sperm extraction in azoospermic cancer patients before chemotherapy-new guidelines? Urology, 2003. 61(2): p. 421-5.

2. Taylor, J.F. and M.A. Ott, Fertility Preservation after a Cancer Diagnosis: A Systematic Review of Adolescents’, Parents’, and Providers’ Perspectives, Experiences, and Preferences. J Pediatr Adolesc Gynecol, 2016. 29(6): p.

585-598.

3. Moody, J.A., K. Ahmed, T. Yap, S. Minhas, and M. Shabbir, Fertility managment in testicular cancer: the need to establish a standardized and evidence-based patient-centric pathway. BJU Int, 2019. 123(1): p. 160-172.

4. Jarow, J.P., M.A. Espeland, and L.I. Lipshultz, Evaluation of the azoospermic patient. J Urol, 1989. 142(1): p. 62-5.

5. Krausz, C., Male infertility: pathogenesis and clinical diagnosis. Best Pract Res Clin Endocrinol Metab, 2011.

25(2): p. 271-85.

6. Shoshany, O., Y. Shtabholtz, E. Schreter, M. Yakimov, H. Pinkas, A. Stein, J. Baniel, et al., Predictors of spermatogenesis in radical orchiectomy specimen and potential implications for patients with testicular cancer.

Fertil Steril, 2016. 106(1): p. 70-74.

7. Dieckmann, K.P. and N.E. Skakkebaek, Carcinoma in situ of the testis: review of biological and clinical features. Int J Cancer, 1999. 83(6): p. 815-22.

8. Eliveld, J., M. van Wely, A. Meissner, S. Repping, F. van der Veen, and A.M.M. van Pelt, The risk of TESE-induced hypogonadism: a systematic review and meta-analysis.

Hum Reprod Update, 2018. 24(4): p. 442-454.

9. Gilbert, K., A.K. Nangia, J.M. Dupree, J.F. Smith, and A. Mehta, Fertility preservation for men with testicular cancer: Is sperm cryopreservation cost effective in the era of assisted reproductive technology? Urol Oncol, 2018.

36(3): p. 92 e1-92 e9.

Monday 18 March 10.30-12.00: Thematic Session 16 When sperm count counts: Male infertility update 2019

DiagnosGc work up tesGcular mass - Ultrasound - Tumor markers - CT

FerGlity assessment - LH, FSH, Testosterone - Semen analysis / sperm cryopreservaGon Window of opportunity in case of azoospermia : Radical orchiectomy + bilateral oncoTESE + contralateral biopsy to rule out Germ Cell Neoplasia In Situ (GCNIS)

Figure 3: sequence of diagnosis and treatment in first line treatment of testicular cancer

Image 3 : sequence of diagnosis and treatment in first line treatment of testicular cancer Monday, 18 March 2019

Digital technologies will change the future of health care The EAU and European Health: The ERN eUROGEN programme Naside Mangir, FEBU ERN eUROGEN Clinical Data Specialist Sheffield (UK)

Feitz (Radboudumc in Nijmegen, NL), work stream 2 on complex urogenital conditions requiring highly specialised surgery is led by Prof Margit Fisch (Universitätsklinikum Hamburg, DE) and work stream 3 on rare urogenital tumours is led by Prof Vijay Sangar (The Christie NHS Foundation Trust, Manchester, UK).

Due to the Brexit developments, the overall ERN eUROGEN coordinatorship by Prof. Chris Chapple was recently transferred to Prof. Wout Feitz of Radboudumc with the approval of our current Members.

With increased longevity and the rising prevalence of chronic conditions, the costs of health and long-term care have grown over recent decades. Additionally, increased public expenditure on health and advancements in medical and surgical sciences have not necessarily translated into good health for ageing people. Therefore, greater effort is needed to build more effective, accessible and sustainable health care systems.

The European Commission and our health care The European Commission has been developing strategies to cope with the challenges that lie ahead for health care systems. Digital technologies are increasingly becoming a part of our daily lives and can offer solutions and opportunities to tackle some of the challenges faced by health care systems.

The eHealth programme focuses on the deployment of modern and efficient digital cross- border health services throughout Europe. The EU eHealth action plan 2012-2020 is closely linked to the cross-border healthcare directive which gives patients the right to receive medical treatment in another EU country. To facilitate the cross-border movement of health information securely and effectively, digital service infrastructures have been developed. As of now, ePrescription, eDispension and ePatient Summary services have been piloted. With these services, patients can take their summary of medical records to, or acquire medications in, any other EU country.

ERN eUROGEN’s health care providers are connected through a dedicated IT platform called the Clinician Patient Management System (CPMS). Via this web-based platform, patient information can securely and effectively be uploaded and shared among centres. The system pseudonymises patient data (at both the level of the patient/clinician and the researcher) after the case is closed (and when consent has been provided), stores the data in a low accessibility database and provides a mechanism to allow an ERN or the Contracting Authority to collect and export data (e.g. relational database) for potential sharing or future use in clinical decision-making tools, protocols, guidelines, case libraries or research.

“ERN eUROGEN enables health professionals working on urogenital diseases anywhere in Europe to access a ‘virtual’ advisory board of medical specialists using telemedicine tools to review a patient’s condition for diagnosis or treatment.”

Effective management system The CPMS is very effective in generating structured general patient information (e.g. name, history, pedigree), viewing digital medical images through Picture Archive and Communication Systems (PACS) in multiple formats, including magnetic resonance imaging (MRI) and computerised tomography (CT).

Currently, new add-ons are being integrated that will allow the sharing of histopathological information between centres.

Continuity of care All of these measures, ultimately, aim to ensure continuity of care by establishing interoperability between health systems. Therefore eHealth, telemedicine and other digital technologies such as artificial intelligence and supercomputing, are acknowledged as new tools and strategies to address the current challenges for health care systems in Europe and to transform them into more cost-effective and sustainable systems.

Looking at the future, developers are working to allow CPMS to extract data on specific patients by The European Reference Networks (ERNs) are key to interfacing with the electronic patient records of facilitating the cross-border exchange of health data health care providers. Radboudumc and and clinical expertise between member states. The Universitätsklinikum Hamburg-Eppendorf are two of ERNs were endorsed under the EU Directive 2011/24/ ERN eUROGEN’s health care providers who are EU on patients’ rights in cross-border healthcare. currently working intensively with the European ERNs are virtual networks between health care Commission’s IT teams to test this CPMS functionality. providers and centres of expertise across Europe to improve access to diagnosis and the provision of Virtual advisory board high-quality healthcare to all patients with rare or ERN eUROGEN enables health professionals working complex conditions. ERNs currently focus on cases of on urogenital diseases anywhere in Europe to access rare or low prevalence and complex diseases which a ‘virtual’ advisory board of medical specialists using require a particular concentration of resources or telemedicine tools to review a patient’s condition for expertise. The ERNs are also focal points for medical diagnosis or treatment. This allows health training and research, as well as information professionals, who previously would have handled dissemination and evaluation, especially for rare rare and complex cases in isolation, to consult peers diseases. Currently, there are 24 ERNs involving more and seek a second opinion from a colleague. than 900 health care providers and sub-specialty centres from 300 hospitals in 26 EU countries.

A central feature of these tools is interoperability.

Thanks to technology, geographical distance does not eUROGEN need to be a barrier to work in dispersed teams. In ERN eUROGEN is the European Reference Network some cases, phone or video calls will suffice. On other (ERN) for rare urogenital diseases and complex occasions, networks can use dedicated systems to conditions. Its main aim is to improve diagnosis and share tissue samples or high-resolution images of create more equitable access to high quality treatment complex conditions. These technologies can also be and care for patients with rare urogenital diseases and used as a repository of cases, helping to build a large complex conditions needing highly specialised surgery. bank of cases for further study and education.

Currently, ERN eUROGEN comprises of 29 healthcare providers as full members from 11 Member States who Panel case review collaborate to provide diagnoses or recommendations When a clinician is treating a patient who has a rare for the treatment of patients with rare or very complex or complex urogenital condition that cannot easily be urogenital conditions. In close collaboration with managed or treated at national level, and their centre EURORDIS, patient representatives are involved at all is outside of the ERN eUROGEN network, the clinician levels of our organisational structure in order to be can contact ERN eUROGEN and ask for a review of this able to give advice and specialist expertise from the case (after gaining informed consent from the patient patient or parent perspective on rare or highly complex for their data to be shared in CPMS). If agreed, the cases. This adds enormous value and improves the treating clinician can login as a guest to CPMS and overall care for our patients. can upload the relevant medical information with the help of our dedicated small team. ERN eUROGEN can Work streams then hold a panel case review with the appropriate ERN eUROGEN is structured into three work streams, experts from within our network who can give the each with a dedicated lead. Work stream 1 on rare treating clinician advice. All of this can be done congenital urogenital anomalies is led by Prof Wout without the patient having to travel.

Monday, 18 March 2019

eUROGEN is one of the 24 European Reference Networks (ERN) that are approved and funded by the European Union (EU). ERNs are a cross-border cooperation at European level between healthcare providers with the aim of improving care for patients with rare diseases or complex conditions.

Continuity of care, from childhood throughout life We are delighted to announce that ERN eUROGEN has so far conducted a number of panel discussions on rare and complex urogenital cases requiring highly specialised care and surgery. Experts from centres across Europe are impressed by CPMS, in particular by the quality of the medical imaging. By using CPMS, we have been able to provide expert advice more quickly, thereby delivering better care to our patients and reducing the need for them to travel.

Among the other 23 ERNs, ERN eUROGEN is set up in such a way that it can deliver patient care, diagnosis and treatment, ’ensuring continuity of care from childhood throughout life’. This is of particular importance to patients with rare and complex urogenital diseases as they require health care from childhood, throughout adolescence, into adulthood.

This needs to be well organised in order to achieve a successful and satisfactory transition from paediatric care units to adult specialist care units, thereby ensuring the continuity of care.

Partnership between EAU and eUROGEN Additionally, ERN eUROGEN has forged a strong partnership with the European Association of Urology (EAU). This puts ERN eUROGEN in a very strong position to increase awareness of the ERN networks amongst health care professionals. The EAU annual congress is a superb opportunity for clinicians involved in the ERN to use the platform of 16,000 urologists gathered together to reach out to clinicians who might wish to seek the expert advice of ERN eUROGEN for patients with a rare urogenital disease or complex conditions that they may not have seen often before.

One of the objectives of ERN eUROGEN is to transfer knowledge to countries with fewer resources and less expertise. In 2019, the Member States will be busy appointing health care providers in countries where the ERN has no full member (these are called affiliated partners). Latvia and Austria have already contacted the ERN eUROGEN coordination team and we are delighted that we now have an official route for the referral of their patients. This will enable all of

the ERNs to expand their geographical coverage to all EU and EEA member states.

ERN eUROGEN at the Annual EAU Congress This year ERN eUROGEN and our new affiliated partners will be focusing on rolling out the use of CPMS across the whole network, thereby facilitating more discussions and sharing expertise on complex and rare cases. We have plans for this collaboration to intensify and go beyond providing virtual expert clinical advice. ERN eUROGEN will also be working on developing new clinical guidelines where none currently exist, becoming even more research active (driven by the needs of our patients), training, providing education and sharing knowledge, especially in countries with less expertise and fewer resources.

At the 34th Annual EAU Congress, Prof. Chris Chapple, Secretary General of the EAU and CPMS Implementation Lead for ERN eUROGEN, will present on ’The EAU and European Health: the ERN eUROGEN programme’ during plenary session 5 on Monday 18 March 2019. The ERN eUROGEN session will update you on the recent largest health care innovation in Europe involving 30 million patients with rare or complex conditions. This programme on urogenital rare diseases and complex conditions involves the whole spectrum from congenital anomalies to lifelong care and complex functional and rare urogenital tumours.

There will also be a special session at the Annual EAU Congress on ERN eUROGEN on Saturday 16 March with a presentation by the new coordinator, Prof Wout Feitz and other experts and a patient representative involved. We would be delighted to see you there!

Saturday 16 March 10.15-11.45: Specialty Session ERN eUROGEN Monday 18 March 08.00-10.30: Plenary Session 5 Prostate cancer

The eUROGEN team at the strategic board meeting in Noordwijk (2018)

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Booth

#D38

Pioneering in Energy-based Technologies HIFU

Prostate Cancer

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ESWL & LASER Urinary Stones

Monday, 18 March 2019

Social media in office urology How to manage your online presence professionally Dr. Stefan W. Czarniecki Board ESUO EAU Guidelines Office Social Media Dissemination Working Group Warsaw (PL) @DrCzarniecki Office urology is at the intersection of the primary care pathway and the interventional clinical practice where urological procedures are performed and oncological care is provided, depending on the precise organisation of the given healthcare system.

Office urology is very commonly the location where patients first meet their urologist and where the first contact with our urological specialty is made. It is also the gateway to long-term urological follow-up.

More so than ever, the choice for a specific office urologist is not left to chance. The internet has changed the way we actively seek expert medical care, tailored to our expectations and specific medical situation. And this is why social media are the human-generated platforms the office urologist should understand.

Here is a quick guide of where every medical professional should mark his/her place in the online world.

Why maybe? Although Facebook’s terms of service emphatically state that Facebook users ’own’ the data they provide via the service, the company quite explicitly notes that it will share these data with entities “conducting academic research and surveys.”

You have been warned.

Twitter Twitter is a very different social media platform. Twitter is a free social networking and microblogging platform, which allows registered users to post and view short messages – called tweets – limited in length to 280 characters.

Controversially, this has been a significant increase from the previous 140 characters, which promoted brevity and a ruthlessly concise manner of communication. Some die-hards continue the ’old school’ of 140 character’s as a self-imposed regulation. However, despite this limitation tweets can and do include images and videos, meaning that the potential for content sharing is practically unlimited.

Although smaller in range, it boasts 326 million active monthly users, and has time and again been promoted as the prime social media channel for academic exchange. The urological community is very active in this realm.

In fact, the social media special forces working with the EAU Guidelines Office have been very active in promoting the EAU Guidelines using the #eauguidelines hashtag as a marker – reaching over 11 million impressions over a 9-month period on Twitter. A systematic review on dissemination strategies in social media including the details of this data authored by @HendrikBorgmann et al. will be presented at #EAU19.

An Instagram-initiated provocation of a Polish celebrity journalist during the 2018 Urology Week in Warsaw resulted in the first live transmission of a DRE live on television, but Social Media channel impressions matched traditional TV viewership for a total reach of over 850,000 viewers. It has been estimated that this has been the largest ever reach of any Urological awareness campaign in Poland.

Personal website A personal website does actually not count as social media, it’s the modern day version of a business card.

Facebook page The purpose of creating a simple curriculum With over 2 billion active Facebook-users, vitae-based website is not for active engagement with this is the social media platform which requires your your patients. Its purpose is to bring order to (and to attention. It is a Mammoth free social networking link to) all of your online social media emanations, service that allows registered users to create profiles, @LoebStacy published a first-of-its-kind paper in which can have a bit of a life of their own once they upload images and videos, send messages, and European Urology this year on this matter8: Twitter is and should primarily be used by urologists get going. It also replaces the physical sign on the interact with one another. By far the most common as a platform for academic exchange, continuing door of your office informing patients that the doctor “[…]We performed the largest, most comprehensive facet most users know is the Facebook profile that can education, and professional discussion. Countless is a real person, and they have arrived at the right be set up by literally anyone, and interaction is cross-border collaborations are born here all the time. examination of prostate cancer information on YouTube place. By online standards it’s a rather conservative to date, including the first 150 videos on screening and focused on a personal virtual ‘wall’ on which said user and other users can post.

However, many will disagree. It’s a versatile platform treatment. We used the validated DISCERN quality criteria bronze plaque hanging there not subject to further deliberation. This online placeholder does not need to for consumer health information and the Patient - 74% of Twitter users report using the network as be related directly to the institutions you are involved A Facebook page however, is not the same as a their source for news3 and 85% of small and medium Education Materials Assessment Tool, and compared in – this is something different. There are numerous results for user engagement. The videos in our sample personal Facebook profile. It is a critical mistake to businesses use Twitter to provide customer service4. easy ways to set up a simple website, most are based The choice is yours. had up to 1.3 million views (average 45 223) and the mix the two in your online presence. A Facebook overall quality of information was moderate. More videos on the implementation of the open-source WordPress personal profile ought to be used exclusively for website creation tool. This is a sort of base to consider described benefits (75%) than harms (53%), and only communication with your friends, never your patients. Instagram Instagram is a free, predominantly image-based 50% promoted shared decision-making as recommended in your online presence.

If you already have a personal Facebook profile and social media platform. It’s owned by Facebook. As of in current guidelines. Only 54% of the videos defined are a practicing medical professional it makes sense June 2018 there are over 1 billion registered users on medical terms and few provided summaries or references. Physician review websites to have your privacy settings on a very high level on Physician review websites have been ruining this service5. Registered Instagram users can post There was a significant negative correlation between your personal profile, and use a separate Facebook credibility assessment for physicians for years. Many images with text which are visible to followers or the scientific quality and viewer engagement (views/month page to represent your professional self. You may of them guarantee positive reviews magically general public who choose to follow a given account. p = 0.004; thumbs up/views p = 0.015). The comments consider whether you want to make any images appearing on your account as soon as a subscription All users are able to comment on publicly visible section underneath some videos contained advertising publicly available on your private profile that may service is purchased by a physician claiming suggest that your free time is spent in any contrast to posts, but posts from private accounts are only visible and peer-to-peer medical advice. A total of 115 videos to preauthorized subscribers.

(77%) contained potentially misinformative and/or biased ownership of a profile (they often create the profiles your everyday professional capability, or worse, in a without their knowledge). All the more so – genuine content within the video or comments section, with a manner which may affect your working day patient reviews on these sites are a valuable element total reach of >6 million viewers[…].”

Is Instagram an important channel for your urology professional capacity. of a social media presence because being passive practice? The EAU certainly thinks so, and #eauguidelines and other posts are regularly coming There is no reason not to advance your office urology about the way your identity is listed on ’user review’ Image of urological community websites is a mistake. out of the official @Uroweb Instagram account, as the practice, improve its visibility and work to educate We analysed this topic recently with two FEBU account continues to gain popularity and followers. urologists (Roman Sosnowski and Artur Leminski): your patients by recording videos to post on YouTube.

References What image of the urological community is portrayed There are those who argue that a professional social If I’m right it will be an indispensable and expected 1. Koo K, Ficko Z, Gormley EA. Unprofessional content on media presence cannot do without an Instagram on Facebook? Koo Kevin and co-authors tried to element of your online presence and patient account. Although the medium is known best because connection at some point in the near future.

Facebook accounts of US urology residency graduates. answer these questions in a study analysing the it is used by celebrities, it has become much more BJU Int. 2017; 119: 955-960 behaviour of trainees who graduated from urology universal because of its explosive growth over the last As a very early millennial, I can recall that when I 2. Sosnowski R, Czarniecki SW, Leminski A. Can Urologists residency programmes in 2015 in the USA1. Among be permitted to maintain a private Social Media presence identifiable Facebook profiles, 80 profiles (40%) several years and can easily serve as an eye-catching started using YouTube it was through a dial-up in light of the relevant Guidelines and Codes of Conduct, contained unprofessional or potentially objectionable channel of communication to your audience – even if modem that made funny sounds to a staccato which govern the use of Social Media with regard to content, including 27 profiles (13%) exhibiting in an indirect way. pixelated moving image onscreen. Trust me, the ones these professionals? Cent European J Urol. 2017: 70: explicitly unprofessional behaviour. that followed myself and my peers are now used to 445-446.

Why in an indirect way? Well, simply because only 4K YouTube video quality even on a mobile and they 3. http://www.journalism.org/2017/09/07/news-use-acrossThe common categories of unprofessional content 15% current users of this massive service are over expect the brands that they associate with to be social-media-platforms-2017/ included uncensored profanity, images of the the age of 456. If your practice is based on urological available in on-demand video format. That may mean urologist in an intoxicated state, references to diseases occurring more commonly in those over 45, you. Wait, did I not mention that your practice is built 4. https://business.twitter.com/en/basics/intro-twitter-forbusiness.html specific episodes of intoxication, and images of your Instagram communication is likely to reach your on your personal brand?

5. https://www.statista.com/chart/9157/instagram-monthlyunprofessional conduct at work and professional potential patients via their children. But then again, active-users/ functions, such as conferences. Further instances of this is an incredible tool for early-age awareness LinkedIn 6. https://www.statista.com/statistics/325587/instagramunprofessional conduct entailed the posting of building. Either way, it may be a worthwhile LinkedIn is a free professional networking website global-age-group/ explicit patient data, such as radiographic images long-term investment of time and effort. used by 590 million registered users. As with where a specific patient’s name and/or clinical Facebook, Instagram and YouTube, the ’feed’ is central 7. https://www.businessinsider.com/youtube-userstatistics-2018-5?IR=T details were visible, facilitating identification of the YouTube to the service, but only second to the highly detailed patient. The question therefore remains as to It appears that YouTube will play an curriculum vitae which is the backbone of the platform. 8. Loeb S, et al. Dissemination of Misinformative and Biased Information about Prostate Cancer on YouTube. whether we can, or indeed ought to, control and important part in the future of social media, as it is This ’feed’ is where the activity of all other users is Eur Urol (2018), https://doi.org/10.1016/j. influence the behaviour of members of the video based. A whopping 1,8 billion monthly users listed in an endless scrolling list of posts and articles. eururo.2018.10.056 urological community in their personal (private) are fixated on their screens via the youtube.com Although the average user only spends 17 minutes a 9. https://www.omnicoreagency.com/linkedin-statistics/ SoMe presence?2 website or the stand-alone apps. And this number month on LinkedIn and only 3 million share content only counts users that are actively logged in to a weekly, many users have a very high level of activity9.

7 The point is that a dedicated Facebook page and not a registered account during use ! Registered users are Monday 18 March Although LinkedIn is predominantly a B2B sales, Facebook profile should be used as an online able to post and comment on videos, unregistered 10.30-12.00: Thematic Session 20 marketing, and recruiting event that goes on 24-hours placeholder in the social media world as well as a users can view to their hearts desire. It’s free for How to successfully run a urology office in Europe a day, there is certainly justification for a formal gateway for contact with your patients - maybe. anyone to use. presence of your professional practice in the service.

Monday, 18 March 2019

Should your office urology practice take notice? Of course the answer is yes. There is a striking deficit of credible medical information on YouTube and unfortunately misinformation proves more popular than more fair and unbiased content.

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obstruction, incomplete voiding due to detrusor muscle dysfunction) are believed to result in an infection that 3.7.5 Summary of eradicate evidence than and recommendations for the treatment complicated will be more difficult to an uncomplicated infection [151-153].ofThe underlying UTIs factors that are generally accepted to result in a cUTI are outlined in Table 5. The designation of cUTI encompasses a wide Summary of Evidence LE it is variety of underlying conditions that result in a remarkably heterogeneous patient population. Therefore, readily apparent thatwith a universal the evaluation and treatment is treated not sufficient, 1b Patients with a UTI systemicapproach symptomstorequiring hospitalisation shouldofbecUTIs initially with analthough there are general principles of management thaton can be resistance applied todata the and majority of patients with cUTIs. The intravenous antimicrobial regimen chosen based local previous urine culture following recommendations are based the Stichting Werkgroep Antibioticabeleid (SWAB) Guidelines from results from the patient, if available.

Theon regimen should be tailored on the basis of susceptibility the Dutch Working Party on Antibiotic Policy [154]. result.

2 If the prevalence of fluoroquinolone resistance is thought to be < 10% and the patient has Table 5: Commonfor factors associatedcephalosporins with complicated [154-156] ciprofloxacin can be contraindications third generation or anUTIs aminoglycoside, prescribed as an empirical treatment in women with complicated pyelonephritis.

Obstruction at hypersensitivity any site in the urinary tract a cephalosporins UTI in males In the event of to penicillin can still be prescribed, unless the patient 2 has had body systemic anaphylaxis in the past.

Foreign Pregnancy In patients with a cUTI with systemic symptoms empirical treatment should cover ESBL’s if there is an 2 Incomplete voiding Diabetes mellitus increased likelihood in the community, and prior antimicrobial Vesicoureteral reflux of ESBL infection based on prevalence Immunosuppression exposure of theofpatient.

Recent history instrumentation Healthcare-associated infections

Antimicrobial treatment in the hospital setting Indication, route of administration, duration and choice of antimicrobials Professor Suzanne E. Geerlings Dept. of Internal Medicine Amsterdam University Medical Centre Amsterdam (NL) s.e.geerlings@amc.nl Current EAU Guidelines recommendations for the treatment of complicated UTI. A complicated urinary tract infection (UTI) occurs in an individual in whom factors related to the host (e.g. underlying diabetes or immunosuppression) or specific anatomical or functional abnormalities related to the urinary tract (e.g. obstruction, incomplete voiding due to detrusor muscle dysfunction) are believed to result in an infection that is more difficult to eradicate than an uncomplicated infection1. The underlying factors that are generally believed to result in a complicated UTI and the guidelines recommendations for the treatment of a complicated UTI are outlined in the tables below.

Why is guideline adherence important?

Recently, the burden of infections caused by antibiotic resistant bacteria in European countries was published, measured in number of cases, attributable deaths and disability-adjusted life years (DALYs). Results show a total number of 671,689 infections with antibiotic resistant bacteria, which accounted for an estimated 33,110 attributable deaths and 874,541 DALYs. The burden was similar to the cumulative burden of influenza, tuberculosis, and HIV, was notably diverse across countries (highest in Italy and Greece) and has increased between 2007 and 2015.

Most of the estimated burden was in hospitals and other health care settings, which suggests the urgent need to address antimicrobial resistance as a patient safety issue The authors conclude that strategies to prevent and control antibiotic resistant bacteria require coordination at European and global levels2.

The WHO already signalled the emergence of antimicrobial resistance, along with the steady decline in the discovery of new antimicrobials, as a major health threat for the coming decade. Major problems are anticipated for an increasing number of antimicrobial agents and pathogens. Since the total consumption of antibiotics is the main driving force3 in the increase of antimicrobial resistance, a better use of the current agents and a decrease of inappropriate antibiotic use are necessary4. The good news is that efforts to reduce inappropriate antibiotic use have been shown to be beneficial with regard to resistance rates and costs, without an increase in clinical failures5. An important question is how to achieve more improvement.

Antimicrobial Stewardship programmes in health care In acute care hospitals, 20-50% of prescribed antibiotics are either unnecessary or inappropriate6.

In response, a worldwide initiative seeks to incorporate Antimicrobial Stewardship programmes (ASP) in health care, which aim to optimise clinical outcomes and ensure cost-effective therapy whilst minimizing unintended consequences of antimicrobial use, such as emergence of resistant bacterial strains1,7.

Stewardship programmes have two main sets of actions. The first set mandates use of recommended care at the patient level conforming to guidelines. The second set describes strategies to achieve adherence to the mandated guidance. These include persuasive actions, such as education and feedback, together with restricting availability linked to local formularies.

A Cochrane review of effectiveness of interventions to improve antibiotic prescribing practices for hospital inpatients found high-certainty evidence that such interventions are effective in increasing adherence with antibiotic policy leading to reduced antibiotic treatment duration and may also reduce hospital stay.

The review found no evidence that reduced antibiotic usage increased mortality5.

How can we measure guideline adherence?

Therefore, an extra paragraph about ASP is included in the EAU Guidelines of Urological Infections since 20171. One of the key elements of an effective stewardship programme is its ability to monitor the quality of hospital antibiotic use, with the aim to set 8

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priorities and focus improvement7. Monitoring the appropriateness of hospital antibiotic use can be accomplished using quality indicators (QIs), which function as measurable elements for which there is evidence or consensus that they can be used to assess the appropriateness of daily antibiotic care provided.

We developed and validated, using the RANDmodified Delphi procedure, quality indicators for measuring the appropriateness of antibiotic use in complicated UTIs8. The adherence to the different QIs was low, with a wide performance range across hospitals9. Interestingly, appropriate antibiotic use covering all steps in the process of antibiotic use for complicated UTIs, defined by these validated process QIs, was associated with a shorter length of stay and therefore positively contributes to patient outcome and health care costs10.

Improvement of guideline adherence The studies about QIs of complicated UTIs were based on patient cohorts that were included in the QUality of Antibiotic use in uTI patients (QUANTI) trial, which was a multicentre, cluster-randomised trial in which we compared the effectiveness of two different strategies to improve the appropriateness of antibiotic use in patients with a complicated UTI. These two different strategies were: 1) a multi-faceted strategy, including feedback, education sessions, reminders and additional/ optional improvement actions, and 2) a ‘competitive feedback strategy’, i.e. providing professionals with non-anonymous comparative feedback on the department’s appropriateness of antibiotic use in patients with complicated UTIs. The total QI set performance improved significantly in both strategy groups. However, all improvements were only modest, ranging from 3.3% to 7.4% and no significant differences were found between both strategies9. The evaluation of determinants of successful improvement revealed that better compliance with the strategies was associated with more improvement on the total set of QIs. Low department’s baseline performance on the total set of QIs was associated with a larger effect of both improvement strategies. However, results of improvement strategies may not be generalizable, since barriers in one setting may not be present in another9.

“...appropriate antibiotic use covering all steps in the process of antibiotic use for complicated UTIs, defined by these validated process QIs, was associated with a shorter length of stay.”

Changing hospital antibiotic use is challenging and complex In conclusion, changing and improving hospital antibiotic use is challenging and complex. On each level many determinants play a role. It remains difficult to translate the effects of single interventions to ASPs, because they comprise a menu of different interventions, whose effectiveness could be more or different than the sum of effects of single (available) stewardship elements. No ‘magic bullet’ exists, but a comprehensive approach, consisting of a total menu of ASP interventions, with activities on different levels tailored to the local situation might be necessary to improve appropriate antibiotic use5,6,7,11.

ESBL = Extended-spectrum beta-lactamase.

3.7.2 Diagnostic evaluation Recommendations Strength rating 3.7.2.1 Clinical presentation AUse cUTI associated with angle Strong theiscombination of: clinical symptoms (e.g. dysuria, urgency, frequency, flank pain, costovertebral tenderness, suprapubic pain and fever), although in some clinical situations the symptoms may be atypical • amoxicillin plus an aminoglycoside; for neuropathic bladder disturbances or catheter-associated UTI (CA-UTI). Clinical presentation • example, a secondingeneration cephalosporin plus an aminoglycoside; can from severe obstructive acute pyelonephritis with imminent urosepsis to a post-operative CA-UTI, • vary a third generation cephalosporin intravenously as empirical treatment of complicated whichUTI might spontaneously as soon as the catheter is removed. Clinicians must also recognise that withdisappear systemic symptoms. symptoms, especially lower urinary symptoms (LUTS), are not are only< 10% caused

by UTIs but also by other Strong Only use ciprofloxacin provided that tract the local resistance percentages when; urological disorders, suchisas, for orally; example, benign prostatic hyperplasia and autonomic dysfunction in patients • the entire treatment given with lesions neurogenic bladders. Concomitant medical conditions, such as diabetes mellitus and • spinal patients do notand require hospitalisation; renal failure, has which be related urological abnormalities, • patient ancan anaphylaxis fortobeta-lactam antimicrobials.are often also present in a cUTI. Strong Do not use ciprofloxacin and other fluoroquinolones for the empirical treatment of 3.7.2.2 Urine complicated UTIculture in patients from urology departments or when patients have used Laboratory urine in culture is six themonths. recommended method to determine the presence or absence of clinically fluoroquinolones the last significant bacteriuria in abnormality patients suspected of having acomplicating cUTI. Manage any urological and/or underlying factors.

Strong 3.7.3

Microbiology (spectrum and antimicrobial resistance)

3.8 Catheter-associated A broad range of micro-organismsUTIs cause cUTIs. The spectrum is much larger than in uncomplicated UTIs

3.8.1 Introduction andDavey the bacteria likely be resistant in treatment-related cUTI) EJL than those Ronald isolated 9. Veroniek Spoorenberg, Marlies Hulscher, B in 5.

P, Marwickare CA,more Scott CL et al.toInterventions to (especially Catheter-associated UTI refers to UTIs occurringspp., in aKlebsiella person whose urinary tract isspp., currently catheterised uncomplicated UTIs [155, 156].

E. coli, Proteus spp., Pseudomonas Serratia spp.

Geskus, Jan M. Prins and SE Geerlings. A Cluster- and improve antibiotic prescribing practices for hospital or has been catheterised withincommon the past 48 hours.

The urinary catheter literature ispredominate problematic (60-75%), as many Enterococcus spp. areDatabase the most found in cultures.

Enterobacteriaceae Randomized Trial of Two Strategies to Improve Antibiotic inpatients. Cochrane Syst Rev. 2017species Feb published use thecommon term CA-bacteriuria without providing information on what Otherwise, proportion are CA-ABU with9;2:CD003543.

E. colistudies as the most pathogen; particularly if the UTI is a first infection. the Use for Patients with a Complicated Urinary Tractbacterial doi: 10.1002/14651858.CD003543.pub4. and CA-UTI, and some studies use theone term CA-UTI when referring to CA-ABU or CA-bacteriuria [155]. The spectrum may vary over time and from hospital to another [157].

Infection. Plos One. Dec 4;10(12):e0142672.

The Cochrane database of systematic reviews. following recommendations are based on the Stichting Werkgroep Antibioticabeleid (SWAB) Guidelines from 10. V Spoorenberg, MEJL Hulscher, RP Akkermans, JM Prins 2013;4:CD003543. the Dutch Working Party on Antibiotic Policy [154] as well as the IDSA Guidelines [155].

3.7.4 principles of cUTI treatment and SE Geerlings. Appropriate antibiotic use for patients 6.

Hulscher General M, Grol RP, van der Meer JW. Antibiotic Appropriate management of the urological abnormality or with the urinary underlying complicating factor tract infections reduces lengthisofmandatory. hospital prescribing in hospitals: a social and behavioural 3.8.2 Epidemiology, aetiology anddepends pathophysiology Optimal antimicrobial therapy for cUTI on the severity of illness at presentation, as well as local stay. Clin Infect Dis. 2014 Jan;58(2):164-9. scientific approach. Lancet Infect Dis 2010;10:167-75.

Catheter-associated UTIs are the leading cause of secondary health care-associated bacteraemia. resistance patterns and specific host factors (such as allergies). In addition, urine culture and susceptibility 11. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, 7. Tamar F. Barlam, Sara E. Cosgrove, Lilian M. Abb et al..

Approximately hospital-acquired bacteraemias from should the urinary and and the mortality testing should20% be of performed, and initial empirical arise therapy be tract, tailored followedassociated by (oral) Abboud PA, Robun HR. Why don’t physicians follow Implementing an Antibiotic Stewardship Program: administration of an appropriate antimicrobial agent on the basis of the isolated uropathogen. clinical practice guidelines? A framework for Guidelines by the Infectious Diseases Society of America improvement. JAMA 1999 Oct 20;282(15):1458-65 and the Society for Health care Epidemiology of America.

3.7.4.1 Choice of antimicrobials 21 UROLOGICAL INFECTIONS - LIMITED UPDATE MARCH 2018 Clinical Infectious Diseases 2016;62(10):1197–202.

Considering the current resistance percentages of amoxicillin, co-amoxiclav, trimethoprim and trimethoprimMonday 18 March 8. HS Hermanides, ME Hulscher, JA Schouten, JM Prins and sulphamethoxazole, it can be concluded that these agents are not suitable for the empirical treatment of 10.30-12.00 Thematic Session 14 SE Geerlings. Development of quality indicators for the pyelonephritis in a normal host and, therefore, also not for treatment of all cUTIs [158]. The same applies to From everyday clinical practice to curiosities antibiotic treatment of complicated urinary tract ciprofloxacin and other fluoroquinolones in urological patients [158].

- management of hot topics in infectious disease infections: a first step to measure and improve care. Clin Patients with a UTI with systemic symptoms requiring hospitalisation should be initially treated with Infect Dis. 2008 Mar 1;46(5):703-11. an intravenous antimicrobial regimen, such as an aminoglycoside with or without amoxicillin or a second or

20

UROLOGICAL INFECTIONS - LIMITED UPDATE MARCH 2018

What is the SIU?

THE SIU is

130

DIFFERENT COUNTRIES

THE SIU is

10,000 MEMBERS and counting.

References 1. G. Bonkat (Co-chair), R. Pickard (Co-chair), R. Bartoletti, T. Cai, F. Bruyère, S.E. Geerlings, B. Köves, F. Wagenlehner. Guidelines Associates: A. Pilatz, B. Pradere,. R. Veeratterapillay. EAU Guidelines on urological infections. 2018.

2. Alessandro Cassini, Liselotte Diaz Högberg, Diamantis Plachouras, et al. and the Burden of AMR Collaborative Group. Attributable deaths and disability-adjusted life-years caused by infections with antibiotic resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis. Lancet 2019; 19:56-66.

3. Goossens H, Ferech M, Vander Stichele R, Elseviers M; ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005 Feb 12-18;365(9459):579-87.

4. www.who.int/drugresistance/en

Come and visit us at booth E50 to learn more about SIU and our latest programmes and activities.

www.siu-urology.org

Monday, 18 March 2019

ONE HAPPY FAMILY! It’s been a big year for our family of journals. The launch of European Urology Oncology, a new editorial team for European Urology Focus and now an all time high for the European Urology Impact Factor.

To our extended family of authors, reviewers, and readers, thank you.

We really are in this together.

Our 2017 Impact Factor*

*Journal Citation Reports ® (Clarivate Analytics, 2018)

europeanurology.com eufocus.europeanurology.com euoncology.europeanurology.com

It runs in the family Our family of journals — European Urology, European Urology Focus and European Urology Oncology — share a passion for urology, an unending commitment to patients, a dedication to multi-disciplinary science, and a continuous focus on quality. Just like European Urology Focus, our newest offspring European Urology Oncology sits shoulder-to-shoulder with the popular big sister.

COMMITMENT

PASSION

QUALITY

DEDICATION

Welcome to our family.

europeanurology.com eufocus.europeanurology.com euoncology.europeanurology.com

Monday, 18 March 2019

EUT Congress News

9

Spotlights on Office Urology in Europe Results from survey on office urology held in 19 European countries Prof. Helmut Haas Chairman ESUO Heppenheim (DE)

hf.haas-hp@ t-online.de To ensure the unity of all urologists in Europe the EAU has founded the EAU Section of Urologists in Office (ESUO) two years ago.

The section’s mission is to provide office urologists with information that is tailored to their specific working field and to create a Europe-wide network of office urologists.

Office urology is an emerging part of urology providing substantial near-to-home care for our patients suffering from minor to moderately severe diseases. Office urologists are fully educated urologists who spend the majority of their working day on outpatients, by diagnosing them and prescribing conservative drug treatment.

Broad spectrum of working environments Office urology across Europe is characterised by a broad spectrum of different organisational structures.

Office urologists can work: •

• •

in stand-alone offices or in health care centres, economically operated by themselves, without (’office-only’) or with treatment of inpatients part-time in their offices and simultaneously being employed by a clinic as employee in urologic units in hospitals but performing typical office tasks.

Procedures performed in urological offices in all responding countries • • • • •

Uroflowmetry Drug treatment of urinary tract infections Drug treatment of BPH Drug treatment of ED Testosterone substitution

Figure 1: Procedures performed in urological offices in all responding countries

Apart from these five procedures office urology varies significantly in the different European countries. These differences are depending on the individual country’s rules, historic developments (’traditions’), conditions of health insurances and which subspecialties are regarded as an integral part of urology in that particular country. For example, Germany has a long tradition and an elaborate system of office urology; more than half of the German urologists are working in their own office. On the other hand, office urology is unusual in the UK.

“...data show a great variety in organisation of office urology and the diagnostics and therapy performed in offices.”

office urologists themselves in their offices. To fulfil all their tasks in all urological fields requires close collaboration (’share work’) with other specialties (laboratory medicine, radiology, etc.) and urological clinics are essential.

In many countries laboratory diagnostics are not performed in offices but in collaboration with a laboratory. Only urinalysis is done in urological offices in nearly all countries.

Imaging in offices is done by abdominal and transrectal ultrasound and performed by office urologists in almost all countries.

Urethrocystoscopy and prostate biopsy are key procedures in urology and are performed as an office procedure in most of the countries.

In nearly all countries there extensive for drug treatment of non-oncological diseases in the office.

Drug therapy of urological tumours is regarded as a key function of urologists. Nearly all of the office urologists treat prostate cancer by luteinizing hormone-releasing hormone (LHRH)-substances and antiandrogens, but only in half of the countries they prescribe enzalutamide and abiraterone. In Germany office urologists with a special qualification are allowed to perform chemotherapy in prostate cancer and drug treatment of renal cell carcinoma with the new substances in their offices.

In the majority of countries, over 80% of office urologists have the opportunity of treating their own patients in a hospital.

In more than half of the countries, instillation therapy of bladder cancer is only done at the hospital.

Remarkable variety in diagnostics and therapy in urological offices The following charts give a quick overview of the diagnostic and therapeutic methods performed by

In only three countries the management of catheters and cystostomies is not a task of urological offices but is done in the hospital. The ureter is predominantly the domain of the clinic.

Outpatient surgery is performed in urological offices in two-thirds of the responding countries.

Our – still preliminary – data show a great variety in organisation of office urology and the diagnostics and therapy performed in offices. This is a challenge for the EAU, because it wants to give the best information to all office urologists adjusted to their national spectrum of tasks. The knowledge about this variety will lead to bespoke offers in the EAU educational activities during congresses and meetings, journals and online programmes.

“There are only five diagnostic and therapeutic procedures which are performed in urologic offices in all responding nineteen countries.”

During the Annual EAU Congress in 2019 in Barcelona the ESUO section presents two sessions. On Saturday 16 March from 10.15 to 14.00, you will learn more about infections in the ESUO-ESIU-joint meeting Urogenital infections: What is important in office? that is performed together with the EAU Section of Infections in Urology. And on Monday 18 March from 10.30 – 12.00, core challenges in the urological office are discussed in the session How to run a European urologic office successfully.

Moreover our section is interested in getting in contact with office urologists throughout Europe: Please send an email to: ESUO@uroweb.org Monday 18 March 10.30-12.00: Thematic Session 20 How to successfully run a urology office in Europe

They are remunerated by patients, private or public health insurances in various combinations in different countries.

To learn more about office urology in Europe the EAU section ESUO has conducted a written interview.

The following data come from nineteen responding countries.

The proportions of urologists working in office and their absolute numbers differ remarkably from country to country (see Figure 2).

There are only five diagnostic and therapeutic procedures which are performed in urologic offices in all responding nineteen countries (see Figure 1).

Figure 2: Number and proportion of office urologists in European countries

Figure 3: Subspecialties as an integral part of urology

Figure 4: Office urologists treating in-patients

Figure 5: Laboratory diagnostics in urological offices

Figure 6: instrumental diagnostics in urological offices

Figure 7: Drug therapy in urological offices

Figure 8: Tumour therapy in urological offices

Figure 9: Instrumental and surgical therapy in urological offices

10

EUT Congress News

Monday, 18 March 2019

A roundup of ESU courses and HOT courses Save the date, 18 March, for an array of noteworthy ESU courses and Hands-on Training (HOT) courses assorted according to topics.

Enrich what you know and enhance your skills.

Topics

ESU Courses

Speakers

Time

Rooms

Andrology

ESU Course 41: The infertile couple - Urological aspects

W. Aulitzky (AT)

08:30 – 11:30

Green room 16

ESU Course 54: Office management of male sexual dysfunction

C. Stief (DE)

12:00 – 15:00

Green room 23

Female urology

ESU Course 42: Prolapse management and female pelvic floor problems

E. Kocjancic (US)

08:30 – 11:30

Green room 15

General urology

ESU Course 43: Ultrasound in urology

T. Loch (DE)

08:30 – 11:30

Green room 14

ESU Course 45: Updated renal, bladder and prostate cancer guidelines 2019: What has changed?

H.G. Van Der Poel (NL)

08:30 – 11:30

Green room 21

ESU Course 47: Improving your communication and presentation skills

D. Veneziano (IT)

08:30 – 11:30

Green room 23

ESU Course 55: How to proceed with hematuria

S. Boorjian (US)

14:15 – 16:15

Green room 13

Male LUTS

ESU Course 48: Male urinary incontinence management

E. Chartier-Kastler (FR)

12:00 – 15:00

Green room 16

Neurogenic and non-neurogenic voiding dysfunction

ESU Course 52: Lower urinary tract dysfunction and urodynamics

P. Abrams (GB)

12:00 – 15:00

Green room 21

Penile and testicular cancer

ESU Course 51: Penile diseases

S.S. Minhas (GB)

12:00 – 14:00

Green room 13

Renal tumours

ESU Course 49: Robot renal surgery

A. Mottrie (BE)

12:00 – 15:00

Green room 15

Urolithiasis

ESU Course 44: Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips and tricks, indications

O. Traxer (FR)

08:30 – 11:30

Green room 13

ESU Course 50: Percutaneous nephrolithotripsy (PCNL)

E. Liatsikos (GR)

12:00 – 15:00

Green room 14

Urological surgery

ESU Course 53: Advanced course on upper tract laparoscopy: Kidney, UPJ, ureter and stones

G. Janetschek (AT)

12:00 – 15:00

Green room 22

Urothelial tumours

ESU Course 46: Nerve-sparing cystectomy and orthotopic bladder substitution - Surgical tricks and management of complications

A. Stenzl (DE)

08:30 – 11:30

Green room 22

Topics

HOT Courses

Speakers

Time

Rooms

Diagnostics and follow-up

HOT 24: ESU/ESUI Hands-on Training Course in Prostate MRI reading for urologist

V. Kasivisvanathan (GB)

9:00 – 12:30

Green room 9

Laparoscopy

HOT 23: ESU/ESUT Hands-on training Course in Laparoscopic and robotic paediatric urology

M. S. Silay (TR)

9:30 – 12:30

Green room 6

Innovators in Bladder Cancer website Launching in March 2019!

The Innovators in BC website is a science-based, international forum providing the latest scientific and clinical information to urologists, oncologists and uro-oncologists managing BC.

Innovators in BC aims to provide an accessible scientific resource to facilitate: • sharing up-to-date information in the field • assisting the optimisation of daily clinical practice • supporting peer-to-peer learning by facilitating the sharing of content

To register for access, please visit the Ipsen Booth: E38 in Hall 8.1

Hot topics

Congress highlights

Knowledge modules

Guidelines

Publication summaries

Useful dates and links

HEX-ES-000005 l February 2019

Monday, 18 March 2019

EUT Congress News

11

Rouprêt envisions revamp and evolution of ESOU New section Chairman talks about aims & current onco-urology challenges For this edition, we interviewed the new Chairman of the EAU Section of Oncological Urology (ESOU), Prof. Morgan Rouprêt (FR), who shared his vision for the ESOU, his insights on the current challenges in onco-urology and the possible breakthroughs in the coming decade.

ESOU is the perfect combination of the chance to take the lead of an important section of EAU, and to move forward in service of my colleagues and for the aims of the association.

What attracted you to the role of ESOU Chairman?

As ESOU Chairman I oversee and coordinate with the section board, a multi-tasking group that conceptualises strategies for all exciting ESOU activities, notably the organisation of scientific events e.g. ESOU’s yearly meeting, European Multidisciplinary Congress on Urological Cancers (EMUC), EAU annual congresses and stand-alone meetings.

From the beginning of my career, I have always been inspired by the EAU. It’s an exceptional organisation where one can invest on one’s self in terms of science, education and research.

I have had opportunities to partake in various segments and activities of the EAU such as the Scientific Committee Office (SCO), EAU Guidelines, and at courses organised by the European School of Urology (ESU), but I had no official position in the association yet. In the meantime, I became the Head of the onco-urology unit of the Department of Urology at the Pitié Salpêtrière Hospital in Paris (Assistance Publique – Hôpitaux de Paris), and have been leading the Committee of Cancerology of Association of French Urology (CCAFU) – bladder for the last five years.

When the opportunity arose to be the next Chairman of the ESOU, it was undoubtedly a “yes” for me. The

What will your responsibilities be as Chairman?

In addition, I will take several initiatives and put all my energy in implementing new activities for the section: articles, lectures, online videos, and debates.

I aim to bolster efficiency and proactivity so that we at ESOU receive immediate reliable feedback on activities we are involved in.

Frankly, the ESOU is a remarkable section with its full potential ready to be untapped. The ESOU will work on numerous initiatives for the valorisation of urologists in the treatment of cancers.

annual meeting 4. EAU Patient Information to optimise campaigns directed at patients 5. Other Section Offices to enhance the visibility of urologists not only in surgical aspect but also in the medical management of genitourinary (GU) cancers 6. Other societies such as European Society for Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO), and the Society of Urologic-Oncology (SUO) to name a few and to reach out to them for collaborative reasons 7. European Urology Oncology journal’s Editor-inChief and Editorial Board as the journal is more likely to become the official journal of the section In your opinion, what are the major challenges in the field and how would you help resolve them?

The first challenge is to promote the role of European urologists as principal caregivers in the field of GU cancers. To address this, the ESOU will work on providing a strong network comprised of a multitude of sites where colleagues involved in oncology can connect one another.

Another challenge is to improve the access of the EAU to finding trials related to GU cancers. For urologists, it is important that they remain the main advocates of large uro-oncological trials. It is also I want to redesign the activities of the ESOU to show that it is clearly a notable EAU section, and to increase important in an area where low-level evidence exists because this will promote consensus its presence in the onco-urology field. statement articles that link the EAU and the major uro-oncological societies.

Borders and blurred lines between the roles of oncologists and urologists are becoming non-existent.

Therefore, the ESOU will now collaborate and serve a What are the breakthroughs in the field that you expect in the coming decade? scientific alliance with the: What do you aim to achieve in this role?

Prof. Rouprêt (middle) chairs EAU18 Nightmare Session on BCa management

1. ESU to optimise oncological educational programmes 2. EAU Research Foundation (EAU RF) to develop innovative research in oncology 3. SCO to optimise the Scientific Programme of the

future, the urologists have to be aware that the focus will be more on the treatment of these cancerous cells rather than on the surgical extirpation of the organ.

Thus we will have to invest more in medicine(s) that uses information such as a patient’s genes, proteins and environment to prevent, diagnose and treat disease.

The conflict between standardisation and individualisation has always been a characteristic of medical activity. The high cost of testing and treatments are among the most important factors that influence the integration of individualised medicine approaches in general practice. There are some key areas for the future management of GU cancers: genetic polymorphism, the influence of environmental factors, chemoprevention and focal therapies.

In oncology, individual therapy and personalised medicine will jump from theory to practice very rapidly. The treatment of cancer is not a fight against disease in an organ, but a fight against cancerous cells that can spread out beyond the organ. In the

EAU onco-urology series A unique series of educational updates in onco-urology

With the fast-changing treatment landscape in onco-urology, diagnosing and managing GU cancers require healthcare specialists to be highly profi cient in decision-making and knowledgeable on various treatment approaches including novel therapeutic strategies.

The European Association of Urology (EAU) and the European School of Urology (ESU) have pooled their expertise to organize concise and educational updates in the fi eld of prostate, bladder and kidney cancer.

This unique series of compact educational updates in onco-urology will address new challenges and pitfalls in various phases of decision-making, while taking into account disease stage, progression and bladder cancer patient characteristics. Expert faculty will present real-life case discussions with direct voting for optimal interactivity and direct assessment.

12

EUT Congress News

Monday, 18 March 2019

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䘀漀挀愀氀 吀栀攀爀愀瀀礀 䴀䐀吀 䌀愀猀攀ⴀ䈀愀猀攀搀 匀攀猀猀椀漀渀

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㔀ⴀ㘀 䄀瀀爀椀氀 ㈀ ㄀㤀

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Monday, 18 March 2019

EUT Congress News

13

From the EAU Scientific Congress Office

Briganti strives for further advancement of uro-oncology Dynamism in his new and current roles and responsibilities In this edition of the EAU19 Congress Newsletter, we have had the honour of interviewing internationallyrenowned, Prof. Alberto Briganti (IT), an invaluable member of the EAU’s Scientific Congress Office (SCO) and the Guidelines Office Board.

With over 450 peer-reviewed published publications under his belt and recipient of the coveted EAU Crystal Matula Award, the most prestigious prize given to a young promising European urologist who has the potential to become one of the future leaders in academic European urology, Prof. Briganti continues to help cultivate the advancement of research in urological oncology. In this article, he gives us an insider’s look in his role in the SCO and as the Editor-in-Chief of the new EAU journal, European Urology Oncology.

What was your role in the SCO? As a member of the SCO, I was one of the persons responsible for prostate cancer (PCa) including the subtopics, which comprise of clinical diagnosis and treatment of localized and locally advanced diseases.

up-to-date research for PCa are the rewarding parts of the job.

What are your plans after your term as an SCO member ends?

It’s unfortunate that there’s a maximum of two terms of four years each to serve as an SCO member as I’ve truly enjoyed my time there. I do look forward to further contributing to the EAU through several activities: fulfilling my duties as the Editor-in-Chief of the European Urology Oncology journal; contributing as a member of the Guidelines Office Board of the EAU; partaking as a fellow of the European Board of Urology (EBU); and sharing what I know as faculty member of the European School of Urology (ESU) and the European Multidisciplinary Congress on Urological Cover of the February 2019 issue of European Urology Oncology Cancer (EMUC).

Prof. Alberto Briganti

What do you think is your greatest achievement and what did you enjoy the most in this role?

One of the primary responsibilities of SCO members is to organise a quality Scientific Programme for the EAU annual congress. I’m pleased to work together with dedicated, high-calibre colleagues to evaluate abstracts and create sessions made up of novelty developments.

To come up with a Scientific Programme par excellence every year is an achievement in itself.

The camaraderie, mutual respect for one another and singular objective of delivering modern relevant updates in the field while receiving

Members of the Scientific Congress Office

Kindly tell us about the journal and your main tasks as Editor-in-Chief.

European Urology Oncology is the first official publication of the EAU fully devoted to the study of genitourinary malignancies, and the new sister journal to European Urology (EU) and European Urology Focus. The main aim of the journal is offer first-rate research with a multidisciplinary approach to advance research in urological oncology.

My role as Editor-in-Chief is to oversee this fusion of urology, medical oncology, and radiation therapy among many others. Together with the Board, we commission original articles, opinion-piece editorials and invited reviews covering clinical, basic and translational research papers. We receive original papers directly or through the EU journal. All submitted manuscripts will be peer-reviewed by a panel of experts before being considered for publication.

European Urology Oncology is published six times a year in electronic format and supports Open Access.

We plan to have the journal accepted for inclusion in

MEDLINE®. The journal is an emerging frontline publication, a staple read for both young and experienced urologists.

About Prof. Briganti Prof. Briganti is Full Professor of Urology at VitaSalute University San Raffaele in Milan, Italy where he also acts as Deputy Director of Urological Research Institute (URI). He is also a member of the Guidelines Office Board of the EAU. Prof. Briganti earned his MD in 2002 at Vita-Salute University where he also pursued his residency.

He completed uro-oncological fellowship at the Cancer Prognostics and Health Outcomes Unit of the University of Montreal in 2006. In 2016, he obtained his PhD in Clinical and Experimental Biotechnology in Urology at Magna Graecia University in Italy.

For more information about European Urology Oncology Journal, feel free to explore the official website at http://www.euoncology.europeanurology. com/”www.euoncology.europeanurology.com.

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EUT Congress News

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Monday, 18 March 2019

The new General Data Protection Regulation Implications of the GDPR for daily clinical practice Dr. Stefan Haensel Board Member EAU Section of Urologists in Office Rotterdam (NL)

On 25 May 2018, the General Data Protection Regulation (GDPR) of the European Union was effectuated1. With its introduction, a large media campaign was carried out and fines were announced if organisations did not meet the new criteria. Protection of personal data is of particular importance in the health sector; the basic requirement of confidentiality of diagnostic and therapeutic information requires special attention in the digital environment. The new GDPR implies that all health organisations processing personal data must be able to prove that they comply with the rules. Our attention was drawn: what are the consequences for our daily work as physicians?

Rights of patients Although the new GDPR applies to all domains of the public and private sectors, some specific derogations (legal exemptions) are defined for data concerning health, meant to protect the rights of patients and confidentiality of their personal health data2. The main purpose of the GDPR is to define and update several basic rights of patients regarding control of and access to their personal data, and to implement common rules for data protection in all member states.

Key elements of the new regulation include the need for clear and affirmative consent by the patient concerned; destruction of data if storage is no longer necessary for the initial purpose or after withdrawal of consent by the subject (‘the right to be forgotten’); the right to obtain rectification of his/her personal data; the right of the patient to transfer personal data to another institution (‘data portability’); the right of the subject to be informed when his/her data have been hacked.

The GDPR applies to data concerning health and genetics. Health data are personal data related to the physical or mental health of a person, including the provision of health care services, which reveals information about a person’s health status. Genetic data are defined as personal data relating to the ’inherited or acquired genetic characteristics of a person’, which give unique information about the physiology or the health of that person.

“An important safeguard for the patient is that personal data can only be collected, used and shared by a person subject to professional secrecy.”

Consent The new regulation explains that consent must be explicit and unambiguous, that is to say it needs to be given through a clear affirmative act. It has to be given freely, and be an ’unambiguous indication of a data subject’s agreement to the processing of their personal data’. This can be written, electronic or oral.

Silence or inactivity (e.g. a pre-ticked box) cannot be considered as consent anymore. For example, a written statement in the patients’ file that ’he was informed and stated that he agrees to share his personal data’ is agreeable, but a disclaimer on the website of the institution that ’by making an appointment we assume that the patient agrees with sharing his personal data’ is not. Moreover, patients should be informed on how to withdraw consent prior to giving it.

Sharing data In health care, the rules on data protection allows for patients’ data to be processed as long as the person who does the processing is bound by professional secrecy. This means that health care professionals and health care institutions do not have an obligation to ask systematically for a patient’s consent before they can use the data. However, they are bound by the principle which ensures the exemption from consent is proportionate and limited to what is necessary for a patient’s health and social care.

Monday, 18 March 2019

This greater flexibility in health care to use data without consent can be positive and efficient in several respects, as it means that there is more communication of data possible within a patient’s health care team which is important for integrated care. Therefore, the GDPR is less burdensome for health care workers. For example, if a patient is presented in a transmural (video) conference, no explicit consent is required. Also, if a general practitioner needs to be informed about the health of a patient, or if a patient is referred to another hospital and a colleague needs to be informed, no consent is required. Even if the urologist needs information from physicians from other institutions that were consulted earlier by the patient, no consent is required. An important safeguard for the patient is that personal data can only be collected, used and shared by a person subject to professional secrecy.

“The main purpose of the GDPR is to define and update several basic rights of patients regarding control of and access to their personal data, and to implement common rules for data protection in all member states.”

Research The data protection law only applies to personal data — that is, data that directly or indirectly identifies an individual. Other data are still fully available for medical research. In the ideal (legal) world, the subjects’ data for research need to be anonymised. In practice, this is not feasible because these patients’ data require some kind of reversibility3. To anonymise the data, it is not sufficient to simply delete name and address. In fact, truly anonymised data cannot be linked back to an individual, which means that verification of data is absolutely impossible.

Therefore, some kind of reciprocity is required. This is called pseudonymised data. A third party has identifiers removed and replaced by a unique key code. The researchers do not possess the requisite key code. This key code can be used to trace the data back to an individual, enabling any safety concerns to be acted upon and data to be verified. Pseudonymised data must be treated as precious as personal data.

That is because of the increased vulnerability of data: if the key code is hacked, all the data can be linked to an individual.

Whether an exemption should be made from the obligation to always seek consent before using patients’ data for research in cases when this is impossible, is under debate. The European Patients’ Forum, an umbrella organisation working with patients’ groups across Europe, states that although informed consent is a fundamental right and should be the rule, in some cases exemptions this consent are needed to make research possible. In these circumstances other safeguards need to be in place to ensure patients’ rights.

Patients’ rights The right to access a medical record is explicitly mentioned in the new Regulation4. The institution’s data controller can charge a fee for administrative cost of providing the data when the request was done ’repetitive or unfounded’. The patient can request to receive a copy of the health data in order to transfer these to another entity or person.

There is also the ’right to be forgotten’. This applies in three circumstances: 1. If patients have withdrawn consent and the data controller has no other grounds for processing their data.

2. If there is no longer a purpose to process the data, in accordance with the principle of limited storage and data minimisation. In practice, there is no fixed period when it comes to how long the medical file should be kept; it still needs to be defined.

3. If the processing is unlawful in the first place, for example when the data controller has made the information public. He has to take reasonable step to ensure other controllers also remove links etc..

patients’ right to access medical information is possible when it would impair the achievement of the purpose of the research, or render it impossible.

Providing patients with certain information could be a problem in a blind trial, or could come at great cost when it concerns a large number of participants.

Restriction of or objection to processing one’s data can also introduce bias in the data sample used. It is recommended to make a statement on this issue in the Informed Consent form, which is signed by a patient before entering a research trial.

Registration of implants Many countries started the unique coding and central registration of medical implants for matters of safety. This could for example be relevant in the event of a recall. It should always be clear which implants have been used in which patient. These data need to be pseudonymised as well. A complicating factor is that the implants are typically used in many institutions nationwide or even internationally. Therefore, the pseudonymisation of the personal data of the patients may be challenging for all parties. Thus, in The Netherlands The Dutch National Implants Registry became effective recently. To meet the GDPR criteria the data are controlled by the Health Care Inspectorate (HCI) for pseudonymisation and registration. In case of a recall, individual medical institutions and patients are approached by the HCI. Audit Audits for quality control are frequently carried out in our medical institutions. The GDPR considers audit and health care management a primary use of health care data, directly relevant to monitoring and improvement of the quality of health care.

Therefore, it is seen as primary use of data and requires no encryption of data or separate consent.

In contrary, as stated above, research is considered secondary use of data. Sometimes an audit could be marked as research, e.g. if an audit compares health care systems to discover which is most effective. This can be categorised as research, as the practices are

not compared to a gold standard and there is a hypothesis being generated or even tested by finding associations. Therefore, these kind of auditory surveys require pseudonymisation as described above.

The GDPR: a burden or a blessing?

In my opinion, this is not a relevant question. In daily practice the new GDPR is aimed at patient’s rights and asks for an active approach from the physician, e.g. by the obligation to actively ask for consent and to provide information at the request of the patient. In research, pseudonymisation of personal data requires a third party to be involved and could be demanding for both organisation and budget.

A national implant registration needs political support to be organised properly. A health organisation should be able to show what action is taken to comply with the GDPR. In an age of increasing use of social media, big data analyses and evolving technical possibilities to communicate the hazard is that we may lose control over our privacy. The GDPR has been set up to protect the individual patient in a transparent manner. In daily clinical practice, some simple adjustments are usually sufficient to comply with this new law.

References 1. http://www.privacy-regulation.eu/en/ 2. Editorial. The new EU General Data Protection Regulation: what the radiologist should know. Insights Imaging 2017;8:295–299 DOI 10.1007/s13244-017-0552-7 3. Rumbold JMM, B Pierscionek. The Effect of the General Data Protection Regulation on Medical Research. J Med Internet Res 2017;19(2):e47 doi:10.2196/jmir.7108 4. http://www.eu-patient.eu/whatwedo/Policy/DataProtection/

Monday 18 March 10.30-12.00 Thematic Session 20 How to successfully run a urology office in Europe

3 - 6 September 2019

Leading Continence Research and Education Call for Abstracts: 1 March - 1 April 2019 International Continence Society 49th Annual Meeting

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Data leak In case of a data leak (’security breach’) the patient needs to be informed and updated if ’rights and freedom are at risk’. In research, a derogation of the EUT Congress News

15

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16

EUT Congress News

Monday, 18 March 2019

Figure 1. The pathway in major uro-oncological surgery (Courtesy of Jense The role of the nursing in ERAS Urol. pathways 2018;May28(3):243-253)

Nurses will play an important part in future integrated prehabilitation programmes Bente Thoft Jensen Dept. of Urology & Urological Research Unit Aarhus University Hospital (DK)

The success of enhanced recovery after surgery (ERAS) began more than 25 years ago in Denmark in the field of colorectal surgery led by Professor Henrik Kehlet. He immediately embraced nursing as one of the key players of the surgical team. He challenged old conservative doctrines across perioperative care by letting patients drink clear fluids up to two hours before surgery and by eliminating most bowel preparation before surgery. Post-surgery, the concept recommended to avoid drainage/tubes or remove them immediately after surgery, let patients drink and eat as soon as possible after surgery as well as early progressive mobilisation by sitting and walking on the same day the patient was operated1. In total, these changes in the surgical paradigm called for a complete change of the nursing role; by thinking ’what`s best for the patient’ and ’what is pro-active supportive care’ the nurse became a highly recognised part of the surgical team.

Surgery remains a cornerstone in uro-oncology treatment. To some degree, minimally invasive approaches including robot-assisted procedures have improved safety and patient outcomes. However, despite these advances, high postoperative morbidity persists after resection of the bladder, even for lower-risk procedures such as nephrectomy and prostatectomy, and may cause long-term impairment for the patient2. The changes in demographics and the ascending age of surgical candidates add to the growing demand of assessing every patient very carefully3. Thus, there is a need to consider further optimisation of the patient pathway beyond surgery itself4,5.

Multimodal approach ERAS is based on a multimodal approach, usually involving multi-professional health care teams including nurses, nurse leaders/nurse coordinators, dieticians, physiotherapists, oncologists, anaesthesiologists and surgeons. Although the evidence of the ERAS concept has mainly been gained in colorectal surgery, ERAS has successfully improved recovery across surgical specialties6. The concept is internationally recognised as standard of care, however, interpreted differently and lacks full implementation. Especially the urology community has been criticised for reluctant implementation7.

ERAS has significantly changed the classic scope of nursing in surgical pathways (see Figure 1), and currently the focus along the core cancer continuum of care is to prevent and reduce the symptom burden and long-term impairment (see Figure 1). Thereby a new role of nursing care has arisen.

has a pivotal role and a significant opportunity to impact the core surgical cancer care continuum, from diagnosis to survivorship (see Figures 1 and 2)6.

Figure 2 illustrates that nursing is in the forefront in any phase of the ERAS pathway and emphasises the importance of recognising the multi-professional approach.

The wide range of nursing activities in the ERAS programme is a necessity for success, and a continuous investment in nursing education is of paramount importance to maintain and accommodate the need of highly skilled, specialised nurses, nurse coordinators and discharge nurses in ERAS8. ERAS protocols (ERP) are continuously refined with respect to new evidence in treatment and care, which in practical terms means the nurse needs to be flexible and adjust care pathways to recent evidence.

Currently, there is an increasing awareness of the idea of ’prehabilitation versus rehabilitation’ and the ERAS concept is now expanding its role into prehabilitation interventions9-11. Prevention, assessment, information and education are cornerstones in nursing. Early procedure specific nursing intervention in prehabilitation will e.g. imply early patient screening, pre-assessments, a shared decision-making process and documentation. The nurse will in cooperation with the team and the patient provide evidence-based interventions designed to improve physical and psychological health, optimise adherence to treatment and care and contribute to the efforts of reducing the likelihood of patients developing future chronic impairments (see Figure 1)9.

“...the nursing profession has a pivotal role and a significant opportunity to impact the core surgical cancer care continuum, from diagnosis to survivorship.”

The surgical challenge Surgery causes a cascade of reactions including release of stress hormones and inflammatory mediators such as cytokines, responsible for the Systemic Inflammatory Response Syndrome (SIRS)12.

SIRS causes a catabolism of glycogen, fat and protein. The consequences of protein catabolism is the loss of muscle tissue, which is a short or long-term burden for functional recovery. The ultimate goal of ERAS is to reduce SIRS and minimise per- and postoperative organ dysfunction, postoperative morbidity and enhance rehabilitation leading to improved patient outcomes and maintaining health-related quality of life. Figure 1 illustrates the advanced ERAS pathway and the ongoing progress of implementing systematic prehabilitation interventions to help the individual withstand the upcoming surgical challenge.

Figure 2: Nursing within ERAS

Figure 2. Nursing within ERAS

great risk of having peri- and postoperative morbidity, even mortality despite less invasive surgical procedures and optimised anaesthetic regimes3.

Regardless of age, malignancies usually entail massive physiological disturbances, such as anaemia, organ dysfunction and massive muscle wasting (sarcopenia), and in addition psychological strains, such as anxiety and stress. Consequently, elderly patients often have reduced physiological reserves [Skriv her] and comorbidities. In the process of reducing SIRS and facilitate the protein turnover, the clinical nurse should focus on anabolic factors such as prevention or reduction of protein catabolism and possible malnutrition combined with enhanced physical activity. These components are considered synergistic and are standard elements in integrated prehabilitation programmes before major surgery13,14.

Decision-making process To ensure adherence to treatment and care, it is imperative to involve patients and families in a shared decision process in order to adjust mutual expectations. Nurses must be aware that the decision-making process may be different for men and women; women with bladder cancer often view family members as participants in the decisionmaking process while most men prefer to retain control over treatment decision making15,16.

Clearly, there is an opportunity to use the time span from diagnosis to surgery more efficiently in everyday practice. The Danish Health Authority has recently redefined the national recommendations for uro-oncological surgery in cooperation with the Danish Regions (healthcare providers and political responsible parties), Danish Nurses Organisation, Danish Urological Society, The Bladder-cancer Advocacy and the Danish Cancer Society. In the upcoming publication of the national recommendation 2019, prehabilitation is integrated in the clinical pathway including physical exercises, nutritional intake and supplements, stop alcohol and smoking and stoma-care education (www.sst. the ERAS concept concept is is now now dk) ERAS the

Prehabilitation Recently, at the world conference on prehabilitation in Eindhoven in June 2018, the ERAS Society Nursing from A-Z in ERAS stressed the importance of pre-assessment and One of the overarching goals for the ERAS nursing optimisation as an integrated part of the ERAS team is to identify frail patients with specific needs pathway and a high need to evaluate and manage increasing awareness of thetoidea idea of of ’prehabilitation ’prehabilitation versus rehabilitation’ and andincreasing timely modify their condition inof order the patient beyond surgical specific issues for awareness the versus rehabilitation’ and 9-11 withstand the upcoming surgical in the best interventions several reasons. 9-11.. Prevention, expanding its role role intochallenge prehabilitation interventions Prevention, assessment, assessment, information information and and education education expanding its into prehabilitation possible The genesis of in ERAS is based on the procedure specific nursing intervention in prehabilitation Rehabilitation are way. cornerstones nursing.

Early will e.g. e.g. imply imply are cornerstones in nursing.

Early procedure specific nursing intervention in prehabilitation will The patient population undergoing major cancer question this patient a good candidate for common outcome measure early‘ispatient patient screening, pre-assessments, a shared shared decision-making process The andmost documentation.

The used to assess early screening, pre-assessments, a decision-making process and documentation.

The surgery is becoming increasingly older involving a surgery?’, or ’why is the patient still in hospital the success of an ERP is length of stay (LOS). nurse will in will cooperation with the team teamsubstantial and the thenumber patient provide evidence-based evidence-based interventions designed to in the nurse in cooperation the and patient provide interventions designed to of comorbidities, polypharmacia today?’.

The will answer clearly addresswith the patient’s Although it was an outcome of interest improve physical and psychological health, optimise adherence to treatment treatment and careofand and contribute to the the marker improve psychological optimise adherence to and care contribute to and postoperative complications (surgical and individual needsphysical or potentialand recovery problems. The health, beginning the ERAS era, it is a surrogate 9 9 efforts of indicates reducing the likelihood of patients patients developing future chronic impairments (see Figure 1)comparable medical).developing Thus, a significant part ofchronic the patients are in of recovery question clearly that the the nursing profession andFigure usually not between efforts of reducing likelihood of future impairments (see 1) .. institutions, due to the variety of ERPs and the nature of healthcare system. LOS does not necessarily reflect the true state of functional recovery and how the patient is recovering at home.

Figure 1: The pathway in major uro-oncological surgery (Courtesy of Jensen BT et al. Curr Opin Urol. 2018;May28(3):243-253)

So in order to become more transparent, it is a necessity to focus on alternative outcome measures reflecting the actual state of recovery by understanding the factors that influence the physical function and the ability to return to daily living after discharge from the hospital. Therefore, parameters reflecting physical function, nutritional status and self-efficacy should be considered as outcome measures similar to e.g. LOS and the grade of complications as key indicators of ERP recovery from baseline throughout the follow up period17,18. Clearly, no patient should leave the hospital without a plan for rehabilitation and contact with the supporting team or survivorship clinic.

Figure Figure 1.

1. The The pathway pathway in in major major uro-oncological uro-oncological surgery surgery (Courtesy (Courtesy of of Jensen Jensen BT BT et et al. al. Curr Curr Opin Opin Urol. 2018;May28(3):243-253)

Monday, March 2019 Urol.18 2018;May28(3):243-253)

The model in figure 1 suggests several challenges after discharge. Short length of stay (LOS) is not a goal in itself, and early discharge from the highly specialised departments makes it necessary to focus on a multi-professional ’post-discharge’ effort to reduce short and long-term impairments after surgery. The short LOS requires a skilled discharge nurse to secure that comprehensive discharge plans are safe and adjusted to the patient’s needs and in close cooperation with the primary care and survivorship clinic. Because of the relatively short time to recover in the hospital, an optimal discharge plan should already be considered when the patient is Admitted to the hospital based on the experience during prehabilitation.

Organisation The ERAS pathway requires anchor-based leadership and ownership among the contributors. Thus, consensus on treatment and care pathways are key factors and a necessity for successful implementation, medical performance, clinical outcome and patient satisfaction8. It is essential to define the responsibilities of each healthcare professional involved and ERAS requires both commitment and a team approach. The nurse leaders and ERAS coordinators ensure that every team member is accountable, contributes to the implementation, and proceed as per protocol. Nursing standard of care pathways and algorithm must be evidence-based and clearly described in ERP`s for pre- and postoperative interventions, including everyday goals and documentation of achievements. Moreover, the progress of different aspects of patient education must be documented to estimate the level of self-efficacy. The need of a survivorship programme after cancer treatment is highly recognised. Along with the growing evidence of preoperative interventions and the concept of reacting proactively, it has led to the establishment of nurse-led multiprofessional prehabilitation academies in some countries (DK & NL), which systematically optimise the individual’s condition. Moreover, the aim is to involve the patient and family by using shared decision tools and to educate and inform each family in concordance with the patient’s needs.

Moving forward Through the recent development of the ERAS pathway, nursing will continue to have a pivotal role in surgical pathways. With the change in the surgical paradigm, and the trend of outsourcing service to primary health care settings, the future ERAS nursing team and the specialised nurses will carry an even higher responsibility by ways of assessing, educating, coordinating and evaluating. However, these skills are inherent to our profession and by close cooperation, flexibility and mutual respect among the team members, the ERAS nursing teams are looking forward to the challenge. Together with the whole ERAS team there is room for further improvement of the pathways for the benefit of the patients.

Editorial Note: Due to space constraints, the reference list can be made available to interested readers upon request by sending an email to: communications@uroweb.org Monday 18 March 10.30-12.00: Thematic Session 13 Let’s reduce the harm of surgery!

EUT Congress News

17

Quality of life with cancer Returning to work

16-18 March 2019, Barcelona work provides income and with it comes status as a ‘provider for the family’, a productive ‘member of society’.

Dr. Ian Banks President European Men’s Health Forum Brussels (BE)

SUPPORTED BY:

Not surprising that so many men with cancer want to do the seemingly opposite of what you might expect.

Employers and even sometimes trade unions often fall into the same presumptive trap. Thinking they are doing the guy a favour they will sort out attractive packages for leaving work but neglecting the one essential ingredient: actually being at work.

ian.banks@emhf.org Whenever you ask people with cancer what they would consider the best outcome for their treatment, they invariably say ‘normality’. Maybe not in so many words. They might say ‘I want to look after the kids’ or ‘to be pain free’ but many also say ‘to return to work’.

The European Men’s Health Forum (EMHF), in partnership with a plethora of organisations ranging from trade unions, charity organisations, government bodies, universities, employers, health care providers and many more, came up with a way to address the conundrum…

This might sound strange at first; who in their right mind would want to work after being diagnosed and treated for cancer, for goodness sake. Yet, especially for men, this is one of the most common desires in cancer patients. With a little thought it is actually obvious. When two men meet for the first time, what do they ask of each other over their handshake? OK, perhaps which football team they support, or whether they ever saw such terrible weather. Mostly, however, they ask each other: ‘what do you do for a living’?

“Without doubt, men do use dark humour to help deal with a difficult situation especially when it comes to the threat of ill health.”

Where you work is who you are Men identify with their work very strongly indeed.

Even when retired they say, ‘I’m a retired postman’ or ‘I used to drive a truck’. It is an opening line which guarantees a common ground while establishing ‘what I am’. Men also tend to have their mates at work rather than at home. Women, on the other hand, seem to have both and keep their friends from job to job. Take the workplace away from the man and you rob him of his identity and his mates.

These are the people to whom he would often turn to discuss a problem, seek advice, encourage and support him in difficult times. More to the point,

A workshop manual for working with cancer Men often absorb health information very differently than women. Without being too stereotypical, women do tend to confront health issues ‘head on’. Men, contrary to the John Wayne image, tend to deflect such confrontation. The EMHF has found that humour (even dark humour) along with cartoons (rather than graphic photos) generally bring the message better across with men. Without doubt, men do use dark humour to help deal with a difficult situation especially when it comes to the threat of ill health. For example, ‘What is the definition of male middle age?

When your prostate is bigger than your brain’.

I challenge all readers to give me a similar joke over say, ovarian cancer. It is not that men are more stupid or insensitive, it is often down to the way

emhf men’s health

WORKING WITH CANCER

a guide for men during & after diagnosis

The guide ’Working with cancer’ for men with cancer was supported by many organisations including EAUN

boys are brought up to be men. It is neither better nor worse, just different. And it is a very good way of engaging with them. Instead of complaining about men, we use their psychology to their own benefit. This is the basis of the highly successful range of Man Manuals.

employer and mates at work along with his need for treatment concordance.

“Take the workplace away from the man and you rob him of his identity and his mates.”

This article is based on a lecture I will hold today in the EAUN19 Thematic Session ‘Urological Cancer Survivorship’ this morning. Different aspects of survivorship will be discussed. Join us if this topic has your interest!

The manual at the 20th International EAUN Meeting To reinforce this mode of presentation, the manual was accompanied by a language free video which highlighted the problem and the solution. It focused on the identity of the man, his relationship with his

Next time you shake hands with a man, think about what he is rather than just what he does.

Take a look at this work on www.emhf.org

Monday 18 March 08.30-09.30: Thematic Session 10 at 20th International EAUN Meeting Urological Cancer Survivorship

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European Association of Urology European Nurses Association of Urology Nurses Monday, 18 March 2019

Neglected sexual side effects of prostatectomy How to combat sexual dysfunction after radical prostatectomy and pelvic radiotherapy Dr. Pedro Vendeira President of the Portuguese Society of Andrology, Sexual Medicine and Reproduction Clínica do Dragão Oporto (PO)

Changes to sexual function and sexuality after prostate cancer (PCa) treatment are ubiquitous and distressing. It is well known that radical prostatectomy (RP) (open, laparoscopic or robotassisted) for prostate cancer can cause lesions to the neurovascular bundle and thus neurogenic erectile dysfunction (ED). Mechanical manipulation, heating, ischemic effects, and local inflammation are the key issues in this matter. Prostate irradiation (externalbeam radiation therapy or brachytherapy) also results in damage to the neurovascular bundles, penile vasculature and the structure of cavernous tissue. However, bilateral nerve-sparing RP aims to preserve cavernous nerve function. But even when it is correctly performed the postoperative incidence of ED ranges from 6 to 68%, according to the different methods and assessment tools for ED evaluation1.

Management of climacturia includes voiding before sex, using a condom and adopting suitable positions.

Imipramine 25mg tid as well as pelvic floor training, and the use of a variable tension penile loop designed to compress the urethra are different possibilities but there are no formal outcome analyses available. The use of an artificial urinary sphincter or urethral slings should be considered only in specific cases of severe symptoms and as a last resort method. Recently, a report with 38 post-RP patients that underwent the Adrianne mini-jupette procedure, showed what seems to be a feasible adjunct to inflatable penile prosthesis placement and that it can be used for a subset of patients with post-RP climacturia and/or minimal incontinence6.

Change in orgasmic function Preserving the ability to achieve an orgasm is considered extremely important in elderly men and it is true that after RP, all patients say that ’orgasm is somehow different’. In this context, alteration of orgasmic function is in fact described by up to 80% of men. Orgasmic disturbances can be divided in altered perception of orgasm, anorgasmia and orgasmassociated pain (dysorgasmia). Almost 70% of patients complain of having decreased orgasmic pleasure, and about 30-40% experience anorgasmia or delayed orgasms (60%)7,8. However, 4-8% experience increased orgasm intensity. Also, in an interesting review paper by Wibowo et al. about male Erectile dysfunction studies multiple orgasms, data from post-RP prostate cancer ED is the most studied sexual side effect in this patients suggest that eliminating or impending context and several investigations led to the ejaculation may influence (in a positive way) the development of multiple rehabilitation programmes capacity for multiple orgasms9. Factors that influence this phenomenon are very poorly defined. Nerve to improve erectile function. However, sexual dysfunction after surgery or radiotherapy goes beyond sparing techniques, lower age, a small prostate and the penis – there is a ’dark side’. Even when possible, good post-operative erections seem to be protective for the orgasmic function. restoring the erection might not be enough to accomplish a satisfactory sexual life as assessed by It seems that orgasmic function improves with time the patient and his partner, because there is a group and orgasmic score increases linearly with erectile of understudied complications known as neglected function recovery10. ED treatment may improve sexual side effects that can also occur and do affect the quality of life of many men. orgasms. In a randomised, placebo-controlled, double-blind trial, Nehra et al.11 reported a significant improvement in the orgasmic domain of the “It is important for clinicians to International Index of Erectile Function with vardenafil inform patients that, regardless of 10 or 20 mg on demand, although it can be the lack of ejaculate and sometimes speculated that these improvements were due to the overall improvement in erectile function and overall erection, they should still pursue satisfaction with the sexual experience. Cabergoline, a dopamine agonist that can potentially improve sexual activity and be able to orgasm sensation in men was tested in RP patients achieve orgasm after RP.” with interesting results, but the multivariable analysis showed that the RP history did not influence the outcome, when compared with other men with These complications include urinary incontinence orgasmic disturbances. Psychological aspects should during sexual activity (climacturia) and orgasmic not be neglected. In fact, partner involvement with disturbances that encompass anorgasmia, changes in orgasmic sensation and painful orgasms, anejaculation, communication training and cognitive-behavioural therapy could be quite positive in educative penile deformities, and loss of sexual desire, among counselling. It is crucial that both patient and partner other things. Although the body of research is still keep in mind that the ability to reach orgasm can be growing, there remains a need for physician and retained even in cases of persistent ED. patient awareness of these potentially problematic complications2.

Pain Sexual side effects Dysorgasmia is quite a distressing problem affecting True anejaculation (aspermia) is the rule after RP. It is patients after RP with a prevalence of 3 to 20%. About the anatomical consequence of the surgical principles 30% experience it with every orgasm, 15% frequently, used in the radical technique. Lower sexual desire is 35% occasionally and 20% rarely. Pain is usually generally reported in more than 50% of men after RP moderate in severity, and lasts for less than 1 minute in and radiotherapy, and this effect is mainly due to most of the cases. It is most commonly experienced in psychological factors related to low self-esteem and the penis, testis and rectum. Intensity and frequency masculinity, even in the presence of successful can decrease with time as seen during follow-up. Older oncological outcomes. It must be said that researchers age seems to be protective against painful orgasms and have discovered that more than 60% of men were the same is true for robot-assisted RP when compared unware that they would not ejaculate after RP3. to open surgery. However, there is no difference in time Psychological and sexual counselling may play an to recovery between the two procedures. There is an increased risk of dysorgasmia in the presence of important part in the rehabilitation and treatment of bilateral seminal vesicle sparing, probably because the these disorders. filling and contracting of these remnants might By definition, climacturia is the occurrence of urinary overstretch the wall of the vesicles and cause pain. incontinence at the time of orgasm, and also includes Concerning management, sexual activity should be urinary incontinence with arousal. Prevalence ranges highly encouraged, because time is friendly in this field despite temporary pain, and alpha-blockers from 20 to 64%, but up to 93% of the patients (tamsulosin 0,4mg qd) were studied with positive experience these conditions at some point following RP. Half of the affected patients are bothered with the results by acting on seminal vesicle contraction. problem together with a depressed mood, higher Psychosexual therapy and non-steroidal antiinflammatory drugs show little benefit. According to anxiety levels, and worse quality of life. Previous transurethral resection of the prostate is the only Clavell-Hernández et al.2: “It is important for clinicians to known predicting factor. Climacturia tends to decrease inform patients that, regardless of the lack of ejaculate throughout the postoperative period. In fact, one and sometimes erection, they should still pursue sexual larger study found that the rate of climacturia was activity and be able to achieve orgasm after RP.” 24% in patients within 12 months after RP when compared with 12% in those presenting after one More side effects year4. No difference was found between surgical Penile shortening and de novo penile deformities methods, but there is a trend concerning a better have been described. The pathophysiology of these (faster) recovery over time after robot-assisted conditions is based in mechanisms related to neural procedures when compared with open surgery5. damage, penile hypoxia, smooth muscle apoptosis, Monday, 18 March 2019

fibrosis, and sympathetic system overactivity leading to a chronic contraction of the cavernous smooth muscle tissue. There are some contradictory data regarding the real prevalence of penile shortening, that could range from 10 to 50%, depending on the degree of shortening that can be as little as 2 mm to more than 1 cm, and also depending on the time of examination since the strongest studies refer to a maximum shortening in the period of one month after RP. There is evidence that some protective factors can be found for post-operative penile size. Most important are nerve-sparing surgery, recovery of erectile function, and the use of sustained oral PDE5Is. On the other hand, a high body mass index and increased pre-pubic fat can lead to a buried penis that contributes to a ’subjective’ penile shortening.

“...full sexual rehabilitation (not only erection) should address all these neglected sexual side effects, taking into account all the psychological issues, including high levels of anxiety, the loss of masculine identity and self-esteem, and involving the partner whenever possible as sexual dysfunction in patients increases dramatically in these situations.”

In a study with more than 1,000 RP patients, the accumulated incidence of Peyronie’s disease (PD) was 16%12. Men presenting with sexual dysfunction after RP have higher PD incidence than the general population. Lack of nerve-sparing was a significant predictor for PD. Younger age and white race were independent predictors of PD occurrence after RP. Concerning management of penile shortening, some reports suggest that chronic treatment with longacting PDE5I’s – tadalafil or the use of a vacuum erection device - could decrease or even prevent fibrosis and subsequent penile length loss13.

Psychological ’damage’ control is a rule in this matter.

In fact, preoperative measurement of penile length is paramount, because of the subjective feeling experienced by patients that the penis is shorter after RP, although sometimes no changes are found when an objective evaluation is well undertaken.

Prevalence and predicting factors Only very few studies investigated the prevalence and predicting factors of these commonly neglected sexual side effects after external beam radiation therapy (EBRT) and brachytherapy (BT). As reported by Frey et al.14, we need much more data in this field, especially because nowadays patients are faced with a choice between equally effective treatment options, so this choice will be largely dependent on the expected side effects. 109 sexually active patients after EBRT were included in this study. 26 patients (24%) reported anorgasmia and 48 (44%) reported a decreased intensity of their orgasms. Thirty-two patients (29%) reported no change in orgasm intensity, and 2 patients (2%) reported an increased intensity of their orgasms. Twelve patients (11%) reported anejaculation and 16 patients (15%) were complaining of orgasm-associated pain. Loss or decrease in ejaculate volume was seen with BT and the ejaculate might contain blood. Poor orgasm ability was associated with being older and a poor erectile

function. Most patients treated with BT conserve orgasm, although at least half of them describe an altered orgasm (week, difficult or absent)15.

My take home message: full sexual rehabilitation (not only erection) should address all these neglected sexual side effects, taking into account all the psychological issues, including high levels of anxiety, the loss of masculine identity and self-esteem, and involving the partner whenever possible as sexual dysfunction in patients increases dramatically in these situations.

References 1. Liu C, Lopez D, Chen M, et al. Penile Rehabilitation Therapy Following Radical Prostatectomy: A MetaAnalysis. J Sex Med, 14: 1496-1503, 2017.

2. Clavell-Hernández J, Martin C, Wang R Orgasmic Dysfunction Following Radical Prostatectomy: Review of Current Literature. Sex Med Rev, 6: 124-134, 2018.

3. Deveci S, Gotto G, Alex B, et al. A Survey of Patient Expectations Regarding Sexual Function Following Radical Prostatectomy. BJU Int, 118: 641-645, 2016.

4. Choi J, Nelson C, Stasi J et al. Orgasm Associated Incontinence (Climacturia) Following Radical Pelvic Surgery: Rates of Occurrence and Predictors. J Urol, 177: 2223-2226, 2007.

5. Capogrosso P, Ventimiglia E, Serino A, et al. Orgasmic Dysfunction After Robot-Assisted Versus Open Radical Prostatectomy. Eur Urol, 70: 223-226, 2016.

6. Yafi F, Andrianne R, Alzweri L, et al. Andrianne Mini-Jupette Graft at the Time of Inflatable Penile Prosthesis Placement for the Management of Postprostatectomy Climacturia and Minimal Urinary Incontinence. J Sex Med, 15: 789-796, 2018.

7. Messaoudi R, Menard J, Ripert T, et al. Erectile Dysfunction and Sexual Health After radical Prostatectomy: Impact of Sexual Motivation. Int J Impot Res, 23: 81-86, 2011.

8. Fode M, Serefoglu E, Albersen M et al. Sexuality Following Radical Prostatectomy: Is Restoration of Erectile Function Enough? Sex Med Rev, 5: 110-119, 2017.

9. Wibowo E, Wassersug R Multiple Orgasms in Men – What We Know So Far. Sex Med Rev, 4: 136-148, 2016.

10. Salonia A, Burnett A, Graefen M, et al. Prevention and Management of Postprostatectomy Sexual Dysfunctions Part 2: Recovery and Preservation of Erectile Function, Sexual Desire, and Orgasmic Function. Eur Urol, 62: 273-286, 2012.

11. Nehra A, Grantmyre J, Nadel A, et al. Vardenafil Improved Patient Satisfaction With Erectile Hardness, Orgasmic Function and Sexual Experience in Men With Erectile Dysfunction Following Nerve Sparing Radical Prostatectomy. J Urol, 173: 2067-2071, 2005.

12. Tal R, Heck M, Teloken P, et al. Peyronie’s Disease Following Radical Prostatectomy: Incidence and Predictors. J Sex Med, 7: 1254-1261, 2010.

13. Brock G, Montorsi F, Costa P, et al. Effect Of Tadalafil Once Daily on Penile Length Loss and Morning Erections in Patients After Bilateral Nerve-Sparing Radical Prostatectomy: Results From a Randomized Controlled Trial. Urology, 85: 1090-1096, 2015.

14. Frey A, Pedersen C, Lindberg H, et al. Prevalence and Predicting Factors for Commonly Neglected Sexual Side Effects to External-Beam Radiation Therapy for Prostate Cancer. J Sex Med, 14: 558-565, 2017.

15. Elliott S, Matthew A Sexual Recovery Following Prostate Cancer: Recommendations From 2 Established Canadian Sexual Rehabilitation Clinics. Sex Med Rev, 6: 279-294, 2018.

Monday 18 March 08.00-10.15: Plenary Session 6 The role of the urologist in sexual and fertility issues of cancer survivorship

EUT Congress News

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How to deal with tumours in transplant and native kidneys Ultrasound screening of native and allograft kidneys is recommended before and after transplantation Prof. Mireia Musquera Consultor in Urology at Hospital Clínic de Barcelona Barcelona (ES) MMUSQUER@ clinic.cat The worldwide prevalence of renal cell carcinoma (RCC) has increased significantly over the last years, representing 4% of all solid tumours. Several risk factors have been described such as hypertension, obesity, tobacco and acquired renal cystic disease (ARCD). ARCD is of special interest in patients with end stage renal disease (ESRD), because in some studies it has been demonstrated to be an independent risk factor for RCC. It has been proven that the prevalence of ARCD is directly related to the duration of dialysis. The prevalence of ARCD is around 20% when the patient is on dialysis for less than 3 years and increases to up to 90% in patients on dialysis for more than 5 years.

Consequently, the ESRD population - and specially patients on dialysis treatment - have a higher risk of developing renal cell carcinoma compared to the general population. The estimated prevalence of RCC in ESRD patients on dialysis is 3-4% which corresponds to a 100 times higher rate than in the general population and this risk is maintained after kidney transplant.

Different nature and prognosis of RCC Although RCC is more common in this population, its nature and prognosis may differ from the general population. In this setting, renal cell carcinomas affect a younger population, are smaller in size and stage with a better prognosis and a different subtype distribution.

Clear cell renal cell carcinoma (ccRCC) is still the predominant subtype, but at a lower percentage. The papillary subtype increases in percentage (35-45%).

This higher percentage can be explained by the existence of papillary hyperplasia and adenomas in the kidneys, being considered the origin of future renal tumours.

According to the 2016 World Health Organisation Classification of tumours of the urinary system and male genital organs, two new histology types have been added to RCC: ARCD associated renal cell carcinoma and clear cell papillary renal cell carcinoma, which have an indolent clinical course.

RCC treatment has a special connotation in ESRD patients as haemodialysis is associated with an increased mortality risk, which is approximately 6.3% per year in patients in the waiting list, and the 5 years.

Overall survival for patients with with pT1 low grade RCC is >90% and have low risk of metastasis. Some of those patients are suitable for transplantation and they will required immunosuppressive therapy.

Laparoscopic nephrectomy in native kidneys With RCC in the native kidney during a pre-transplant situation, laparoscopic nephrectomy is the treatment of choice. The patient, if suitable, can be placed on the waiting list immediately because usually these lesions are small tumours of low grade and stage.

Specifically, the European Renal Best Practice (ERBP) transplantation guidelines recommend that patients with small and low grade RCC who are appropriately treated are immediately eligible to be placed on the waiting list.

A controversial situation may occur with the diagnosis of small RCC in the native kidney in a pre-emptive status, if radical nephrectomy causes initiation of dialysis. In this situation, an option to avoid starting dialysis could be living donor kidney transplantation followed by native nephrectomy.

Some authors analysed specimens from native nephrectomy performed at the time of kidney transplantation in asymptomatic patients with ESRD. The incidence of RCC was around 5%. Similar percentage to our recent analyses of 230 specimens of native kidneys in orthotopic kidney transplantation and we found 4 cases (3%) of RCC with a mean tumour size of 1.3 cm. Without any tumor recurrence during follow-up. Bilateral RCC in the native kidney has been reported in the literature in up to 20% of patients, so they will require bilateral nephrectomy. In these cases this can be performed at the same time.

To minimise morbidity, a Laparo Endoscopic Single Side (LESS) bilateral nephrectomy is an interesting approach. We have performed bilateral LESS nephrectomy in some ESRD patients with very good results, as it avoids performing two incisions for kidney removal.

“The estimated prevalence of RCC in ESRD patients on dialysis is 3-4% which corresponds to a 100 times higher rate than in the general population and this risk is maintained after kidney transplant.”

RCC in grafted kidneys As mentioned before, the higher risk of RCC after kidney transplantation still persists and in this situation RCC may also affect the grafted kidney.

Allograft tumours are less common than in native kidneys and occur in 0.2-0.34% of renal transplant patients. Those tumours can develop de novo or as a consequence of occult malignancy donor transmission, and are usually detected incidentally during kidney transplant follow-up with routine ultrasound.

Increased risk of malignancies after transplantation has been attributed to long-term immunosuppressive therapy, but the incidence of RCC in kidney transplant

Picture 3. We performed a par/al laparoscopic graB nephrectomy.

patients is higher than in other solid transplant patients, probably due to the previous status of ESRD and dialysis treatment. Those tumours are usually detected at a small and low stage due to routine imagining, permitting nephron-sparing techniques.

From the different papers published to date, it also seems that among RCC arising in the graft, the papillary subtype has a higher incidence, but the small number of cases is insufficient to confirm this prediction.

Preserve kidney function RCC treatment has a special connotation in kidney transplant patients, because haemodialysis is associated with poor quality of life and increased mortality risk, so it is very important to preserve kidney function as much as possible.

RCC management in the grafted kidney depends on patient’s age, previous renal function and size and situation of the tumour. Nonetheless, an individual management approach must be undertaken for each case with all options available for RCC treatment: active surveillance, partial nephrectomy, radiofrequency, cryoablation or radical nephrectomy.

Few groups have published their experience with RCC in the renal allograft. They agree that, when the tumour arises from the graft, a trend towards nephron-sparing techniques is the gold standard, to avoid entering dialysis which causes a real increased mortality risk.

Partial graft nephrectomy Several retrospective studies demonstrated that partial nephrectomy of the graft is a safe procedure with good oncologic results, while preserving renal function. Partial nephrectomy in a graft can be performed open, laparoscopically and even robotically with good results. Depending on the case and the surgeon’s experience, all these options are possible.

Picture 1: Bilateral na/ve RCC, treted by Bilateral LESS nephrectomy

A few years ago we published our experience on partial graft nephrectomy with excellent functional and oncologic results. More recently we performed partial and radical laparoscopic graft nephrectomies with excellent results. Vascular pedicle dissection was more difficult, but feasible. For tumours arising in the peritoneal surface, the laparoscopic approach is a good option.

Open surgery is gold standard Open surgery has been the gold standard for partial nephrectomy in the graft. In some cases, it permits to perform no clamping techniques, reducing the effect of warm ischaemia time, by making hand compression of the renal parenchyma. More recently, robotics were used in this setting; a partial nephrectomy in a 7 cm tumour was undertaken in a grafted kidney, obtaining renal function preservation.

Picture 2: Intra-renal graB tumor, treated by clamp less open par/al nephrectomy

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EUT Congress News

Percutaneous ablation techniques (radiofrequency {RFA} or cryotherapy) have been used in several cases with functional and oncologic success. Cornelius et al.

demonstrated robust midterm oncological results and renal function preservation in a group of 24 graft tumours treated with RFA. Management of immunosuppressant treatment in post-transplantation RCC remains a challenge.

M-TOR inhibitors have been associated with a significant reduction of post-transplant malignancies, and also have been used to treat advanced RCC in the general population. More data are required to confirm the importance of the treatment switch.

Conclusions Due to the increased risk of RCC in ESRD patients, ultrasound screening of native and allograft kidneys is recommended on an annual or biannual basis before and after transplantation.

“Management of immunosuppressant treatment in post-transplantation RCC remains a challenge.”

Radical nephrectomy is the treatment of choice for RCC arising from native kidneys. For tumours arising from the graft, an individual management approach must be undertaken for each case with all options available for RCC treatment, with the principle of maintaining renal function being important.

References 1. Dunnill MS, Millard PR, Oliver D. Acquired cystic disease of the kidneys: a hazard of long-term intermittent maintenance haemodialysis.J. Clin. Pathol.1977;30: 868–77 2. Denton MD, Magee CC, Ovuworie C, et al. Prevalence of renal cell carcinoma in patients with ESRD pretransplantation: a pathologic analysis. Kidney Int. 2002;61(6):2201-2209 3. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341(23):17251730.

4. Ribal MJ, Rodriguez F, Musquera M, Segarra J, Guirado L, Villavicencio H, Alcaraz A. Nephron-sparing surgery for renal tumor: a choice of treatment in an allograft kidney.

Transplant Proc. 2006 Jun;38(5):1359-62.

5. Leveridge M, Musquera M, Evans A, Cardella C, Pei Y, Jewett M, Robinette M, Finelli A. Renal cell carcinoma in the native and allograft kidneys of renal transplant recipients. J Urol. 2011 Jul;186(1):219-23. doi: 10.1016/j. juro.2011.03.032. Epub 2011 May 14.

6. Cornelis F, Buy X, Andre M, et al. De novo renal tumors arising in kidney transplants: midterm outcome after percutaneous thermal ablation. Radiology. 2011; 260: 900 7. Campistol JM. Minimizing the risk of posttransplant malignancy. Transplantation. 2009 Apr 27;87(8 Suppl):S19-22. doi: 10.1097/TP.0b013e3181a07a57.

Monday 18 March 10.30-12.00: Thematic Session 18 Cancer in end-stage renal disease and after renal transplantation

Monday, 18 March 2019

ELUTS19 European Lower Urinary Tract Symptoms meeting 31 October - 2 November 2019 Prague, Czech Republic By

www.eluts19.org

In collaboration with

UROGENITAL CANCER TREATMENT AT A GLANCE PA S T, P R E S E N T A N D F U T U R E

34TH ANNUAL EAU CONGRESS, BARCELONA AN IPSEN SPONSORED SATELLITE SYMPOSIUM

CHA I RED BY PROFESSOR LUIS MARTÍNEZ- PIÑEIRO (SPAIN)

Oncology Inspired

S AT U R D AY 1 6 M A R C H Dr María Ribal (Spain)

Challenging paradigms in advanced prostate cancer: A new era The treatment landscape for prostate cancer is constantly evolving to improve patient outcomes. Dr Ribal provided an overview of how treatments for prostate cancer have changed over time, with a specific focus on androgen deprivation therapies (ADTs). The latest key clinical trials and data supporting the use of ADT in prostate cancer were summarised, including evidence that explores the use of ADT as a backbone therapy for combination treatments.

Professor Marc Oliver Grimm (Germany)

Visit Booth A38 to learn more about our focus on transforming the lives of people impacted by cancer through science and innovation.

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Monday, 18 March 2019

The changing landscape in advanced Renal Cell Cancer management Treatment with both tyrosine kinase receptors (TKIs) and immunotherapies have been shown to improve patient outcomes, and should be adapted into the treatment landscape for advanced renal cell carcinoma (aRCC). Prof Grimm discussed the development of these two therapies and the latest clinical evidence exploring combination treatment of TKIs and immunotherapies, and how this could potentially improve patient outcomes. Understanding the evolution of the treatment landscape for aRCC is important in order to better understand how the approach to treatment sequencing and selection, based on individual patient characteristics, can impact patient outcomes.

Professor Yair Lotan (USA)

Blue light flexible cystoscopy: Improving the patient experience Non-muscular-invasive bladder cancer management has a significant impact on urology services due to its high risk of recurrence. Clinical guidelines support the use of photodynamic diagnosis to improve detection, particularly in high risk tumours. Prof Lotan presented recent evidence with blue-light flexible cystoscopy (BLFC) outpatient surveillance that demonstrated superior outcomes versus white light where, most notably, every third patient with carcinoma in situ was only detected with BLFC. Study participant anxiety levels were also lower. Prof Lotan also described clinical scenarios where BLFC could be employed and identified service design considerations.

CBZ-ALL-001441 FEBRUARY 2019

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VISIT US AT BOOTH #H26

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Monday, 18 March 2019

New working group on Male Sexual & Reproductive Health New European Association of Urology Guidelines group focuses on men’s health Prof. Andrea Salonia Chair of EAU Guidelines Panel on Sexual and Reproductive Health Milan (IT)

Mr. Suks Minhas Vice-Chair of EAU Guidelines Panel on Sexual and Reproductive Health London (GB)

In 2018, a new guidelines group was formed by the EAU guidelines board. The previous and historical guidelines groups on sexual dysfunction, male infertility and hypogonadism have now blended into a single guidelines group with the specific aim to further support the overall concept of men’s health. The chair and vice-chair of the new guidelines working group are Andrea Salonia from Milan (IT) and Suks Minhas from London (UK).

develop and publish systematic reviews and meta-analysis in areas of controversy and areas with limited evidence base, to provide consensus opinions.

Including a psychosexual therapist For the first time a psychosexual therapist has been appointed as a member of the guidelines group, which not only reflects the great advances in the treatment of men’s health in general but also recognises the multi-disciplinary approach to treatment of these conditions.

The importance of men’s health has been raised by a number of charities and groups, including the Men’s Health Forum, Prostate Cancer UK and the Movember campaign.

“Although male life expectancy has increased, there is still a large gender difference in life expectancy between men and women.”

Gender inequality in health While in the United Kingdom there have been improvements in male life expectancy and information from the Office for National statistics show that the average life expectancy for a man was 73 years in 1992, which has meanwhile risen to 79 years, there is still a significant gender gap in mortality. A recent WHO report, the health and wellbeing of men in the WHO region: better health through a gender approach, has highlighted that throughout Europe many men die prematurely.

Although male life expectancy has increased, there is still a large gender difference in life expectancy between men and women. In the United Kingdom in 2014-2016, life expectancy for a man was 79.5 years compared to 83.1 years for women, highlighting significant health care inequalities between men and women. There are a number of explanations, including obesity, higher alcohol consumption, increased suicide rates, smoking, lack of exercise and social inequalities including access to health care in men compared to women.

For example, it is now clear that not only is erectile dysfunction a proxy of men’s cardiovascular health but there is increasing evidence to suggest that

men with infertility (which affects approximately 7.5% of couples in Europe) have a higher risk of cancer and cardiovascular diseases. Yet in spite of this, there is variation in medical treatment and access to care throughout Europe. It is also interesting to note that the recent 2018 WHO report highlights the fact that very few data are available on the male reproductive and sexual health statistics.

“...very few data are available on the male reproductive and sexual health statistics.”

Finally: a new EAU guidelines group on men’s health Therefore the time has come for the European Association of Urology to develop a new guidelines group, which will provide clinicians and patients with a systematic and evidencebased approach to male reproductive and sexual health. We hope that the new guidelines group will raise the profile of men’s health in general and increase awareness of gender health inequalities globally.

The guidelines working group is composed of internationally renowned members who are experts in the field of men’s health and reproductive/sexual health, which is reflected in the group’s composition. There are also guideline associate members whose role will be to facilitate and develop these comprehensive evidencebased guidelines. Likewise, the group will

STEPS Sessions To Evaluate luate Progres ProgresS in the management of o urological cancers

Interactive, Insightful and Independent Education Learning from Experts in Onco-Urology Applications now open!

Visit Ipsen booth E38 during EAU19 to learn more

What is STEPS? STEPS, or “Sessions To Evaluate ProgresS in the management of urological cancers”, is a programme specifically designed for recently specialised onco-urologists who want to learn directly from worldleading experts in bladder, prostate, renal and testis cancers. The CME-accredited programme is a fundamental part of the EAU/ESOU strategic partnership with Ipsen. It is founded on our shared commitment to the education of young urologists.

Bringing together a multinational group of medical professionals across several areas of expertise, and with different experiences, allows the fellows to see a variety of new treatment possibilities.

It can highlight the pitfalls and solutions provided by diverse approaches. It also opens the door to creating international ties among medical practitioners, and a networking opportunity that can prove invaluable to the careers of young clinicians.

“STEPS connects younger urologists from different countries – it’s very interactive with lots of new information and data discussed” STEPS fellow 2018

To date, 20 different internationally recognised experts, supported by the ESOU Board, have inspired 158 fellows from 30 countries – and our objective is to continue supporting STEPS to help improve the management of all patients with urological cancers.

Who should apply?

Recently specialised clinicians with a firm interest in the management of urological cancers, who: - Can demonstrate support from their Head of Department

Next event: Meet-the-Expert Session during the 17th Meeting of the EAU Section of Oncological Urology (ESOU) Saturday 18th January 2020 Dublin, Ireland

- Are keen to participate in ESOU and EAU programs - Understand and speak English fluently “Within STEPS I really like the enthusiasm of the delegates and the interaction I can have with them as an expert” Peter Mulders, STEPS mentor 2018

Find out more about STEPS from the ESOU website: http://uroweb.org/section/esou/information/

TRI-ALL-000551

Monday, 18 March 2019

The STEPS programme is supported by Ipsen.

EUT Congress News

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Monday, 18 March 2019

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