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European Urology Today Official newsletter of the European Association of Urology

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Vol. 31 No.2 - March/May 2019

Overview of all EAU19 Prize Winners

Neuro-urology and LUTS

EAU Research Foundation launches PHOENIX

EAU Awards, the best new science and YUORDay winners

Tips and tricks to optimise management

Registry for patients undergoing penile prosthesis

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Prof. T. Kessler

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C. Caris

EAU19: Once more raising the bar for urological meetings 34th Annual Congress in Barcelona presented the best in urology science, surgery and training By Loek Keizer, Erika De Groot and Jen Tidman The EAU held its 34th Annual Congress in Barcelona on 15-19 March, a recurring highlight for the Association and for urology in general. While the presenting of the latest EAU Guidelines, holding meetings for its Board and Sections and setting agendas for the coming year are essential to the running of the Association, it is the latest scientific developments in urology that took centre stage in Barcelona. Scientific Congress Office Chairman Prof. Arnulf Stenzl (DE) presided over the scientific programme one last time, stepping down to join the EAU Executive as Adjunct Secretary General (Science). He was congratulated on his track record and particularly the comprehensive and diverse five-day programme that greeted the nearly 12,000 participants from 127 countries in Barcelona.

“I think it’s time to pay attention to vaginal-sparing and ovarian-sparing surgery, and to put more focus on sexual function. Careful assessment of the vagina is needed, and bladder-neck urethral biopsies should be considered pre-operatively,” stated Dr. Cresswell. Nightmare Session Veteran consultant solicitor Mr. Bertie Leigh (GB), challenged some of Europe’s best surgeons on cases presented during the second Plenary Session, which was a so-called ‘nightmare session’ on urological stones. Between five and ten percent of the audience admitted to once accidentally leaving a stent in a patient. “As a urologist, it IS your job to monitor your patients’ stents,” stated Prof. Palle Osther (DK). The former EULIS Chairman offered a variety of possible approaches: an electronic registry that warns the urologist when placed stents are set to expire; equipping patients with wristbands; or with the help of smartphone apps.

This article provides some highlights from the 263 different scientific sessions at EAU19. For the most complete coverage, see the on-site news reports on www.eau19.org/news.

Solutions offered by the panel and the audience included co-signed forms; every new stent to include a distinctive wristband per patient; and the creation of stent guidelines. The Nightmare Session further discussed the cases of severe sepsis following BCa in the young patient ureteroscopy, and bowel injury as a result of Prof. Fiona Burkhard (CH) kick-started the first Plenary percutaneous nephrolithotomy. Session at EAU19 on Saturday, ‘Bladder cancer in the young patient: Unique aspects’ with compelling MRI-targeted biopsy statistics on bladder cancer (BCa) and a patient case The results of two new studies were announced on of a 34-year-old female with a smoking history of 10 the third day of EAU19: the eagerly awaited and pack-years. The patient had an initial transurethral possibly paradigm-changing ARAMIS study and new resection of the bladder (TURB) with a pT1G3, research into fast bi-parametric MRI. Delegates followed by a re-resection when muscle-invasive braved the early hours of Sunday morning to attend disease was found. The patient disclosed that she the Breaking News Session that was part of Plenary wishes to have a second child. 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.” Profs. Chapple and Stenzl chair the final Plenary Session on Tuesday morning

Prof. Burkhard stated that the initial step is preoperative assessment, in which oncological aspects (tumour location) are prioritised over preserving fertility. Following this, specific surgical aspects are considered: nerve-sparing, organ-sparing, and the type of diversion to be offered to the patient. Then, if the patient is pregnant, the focus shifts to care during pregnancy and delivery. Prof. Burkhard co-chaired the Plenary Session with Prof. Morgan Rouprêt (FR). In the same session, Dr. Jo Cresswell (GB) spoke on surgical aspects of fertility in the young female patient with bladder cancer, stating that it is not uncommon to see young female patients wanting to have children; however for a number of young women who have/will undergo radical cystectomy (RC) or have BCa, sexual function may also be of importance.

March/May 2019

Prof. Jelle Barentsz (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. Opposing views on the efficacy and significance of MRI-targeted biopsy were presented during “Is MRI-targeted biopsy enough?” the first debate in the third Plenary Session on imaging in PCa, chaired by Dr. Jochen Walz (FR) and Prof. Francesco Montorsi (IT) on Sunday. In the presence of a positive MRI, Dr. Veeru Kasivisvanathan (GB) shared the advantages of MRI-targeted biopsy without TRUS biopsy such as the decrease of patient burden and risk of (infectious) complications due to fewer biopsy cores per procedure. In his counter-arguments, Dr. Guillaume Ploussard (FR) mentioned the possible registration errors in MRI-targeted biopsy, and tumour evaluation (e.g. multifocality, heterogeneity) can be suboptimal if MRI-targeted biopsy is performed without TRUS biopsy.

Plenary Session 5 presented some controversial topics related to prostate cancer in a novel way. Experts with different backgrounds were put "in the hot seat" during a series of case discussions

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 Grade Group (GG) ≥ 2 (Gleason ≥ 3+4) prostate cancer (PCa). Dr. Christian Arsov (DE) raised opposing points such as the significant learning curve associated with multi-parametric MRI (mpMRI) reading, and a lack of mpMRI quality control. 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 are individualised strategy with upfront risk-stratification and the combination of MRI-targeted biopsy and TRUS biopsy in case of elevated risk.

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 body mass index (BMI) of 31. Three experts discussed her treatment. Prof. Charles Karim Bensalah (FR) stated that partial nephrectomy (PN) was the primary option due to fewer complications and a comparable survival rate. PN can improve outcomes in obese patients with toxic fat as the only potential obstacle, which can be surmounted with good training and ultrasound identification of the

RCC matters Plenary Session 4, dedicated to Renal Cell Carcinoma (RCC), featured several debates. Prof. Alexandre Mottrie (BE) argued that the benefits of new technologies, including robotic-assisted partial nephrectomy (RAPN), are unlimited compared to classical surgery, which results in too many complications. RAPN spares more healthy tissue, avoids large painful incisions, and gives good oncological and functional outcomes. However, Prof. Mottrie emphasised the need for proficiency-based, standardised, and quality-assured education to prevent human error. As counter-arguments, Prof. Markus Kuczyk (DE) said that RAPN results in decreased patient

Prof. Jelle Barentsz gave several talks on the feasability of fast prostate MRI Continued on page 2

www.eau20.org

Abstract submission opens 1 July 2019

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

TTH or no TTH Also on Monday, Plenary Session 6 examined the role of the urologist in sexual and fertility issues of cancer survivorship. Testosterone therapy (TTH) was examined as a plausible treatment for a patient case presented by moderator Assoc. Prof. Ege Can Serefoglu (TR). One of the presenters, Prof. John Mulhall (US) gave the caveat to use the term TTH instead of testosterone replacement therapy (TRT).

Dr. Umberto Capitanio (IT) favoured local tumour ablation (e.g. cryoablation, radiofrequency, microwaves, or irreversible electroporation) especially in a patient at high risk of PN complications. However, more research was needed in view of weaker evidence. The patient is a 58-year-old male suffering from PCa with a PSA level of 7.6 ng/ml. He underwent TRUS-guided biopsy, which revealed that he had a Dr. Antonio Finelli (CA) suggested active surveillance Gleason score of 3 + 3 PCa. He reported no erectile (AS) rather than potentially unnecessary surgery. He noted that 80-90% of <4 cm masses grow at only 0.22 dysfunction (ED). cm per year on average and it is not uncommon for <1 The patient underwent robotic-assisted radical cm tumours to disappear. In addition, as obesity is a prostatectomy (RARP) with bilateral nerve-sparing risk for RCC, de novo tumours might develop after (BNS). The pathology revealed that he has a Gleason initial surgery. score of 4 + 3 PCa. He was taking a daily dose of 5mg In conclusion, the experts agreed that in this particular of Tadalafil. case, all modalities were valid, depending on biopsy During a follow-up three months after the operation, results and discussion with the patient. his PSA was undetectable and the patient was suffering from ED despite the Tadalafil. On the Breaking news: PCa trials sixth-month, his PSA was still undetectable and still Prof. Axel Merseburger (DE) presented the results of suffered from ED. This time, the patient reported the SAUL trial during the breaking news session that depressive thoughts, fatigue and loss of libido. preceded the fifth Plenary Session on prostate cancer on Monday morning. This trial is the largest prospective clinical trial of immunotherapy in advanced urinary tract carcinoma examining the use of atezolizumab. According to Prof. Merseburger, SAUL confirms the tolerability of atezolizumab in a “real-world” urothelial carcinoma (UC) and non-UC population. “Efficacy in both the IMvigor211-like subgroup and the broader unselected population is consistent with previous anti-PD-L1/PD-1 pivotal UC trials. These results support use of atezolizumab in UC or non-UC, including Sometimes a quick show of hands is enough to make a point. patients with limited available treatment options.” Plenary Session 7 closed the Congress on Tuesday

Prof. Jens Bedke (DE) cautioned that while atezolizumab use yielded no increased toxicity, individual data on after-effects (AE) with special interest in respective subgroups was still lacking.

European Urology Today Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Dr. D. Karsza, Budapest (HU) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Dr. F. Sanguedolce, Barcelona (ES) Special Guest Editor Mr. J. Catto, Sheffield (GB)

Prof. Mulhall said the patient is a candidate for TTH. “If the patient is highly symptomatic, TTH should be seriously considered. The comorbidities associated In the same Plenary Session, Prof. Antonio Alcaraz (ES) with low T level may be more likely to kill him rather presented the latest findings of the ARCHES trial, which than his prostate cancer,” said Prof. Mulhall. examines enzalutamide (enza) in combination with androgen deprivation therapy for men with metastatic While larger, longer analyses are required, there is a signal that testosterone therapy is safe in a man with hormone-sensitive prostate cancer (MHSPC). this patient’s pathology (Gleason 7 or organ-confined). “I encourage all of the oncologists in the room to not “The efficacy and safety of enza in combination with be too PSA-centric and to focus on quality of life and androgen-deprivation therapy (ADT) in men with MHSPC, based on geographic location, disease volume overall holistic help of the patient. Until we have data demonstrating that TTH is unsafe in the prostate cancer (high or low), Gleason score (<8 or ≥8), prior docetaxel, prior local therapy and in newly-diagnosed population, I believe that choosing the scientific approach should lead us to prescribe TTH if the patient patients,” stated Prof. Alcaraz. so wishes.” With regard to a number of studies looking into the ADT and enza combination, Prof. Noel Clarke (GB) said, In contrast, Prof. Bertrand Tombal (BE) stated that he would be reluctant to give the patient TRT “Radiographic progression-free survival is clearly improved and we must compare these with the results because evidence is “weak” and the risk of recurrence is not negligible. He asserted that the of trials studying abiraterone. This may translate to testosterone levels of the patient should have been improved overall survival but further follow-up is measured before the prostatectomy and that the required.”

Prof. Tombal discussed the Coffey Paradox: If PCa cells retaining Androgen Receptor (AR) expression, TRT-induced AR signalling up-regulates c-Myc translation and protein stability to stimulate malignant growth. Thus in AR expressing PCa cells, AR signalling is converted from a growth suppressor to an oncogene. He underlined that 5 alpha-reductase inhibitors reduce the risk of progression, and provided data that show testosterone made the PCa more aggressive. This Plenary Session was chaired by Dr. Maarten Albersen (BE) and Prof. Jens Sønksen (DK). Souvenir Sessions Presided over by EAU Secretary-General Prof. Chris Chapple (GB) and outgoing Scientific Congress Office (SCO) Chairman Prof. Arnulf Stenzl (DE), members of the SCO each gave summaries of important data presented at EAU19 during the Souvenir Session that followed Plenary Session 7 (optimal treatment for patients with male LUTS). One of the BPH highlights at EAU19, as pointed out by Prof. Jean-Nicolas Cornu (FR), was abstract 1112, Lim et al, who presented a proof of concept with high-quality illustrations on electrochemical ablation, or electrolysis treatment. The first results are encouraging, but data is not yet available. Prof. Thomas Knoll (DE) gave a summary of the biggest innovations in urolithiasis presented at EAU19, and drew the audience’s attention to poster 336 (Grivas et al), which pointed out the 2019 updates on paediatric urolithiasis in the EAU Guidelines. The indications for recommended treatment are very similar to adults and endoscopy clearly benefitted from miniaturisation. Discussing highlights in RCC and transplantation, Prof. Marc-Oliver Grimm (DE) pointed to awardwinning poster 757 from the ERUS group, presenting encouraging results on 185 cases of robotic-assisted kidney transplant (ERUS-RAKT). Sullivan et al (767) was one of several papers that compared robotassisted partial nephrectomy to open surgery, another being 341. After much attention for the ERAS protocol at ERUS18 in Marseille, one study (1016, Withington) now examined it when dealing with RCC. The length of the patient’s hospital stay was halved, with a lower readmission rate. Grimm pointed out that more robotic surgery was used after ERAS was implemented, somewhat skewing the results. Nevertheless, it was determined that the biggest impact on length of stay was the ERAS programme itself. In total, twelve separate topics were discussed for ten minutes each, giving the remaining delegates a highly concentrated dose of the EAU19 scientific content. Explore the rest via EAU19’s Resource Centre at www.eau19.org/resource-centre

Chapple starts second term

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

New Adjunct Secretary General - Science and Membership Chairs approved

Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL)

By Loek Keizer

EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680 F +31 (0)26 389 0674 EUT@uroweb.org Disclaimer No part of European Urology Today (EUT) may be reproduced without written permission from the Communication Office of the European Association of Urology (EAU). The comments of the reviewers are their own and not necessarily endorsed by the EAU or the Editorial Board. The EAU does not accept liability for the consequences of inaccurate statements or data. Despite of utmost care the EAU and their Communication Office cannot accept responsibility for errors or omissions.

EAU19, like all Annual EAU Congresses before it also serves to give members an update on the Association’s activities and to give them a say in the appointment of the EAU’s Board and Executive members. The General Assembly took place on Saturday morning, the third day of the Annual Congress. The EAU’s Executive gave updates on the Offices’ activities in the past year, also unfolding plans for the coming period. The Science Offices have established an Onco-Urology Taskforce to promote urologists as the principal care givers in the field of GU-cancers, not only in the field of surgery but in medical management as well. By coordinating and promoting research (networks, grants), clinical trials and education, the task force hopes to put urologists at the centre of the multidisciplinary approach to genitourinary cancers. This year will see the first dedicated update on RCC, joining previous meetings on PCA and BCA and EMUC as the EAU’s oncology update meetings. With the launch of European Urology Oncology, the EAU now has three journals under its wing. Its impact

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patient should have been given a questionnaire to check for preliminary signs of androgen-deficiency.

European Urology Today

factor is pending, as is EU Focus’s, while European Urology achieved 17.581 in 2018. Over 2.2 million PDF editions were downloaded in 2018, in addition to print editions and the apps that are available for smartphones and tablets. The EAU’s website received almost one million unique visitors over the course of 2018, with Spain, Germany, Italy, the United States and the United Kingdom making the greatest contributions to this figure. The EAU’s social media channels (Facebook, Twitter, LinkedIn, Instagram) saw a 17% jump in followers compared to 2017, passing 40,000 total followers in late 2018. Total membership stands at 18,404 as measured on 1 March. New appointments The General Assembly approved Prof. Chris Chapple for a second four-year term as Secretary General, ending in 2023. Prof. Arnulf Stenzl was approved as the new Adjunct Secretary General - Science, as Prof. Francesco Montorsi is stepping down from that position. Both candidates were approved by the membership with large majorities. Candidate Prof. Stenzl’s last Annual Congress as Chairman of the Scientific Congress Office, the Search and Nomination Committee is looking for a new SCO Chairman.

In addition, the EAU Membership Office is welcoming not one but two Chairmen to replace Prof. Igor Korneyev. The General Assembly approved the appointment of Prof. Bernard Malavaud as Chair and Prof. Dimitry Pushkar as Vice-Chair, together overseeing and improving the EAU’s relationship with its members and related activities. Five new Honorary EAU Members were proposed and approved by the General Assembly: Prof. Yuri Alyaev (RU), Prof. Michael Jewett (CA), Prof. Michael Droller (USA), Prof. Hartwig Huland (DE) and Prof. Jørgen Nordling (DK).

Secretary General Prof. Chapple informing the members on EAU’s international endeavours

March/May 2019


Systemic therapy in genitourinary cancers Souvenirs from the 34th Annual EAU Congress in Barcelona Prof. Maria De Santis Charité University Hospital Dept. of Urologic Oncology Berlin (DE) maria.de-santis@ charite.de

Professor Shore concluded that: • requirements for effective immunotherapy include adequate number of immune cells that can recognise and kill tumour cells; • we should allow those cells to be functional in a tumour micro-environment; • one way to generate tumour specific immune cells is a vaccine, but vaccine alone is not likely to be sufficient to cause an overall response rate in mCRPC; • immune checkpoint inhibition is unlikely to provide measurable response in mCRPC; • combination approaches are necessary to provide the best opportunity for clinically relevant activity.

Systemic therapy in genitourinary (GU) cancers is rapidly evolving. Nearly all GU tumours are suitable for treatment. The immune system is in the focus of many researchers and has widened our understanding of cancer development. Immunotherapy (IO) has added With regard to clear cell renal cell cancer (ccRCC), the to the current treatment paradigm, in particular for souvenir session provided a summary, particularly renal cell and urothelial cancer. pointing out that immunotherapy has entered the first-line setting for metastatic ccRCC. The guidelines In Thematic Session 1, Prof. Laurence Albiges (FR) have already been adapted and followed the summarised the exciting research on the human significantly positive results of the CheckMate 214 microbiome and in particular preclinical data on gut trial: the combination ipilimumab/nivolumab has microbes and how this can change our immune become the recommended treatment for intermediate response and response to treatment. Humans are and poor risk metastatic ccRCC. home to 39 trillions of microbes that process nutrients, produce vitamins and protect from new microbes. The But there is more to come: the combination of axitinib microbiome can shape the immune system and change plus pembrolizumab versus sunitinib was positive for the first endpoints progression free survival (PFS) and microbes in the host, which has shown to induce response to immunotherapy in mice. In summary, Prof. overall survival (OS) in all risk groups and independent of any biomarkers. The combination axitinib plus Albiges pointed out that there has been a paradigm avelumab provided first positive PFS data in biomarker shift in oncology, from tumour cells, to the immune selected programmed death-ligand 1 positive (PD-L1+) system and now to the host and its environment. patients (co-primary endpoint) compared to sunitinib. This includes hosted microbes and life style. The results of the co-primary endpoint OS in PD-L1+ patients are still pending. Professor Neal Shore (US) gave a lecture on immunotherapy for prostate cancer (PCA) and explained that its current role in prostate cancer is still In summary, for patients with metastatic ccRCC we do have a new standard of care with ilimumab/ limited and research is ongoing. He shared with the nivolumab for intermediate and poor risk patients. audience the experimental algorithm for Two TKI/IO combinations are awaited for unselected immunotherapy for metastatic castration-resistant patients in the first line setting (axitinib/ prostate cancer (mCRPC). This is based on the pembrolizumab in all patients and axitinib/avelumab approval of the PD-1 inhibitor pembrolizumab for all in PD-L1 positive patients). cancers that show microsatellite instability high (MSI-H) status1. Only 5% or less of PCA patients are MSI-H. Nonetheless, it is important to know that such patients show a significant response to the checkpoint inhibitor (CPI) pembrolizumab and also long-term benefit. In some institutions, this led to the testing of all mCRPC patients for MSI-H. The majority of PCA patients who are MSI-H negative should not receive monotherapy with CPI but should be included in IO combination trials. A plethora of such trials is ongoing including IO plus PARP inhibitors, IO plus radium 223, IO plus chemotherapy and IO plus hormonal combinations such as androgen deprivation therapy ©M De Santis, EAU 2019 Souvenir Session (ADT) and enzalutamide or abiraterone/prednisolone. Is early Immunotherapy better? [©N Shore, EAU 2019] Sipuleucel-T remains the only approved IO for PCA in the US. It improves overall survival (OS) but has limited impact on PSA or other clinical parameters. There is evidence that it is best given early in mCRPC. One interesting trial is the ProVent study that randomises Sipuleucel-T versus standard active surveillance in low risk/ISUP grade 1 or 2 patients who are eligible for active surveillance.

Moving IO therapy to an earlier phase in the treatment paradigm is in the focus of clinical research, also in RCC.

Expert guided poster tour In the expert guided poster tour, Prof. Bjartell discussed the concept of the ‘trial in progress’ poster, PT128 on CheckMate 914, a phase 3 randomised controlled trial (RCT), in which adjuvant nivolumab Another DNA-vaccine trial (see slide below) is aiming plus ipilimumab or placebo are under investigation in at an immune response and altering the biology of high risk RCC patients. early PCA. There were no significant safety findings The IO/IO combination is and most AEs were associated with injection site planned for 24 weeks. reactions. The interesting news is that there are This trial explores the significant clinical effects: concept of moving the • Evidence of dampening % rise in PSA and increased prostate specific antigen (PSA) doubling successful combination upfront, hoping to time (DT) in the majority of patients. improve survival and • A PSA stabilising effect of immunotherapy was cure. The trial started in noted in patients with no demonstrated disease progression or additional therapies by week 27. This July 2017 and the targeted stabilising effect continued into week 72. This effect number of patients is around 800 in 20 was noted in all patients, regardless of baseline countries. PSA-DT or patients with baseline DT < 6 months. • Further analysis is ongoing to elucidate correlation The current treatment of immunologic efficacy and clinical benefit. highlights for advanced and metastatic prostate cancer were mainly in the metastatic hormone sensitive (mHSPC) and the non-metastatic CRPC (M0CRPC) settings. In the latter, apalutamide and enzalutamide were recently approved for the treatment of M0CRPC. At this EAU meeting, data March/May 2019

on darolutamide were presented and discussed in the plenary session. Darolutamide is structurally distinct from apalutamide and enzalutamide. It shows low blood–brain barrier penetration and low potential for drug–drug interaction. Darolutamide is of special interest because these features could result in less central nervous system toxicity and improved tolerability. The summary of the ARAMIS trial, which compared darolutamide to placebo in men with M0CRPC and PSADT ≤ 10 months, was that the agent significantly improves metastasis-free survival (MFS, primary endpoint) in this patient group. The median MFS was 40.4 months with darolutamide versus 18.4 months with placebo. Also, darolutamide has a favourable safety profile which makes it an attractive option for treating nmCRPC2.

For mHSPC both docetaxel and abiraterone/ prednisolone showed to improve survival in phase 3 randomised controlled trials and meta-analyses. In the same patient population, ARCHES evaluated enzalutamide versus placebo and showed a significant radiographic progression-free survival benefit. The OS data is still immature and eagerly awaited.

In summary, at this year’s EAU annual meeting, exciting news on immunotherapy for GU cancers was presented and discussed. The programme also included sessions for mRCC and metastatic prostate cancer with regard to new data and treatment options which were put into clinical context for daily practice. References 1. Le DT, Uram JN, Wang H, et al. PD-1 Blockade in Tumors with Mismatch-Repair Deficiency. N Engl J Med 2015;372:2509–20. 2. Fizazi K, Shore N, Tammela TL, et al. Darolutamide in Nonmetastatic, Castration-Resistant Prostate Cancer. N Engl J Med 2019;380:1235–46.

EAU19 section: EAU19: Once more raising the bar for urological meetings. . . . . . . . . . . . . . . . . . . . 1 Chapple starts second term . . . . . . . . . . . . . . 2 Systemic therapy in genitourinary cancers. . . 3 Three prostate imaging techniques highlighted. . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Overview of new developments in urothelial cancer . . . . . . . . . . . . . . . . . . . . . . 4 How Spain’s urology was shaped by its empire. . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 EAU19 update from the Guidelines Office. . . . 5 Overview of pizes and awards at the 34th Annual EAU Congress. . . . . . . . . . 6-9 EAU Patient Information Specialty Session at EAU19 . . . . . . . . . . . . . . . . . . . . . 10 EAU Patients Advocacy Group (EPAG). . . . . . 10 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . 11-14 Prague meeting to give complete LUTS update. . . . . . . . . . . . . . . . . . . . . . . . . 16 EULIS19 to present stone management essentials in Milan. . . . . . . . . . . . . . . . . . . . 16 ESU section: ESU unveils urolithiasis updates at Pan-Hellenic congress . . . . . . . . . . . . . . . . . 17 ESU offers UTI & ED fundamentals at RSU congress. . . . . . . . . . . . . . . . . . . . . . 17 Participants review NMIBC Masterclass. . . . . 18 FT masterclass presents disruptive technologies. . . . . . . . . . . . . . . . . . . . . . . . . 19 1st UROBESTT features fresh innovations and talent. . . . . . . . . . . . . . . . . 20 CAUREP unveils urology essentials in Punta Cana. . . . . . . . . . . . . . . . . . . . . . . . 22 Pre- and post-pubertal fertility preservation in males. . . . . . . . . . . . . . . . . . 23 ESUO: Treatment of simple urinary tract infections in Europe. . . . . . . . . . . . . . . 24 ESFFU: Tips & tricks to avoid complications, optimise management . . . . . 25 Clinical Challenge. . . . . . . . . . . . . . . . . . . . . 26 EAU RF launches PHOENIX registry. . . . . . . . 27 EBU: Berne Urological University Hospital EBU re-certified . . . . . . . . . . . . . . . 27 YUO section: Nightmare case: Rare gigantic emphysematous cystitis. . . . . . . . . . . . . . . . 28 The BURST Collaborative: Progress and news. . . . . . . . . . . . . . . . . . . . 29 USANZ Trainee Week . . . . . . . . . . . . . . . . . . 30 EULIS: Robotic flexible ureteroscopic stone management. . . . . . . . . . . . . . . . . . . . 30 EAU RF: BCG biomarker research profits from NIMBUS trial. . . . . . . . . . . . . . . 31 ESOU19 sums up vital onco-urology updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 ERUS19: New indications, new technology, new training . . . . . . . . . . . 33 European Tour 2019: Academic Exchange Programme with Taiwan and Japan . . . . . . . 34 European Tour 2019: Academic Exchange Programme with Canada . . . . . . . . . . . . . . . 36 EAUN section: Highlights and impressions of EAUN19 in Barcelona . . . . . . . . . . . . . . . . . . Animated narratives in a digital platform. . . 4th EAUN workshop at EUSC 2018 in Dubai. . . . . . . . . . . . . . . . . . . . . . . . . . . . Annual Conference 2018 of Society of Urologic Nurses. . . . . . . . . . . . . . . . . . . . Anniversary 20th EAUN Meeting in Barcelona. . . . . . . . . . . . . . . . . . . . . . . . .

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Three prostate imaging techniques highlighted Souvenir Session, Plenary Session 7: Imaging in Urology • In cases of previously negative biopsy and contraindications to/negative mpMRI, (claustrophobia, pacemaker) PSMA PET is capable of detecting malignant lesions and identify with a high sensitivity clinically relevant prostate cancers (Fig. 2) (PT 140)(PT141). I saw some of these situations in my practice. This could be a useful option (outside guidelines).

Prof. Arnauld Villiers CHRU de Lille Dept. of Urology Lille (FR)

arnauld.villers@ wanadoo.fr

Use of PET-PSMA in localised Pca There was a plenary discussion about PSMA PET in Fig. 1: DWI sequences (ADC and b1400) and axial T2-W are part primary high risk cancers. Does ‘seeing more’ mean Imaging was everywhere during scientific abstracts of Fast bi-parametric MRI protocol. Dynamic Contrast ‘curing more’? Mostly small retrospective studies and plenary sessions at the 34th Annual EAU sequences and sagittal and coronal T2-W are not performed. were performed in the field. There are infrequent Congress. Among all genito-urinary organs, I selected pathological data and issues with regard to cost and 3 prostate imaging topics which were presented and availability. No impact on survival has been shown debated. yet. We might not know yet how to best treat patients Is it possible for fast bpMRI to replace mpMRI in all with these findings. We expect that we will learn how patients? For detection it is. Then mpMRI could be • Fast bi-parametric MRI, screening test at low performed for staging and treatment planning in case to use the information obtained; it might be useful for cost? bpMRI without contrast has equal results of a diagnosis of clinically significant cancer. But is it patient counselling. compared to mpMRI with contrast for cancer only possible at selected centres? Additional detection. Should we use PSMA PET in primary high-risk multicentre studies are necessary to confirm this localised Pca patients (where it has a higher clinical protocol. A future direction may well be a non• Use of PET-PSMA in localised Pca? If available invasive, fast, low cost and better screening tool if PSA impact)? Is it a game changer? Future directions: if consider for high-risk patients (if possible in available consider using PET-PSMA (if possible in is suspicious (along with other markers). trials) or in the event of contraindications to MRI trials), if not available, stick to the guidelines (claustrophobia, pacemaker). (conventional imaging). Other interesting findings were: • Structured reporting of prostate MRI improves • Micro-US (high-frequency 29 MHz) TRUS is one of Micro-US interdisciplinary communication and can help the promising new imaging modality. Are ultrasounds genuine competitors to detect facilitate surgical planning (PT149). • The importance of MRI reading skills by urologists clinically significant prostate cancer (csPCa)? mpUS Fast bi-parametric MRI demonstrated improved diagnostic accuracy in reducing the chance of missing significant Prof. Jelle Baretsz (NL) presented the latest results compared to US modalities in a stand-alone setting prostate cancer on biopsies was also reported from a multi-centre study on 626 biopsy naive for all different thresholds of imaging and csPCa. We (PT157). patients, showing that a ‘fast’ prostate MRI without still need more mature data (PT150)(PT162). Micro-US contrast is cheap, non-invasive and can double (high-frequency 29 MHz) TRUS is a promising new prostate MRI capacity (Fig. 1). Fast bpMRI without imaging modality. We will gain in quality and contrast agent significantly lowers costs (55%) and quantity of information unknown before. Prospective avoids the potential side-effects of Gd-injection validation of a protocol for real-time lesion (e.g. Gd-brain deposition, allergic reaction). identification and biopsy targeting (PRI-MUS™) Comparison of protocols: PI-RADS 3: +5% (6% showing high sensitivity to detect csPCa (Fig. 3) versus 11%). Number of biopsies indicated: +2% (553, 161). (51% versus 53%). Insignificant PCa: +1% (13% Fig. 2: PET-CT showing a large anterior suspicious lesion in a versus 12%). Equal detection rate for clinically patient with previous negative systematic posterior biopsies. References & abstracts 1. Van der Leest, Barentsz, J Eur Urol 2019 in press significant PCa. TRUS targeted biopsies were positive for 3+4 cancer.

Fig. 3: Targeted Biopsy using Fusion Vu Right Apex Lesion identified on MRI (Courtesy of J Walz)

2. T. Maurer, Hamburg (DE) S. Joniau, Leuven (BE) PT149: Improved interdisciplinary communication – the impact of structured reporting of prostate magnetic resonance imaging. Wetterauer C. Basel, Switzerland. PT157: How important are prostate MRI reading skills to urologists? Sternberg I. Kfar Saba, Israel. PT140: Clinical utility of prebiopsy PSMA PET CT in patients suspected of carcinoma prostate. Jain H, Sood R. et al. New Delhi, India PT141: Potentials of 68Ga- PSMA PET/CT for primary diagnosis of prostate cancer. Lazzeri M. et al, Rozzano, Italy. PT150: 3D multiparametric contrast ultrasound predicts the histopathological outcome of systematic biopsy. Mischi M. et al. Eindhoven, The Netherland. PT162: Multiparametric ultrasound for the diagnosis of prostate cancer: Greyscale, shearwave elastography and contrast-enhanced imaging in comparison with radical prostatectomy specimens. Mannaerts C.K et al. Amsterdam, The Netherlands. 553: A multi-institutional randomized controlled trial comparing novel first generation high-resolution micro-ultrasound with conventional frequency ultrasound for TRUS biopsy. Pavlovich C., Baltimore, USA. 161: Assessing the diagnostic accuracy of micro-ultrasound for the detection of clinically significant prostate cancer: Results from a single-institutional experience. Lughezzani G. et al. Milan, Italy.

Overview of new developments in urothelial cancer Souvenir Session, Plenary Session 7: Urothelial cancer Prof. Morgan Rouprêt Hospital La Pitié-Salpétrière Academic Dept. of Urology ESOU Chairman Paris (FR) morgan.roupret@ aphp.fr A subjective selection of presentations on urothelial cancer is presented here. A selection was made from plenary, thematic and poster sessions, related to the current ongoing discussions in the field of bladder and upper-tract urothelial cancer. EDIFICE 6 survey De la Motte Rouge et al. reported on the French nationwide observational survey EDIFICE 6 which was conducted online in July 2017 on 12,046 individuals. Representativeness was ensured by quota sampling on age, gender, profession, and stratification by geographical area and type of urban district. The purpose of the survey was to investigate the knowledge of bladder cancer in the French population. Only 39% of the population believed there were symptoms of bladder cancer and cited pain (33%), bleeding (29%), and urinary disorders (25%). Among the top five risk factors cited, tobacco was ranked as having the least impact. The majority of respondents (69%) declared they had no knowledge of a test to detect bladder cancer. According to 21%, imaging techniques are used and 12% believe bladder cancer can be detected by a urine test. These results highlight a number of misconceptions and a lack of understanding of bladder cancer disease among the French population. Notably the severity of the disease was underestimated, likely because it is not well known in the general population. More importantly, tobacco was not acknowledged as the primary risk factor and the warning signs are still widely unknown. There is a need for appropriate 4

European Urology Today

information about bladder cancer in the mass media. Predicting recurrence The EAU guidelines panel on bladder cancer reported the prognostic value of the WHO 1973 and 2004/2016 grading system in primary Ta/T1 NMIBC (Van Rhijn B, et al.). Individual patient data for 5,049 primary Ta/T1 NMIBC patients from 17 centres were reviewed. Neither grading system predicted recurrence. WHO 1973 & 2004/16 both predicted progression, disease specific survival and overall survival, but not recurrence. The greatest prognostic value was obtained from a combination of WHO1973 & 2004/16. The EAU guidelines, which advocate using both WHO systems in daily practice, remain correct. Soria et al. reported on a multicentre retrospective study (N = 291) on the predictive factors for the absence of residual disease at repeated transurethral resection of the bladder (TURBT). In pT1 high-grade NMIBC patients who underwent a full and exhaustive complete first TURBT, criteria linked with the absence of tumour at the time of the 2nd consultation were evaluated. From the multivariate analysis, the following factors were identified: presence of muscle in the specimen, concomitant carcinoma in situ (CIS), en bloc TURBT. The authors claim that a urologist could avoid a repeat TURBT in these selected patients. Only a prospective study will be able to confirm this conclusion. FGFR3 mutation and overexpression Mertens et al. reported on FGFR3 mutations and FGFR3 expression and clinical outcome in radical cystectomy specimen. The authors have included 1,000 cN0M0 chemo-naïve bladder cancer patients who underwent radical cystectomy (9 hospitals). The specimen were reviewed by experienced uropathologists. They found a FGRFR3 mutation in 11% of cases and an FGRFR3 overexpression in 28% of cases. The FGFR3 mutation had a favourable prognostic impact regardless of FGFR3 expression. FGFR3 overexpression had no prognostic

impact. For the selection of patients for targeted therapy with an anti-FGFR3 agent, FGFR3 mutation seems to be the key rather than FGFR3 expression. Regarding mortality after radical cystectomy (RC), Cascales G. et al. reported about a Spanish register study among 12,154 RC patients in 196 hospitals over the period 2011-2015. It was found that a majority of hospitals in Spain were doing less than 10 RCs per year and only 5 units were performing more than 38 per year. The mortality rates at 30, 60 and 90 days were 2.9%, 5.1% and 6.5%, respectively. The lower rate of mortality at 90 days was 3.3% and came from a high-volume centre (> 38 RC per year). If a centre increases the number of RCs by 10 in a year then a decrease of 20% in mortality at 90 days can be expected. Ileal conduit or continent diversion During a thematic session, a debate about the question ‘ileal conduit or continent diversion: which is the better choice for most patients?’ was started. Dr. Palou reminded the audience that most of the urinary diversions that are performed today are ileal conduit (80%) compared to orthotopic neobladder (19%) and continent cutaneous diversion (1%). Palou talked about the TRIFECTA purpose in bladder cancer: to achieve the same oncological results, while maintaining correct voiding and sexual activity. Palou claimed that surgeon experience and preferences play an important role in the patient’s decision. The real contra-indications for neobladder are: positive urethral margin peroperatively, impaired liver or renal function, debilitating neurological or psychiatric illnesses (cognitive function) and limited life expectancy. Unfortunately, the disparity in the quality of surgical complication reporting in urologic oncology makes it impossible to compare the outcomes. Quality of life Sparse information is available regarding quality of life after cystectomy. The evaluation of quality of life after a urinary diversion is complex and the following should

Regenerative Outcome of NUC in Pt.5 - Explanted 10 months

be considered: psychological well-being, overall state of health, functional capacity and personal and professional relationships. Taylor and Palou discussed discrepancies between Europe and the USA, where more continent diversions are proposed to patients and only high-volume centres are performing RC. To look ahead, a very interesting phase I clinical trial was presented by Bivalacqua et al. about the use of tissue-engineered neo-urinary conduit using adiposederived smooth muscle cells (AD-SMC) for urinary reconstruction. Successful regeneration of urinary tissue in humans occurs when autologous AD-SMC is used. Translation of technology from pre-clinical models is demonstrated through native-like urinary tissue regeneration in humans enrolled in a Phase 1 clinical trial. However, despite tissue regeneration the tissue engineered neo-urinary conduit was not durable. Last but not least, a lecture from Zlotta et al. on upper-tract cancer has emphasised that these tumours are part of the Lynch Syndrome (LS) tumour spectrum. Any cancer with microsatellite instability (i.e. LS) harbours high mutation rates. The production of many mutant immunogenic proteins is typically associated with a lymphocytic infiltrate and with an overexpression of immune-checkpoints proteins (PD1 and CTLA-4), paving the way for dedicated trials of checkpoint inhibitors in upper tract cancers. March/May 2019


How Spain’s urology was shaped by its empire History Office Specialty Session highlights Spanish contributions to early urology By Loek Keizer

to have been the result of sexually-transmitted urethritis), together with benign and malignant prostatic diseases, although they could not yet be differentiated from diseases of the urethra and bladder neck.

Spain has greatly contributed to the field of urology, through its scholars, surgeons and innovators, the audience learned at the EAU History Office’s Special Session on Friday afternoon at EAU19. Particularly striking is the role that Spain’s former empire played in the development of Spanish urology: from previously unknown diseases and herbs that reached Spain from the New World to the LatinAmerican urologists who trained and worked in Spain, reaching great new heights. The tale of Prof. Perez-Castro (centre) surprised EAU History Office Spanish urology is inextricably linked with Spain’s Chairman Prof. Van Kerrebroeck (left) and Session Co-Chair history of overseas conquest. The EAU History Office typically organises a session at every EAU Annual Congress highlighting the history of urology in the host country. Last year saw an extensive session on Danish urology, and in 2017 the History Office collaborated with BAUS in London. This year, the session was chaired by EAU History Office Chairman Prof. Philip Van Kerrebroeck (NL) and Dr. Luis Fariña-Péres (ES). In addition to the Specialty Session, the EAU History Office organised the Historical Exhibition at the EAU Booth (also with highlights from Spain), held a Poster Session to showcase new research, and published a new volume of De Historia Urologiae Europaeae. Renaissance Spain and Urology Prof. Remigio Vela Navarrete (ES) spoke about the birth of urology in renaissance Europe, in particular the Spanish contributions in the 16th century. Vela Navarrete felt that Spanish achievements in early urology have been historically overlooked, for instance in Ernest Desnos’s influential History of Urology (1914), which makes no mention at all of Spanish developments in the field. In the discussion that followed his presentation, he attributed this to a climate of French nationalism surrounding the First World War. EAU History office

Dr. Luis Fariña-Péres (right) with a donation to the EAU’s instrument collection

One Spanish renaissance ‘proto-urologist’ is Andreas Vesalius (1514-1564), the so-called ‘prince of anatomy’ and personal doctor of Charles V and Philip II. Several Spanish anatomists were active in Paris at the time. A lesser-known contemporary of Vesalius was Andres Laguna (1499-1559), author of Anatomical Method (1535). This work describes horseshoe kidney and ileocecal valve. Juan Valverde de Amusco (1525-1587) published anatomical work in Rome in 1556. His illustrations (and even a portrait painting of him) are often confused with Vesalius. Valverde described the prostate as a “spherical mass of meat”. The Newly printed treatise of all the diseases of the kidneys, bladder and carnosities of the phallus and urine (1588) by Francisco Díaz, is a compendium of anatomy, medicine and practical surgery, dealing for the first time with the diseases of the urinary tract as an anatomical and functional unit. This treatise is considered by some to be the first integral book on urology. The third part of this book –translated into English in 2018 by the History Office of the Spanish Association of Urology- deals with strictures of the urethra that had become highly prevalent (nowadays considered

Diaz’s treatise was rediscovered at the end of the 19th and the beginning of the 20th century, and praised by several humanistic surgeons, and afterwards by the influential urologist Antonio Puigvert, who in 1973 created the Francisco Díaz medal. This medal was adopted by the Spanish Association of Urology as an annual award to a Latin-American or international urologist, recognising a scientific, associative or educational achievement. Prof. Vela Navarrete also painted a picture of Spain’s colonial past, and the way that it gave the country a unique urological history. Over a period of several decades in the 16th and 17th centuries, descriptions can be found in Spanish medical sources of prostatism, stone treatment, and particularly and uniquely, New World remedies. Spanish doctors and scientists studied chocolate, cacao and cantarida (“Spanish fly”) as aphrodisiacs. Pharmacology also made new strides in the Spanish Empire. New plants and herbs were studied in Sevilla (1492-1540), like tobacco, guayacan, cacao. Hospitals and botanical gardens were established in the Spanish Americas, some of which persist until today.

all intents and purposes “a Spanish man” according to Prof. Cuesta. Albarrán was orphaned at an early age and taken to Spain for his studies. He earned his medical degree at age 17, at the Faculty of Medicine of the University of Barcelona. After becoming one of Europe’s foremost urologists, he influenced dozens of followers in the Spanish and French medical world. Dr. José Maria Gil-Vernet Sedo (ES) spoke on his grandfather Salvador’s work in the 1940s, particularly his publication of Patologia Urogenital (1944), a hugely influential and beautifully illustrated volume. The role of the medical illustrator (particularly with regard to Spanish urology) is further highlighted in Dr. Luis Farina’s chapter in De Historia Urologiae Europaeae Vol. 26, which was presented at EAU19 and free for EAU members. The digital version is now available on UROsource. Dr. Enrique Perez-Castro Ellendt (Madrid, ES) completed the session with his talk on the beginnings of ureteroscopy (URS), in which Spanish urologists had a prominent role.

The New World also brought (urological) disease, and Spanish doctors pioneered the description and treatment of syphilis, which originated in Hispaniola and reached Europe through Barcelona(!) and Naples. Spanish innovators Prof. Javier Angulo Cuesta (ES) explored the life of renowned Cuban-born urologist Joaquín María Albarrán (1860-1912), particularly how he was influenced by Spain, and how in turn he impacted Spanish urology. Cuba was at the time one of Spain’s last overseas possessions, closely tied to Madrid. This, combined with his Spanish father, made Albarrán for

Objects of significance for the history of Spanish urology from the Spanish Urological Society and Barcelona’s Puigvert Foundation were on display at the Historical Exhibition

EAU19 update from the Guidelines Office Guidelines activities prove hugely popular in Barcelona The EAU19 congress proved most successful for the EAU Guidelines Office (GO) with the updated publications of the EAU Guidelines, two very busy interactive Guidelines Controversies sessions and a well-attended Guidelines Poster Walk. Guidelines Controversies Two interactive Guidelines Controversies sessions were held on Saturday, 16 March. Controversies session I, addressing: • Non-muscle-invasive Bladder Cancer “Should a TUR be done in all bladder tumours?” • Urolithiasis - “PCNL: Does the instrument size matter?” • Upper tract urothelial carcinoma “Is there a role for systemic neoadjuvant chemotherapy in high-risk tumour?”

Guidelines Controversies Session I: waiting to join the session.

EAU members lining up at the EAU Booth for their complimentary copy of the 2019 Edition of the EAU Guidelines. Approximately 2,900 copies were handed out in Barcelona.

attracted a record number of 465 participants. Many were waiting in line to join. Guidelines Controversies Session II topped those results with 782 recorded participants: • Prostate Cancer - No biopsy in case of a normal MRI • Male Sex Health - Focal therapy vs. Robotic surgery for prostate cancer: Reported sexual function outcomes are misleading and require standardisation in guidelines • Renal Cell Carcinoma – “Should we be doing cytoreductive nephrectomies in M1 patients requiring targeted therapy?” This success is very much based on the enthusiasm and support of the experts included in our Guidelines Panels for which the GO is most grateful.

Guidelines Office

March/May 2019

Guidelines Controversies Session II chairs, left to right: Prof. R. Sylvester, Prof. J. N’Dow; faculty, Prof. O. Rouvière, Prof. C. Moore, and Prof. N. Mottet; presenter: Prof. S. Carlsson.

Dr. James Donaldson (Aberdeen) received a Best Poster Award for his poster "Treatment of bladder stones in children: A systematic review on behalf of the EAU Urolithiasis Guideline Panel". Congratulation to him and the Urolithiasis Guidelines Panel!

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Overview of prizes and awards EAU Willy Gregoir Medal 2019

EAU Frans Debruyne Life Time Achievement Award 2019

F. Hamdy, Oxford, United Kingdom - Handed out by C.R. Chapple

F. Montorsi, Milan, Italy - From left to right: F. Debruyne, F. Montorsi, C.R. Chapple

Opening Ceremony Friday, 15 March EAU Crystal Matula Award 2019

EAU Hans Marberger Award 2019

M. Albersen, Leuven, Belgium Supported by LABORIE - From left to right: M. Fürstenberg (LABORIE), M. Albersen, C.R. Chapple

G. Simone, Rome, Italy Supported by KARL STORZ SE & CO.KG - From left to right: E. Dourver (KARL STORZ SE & CO.KG), G. Simone, C.R. Chapple

New EAU Honorary Members

Y. Alyaev, Moscow, Russia - Handed out by C.R. Chapple

M. Droller, New York, United States of America - Handed out by C.R. Chapple

EAU Innovators in Urology Award 2019 P. Alken, Mannheim, Germany - Handed out by C.R. Chapple

H. Huland, Hamburg, Germany - Handed out by C.R. Chapple

M. Jewett, Toronto, Canada - Handed out by C.R. Chapple

EAU Ernest Desnos Prize 2019 KARL STORZ SE & Co.KG - Handed out by C.R. Chapple to S. Storz

J. Nordling, Herlev, Denmark - Handed out by C.R. Chapple

EAU Prostate Cancer Research Award 2019 V. Kasivisvanathan, London, United Kingdom Supported by the FRITZ H. SCHRÖDER FOUNDATION - From left to right: F.H. Schröder (FRITZ H. SCHRÖDER FOUNDATION), V. Kasivisvanathan, C.R. Chapple

Prize for the Best Paper published on Fundamental Research in the Urological Literature (2 awards) T. Mitchell, S. Turajlic, A. Rowan, D. Nicol, J. Farmery, T. O’Brien, I. Martincorena, P. Tarpey, N. Angelopoulos, L. Yates, A. Butler, K. Raine, G. Stewart, B. Challacombe, A. Fernando, J. Lopez, S. Hazell, A. Chandra, S. Chowdhury, S. Rudman, A. Soultati, G. Stamp, N. Fotiadis, L. Pickering, L. Au, L. Spain, J. Lynch, M. Stares, J. Teague, F. Maura, D. Wedge, S. Horswell, T. Chambers, K. Litchfield, H. Xu, A. Stewart, R. Elaidi, S. Oudard, N. McGranahan, I. Csabai, M. Gore, P. Futreal, J. Larkin, A. Lynch, Z. Szallasi, C. Swanton, P. Campbell, the TRACERx Renal Consortium (Hinxton, Cambridge, London, Oxford, St. Andrews, United Kingdom; Baracaldo, Spain; Paris, France; Budapest, Hungary; Houston, Boston, USA; Lyngby, Denmark) For the paper: “Timing the Landmark Events in the Evolution of Clear Cell Renal Cell Cancer: TRACERx Renal” Cell (2018) Vol 173, 611-623. https://doi.org/10.1016/j.cell.2018.02.020 - Handed out by C.R. Chapple

Award Gallery

S. Turajlic, H. Xu, K. Litchfield, A. Rowan, T. Chambers, J. Lopez, D. Nicol, T. O’Brien, J. Larkin, S. Horswell, M. Stares, L. Au, M. Jamal-Hanjani, B. Challacombe, A. Chandra, S. Hazell, C. Eichler-Jonsson, A. Soultati, S. Chowdhury, S. Rudman, J. Lynch, A. Fernando, G. Stamp, E. Nye, F. Jabbar, L. Spain, S. Lall, R. Guarch, M. Falzon, I. Proctor, L. Pickering, M. Gore, T. Watkins, S. Ward, A. Stewart, R. DiNatale, M. Becerra, E. Reznik, J. Hsieh, T. Richmond, G. Mayhew, S. Hill, C. McNally, C. Jones, H. Rosenbaum, S. Stanislaw, D. Burgess, N. Alexander, C. Swanton, PEACE, the TRACERx Renal Consortium (London, United Kingdom; Barakaldo, Pamplona, Spain; New York, St. Louis, Madison, Tucson, USA) For the paper: “Tracking Cancer Evolution Reveals Constrained Routes to Metastases: TRACERx Renal” Cell (2018) Vol 173, 581-594. https://doi.org/10.1016/j.cell.2018.03.057 - Handed out by C.R. Chapple to T. O’Brien who accepts the award on behalf of S. Turajlic

Friday, 15 March Prize for the Best Paper published on Clinical Research in the Urological Literature (2 awards) G. Gandaglia, N. Fossati, R. J. Karnes, S. A. Boorjian, M. Colicchia, A. Bossi, T. Seisen, C. Cozzarini, N. Di Muzio, B. Noris Chiorda, E. Zaffuto, T. Wiegel, S. F. Shariat, G. Goldner, S. Joniau, A. Battaglia, K. Haustermans, G. De Meerleer, V. Fonteyne, P. Ost, H. Van Poppel, F. Montorsi, A. Briganti (Milan, Italy; Rochester, USA; Villejuif, France; Ulm, Germany; Vienna, Austria; Leuven, Ghent, Belgium) For the paper: “Use of Concomitant Androgen Deprivation Therapy in Patients Treated with Early Salvage Radiotherapy for Biochemical Recurrence After Radical Prostatectomy: Long-term Results from a Large, Multi-institutional Series” European Urology 73(2018) 512-518. https://doi.org/10.1016/j.eururo.2017.11.020 - Handed out by C.R. Chapple

A. Territo, L.Gausa, A. Alcaraz, M. Musquera, N. Doumerc, K. Decaestecker, L. Desender, M. Stockle, M. Janssen, P. Fornara, N. Mohammed, G. Siena, S. Serni, S. Sahin, V. Tugcu, ˇ G. Basile and A. Breda (Barcelona, Spain; Toulouse, France; Ghent, Belgium; Homburg/Saar, Halle, Germany; Florence, Italy; Istanbul, Turkey) For the paper: “European experience of robot-assisted kidney transplantation: minimum of 1-year follow-up” BJUI International (2018) 122:255-262. doi: 10.1111/bju.14247 - Handed out by C.R. Chapple

34th Annual EAU Congress 6

European Urology Today

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at the 34th Annual EAU Congress Prize for the Best Scientific Paper published in European Urology J. Bosschieter, J. Nieuwenhuijzen, T. Van Ginkel, A. Vis, B. Witte, D. Newling, G. Beckers, J. Van Moorselaar (Amsterdam, The Netherlands) For the paper: “Value of an Immediate Intravesical Instillation of Mitomycin C in Patients with Non–muscleinvasive Bladder Cancer: A Prospective Multicentre Randomised Study in 2243 patients” European Urology, Vol. 73, Issue 2, p226–232 Supported by ELSEVIER - From left to right: N. Van Dijk (ELSEVIER), J. Bosschieter, J. Catto

Prize for the Best Scientific Paper published on Fundamental Research in European Urology Y. Deruyver, E. Weyne, K. Dewulf, R. Rietjens, S. Pinto, N. Van Ranst, J. Franken, M. Vanneste, M. Albersen, T. Gevaert, R. Vennekens, D. De Ridder, T. Voets, W. Everaerts (Leuven, Belgium) For the paper: “Intravesical Activation of the Cation Channel TRPV4 Improves Bladder Function in a Rat Model for Detrusor Underactivity” Intravesical Activation of the Cation Channel TRPV4 Improves Bladder Function in a Rat Model for Detrusor Underactivity Supported by ELSEVIER - From left to right: N. Van Dijk (ELSEVIER) Y. Deruyver, J. Catto

Prize for the Best Scientific Paper published on Clinical Research in European Urology M. Liss, J. White, M. Goros, J. Gelfond, R. Leach, T. Johnson-Pais, Z. Lai, E. Rourke, J. Basler, D. Ankerst, D. Shah (San Antonio, Baltimore, United States of America) For the paper: “Metabolic Biosynthesis Pathways Identified from Fecal Microbiome Associated with Prostate Cancer” European Urology, Vol. 74, Issue 5, p575–582 Supported by ELSEVIER - From left to right: N. Van Dijk (ELSEVIER), M. Liss, J. Catto

Prize for the Best Scientific Paper published on Robotic Surgery in European Urology B. Bochner, G. Dalbagni, K. Marzouk, D. Sjoberg, J. Lee, S. Donat, J. Coleman, A. Vickers, H. Herr, V. Laudone (New York, United States of America) For the paper: “Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes” European Urology, Vol. 74, Issue 4, p465–471 Supported by the VATTIKUTI FOUNDATION - From left to right: J. Catto, G. Dalbagni who accepts the award on behalf of B. Bochner, M. Bhandari (VATTIKUTI FOUNDATION)

First Prize for the Best Abstract (Oncology) L. Mertens, B. Van Rhijn, R. Mayr, P. Bostrom, M. Marquez, E. Zwarthoff, J. Boormans, C. Abas, G. Van Leenders, Y. Neuzillet, M. Van Der Heijden, F. Real, R. Stohr, A. Zlotta, M. Eckstein, Y. Soorojebally, M. Burger, F. Radvanyi, N. Sirab, D. Pouessel, T. Van Der Kwast, N. Malats, A. Hartmann, Y. Allory, T. Zuiverloon (Amsterdam, Rotterdam, The Netherlands; Regensburg, Erlangen, Germany; Turku, Finland; Madrid, Spain; Toronto, Canada; Paris, France) For the abstract: “1074: FGFR3 mutations and their relation to FGFR3 expression and clinical outcome in a large radical cystectomy cohort: Implications for anti-FGFR3 bladder cancer treatment?” - Handed out by A. Stenzl

Second Prize for the Best Abstract (Oncology) C. Bravi, N. Fossati, N. Suardi, L. Boeri, R. Karnes, A. Heidenreich, A. Kretschmer, A. Buchner, C. Stief, A. Battaglia, S. Joniau, H. Van Poppel, A. Kalz, D. Osmonov, K. Juenemann, A. Hiester, S. Shariat, P. Albers, D. Tilki, M. Graefen, A. Ashrafi, I. Gill, A. Mottrie, F. Montorsi, A. Briganti (Milan, Italy; Rochester, Los Angeles, USA; Cologne, Munich, Kiel, Dusseldorf, Hamburg, Germany; Leuven, Melle, Belgium; Vienna, Austria) For the abstract: “769: Long-term oncologic outcomes of patients treated with salvage lymph node dissection for nodal recurrence of prostate cancer: Results from a large, multi-institutional series” - Handed out by A. Stenzl

Award Gallery Friday, 15 March

First Prize for the Best Abstract (Non-Oncology) K. Monastyrskaya, M. Besic, A. Hashemi Gheinani, F. Burkhard (Berne, Switzerland) For the abstract: “534: Dysregulation of phospholamban and beta 3-adrenergic receptor expression might lead to bladder detrusor overactivity via SERCA inhibition” - Handed out by A. Stenzl

Second Prize for the Best Abstract (Non-Oncology) M. Abdelbaset, A. Hashem, A. Eraky, O. Ezzat, M. Sharaf, A. El-Assmy, K. Sheir, A. Shokeir (Mansoura, Egypt; Waren, Germany) For the abstract: “281: Optimal non-invasive treatment of 1-2.5 cm radiolucent renal stones: Oral dissolution therapy (ODT), shock wave lithotripsy (SWL) or combined treatment: A randomized controlled trial” - Handed out to M. Abdelbaset

Third Prize for the Best Abstract (Non-Oncology) B. Goulao, S. Carnell, J. Shen, G. MacLennan, J. Norrie, J. Cook, E. McColl, M. Breckons, L. Vale, R. Forbes, S. Currer, M. Forrest, J. Wilkinson, D. Andrich, S. Barclay, A. Munday, J. N'Dow, S. Payne, N. Watkin, R. Pickard (Aberdeen, Newcastle, Oxford, London, Manchester, United Kingdom) For the abstract: “399: Surgical treatment for recurrent bulbar urethral stricture: A randomised open label superiority trial of open urethroplasty versus endoscopic urethrotomy (The OPEN Trial)” - Handed out by A. Stenzl to N. Watkin who accepts the award on behalf of B. Goulao

First Video Prize F. Porpiglia, E. Checcucci, D. Amparore, F. Piramide, P. Piazzolla, A. Bellin, C. Fiori (Turin, Italy) For the video: “V59: 3D elastic augmented reality robot-assisted partial nephrectomy for central and posterior renal masses: A new tool for a better resection of the tumor” - From left to right: M. Al Zaharani, A. Messas, F. Porpiglia, B. Rocco

Second Video Prize R. Martos Calvo, L. Peri, M. D'anna, M. Ribal, A. Alcaraz (Barcelona, Spain) For the video: “V58: Renal cell carcinoma with inferior vena cava thrombus: 3D laparoscopic approach” - From left to right: M. Al Zaharani, A. Messas, M. Martos Calvo, B. Rocco

Video Award Session Saturday, 16 March

Third Video Prize K. Black, A. Aldoukhi, W. Roberts, T. Hall, K. Ghani (Ann Arbor, USA) For the video: “V57: Exploring the parameters affecting stone retropulsion in holmium laser lithotripsy: A video analysis” - From left to right: K. Black, M. Al Zaharani, A. Messas, B. Rocco

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Overview of prizes and awards ESUI Vision Award 2019

ESTU - René Küss Prize 2019

G. Gandaglia, Milan, Italy For the abstract: “A Novel Nomogram to Identify Candidates for Extended Pelvic Lymph Node Dissection Among Patients with Clinically Localized Prostate Cancer Diagnosed with Magnetic Resonance Imaging-targeted and Systematic Biopsies” Supported by INVIVO, a Philips Company - From left to right: P. Marchot (INVIVO, a Philips Company), G. Salomon. G. Gandaglia

M. Wettstein, Zurich, Switzerland For the abstract: “Management of end-stage renal disease patients diagnosed with active surveillanceeligible prostate cancer during pre-transplantation work-up: A decision analysis” - From left to right: E. Lledó García, F. Burgos Revilla, M. Wettstein

ESTU - Research Grant 2019

Section Awards Saturday, 16 March

R. Boissier, Marseille, France For the project: “Perirenal adipose tissue is a non invasive source of donor derived material allowing assessment of senescent profiles associated to poorer prognosis of aging Kidney allograft” Supported by ORGAN RECOVERY SYSTEMS - From left to right: E. Lledó García, F. Burgos Revilla, R. Boissier

EUSP Best Scholar Award Basic Research 2019

EUSP Best Scholar Award Clinical Research 2019 V. De Coninck, Paris, France For the project: “Optimizing the lithotripsy performance by determining the optimal distance between the laser fibre tip and the stone” - From left to right: V. Mirone, V. De Coninck, O. Traxer

M. Vartolomei, Targu Mures, Romania For the project: “Quality indicators for Bladder Cancer” - Handed out by V. Mirone

First Prize EAU Guidelines Cup 2019 M. Ruiz Hernandez, Madrid, Spain - Handed out by J. Gómez Rivas

Second Prize EAU Guidelines Cup 2019 C. Fankhauser, Zurich, Switzerland - Handed out by J. Gómez Rivas

EAU Guidelines Cup 2019

Third Prize EAU Guidelines Cup 2019 P. Kutwin, Lodz, Poland - Handed out by J. Gómez Rivas

Audience Prize EAU Guidelines Cup 2019

Group picture EAU Guidelines Cup 2019

J. Hernández Cavieres, Madrid, Spain - Handed out by J. Gómez Rivas

YAU Awards 2019 - Best paper by YAU in 2018 B. Haid, S. Silay, A. Radford, P. Rein, B. Banuelos, J. Oswald, A. Spinoit (Linz, Austria; Istanbul, Turkey; Leeds, United Kingdom; Berlin, Germany; Ghent, Belgium) For the paper: “Late ascended testes: is non-orthotopic gubernacular insertion a confirmation of an alternative embryological etiology?” - From left to right: S. Silay, B. Haid, A. Stenzl

YUORDay Saturday, 16 March

YAU Awards 2019 - Reviewer of the year from YAU F. Castiglione, London, United Kingdom - From left to right: S. Silay, F. Castiglione, A. Stenzl

Best Booth Award 2019 Coloplast Interventional Urology - From left to right: K. Russell, J. Mahoney, C. Chapple, A. Bournot, S. Achour, N. Dampeyrou, MJ. Landre

Exhibition Saturday, 16 March

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at the 34th Annual EAU Congress First Prize for the Best Abstract by a resident

Second Prize for the Best Abstract by a resident

S. Khadhouri, K. Gallagher, K. Mackenzie, T. Shah, C. Gao, S. Moore, E. Zimmermann, E. Edison, M. Jefferies, A. Nambiar, J. McGrath, V. Kasivisvananthan, The IDENTIFY Study Group (Aberdeen, Newcastle, London, Peterborough, Wrexham, Weston-super-Mare, Swansea, Exeter, United Kingdom) For the abstract: “170: IDENTIFY: The Investigation and DEtection of urological Neoplasia in paTIents reFerred with suspected urinarY tract cancer: A multicentre analysis” - From left to right: M. Sedelaar, S. Khadhouri, D. Pierce (BOSTON SCIENTIFIC)

D. Thurtle, O. Bratt, P. Stattin, P. Pharoah, V. Gnanapragasam (Cambridge, United Kingdom; Gothenburg, Uppsala, Sweden) For the abstract: “164: External validation of the PREDICT Prostate tool for prognostication in non-metastatic prostate cancer: A study in 69,206 men from prostate cancer data base Sweden” - Handed out by M. Sedelaar

Third Prize for the Best Abstract by a resident J. Whitburn, S. Rao, S. Tabata, A. Hirayama, T. Soga, F. Hamdy, C. Edwards (Oxford, United Kingdom; Tsuruoka, Japan) For the abstract: “43: The bone microenvironment drives upregulation of the pentose phosphate pathway in prostate cancer, improving antioxidant properties” - Handed out by M. Sedelaar

YUORDay Saturday, 16 March

Resident’s Corner Awards - Awards for the two Best Scientific Papers published in European Urology by residents K. Pang, R. Groves, S. Venugopal, A. Noon, J. Catto (Sheffield, Derbyshire, United Kingdom) For the paper: “Prospective Implementation of Enhanced Recovery After Surgery Protocols to Radical Cystectomy” - Handed out by J. Catto

A. Soave, R. Dahlem, H. Pinnschmidt, M. Rink, J. Langetepe, O. Engel, L. Kluth, B. Loechelt, P. Reiss, S. Ahyai, M. Fisch (Hamburg, Goettingen, Germany) For the paper: “Substitution Urethroplasty with Closure Versus Nonclosure of the Buccal Mucosa Graft Harvest Site: A Randomized Controlled Trial with a Detailed Analysis of Oral Pain and Morbidity” - Handed out by J. Catto

International Friendship Dinner Sunday, 17 March

The European Urology Platinum Awards 2019

S. Boorjian, Rochester, United States of America - Handed out by J. Catto

P. Karakiewicz, Montreal, Canada - Handed out by J. Catto to S. Shariat who accepted the award on behalf of P. Karakiewicz

P. Mulders, Nijmegen, The Netherlands - Handed out by J. Catto

First Prize for the Best Practicedevelopment Poster Presentation

L. Martínez-Piñeiro, Madrid, Spain - Handed out by J. Catto

M. Ribal, Barcelona, Spain - Handed out by J. Catto

First Prize for the Best Scientific Poster Presentation M. Mannarini, G. Della Giovanna, M. Boarin, G. Villa, E. Marzo, D.F. Manara (Milan, Italy) For the poster: “Self-care in ostomy patients and their caregivers” - Handed out to M. Boarin by S. Vahr

R. McConkey, E. Rogers, F. Darcy, C. Dowling, G. Durkan, K. Walsh, S. Jaffry, P. O' Malley, N. Nusrat, A. Aslam, S. Hahessy (Galway, Ireland) For the poster: “Development of an advanced nurse practitioner led bladder cancer surveillance service in Ireland: Preliminary audit results” - Handed out to R. McConkey by S. Vahr

Second Prize for the Best Practicedevelopment Poster Presentation

Second Prize for the Best Scientific Poster Presentation R. Klauser (Uster, Switzerland) For the poster: “An investigation of the role of the Advanced Practice Nurse caring for urological patients in a regional hospital in Switzerland” - Handed out to R. Klauser by S. Vahr

S. Chagani, Z. Sutria, W. Aziz (Karachi, Pakistan) For the poster: “Grit in the waterworks - patient experiences of living with stones in the upper urinary tract” - Received by P. Allchorne on behalf of S. Chagani

Ronny Pieters Award 2019

EAUN Meeting

- Received by S. Terzoni and S. Vahr on behalf of R. Pieters

Monday, 18 March

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EAU Patient Information Specialty Session at EAU19 Updates on PCa, BCa and RCC and GU cancer patient organisations By Patricia Chang Prof. Hein Van Poppel (BE) and Dr. Antonella Cardone (BE), chaired the EAU Patient Information (EAU PI) Session on Sunday afternoon, 17 March 2019. Prof. Van Poppel warmly welcomed the attendants to this Specialty Session.

the newly-established World Bladder Cancer Patient Coalition (WBCPC) which was officially launched during EAU19. Dr. Makaroff also presented the results of the Bladder Cancer Patient Experience Survey, a global survey of 1,615 bladder cancer patients and their carers from 39 countries.

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 EAU PI. 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 player for medical professionals, patients and policymakers both across the EU and beyond”, Dr. Behrendt explained. Dr. Antonella Cardone (BE), Director of the European Cancer Patient Coalition (ECPC), 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 screening via three pillars: awareness, PSA-led screening and cancer centres.

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. Dr. Rachel Giles (NL), Chair of the International Kidney Cancer Coalition (IKCC), highlighted IKCC’s activities and its 2019 Strategy as well as their InfoHub as a way to share information.

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 diseases. Therefore, it is necessary to provide better information and material for patients for early education and detection. EAU Guidelines Prof. Nicolas Mottet (FR), Chairman of the Prostate Cancer Guidelines panel, 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

Mrs. Michelle Battye (GB), Centre Manager for the European Reference Network (ERN) on rare uro-rectal-genital diseases, eUROGEN, introduced the ERN Clinical Patient Management System (CPMS), which facilitates virtual multi-disciplinary team meetings to improve diagnosis and treatment of rare or low-prevalence complex diseases and conditions. Know more about EAU Patient Information via https://patients.uroweb.org, or follow us on Twitter and Facebook: https://twitter.com/EauPatient https://www.facebook.com/EAUPatientInformation/

EAU Patients Advocacy Group (EPAG) Joint efforts in improving cancer patient advocacy By Esther Robijn and Patricia Chang The kick-off meeting of the General Assembly of the EAU Patients Advocacy Group (EPAG) took place at the 34th Annual EAU Congress in Barcelona. During this meeting, healthcare professionals (HCPs) and patient advocates (PAs) shared their ideas, needs and knowledge and explored ways to collaborate. What is EPAG? EPAG consists of the following HCPs and GU cancer patient organisation representatives: Prof. Hein Van Poppel Dr. Mark Behrendt Mr. Philip Cornford Dr. Sara Maclennan Dr. Joan Palou Mrs. Corinne Tillier Dr. Antonella Cardone Mr. Ernst-Günther Carl Mr. John Dowling Dr. Rachel Giles Dr. Lydia Makaroff

EAU Executive for Education EAU Patient Information EAU Guidelines Office EAU Guidelines Office EAU Education Office EAU Nurses (EAUN) European Cancer Patient Coalition (ECPC) EUomo/Male GU Cancers (Prostate, Penis, Testis) EUomo International Kidney Cancer Coalition (IKCC) World Bladder Cancer Patient Coalition (WBCPC)

What does EPAG want to achieve? EPAG’s objective is to increase and improve patient involvement in EAU activities, patient empowerment

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and engagement in the development, dissemination and impact assessment of guidelines and patient information and to support educational events for patients and PAs. This joint effort is to draw from each other’s expertise in order to take on the challenges that come with expanding activities on a European level that have significant impact and force change in legislation, as well as the involvement of patients in clinical care, research and medical congresses in the field of oncology and nononcology diseases. EPAG activities during the EAU Annual Congress In addition to developing the EAU PI scientific programme, bringing together PAs from across Europe in a Q&A session that is designed to create interaction between experts and patient advocates on any topic of their choice and the facilitation of a PA meeting point, are but a few activities deriving from this kick-off meeting. To help set up the Q&A session, EPAG seeks collaboration with European patient advocacy groups (PAGs). You can help us achieve this goal.

www.gua-cca19.org

GUA-CCA19 1st Georgian Urological Association Caucasus Central Asia Meeting 4-5 October 2019, Tbilisi, Georgia In conjunction with the European Association of Urology (EAU)

If you are an HCP and want to contribute to this cause, you can do so by informing us of PAGs active in your country. Please send your e-mail to Ms. Esther Robijn, EAU Patient Information Sr. Coordinator, e.robijn@uroweb.org.

March/May 2019


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

Oliver.Hakenberg@ med.uni-rostock.de

Helping patients understand risks of new prostate cancer diagnosis Men facing a new diagnosis of non-metastatic prostate cancer are frequently confused about the need for treatment. Treatment decisions are complex with the risk of cancer-related mortality having to be balanced against the potential morbidity associated with treatment and competing mortality risks. The diagnosis of cancer causes immediate concerns but data from the PIVOT and ProtecT trials suggest non-inferiority of conservative management when compared with radical therapy in many early cancers. This paper attempts to move beyond the currently used risk groups to allow the calculation of individual relative prostate cancer-specific and overall survival outcomes and allow modelling of the potential benefit of treatment on these outcomes. This group used data from the UK National Cancer Registration and Analysis Service on 10,089 men diagnosed with non-metastatic prostate cancer between 2000 and 2010 in Eastern England. Median follow-up was 9.8 years with 3,829 deaths (1,202 prostate cancer-specific). Totals of 19.8%, 14.1%, 34.6% and 31.5% of men underwent conservative management, prostatectomy, radiotherapy (RT), and androgen deprivation monotherapy, respectively. Data were randomly split 70:30 into model development and validation cohorts. Fifteen-year prostate cancer-specific mortality (PCSM) and non-prostate cancer mortality (NPCM) were explored using separate multivariable Cox models within a competing risks framework. Age, prostate-specific antigen (PSA), histological grade, biopsy core involvement, stage, and primary treatment were all independent prognostic factors for PCSM, whilst age and comorbidity were prognostic for NPCM. These were then used to construct a multivariable model estimating individualised 10 and 15-year survival.

…as yet there is insufficient data to compare outcomes from surgery versus radiotherapy… A total of 2,546 men diagnosed in Singapore between 1990 and 2015 represented an external validation cohort. The model demonstrated good discrimination, with a C-index of 0.84 (95% CI 0.82–0.86) and 0.84 (95% CI 0.80–0.87) for 15-year PCSM in the UK and Singapore validation cohorts. Discrimination was maintained for overall mortality, with C-index 0.77 (95% CI 0.75–0.78) and 0.76 (95% CI 0.73–0.78). The model accuracy was investigated in the UK validation cohort by comparing observed and predicted deaths with no significant difference observed for either prostate cancer-specific (p = 0.19) or overall deaths (p = 0.43). This has now been developed as a free web-based interface (www.prostate.predict.nhs.uk).

Understanding surviving prostate cancer

surveys of the general population. This was more of an issue for younger men. It is most concerning that many men reported not being offered access to The number of men alive with a previous diagnosis of treatments. In addition, more than with other prostate cancer continues to increase. In England, treatments, patients treated with ADT reported poorer there are an estimated 325,000 men alive who were outcomes. This study suggests that there are diagnosed with prostate cancer between 1995 and subgroups of men who would benefit from service 2015. The quality of survival experienced is driven by a improvements around sexual rehabilitation and combination of the extent of disease and the measures to reduce the effects of ADT. consequences of treatment. Curative treatment of Source: Quality of life in men living with localised disease can result in substantial sexual, advanced and localised prostate cancer in the urinary and bowel morbidities, whilst there are UK: A population-based study. Downing A, particular problems and challenges faced by those Wright P, Hounsome L, et al. living with advanced disease. The Life after Prostate Lancet Oncol. 2019; 18: 436-47. Cancer Diagnosis (LAPCD) study has attempted to measure health-related quality of life (HRQOL) in a national population of prostate cancer survivors 18-42 months after diagnosis. This timeframe was chosen because it represents the period when initial Beware of multi-modality treatment is complete and side-effects and HRQOL treatments in prostate cancer have begun to stabilise. All UK National Health Service (NHS) hospital trusts and boards treating patients with prostate cancer in the UK were approached. Men who were alive 18–42 months after a diagnosis of prostate cancer in participating trusts and boards were identified from national population-based cancer registries in England, Northern Ireland, and Wales. In Scotland, because of privacy restrictions, men were identified through hospital activity data and verified through the cancer registry. There was no age limit for inclusion. A postal survey was administered, which contained validated measures to assess functional outcomes (urinary incontinence, urinary irritation and obstruction, bowel, sexual, and vitality and hormonal function), measured with the Expanded Prostate Cancer Index Composite short form (EPIC-26), plus questions about use of interventions for sexual dysfunction and generic HRQOL measuring mobility, self-care, usual activities, pain or discomfort, and anxiety or depression, plus a rating of self-assessed health. Log-linear and binary logistic regression models were used to compare functional outcomes and HRQOL across diagnostic stages and self-reported treatment groups. Each model included adjustment for age, socioeconomic deprivation, and number of other long-term conditions. Approximately 82% of eligible men with prostate cancer across the UK were invited to participate. 59,990 men were identified; 1,060 (1·8%) died during the study period, giving a final sample of 58,930 men. Of these men, 35,823 (60·8%) returned completed questionnaires. Disease stage was known for 30,733 (85·8%) of 35,823 men; 19,599 (63·8%) had stage I or II, 7,209 (23·4%) stage III, and 3,925 (12·8%) stage IV disease. Mean adjusted EPIC-26 domain scores were high, indicating good function, except for sexual function, for which scores were much lower. Men treated surgically reported more urinary incontinence (23.4% leaked at least once a day and 31.4% used one or more pads per day), whilst amongst those treated with EBRT 11.4% reported moderate or severe problems with bowel urgency.

Abiraterone and radium-223 have both been shown to improve overall survival for men with metastatic castration-resistant prostate cancer. They have different and potentially complementary mechanisms of actions. In an international, early-access, open label, single-arm, phase 3b study, overall survival was longer in patients who received radium-223 in combination with either enzalutamide or abiraterone acetate plus prednisone or prednisolone than in those who received radium-223 alone, although significance was not reported. As a consequence, it was postulated that a combination of abiraterone acetate plus prednisone or prednisolone and radium-223 would improve symptomatic skeletal event-free survival to a greater extent than either agent alone.

…and certainly the combination of abiraterone and radium-223 should be avoided… This study reports a randomised, double-blind, placebo-controlled, phase 3 trial at 165 oncology and urology centres in 19 countries. Eligible patients had histologically confirmed, progressive, chemotherapynaive, asymptomatic or mildly symptomatic, castration-resistant prostate cancer and bone metastases (but no brain or visceral metastases), a performance status of 0 or 1, life expectancy of at least 6 months, and adequate haematological, renal, and liver function. Participants were randomly assigned (1:1) to receive up to six intravenous injections of radium-223 (55 kBq/kg) or matching placebo once every 4 weeks. All patients were also scheduled to receive oral abiraterone acetate 1000 mg once daily plus oral prednisone or prednisolone 5 mg twice daily during and after radium-223 or placebo treatment. The primary endpoint was symptomatic skeletal event-free survival, which was assessed in the intention-to-treat population.

Between 30 March 2014 and 12 August 2016, 806 patients were randomly assigned to receive (n=401) or placebo (n=405) in addition Most men living 18-42 months after radium-223 to abiraterone acetate plus prednisone or prednisolone. The study was unblinded prematurely, a diagnosis of prostate cancer can 17 November 2017, after more fractures and expect as good a HRQOL as men in on deaths were noted in the radium-223 group than in the placebo group (in an unplanned ad-hoc the general population… analysis), but all patients had completed radium-223 or placebo before this date. At the primary analysis Compared with men who did not receive androgen (data cut off 15 February 2018), 196 (49%) of 401 deprivation therapy, more men who received the patients in radium-223 group had had at least one therapy reported moderate to severe problems with symptomatic skeletal event or died, compared with hot flushes (30·7% [95% CI 29·8–31·6] vs. 5·4% 190 (47%) of 405 patients in the placebo group The data will be particularly useful for men [5·0–5·8]), low energy (29·4% [95% CI 28·6–30·3] vs. (median follow-up 21·2 months [IQR 17·0–25·8]). considering conservative management, although as 14·7% [14·2–15·3]), and weight gain (22·5%, 21·7–23·3) Median symptomatic skeletal event-free survival yet there is insufficient data to compare outcomes vs. 6·9% [6·5–7·3]). Poor sexual function was was 22·3 months (95% CI 20·4−24·8) in the from surgery versus radiotherapy. In addition, it may common (81·0%; 95% CI 80·6–81·5), regardless of radium-223 group and 26·0 months (21·8−28·3) in be affected by the move from systematic biopsy to stage, and more than half of men (n=18,782 [55·8%]) the placebo group (hazard ratio 1·122 [95% CI targeted biopsy. In order to compensate this, the 0·917−1·374]; p=0·2636). Fractures (any grade) suggestion is to consider any biopsies from a target as were not offered any intervention to help with this condition. Overall, self-assessed health was similar in occurred in 112 (29%) of 392 patients in the a single core. However, when compared to existing radium-223 group and 45 (11%) of 394 patients in published risk groups this appears to be significantly men with stage I–III disease, and although slightly reduced in those with stage IV cancer, 23·5% of men the placebo group. Median time to fracture was 31·7 more accurate and may help patients reduce both with metastatic disease reported no problems on any months (95% CI 27·6–NE) in the radium-223 group over and under-treatment EQ-5D dimension. but could not be estimated in the placebo group (HR 3·135 [95% CI 2·206–4·455] Fractures were most Source: Individual prognosis at diagnosis in Most men living 18-42 months after a diagnosis of commonly osteoporotic and in nearly 80% of nonmetastatic prostate cancer: Development prostate cancer can expect as good a HRQOL as men occasions occurred at a skeletal site with no bone and external validation of the PREDICT in the general population, including those with stage metastases. The most common grade 3–4 treatmentProstate multivariable model. Thurtle DR, III and many of those with stage IV disease. More than emergent adverse events were hypertension (43 Greenberg DC, Lee LS, et al. 80% of men reported poor or very poor sexual [11%] patients in the radium-223 group vs. 52 [13%] PLoS Med. 2019;16(3):1-19. function, compared with approximately 50% in patients in the placebo group), fractures (36 [9%] vs. Key articles

March/May 2019

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de 12 [3%]) and increased alanine aminotransferase concentrations (34 [9%] vs. 28 [7%]). Serious treatment-emergent adverse events occurred in 160 (41%) patients in the radium-223 group and 155 (39%) in the placebo group. Treatment-related deaths occurred in two (1%) patients in the radium-223 group (acute myocardial infarction and interstitial lung disease) and one (<1%) in the placebo group (arrhythmia). Overall survival did not differ significantly between groups, but concurrent treatment with abiraterone acetate plus prednisone or prednisolone and radium-223 was associated with increased fracture risk. These findings suggest that radium-223 might contribute to the risk of osteoporotic fractures in patients with prostate cancer and certainly the combination of abiraterone and radium-223 should be avoided. This study also shows the complexity of combining treatments, even when the perceived risks from single agent, such as radium-223, studies were low.

Source: Addition of radium-223 to abiraterone acetate and prednisone or prednisolone in patients with castration-resistant prostate cancer and bone metastases (ERA223): A randomised, double-blind, placebo-controlled, phase 3 trial. Smith M, Parker C, Saad F, et al. Lancet Oncol. 2019; 20: 408-19

Long-term antibiotics for preventing recurrent urinary tract infection in children Many children are given long-term (several months to 2 years) antibiotics aimed at preventing recurrence of urinary tract infection. This is the third update of a review first published in 2001 and updated in 2006 and 2011. The objectives were to assess whether long-term antibiotic prophylaxis was more effective than placebo/no treatment, and if so which antibiotic was most effective in clinical use. The harms of long-term antibiotic treatment were also assessed. Investigators searched the Cochrane Kidney and Transplant Register of Studies until 30 July 2018. Selection criteria were randomised comparisons of antibiotics with other antibiotics, placebo or no treatment to prevent recurrent UTI in children. A random-effects model was used to estimate risk ratio (RR) and risk difference (RD) for recurrent UTI with 95% confidence intervals (CI). Sixteen studies (2,036 children randomised, 1,977 analysed) were included. The number of studies judged to have a low risk of bias were: selection bias (7); performance bias (4); detection bias (1); attrition bias (6); reporting bias (7); and other bias (2). The number of studies judged to be at high risk of bias were: selection bias (0); performance bias (5); detection bias (1); attrition bias (4); reporting bias (6); and other bias (1).

Benefits of long-term antibiotics to reduce UTI risk in children do not outweigh harms... Compared to placebo/no treatment, antibiotics lead to a modest decrease in the number of repeat symptomatic UTI in children; however, the estimate from combining all studies was not certain and the confidence interval indicates low precision which in turn indicates that antibiotics may make little or no difference to risk of repeat infection (RR 0.75, 95 % CI 0.28 to 1.98). When investigators combined only the data from studies with concealed treatment

EAU EU-ACME Office

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

tebj@medisin.uio.no allocation, there was a similar reduction in risk of repeat symptomatic UTI in children taking antibiotics (RR 0.68). Investigators had greater certainty in this estimate because of the more robust study designs, the confidence interval was smaller and it did not include the point of no effect (95 % CI 0.48 to 0.95) The estimated reduction in risk of repeat symptomatic UTI for children taking antibiotics was similar in children with vesicoureteral reflux (VUR) (RR 0.65, 95 % CI 0.39 to 1.07) compared to those without VUR (RR 0.56, 95 % CI 0.15 to 2.12). However there was considerable uncertainty due to imprecision from fewer events in the smaller group of children with VUR. There was no consistency in occurrence of adverse events, with one study having more events in the placebo group and a second study having more events in the antibiotics group. Three studies reported data for antibiotic resistance. The analysis estimated the risk of a UTI caused by a bacterium resistant to the prophylactic antibiotic as almost 2.5 times greater in children on antibiotics than for children on placebo or no treatment (RR 2.40, 95 % CI 0.62 to 9.26). However the confidence interval was wide, showing imprecision and there may be little or no difference between the two groups. Analysis showed that treatment with nitrofurantoin may lead to a lower risk of a UTI caused by a bacterium resistant to the treatment drug compared to children given trimethoprim-sulphamethoxazole as prophylactic treatment (RR 0.54, 95 % CI 0.31 to 0.92). Authors conclude that long-term antibiotics may reduce the risk of repeat symptomatic UTI in children who have had one or more previous UTIs but the benefit may be small and must be considered together with the increased risk of microbial resistance.

Source: Long-term antibiotics for preventing recurrent urinary tract infection in children. Williams G, Craig JC. Cochrane Database Syst Rev. 2019 Apr 01; 4:CD001534

Association between adequate empiric treatment and time-to-cure for patients with bacteraemic UTI The objectives of this retrospective cohort study were to evaluate whether patients with bacteraemic urinary tract infection (UTI) who receive inadequate empiric therapy have worse outcomes than those with adequate therapy. The exposure variable was adequate versus inadequate empiric antibiotic therapy (AEAT vs. IEAT) within 24 hours of culture collection. Primary endpoint was time-to-cure. The primary analysis used propensity score models with inverse probability of treatment weights. A secondary Cox proportional hazards modelling approach was used to test the robustness of this finding, and to evaluate other patient and pathogen predictors of time-to-cure.

…was no association between AEAT and time-to-cure for patients with bacteraemic UTI…

0.08-0.76, p = 0.015), prior stroke (HR 0.73, 95 % CI 0.54-0.99, p = 0.044), empiric receipt of piperacillintazobactam (HR 0.77, 95 % CI 0.59-0.99, p = 0.044), qSOFA score >1 (HR 0.68, 95 % CI 0.55-0.84, p < 0.001) and hospital-onset UTI (HR 0.53, 95% CI 0.39-0.71, p < 0.001). The authors conclude that there was no association between AEAT and time-to-cure for patients with bacteraemic UTI. It may be appropriate to accept a higher risk threshold when choosing empiric antibiotic regimens, even in centres with high rates of resistant uropathogens.

Source: The association of adequate empiric treatment and time to recovery from bacteremic urinary tract infections: A retrospective cohort study. Wiggers JB, Sehgal P, Pinto R, MacFadden D, Daneman N.

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Source: Prospective multicentre validation of androgen receptor splice variant 7 and hormone therapy resistance in high-risk castrationresistant prostate cancer: The PROPHECY Study. Armstrong et al. J Clin Oncol 2019.

Clin Microbiol Infect. 2019 Mar 04.

AR-V7: Confirmed PROPHECY for optimising treatment selection in mCRPC? Androgen receptor splice variant 7(AR-V7) results in ligand-independent activation of the AR even under anti-androgen therapies. Several retrospective reports have suggested the predictive value of this variant in circulation tumour cells (CTCs) for anticipating tumour resistance to abiraterone and enzalutamide. In the present study, the authors conducted a prospective multicentre study to validate these findings. Interestingly, the study design included two types of CTC detection at baseline, the Johns Hopkins University modified-AdnaTest CTC AR-V7 mRNA assay and the Epic Sciences CTC nuclear-specific AR-V7 protein assay. Overall, 118 patients with metastatic castrationresistant prostate cancer (mCRPC) were enrolled before starting abiraterone or enzalutamide, at 5 clinical sites. The primary endpoint was the radiographic or clinical progression-free survival (PFS). The aim was to validate that AR-V7 negative patients have prolonged PFS with enzalutamide or abiraterone compared with AR-V7- positive patients. Median follow-up was 20 months with 102 events and 53 deaths. Thirty percent of men have been previously treated at mCRPC stage. At baseline, 24% of patients were AR-V7 positive with the Johns Hopkins assay and 9% were positive with the Epic assay. The percentage agreement between the two assays was 82%. Progression-free survival and overall survival differed significantly according to the AR-V7 status. Median PFS dropped from 6 to 3 months in AR-V7 positive patients, median overall survival from 27 to 11 months.

One limitation of this prospective study was that prior exposure to enzalutamide or abiraterone was permitted for men who were planning to receive the alternative agent… In multivariable analysis taking into account the Halabi prognostic score and the baseline CTC enumeration, CTC AR-V7 positivity remained independently associated with poorer outcomes. No Epic AR-V7 positive patients had a confirmed PSA or RECIST response, and only 11% of Johns Hopkins assay AR-V7 positive patients experienced a PSA decline. Thus, AR-V7 was associated with strong hormone resistance. Interestingly, the majority of CTCs were AR-V7 negative, even in AR-V7 positive patients, with a median number of 20% of AR-V7 positive CTCs.

One limitation of this prospective study was that the prior exposure to enzalutamide or abiraterone was permitted for men who were planning to receive the alternative agent. We know that sensitivity to 78.5% (368/469) of patients with bacteraemic UTI second-line anti-androgen is weak due to cross received AEAT. There was no significant difference in resistance between abiraterone and enzalutamide. mortality among those receiving AEAT and IEAT Moreover, this introduced a selection bias regarding (adjusted OR 0.86, 95% CI 0.47-1.58) and receipt of the interpretation of the prevalence of AR-V7 in AEAT had no association with time-to-cure (HR 0.93, mCRPC patients, given that AR-V7 expression is 95% CI 0.73-1.19, p = 0.55) or time-to-normalisation of frequently induced by anti-androgens exposure. individual clinical variables. Cox proportional hazards modelling revealed that longer time-to-cure was Thus, in that study, at progression on abiraterone or associated with liver disease (HR 0.25, 95% CI enzalutamide, 20-34% of evaluable men (depending Key articles

on the assay) were AR-V7 positive, which suggested the induction or selection of this variant expression. Analyses stratified by the number of previous mCRPC anti-androgen lines should be added. Finally, is AR-V7 expression a real predictive factor for anti-androgen therapies (and therefore could guide treatment-decision making) or a simple factor of poor response and of disease aggressiveness whatever the therapy used? The same data from a cohort of men treated with taxanes could be interesting to answer this point. The question of the real-world usefulness of AR-V7 assays remains open.

Once-daily plazomicin for complicated urinary tract infections The increasing multidrug resistance among gramnegative uropathogens necessitates new treatments for serious infections. Plazomicin is an aminoglycoside with bactericidal activity against multidrug-resistant (including carbapenem-resistant) Enterobacteriaceae. Investigators randomly assigned 609 patients with complicated urinary tract infections (UTIs), including acute pyelonephritis, in a 1:1 ratio to receive intravenous plazomicin (15 mg per kilogram of body weight once daily) or meropenem (1 g every 8 hours), with optional oral step-down therapy after at least 4 days of intravenous therapy, for a total of 7 to 10 days of therapy. The primary objective was to show the non-inferiority of plazomicin to meropenem in the treatment of complicated UTIs, including acute pyelonephritis, with a non-inferiority margin of 15 percentage points. The primary endpoints were composite cure (clinical cure and microbiologic eradication) at day 5 and at the test-of-cure visit (15 to 19 days after initiation of therapy) in the microbiologic modified intention-to-treat population.

Once-daily plazomicin was non-inferior to meropenem with respect to the primary efficacy endpoints… Plazomicin was non-inferior to meropenem with respect to the primary efficacy endpoints. At day 5, composite cure was observed in 88.0% of the patients (168 of 191 patients) in the plazomicin group and in 91.4% (180 of 197 patients) in the meropenem group (difference -3.4 percentage points; 95% confidence interval [CI] -10.0 to 3.1). At the test-of-cure visit, composite cure was observed in 81.7% (156 of 191 patients) and 70.1% (138 of 197 patients), respectively (difference 11.6 percentage points; 95% CI 2.7 to 20.3). At the test-of-cure visit, a higher percentage of patients in the plazomicin group than in the meropenem group were found to have microbiologic eradication, including eradication of Enterobacteriaceae that were not susceptible to aminoglycosides (78.8% vs. 68.6%) and Enterobacteriaceae that produce extended-spectrum β-lactamases (82.4% vs. 75.0%). At late follow-up (24 to 32 days after initiation of therapy), fewer patients in the plazomicin group than in the meropenem group had microbiologic recurrence (3.7% vs. 8.1%) or clinical relapse (1.6% vs. 7.1%). Increases in serum creatinine levels of 0.5 mg or more per decilitre (≥ 40 μmol per litre) above baseline occurred in 7.0% of patients in the plazomicin group and in 4.0% in the meropenem group. It is concluded that once-daily plazomicin was non-inferior to meropenem for the treatment of complicated UTIs and acute pyelonephritis caused by Enterobacteriaceae, including multidrug-resistant strains.

Source: Once-daily plazomicin for complicated urinary tract infections. Wagenlehner FME, Cloutier DJ, Komirenko AS, Cebrik DS, Krause KM, Keepers TR, Connolly LE, Miller LG, Friedland I, Dwyer JP, EPIC Study Group. N Engl J Med. 2019 02 21; 380(8):729-740.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com

Early stent removal after renal transplantation reduces rate of urinary tract infections Transplant centres have different policies regarding ureteral stent use and when to remove them after the transplantation procedure. This article describes an interim analysis of a randomised, prospective, double-blind trial aimed at detecting differences in urological complications between early ureteral stent removal at 1 week and routine ureteral stent removal at 4 weeks. Between October 2010 and March 2015, 103 patients who underwent living donor renal transplantation at a single centre were pre-operatively randomly assigned to early ureteral stent removal (at 1 week) or routine ureteral stent removal (at 4 weeks). Urinary symptoms, auxiliary examination results, and obstruction events were recorded during 3 months of follow-up.

…ureteral stent removal at 1 week reduces the risk of UTIs compared with removal at 4 weeks… In total, 52 patients in the 1-week stent group and 51 patients in the 4-week stent group were analysed. No serious adverse events were reported. Three episodes of urinary tract infections (UTIs) occurred in the 1-week stent group, and 18 such episodes were recorded in the 4-week stent group (5.8% vs. 29.4%; p < 0.003). After adjusting for age, sex, ischemia time, renal artery number, body mass index, multiple arteries and associated medical illness, regression analysis indicated that only stent duration was associated with UTI (OR 8.791; 95% CI 1.984-38.943; p = .004). The results of this study demonstrate that ureteral stent removal at 1 week reduces the risk of UTIs compared with removal at 4 weeks. Similar effects of ureteral stent removal on other complication rates are observed for these two removal times.

Source: Early removal of double-j stents decreases urinary tract infections in living donor renal transplantation: a prospective, randomised clinical trial. Liu S, Luo G, Sun B, Lu J, Zu Q, Yang S, Zhang X, Dong J. Transplant Proc. 2017, 49(2):297-302.

Multicentre study comparing long-term outcomes renal transplant recipients on AZA, MMF, or CsA Long-term outcomes in renal transplant recipients withdrawn from steroid and submitted to further minimisation of immunosuppressive regimen after 1 year are lacking. In this multicentre study, 204 low immunological risk kidney transplant recipients were randomised 14 months after transplantation (14.2 ± 3.7 months) to receive either cyclosporine A (CsA) + azathioprine (AZA; n = 53), CsA + mycophenolate mofetil (MMF; n = 53), or CsA monotherapy (n = 98). At 3 years post-randomisation, the occurrence of biopsy for graft dysfunction was similar in the bitherapy and the monotherapy groups (21/106 vs. 26/98; p < 0.26). At 10 years post-randomisation, patient survival was 100%, 94.2%, and 95.8% (p < 0.26), and deathcensored graft survival was 94.9%, 94.7%, and 95.2% (p = 0.34) in the AZA, MMF, and CsA groups, respectively. Mean estimated glomerular filtration rate was 70.4 ± 31.1, 60.1 ± 22.2, and 60.1 ± 19.0 ml/ min/1.73 m2, respectively (p < 0.17).

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Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ hotmail.com

year post-transplantation and therefore most likely on long-term allograft function, even at low viral loads. Frequent viral monitoring and subsequent interventions for low BKV and/or CMV viraemia levels and after long cold ischaemia times are recommended.

Source: BKV, CMV, and EBV interactions and their effect on graft function one year postrenal transplantation: Results from a large multi-centre study. Blazquez-Navarro A, Dang-Heine C, Wittenbrink N, Bauer C, Wolk K, Sabat R, Westhoff TH, Sawitzki B, Reinke P, Thomusch O, Hugo C, Or-Guil M, Babel N.

The incidence of biopsy-proven acute rejection was 1.4%/year in the whole cohort. None of the patients EBioMedicine. 2018; 34:113-121 developed polyomavirus-associated nephropathy. The main cause of graft loss (n = 12) was chronic antibodymediated rejection (n = 6). De novo donor-specific antibodies were detected in 13% of AZA-, 21% of Germline DNA repair MMF-, and 14% of CsA-treated patients (p = 0.29).

…cyclosporine monotherapy is safe and associated with better graft survival after one year following renal transplantation… The authors suggested that CsA monotherapy 1 year after renal transplantation is safe and associated with prolonged graft survival in well-selected renal transplant recipient (ClinicalTrials.gov number: 980654).

Source: Minimization of maintenance immunosuppressive therapy after renal transplantation comparing cyclosporine A/ azathioprine or cyclosporine A/ mycophenolate mofetil bitherapy to cyclosporine A monotherapy: A 10-year post-randomization follow-up study. Thierry A, Le Meur Y, Ecotière L, Abou-Ayache R, Etienne I, Laurent C, Vuiblet V, Colosio C, Bouvier N, Aldigier JC, Rerolle JP, Javaugue V, Gand E, Bridoux F, Essig M, Hurault de Ligny B, Touchard G. Transpl Int. 2016; 29(1):23-33.

Interaction and effects of combined BKV, CMV, EBV reactivations on graft function BK virus (BKV), cytomegalovirus (CMV) and EpsteinBarr virus (EBV) reactivations are common after kidney transplantation and associated with increased morbidity and mortality. Although CMV might be a risk factor for BKV and EBV, the effects of combined reactivations remain unknown. The purpose of this study is to ascertain the interaction and effects on graft function of these reactivations. 3,715 serum samples from 540 kidney transplant recipients were analysed for viral load by qPCR. Measurements were performed throughout eight visits during the first post-transplantation year. Clinical characteristics, including graft function (GFR), were collected in parallel.

…BKV-CMV combined reactivation has a deep impact on renal function one year posttransplantation… BKV had the highest prevalence and viral loads. BKV or CMV viral loads over 10,000 copies·mL-1 led to significant GFR impairment. 57 patients had BKV-CMV combined reactivation, both reactivations were significantly associated (p < 0.006). Combined reactivation was associated with a significant GFR reduction one year post-transplantation of 11.7 mL·min-1·1.73 m-2 (p = 0.02) at relatively low thresholds (BKV > 1000 and CMV > 4000 copies·mL-1). For EBV, a significant association was found with CMV reactivation (p < 0.03), but no GFR reduction was found. Long cold ischaemia times were a further risk factor for high CMV load. The authors concluded that BKV-CMV combined reactivation has a deep impact on renal function one Key articles

March/May 2019

mutations and outcomes in mCRPC: Should it affect treatment choice? Mutations in DNA damage repair (DDR) genes are identified in a not negligible proportion of mCRPC patients. The vast majority of these mutations are somatic, acquired by tumour cells during their development. Inherited mutations in DDR genes are less frequent but have been reported to predispose men to prostate cancer and to aggressive, metastatic forms. In the present study, the authors prospectively assessed the prevalence of these germline mutations (ATM/BRAC1/BRCA2/PALB2) and their effect on clinical outcomes. The cohort included 419 patients from 38 sites, a 5-ml blood sample was drawn at study entry for germline DNA extraction. Median age of patients was 66 years (98 % white with Spanish ancestry) and 48 % had metastatic disease. Twenty-six patients (6.2 %) carried a germline mutation in BRCA2 (n = 14), ATM (n = 8) or BRCA1 (n = 4). No mutations in PALB2 were identified. When screening all 107 DDR genes, 16.2 % of patients harboured a mutation. The prevalence of DDR mutations was significantly higher in patients with mCRPC than in control non-cancer populations (OR 1.4-3.2). Regarding oncologic outcomes, median cancerspecific survival was 10 months shorter in DDR carriers than in non-carriers, but difference was not significant. However, this survival was significantly poorer in BRCa2 carriers compared with non-carriers (17.4 vs. 33.2 months; p = 0.027; HR 2.10). The difference was also significant when BRCA2 carriers were compared with other non-BRCA2 DDR carriers. Multivariable analyses confirmed that BRCA2 was an independent prognostic factor for cancer-specific survival.

Multivariable analyses confirmed that BRCA2 was an independent prognostic factor for cancerspecific survival. Interestingly, outcomes were also assessed according to treatment sequence. Shorter survival in BRAC2 carriers was reported in case of first-line mCRPC treatment by taxane, but not after first anti-androgen therapy. Interaction analyses were then conducted to assess whether the impact of carrier status on cancer-specific survival was influenced by the first drug administered. This showed that CSS and PFS2 did not differ between BRCA2 carriers and non-carriers treated with the anti-androgen then taxane sequence. Conversely, BRCA2 carriers treated with the taxane then anti-androgen sequence had poorer outcomes than non-carriers who received the same treatment. Thus, BRCA2 was identified as an independent prognostic factor for survival in mCRPC patients treated with taxanes as first-line therapy. In this study, BRCA2has been confirmed as the most frequently altered DDR gene in mCRPC patients. This prospective study also demonstrated that the impact of germline BRAC2 status on outcomes may be modified by treatment sequence. Nevertheless, given the small number of DDR carriers treated in the present study, these findings about the link between BRCA2 status and treatment sequence choice should be interpreted with caution until large series validation.

However, if confirmed, germline BRCA2 status could be a clinically relevant biomarker to select antiandrogen as the first line of treatment for mCRPC. Inhibitors of PARP may also be considered as an interesting alternative option, but only four patients (1.1 %), all of them non-carriers, received this treatment in the context of clinical trials. The next step should include the analysis of somatic DDR defects (more frequently present in mCRPC patients than germline defects) to test the hypothesis of BRCA2 influence on treatment response in larger populations.

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk

Source: PROREPAIR-B: A prospective cohort study of the impact of germline DNA repair mutations on the outcomes of patients with metastatic castration-resistant prostate cancer. Castro et al.

was primarily related to greater hematologic toxicity in the docetaxel arm. Rates of genitourinary and gastrointestinal toxicity were not different between the two arms.

J Clin Oncol 2019.

This trial showed an overall survival improvement by adding docetaxel to standard of care (radiotherapy plus long-term ADT) in localised high-risk prostate cancer. These findings are not in line with those published from the GETUG-12, SPCG-13 and SPCG-12 trials. One hypothesis addressed by the authors was the difference in patient populations with more aggressive disease in the RTOG trial. Another explanation could be statistical. Indeed, because it was anticipated that ADT plus radiotherapy plus docetaxel would be more toxic and should only be considered if it could prolong overall survival, the study was designed using a one-sided test and not a two-sided one. This choice was also justified by the failure of the previous RTOG 99-02 trial due to an unanticipated toxicity. Moreover, the reduction in hazard (HR 0.69) was not as large as the anticipated HR goal of 0.49. Meta-analysis pooling all these high-risk prostate cancer studies would be of great value.

Combination of docetaxel and androgen deprivation therapy with radiotherapy in high-risk prostate cancer Radiotherapy combined with long-term androgen deprivation therapy (ADT) is a standard treatment option for patients with high-risk localised prostate cancer. The reinforcement of systemic therapy by chemotherapy has previously been assessed in phase III trials (GETUG 12, the Scandinavian trials SPCG-13 and SPCG-12). No benefit was identified in these trials by adding chemotherapy to standard of care, in high-risk prostate cancer patients treated by radiotherapy or radical prostatectomy. In the US, the previous adjuvant CT study RTOG 9902 was terminated early because of thromboembolic toxicity associated with estramustine. However, recent data from CHARTEED and STAMPEDE have demonstrated the oncologic effect of docetaxel in addition to ADT at metastatic castration-sensitive stage, leading to the reconsideration of chemotherapy at earlier stages. This present phase III clinical trial was designed to test the hypothesis that docetaxel could improve overall survival when used in an adjuvant fashion after standard radiotherapy and ADT. The study was designed to detect an improvement in the 4-year overall survival rate from 86% to 93%. Patients were enrolled between 2005 and 2009 (n = 563) and randomly assigned to receive standard long-term ADT with or without adjuvant CT at a one-to-one ratio to control arm or intervention arm (ADT for 8 weeks followed by radiotherapy followed by adjuvant ADT for 24 months plus six cycles of docetaxel and prednisone beginning 28 days after completion of radiotherapy). Either threedimensional conformal or intensity-modulated radiotherapy was allowed (image-guided technique was not required). The National Comprehensive Cancer Network high-risk criteria were used for inclusion. Maximum allowed PSA was 150 ng/ml. Median PSA was 15.1 ng/ml and 53% of patients had a Gleason score 9 to 10. Median follow-up was 5.7 years since randomisation. The primary end point was overall survival and secondary end points included freedom from biochemical failure using the Phoenix definition, freedom from metastasis, and diseasefree survival. There were 102 events at the time of this analysis.

Source: Effect of chemotherapy with docetaxel with androgen suppression and radiotherapy for localized high-risk prostate cancer: The Randomized Phase III NRG Oncology RTOG 0521 Trial. Rosenthal et al. J Clin Oncol 2019.

Rezüm Water Vapour Thermal Therapy for LUTS associated with BPH The authors report 4-year outcomes of the randomised controlled trial of water vapour thermal therapy for treatment of moderate to severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). A subtotal of 135 men - ≥ 50 years old, International Prostate Symptom Score ≥ 13, maximum flow rate (Qmax) ≤ 15 mL/s and prostate volume 30 to 80 cc were treated with Rezüm System thermal therapy and were followed for 4 years. A subset of 53 men requalified for crossover from control to active treatment and were followed 3 years; a total of 188 subjects.

…minimally invasive thermal therapy provides effective symptom relief and improved quality of life…

Lower urinary tract symptoms were significantly improved within ≤ 3 months after thermal therapy and remained consistently durable (International Prostate Symptom Score 47%, quality of life 43%, Qmax 50%, Benign Prostatic Hyperplasia Impact The 4-year overall survival rates were 88.7% (95% CI, Index 52%) for 4 years (p < .0001). The outcomes 84.3% to 91.9%) and 93.3% (95% CI, 89.6% to 95.7%) were similarly sustained in crossover subjects at 3 years. Surgical retreatment rate was 4.4 % over 4 in the control and intervention arm, respectively. years. Of note, no disturbances in sexual function Median survival time was not reached in either arm. were reported. The log-rank test calculated the p-value at 0.034. A sensitivity analysis was performed based on The authors conclude that minimally invasive thermal patients who received full protocol treatment (per therapy provides effective symptom relief and protocol) rather than intention-to-treat. One-sided improved quality of life, which remains durable for log-rank test p value was then 0.009, with an HR of 0.59. The 6-year distant metastasis rates were 14 and over 4 years. The investigators add that Rezüm 9.1% in the control and intervention arm, respectively thermal therapy is applicable to all prostate zones with procedures performed under local anaesthesia (p = 0 .044). in an office setting. Regarding adverse effects, 53.4%, 20.6%, and 1.4% Source: Rezüm Water Vapour Thermal Therapy of patients experienced grade 2, 3 and 4 adverse effects in the control arm, respectively, compared with for LUTS associated with BPH. McVary KT, Rogers T, Roehrborn CG. 28.7%, 37.9%, 25.9%, and 0.7% of patients experienced grade 2, 3, 4 and 5 adverse effects as the Urology. 2019 Jan 21. pii: S0090-4295(19)30070-6. doi: 10.1016/j.urology.2018.12.041. [Epub ahead of print] worst adverse effects in the intervention arm, respectively. The difference between the two arms

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Association between psoriasis and sexual and erectile dysfunction Sexual health is a major aspect of life. Increasing scientific evidence shows a potential association between psoriasis and sexual dysfunction (SD) and erectile dysfunction (ED). The authors published a systematic review by evaluating the available scientific evidence regarding epidemiologic associations and treatment outcomes between psoriasis and SD and ED. Information sources were MEDLINE and Embase databases, using the Scopus search engine. Search terms were psoriasis and sexual or sexual dysfunction.

Prevalence of SD and ED ranged from 40.0% to 55.6% and 34.2% to 81.1%, respectively… Twenty-eight studies representing 52,520 cases of psoriasis and 1,806,022 controls were included for review. Of the 28 studies, 19 were cross-sectional, 3 were clinical trials, 3 were quasi-experimental, 2 were population-based cohort, and 1 was population-based case-control. Prevalence of SD and ED ranged from 40.0% to 55.6% and 34.2% to 81.1%, respectively. Two of 2 studies observed an association between psoriasis and SD after adjusting for physical and psychological comorbidities. Five of 8 studies observed an independent association between ED and psoriasis. Among patients with psoriasis, the features that showed the strongest association with SD were anxiety and depression (5 of 5 studies), psoriatic arthritis (3 of 4 studies), and genital psoriasis (5 of 7 studies). Regarding ED, anxiety and depression (2 of 2 studies) and increasing age (3 of 3 studies) showed the strongest association. All 3 clinical trials using biological drugs showed an improvement in SD compared with placebo.

of the positive urine cultures at discharge and in 53.8% 3 weeks post-operatively.

These findings might question the current use of AB prophylaxis in TURP in patients without a preoperative catheter or pyuria... The data show a low infectious complication rate (2.9%) in patients without a pre-operative catheter or pyuria, undergoing TURP without AB-prophylaxis. These findings might question the current use of AB prophylaxis in TURP in patients without a preoperative catheter or pyuria, in times of antibiotic stewardship due to the high rate of microbial resistance in our population.

Source: Antibiotic prophylaxis in TURP. Baten E, Van Der Aa F, Orye C, Cartuyvels R, Arijs I, van Renterghem K. World J Urol. 2019 Feb 9. doi: 10.1007/s00345-01902676-z. [Epub ahead of print]

Salvage robotic-assisted radical prostatectomy after focal therapy for localised prostate cancer Developments in salvage robotic-assisted radical prostatectomy after focal therapy for localised prostate cancer are ongoing. With the advent of multiparametric MRI (mpMRI), focal therapy (FT) for localised prostate cancer is gaining momentum. Awaiting the results of the PART study, a randomised controlled trial comparing focal High Intensity Focused Ultrasound (HIFU) and radical prostatectomy in intermediate risk prostate cancer, mounting literature is providing more evidence of pros and cons of FT.

The investigators conclude that patients with psoriasis have physical and psychological comorbidities that are associated with a higher risk of SD. In addition, psoriasis may play a role in its development. The presence of anxiety, depression, psoriatic arthritis, genital lesions and increasing age should raise the awareness of SD.

One of the pending issues with regard to the management of patients is after FT-strategy fails with biochemical recurrence. Options may include: observation, re-treatment with focal therapy, whole gland ablation, radical prostatectomy or external beam radiotherapy, provided that there are no signs of systemic spread of disease.

Source: Association between psoriasis and sexual and erectile dysfunction in epidemiologic studies: A systematic review. Molina-Leyva A, Salvador-Rodriguez L, Martinez-Lopez A, Ruiz-Carrascosa JC, Arias-Santiago S.

Studies on outcomes in this setting of patients are scarce; a recent report has just been published regarding the combined experience of 2 centres of excellence including 82 patients undergoing salvage robotic-assisted radical prostatectomy (s-RARP) after focal therapy.

JAMA Dermatol. 2018 Oct 10. doi: 10.1001/ jamadermatol.2018.3442. [Epub ahead of print]

Antibiotic prophylaxis in TURP The authors publish a prospective analysis concerning antibiotic stewardship and a potential reduction of antibiotic use in TURP. Antibiotic prophylaxis is standard procedure in transurethral resection of the prostate (TURP). The authors evaluated the necessity of antibiotic (AB) prophylaxis in TURP due to increasing microbial antibiotic resistance. The trial is a prospective cohort study of 506 patients. Only patients with a pre-operative catheter/pyuria received AB prophylaxis. Urine analysis (preoperative, at discharge, and 3 week post-operative) was performed next to an analysis of the blood culture/irrigation fluid and of the resected prostatic tissue. Statistical analysis was performed using Fisher's exact test. 67/506 (13.2%) patients received prophylactic antibiotics. 56/67 (83.5%) patients had a preoperative catheter and 11/67 (16.4%) had preoperative pyuria in which a fluoroquinoloneresistance (FQ-R) rate of 69.2% in Escherichia coli (EC) was observed. Clinical infectious symptoms were present in 13/439 (2.9%) patients without antibiotic prophylaxis; 12/439 (2.7%) patients had uncomplicated fever (< 38.5°) during or after hospitalisation and in only 1/439 patient (0.2%) high degree fever (> 38.5°) was observed. Uncomplicated fever developed in 7/67 (10.4%) patients who did receive AB-prophylaxis. FQ-R was observed in 60% Key articles

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The final cohort of patients was quite heterogeneous with respect to the type of ablation used (HIFU, cryotherapy, irreversible electroporation, etc.), FT strategy (truly focal, hemiablation, dog-leg) and characteristics of patients at baseline and before s-RARP. Notably a significant proportion of patients (20%) received a re-focal treatment before surgery.

Studies on outcomes in this setting of patients are scarce…

1.53–16.39; p = 0.008) and infield recurrence HR 3.77, 95% CI 1.11–12.85; p = 0.03); the latter was defined as recurrence in the same area of former FT.

Overall, this review shows important details of a new technology which may revolutionise laser employment in the endoscopic treatment of renal and ureteric stones.

Interestingly, authors suggested that in case of incomplete/suboptimal ablation, cancer clones may develop both resistance to treatment and aggressive features for which the cancer may recur infield and spread relatively quickly.

Source: Thulium fiber laser: The new player for kidney stone treatment? A comparison with Holmium:YAG laser. Traxer O, Keller EX.

Regardless of several limitations of the study, these findings identify a group of patients at higher risk after biochemical failure, who may benefit of a more aggressive approach such as surgery. This is to be preferred to the other more conservative treatment options.

Source: Robot-assisted radical prostatectomy after focal therapy: Oncological, functional outcomes and predictors of recurrence. Marconi L, Stonier T, Tourinho-Barbosa R, Moore C, Ahmed HU, Cathelineau X, Emberton M, Sanchez-Salas R, Cathcart P. Eur Urol. 2019 Mar 20. pii: S0302-2838(19)30193-9. doi: 10.1016/j.eururo.2019.03.007. [Epub ahead of print].

Thulium laser in flexible ureteroscopy: The new kid on the block The Holmium YAG laser has revolutionised the endoscopic treatment of renal and ureteric stones. Thanks to small and powerful fibres, lasertripsy could be performed with all types of stones during flexible ureterorenoscopy (URS), with little risk of injury to the surrounding normal tissue because of its limited penetration depth (400 µm). However, the Holmium YAG laser has some limitations, such as the impossibility to further reduce fibre cores to less than 200 µm in diameter size, the pulsatile emission of energy which causes retropulsion of fragments, and the need of bulky generators because of the cooling systems that must be incorporated in them. The Thulium laser has recently been proposed as alternative laser source that could bypass these issues. An interesting and detailed head-to-head comparison of the two types of laser has recently been published by Traxer and Keller. They explain the physical properties of the two energies and give a systematic review of the existing literature. The physics of the Thulium laser (not to be confused with the Thulium YAG laser) allow for a more efficient fibre design, as the spatial beam profile is more uniform and requires less heat dissipation. As a result, the Thulium laser fibre can be smaller (even 50-100 µm), generators are significantly less bulky, and the laser can work in a continuous mode.

… the Thulium laser fibre can be smaller (even 50-100 µm), generators are significantly less bulky, and the laser can work in a continuous mode…

World J Urol. 2019 Feb 6. doi: 10.1007/s00345-01902654-5. [Epub ahead of print]

Preventing forgotten ureteric stent: When technology helps patients and physicians A forgotten ureteric stent is an unfortunate event which may cause severe complications to patients, from infection to sepsis, loss of a kidney, and even death. In some series, it has been reported to affect up to 12% of patients. The reasons for this event to happen are numerous, including patients’ poor compliance to appointments as well as medical malpractice (e.g. patient is unaware of the stent or lack of stent removal appointment). Especially in the latter case, court litigation may occur quite frequently, e.g. up to 14% in a UK series. Depending on the severity of stent encrustation and the possible infection, removal of a forgotten stent may be challenging and complex, including a combined retrograde and percutaneous approach or even open surgery. Some systems have been introduced to assist physicians in tracking patients. Registries are used most commonly and logbook electronic registries are most effective. One example is the British Association of Urological Surgeons (BAUS) stent registry which operates all over the British territory. This electronic registry works by reminding practitioners via email of the expiry of a due date of stent removal and it is the only one operating on a national level. In fact, most of the electronic registries are the prerogative of single institutions with high financial capacity. An interesting alternative, the Ureteral Stent Tracker™ (UST) app, has been promoted by application developers for smartphones. When data of the patients are inserted, it reminds the practitioner of the due date of stent removal, with the option for followers to modulate the frequency and modalities of reminders. A team of Turkish researchers has recently trialled the utility of the app in a prospective cohort of 90 patients who have stents. One group was informed via the app to have their stent removed within 2 weeks after they received an appointment card. In case of a no-show they were contacted by a member of the team. The other group only had the appointment card and did not receive any reminder. All patients were planned to have their stent removed within 6 weeks from the insertion, regardless of compliance to appointments and reminders. One interesting finding was that appointments for stent removal were unattended by a high percentage of patients (22.7% in group 1 and 27.9% in control group). On the other hand, most patients rescheduled their appointments for stent removal within the 6 weeks maximum waiting time, as the main reasons for the delay were of a social or health care nature in both groups.

The interval time between FT and s-RARP was 65 months. The toxicity profile related to s-RARP did not seem to differ from primary RARP as reported in literature, with no intraoperative complications and no major post-operative complications; incontinence rate (defined as 1 or more pad/day) accounted for 17% of the cohort at 12 months follow-up. Overall potency rate was 14%, although erectile dysfunction was present in 33% of the patients and a nerve-sparing approach was attempted in 76% of the cases.

The clinical implications of these characteristics can easily be identified: smaller fibres allow for more deflection of the ureteroscopes and better visibility during flexible ureteroscopy because of reduced force resistance and improved irrigation through the working channel, respectively. Moreover, authors identified an in vitro study which demonstrated that the smallest size of stone fragments was obtained by the smallest operating laser fibres: the smaller the fibre the more efficient the lithotripsy.

Interesting and (maybe) unexpected, oncological outcomes were not quite as good, with progressionfree survival rates of 74%, 48%, and 36% at 12, 24, and 36 months after surgery, respectively. Looking at the histology of the specimen, these outcomes may not surprise as nearly half of the patients had an aggressive (ISUP ≥ 3) and/or locally advanced (≥ p T3/ N1) disease.

The ability to operate in a continuous mode, avoids the retropulsion while targeting the stones, so that a finer fragmentation can be produced. This can be maintained for smaller fibres too thanks to the extended range of frequencies the Thulium laser generator offers.

At the multivariate analysis, the authors found that independent factors associated with the recurrence were pT3b stage (HR 5.0, 95% CI

the authors, with the Thulium laser outperforming the Int Braz J Urol. 2019 Feb 20;45. doi: 10.1590/S1677-5538. IBJU.2018.0707. [Epub ahead of print]. Holmium YAG with a rate of 1.5-4 times faster stone ablation.

However, the UST app helped reducing the mean overdue time (2.5 vs. 16.3 days; p = 0.001) and in avoiding the ‘lost in follow-up’ of patients (by prompting the team member to call the patient). The ‘lost in follow-up’ event, which is directly connected to the forgotten stent, was observed in 3 cases and in none of the control and UST group, respectively (p = 0.001). The main limitation of the app is data protection regulations as the patients’ data need to be uploaded in a ‘cloud’, managed by an external company.

Source: Smartphone-based stent tracking application for prevention of forgotten ureteral double-J stents: A prospective study. Furthermore, these abilities may translate into a faster Ulker V, Atalay HA, Cakmak O, Yucel C, Celik lithotripsy, as suggested by further studies selected by O, Kozacioglu Z.

EAU EU-ACME Office

European Urology Today

March/May 2019


ADVERTORIAL

Benign Prostatic Hyperplasia (BPH) The right treatment for the right patients at the right time If they are expecting a particular treatment – do you go with that or explain all available options?

Prof. Richard Hindley, Basingstoke, UK

When patients come and see you to discuss their urinary symptoms – what are they expecting from you? When patients come and see me with troublesome urinary symptoms, often they have suffered with these symptoms for many years, sometimes a decade or even longer before they finally made it to see a Urologist. It is then very much the case of trying to understand their individual issues and requirements; it might be sleep disruption, it might be embarrassment when having to leave meetings in a hurry in order to run out to the bathroom, it might be that car journeys are difficult, it might be that it takes them an age to empty their bladder. The patients will usually arrive with the appropriate PROM’s completed, which would include EQ5D, IPSS, QoL and IIEF-5 questionnaires. I will always ask what troubles the patient the most with regards to his symptoms, and for the better informed patients if they have any particular concerns regarding the potential side effects of BPH treatments. I am keen to know the PSA level and also the prostate volume as this is central to the discussion of treatment options. By the time the patient comes to see the Urologist, they’ve often had a trial on medication, so often we are looking at a surgical intervention and with that it is important to discuss the whole range of options available to them. We have a duty to do this and it would ideally even include the options not available at our centre.

It is vitally important that the patient understands the full range of options and the advantages and disadvantages of each. No two patients are the same. As a Urologist, I am trying to evaluate what they want from any given intervention, as well as the nature of their possible concerns relating to side-effects of a treatment. A knowledge of the severity of the symptoms; and any associated issues such as bladder dysfunction, as well as any additional health issues and medications that may influence the advice given. So, it’s important to give them an overview before deciding, but there are cases when patients read about something and they have spent a long time thinking about it. In these cases, we may arrive back at the treatment option they initially were most attracted to and they knew something about, and if it remains the preferred option for them following from a more in-depth discussion with an acceptance of the associated risks, then we will agree between us to proceed. GreenLightTM XPS Laser Therapy

How many BPH treatment options do you currently offer to patients? I think it’s important that we offer our patients a range of BPH treatments. It shouldn’t just be medication or TURP as the only avenues. The new gold standard is not a procedure, it is a portfolio; it is our responsibility to encourage a two-way dialogue with our patients to understand the right treatment for them at that given time. Locally I offer a full range, from minimally invasive interventions such as Rezum™ Water Vapor Therapy and prostate artery ¯ embolization, and then ranging through to include the laser treatments for whom I offer men GreenLight™ Laser Therapy System. Other Urologists in other units may offer HoLEP as another very good alternative and then we have TURP, which for me is very much a back stop that I would only use in select scenarios. I personally feel that usually there is almost always another option that I could recommend over TURP as a suitable alternative when it comes to the patient requirements for their treatment. The great thing to come out of this new wave of minimally invasive therapies, is that it gives momentum to the case for BPH urology to become its own sub-specialist entity. We need to have engaged Urologists working in a team, offering a portfolio of options rather than just being the person who does the occasional TURP because they have always done it.

How did you arrive at these techniques? My motivation for embracing these new minimally invasive treatments was and is that I myself wouldn’t really want to have a TURP procedure. While for a vast majority of men, TURP may be an effective treatment option, a significant percentage of patients will suffer complications, some of them long-lasting. So, I think about myself and consider how my patients may feel and so I was always searching for other options. Furthermore, I strongly believe that a BPH intervention should be a day-case procedure where possible. I was also involved in clinical research over 20 years ago, looking at interstitial BPH treatments, and my MSc research project was also on the detrusor muscle ultrastructure in men with detrusor underactivity, so I always had an interest in troublesome LUTS. During my initial exposure to GreenLight™ PVP in 2004, at the end of my five-year training rotation, I was very impressed with the technology and thought that yes this is something that I would consider for myself that can really minimize the likelihood of bleeding. I subsequently decided to introduce this technology to Basingstoke in 2005, shortly after my appointment as a Consultant. More recently, I have become involved with Rezum™, and ¯ this was really born out of the desire to be able to offer men an even more minimally invasive intervention, with a very low risk of side effects particularly preservation of sexual function; as well as offering a lasting solution.

For which patients would you consider using Rezūm - what factors do you use to make this decision?

Rezum™ ¯ Water Vapor Therapy Delivery System with Steam

From my point of view, the decision about which ¯ patient to offer Rezum™ is largely based on whether or not they have a catheter, the severity of their symptoms and as well as whether the preservation of sexual function is of paramount importance . Each patient is different, they may have other health issues and indeed they may be on blood-thinning medications. I would also need to know the size of the prostate gland and how well they are emptying, so there are a number of things that are going into the mix when it comes to decision making. Essentially, those patients who are best suited for Rezum™, ¯ I believe, are those with the gland volume ranging from 30 to 80 mls. We have treated some men with bigger prostates

and some with slightly smaller, but certainly this is the target range. I think it is particularly good for men who are sexually active and who are particularly keen to be back to normal activities as soon as possible. There are some subgroups where ¯ I might gently encourage them away from Rezum™, and we might consider other minimally invasive treatments or a laser therapy such as GreenLight™. I would tend to direct patients more towards laser treatments modalities if they have a large gland over 90-100 mls, if they have signs of detrusor failure or are carrying large residues after emptying their bladder and also if they were on bloodthinning medications and they were at high risk of bleeding.

"It is vitally important that the patient understands the full range of options and the advantages and disadvantages of each." There will be three scenarios where I will be saying, “Look, I think you might be better suited to GreenLight™ laser vaporization”, for example, because we would need to look at a procedure that maximally dis-obstructs them and gives them a chance for their bladder to empty as efficiently as possible. I think prostate volume is increasingly important and that we have an understanding pre surgery of what the prostate volume is. We can do this by looking at the PSA blood test, and we can get a guide sometimes using our examining finger and we can do MRI scans although of course we cannot do these on everybody, and so having an abdominal or transrectal volume estimation is, I think, increasingly useful with regards to having those discussions about the various options. It’s not uncommon for men to end up on an operating list for a TURP with no knowledge of the size of their prostate gland; if they have a 160 mls prostate gland and you embark on a TURP it is very likely to result in significant bleeding and problems, and we really need to know that before they’re having their definitive procedure.

IMPORTANT INFORMATION: These materials are intended to describe common clinical considerations and procedural steps for the use of referenced technologies but may not be appropriate for every patient or case. Decisions surrounding patient care depend on the physician’s professional judgment in consideration of all available information for the individual case. Boston Scientific (BSC) does not promote or encourage the use of its devices outside their approved labeling. Case studies are not necessarily representative of clinical outcomes in all cases as individual results may vary. CAUTION: The law restricts these devices to sale by or on the order of a physician. Indications, contraindications, warnings and instructions for use are found in the labeling supplied with each device. Products shown for INFORMATION purposes only and may not be approved or for sale in certain countries. Please check availability with your local sales representative or customer service. Consult your physician for usage. URO-618811-AA © Boston Scientific Corporation or its affiliates.

March/May 2019

European Urology Today

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Prague meeting to give complete LUTS update ELUTS19 marks first collaboration between EAU and the International Continence Society By Erika de Groot Organised by the European Association of Urology (EAU) and the International Continence Society (ICS), the 3rd edition of the European Lower Urinary Tract Symptoms (ELUTS19) meeting promises to deliver essentials in LUTS management. The meeting also aims to offer well-rounded treatment approaches collated from urological subspecialties. In this article, EAU Secretary General Prof. Chris Chapple (GB) and ICS General Secretary Prof. Sherif Mourad (EG) share their valuable insights on current updates and challenges in LUTS management, potential breakthroughs in the field, and what ELUTS19 participants can expect at the meeting.

(ESGURS), Urologists in Office (ESUO) and Andrological Urology (ESAU), interspersed with the educational ESU-ESFFU Masterclass on Functional Urology organised by the European School of Urology (ESU).

“ELUTS19 is a truly comprehensive meeting; it offers in-depth coverage and provides plenty of opportunities for participants to discuss and brainstorm with field experts.”

“It is also important to bear in mind how to interpret aspects such as post voiding residuals, and to understand when it is appropriate to use urodynamics. Considering that the recent data suggest that pressure flow urodynamics does not necessarily improve outcomes in men prior to transurethral resection of the prostate,” said Prof. Chapple. Prof. Mourad added that urodynamics still needs a global consensus as an investigational tool. Prof. Mourad shared, “Another challenge is having the right medical and surgical tools that can help ‘underactive bladder’ patient cases. The comorbidities that may present with cases of OAB and neurogenic voiding dysfunction (including multiple sclerosis) is challenging at times because a satisfactory treatment for those cases is yet to be achieved.”

Current challenges “Recognising the significance of thorough patient “ELUTS19 features the first collaboration between the evaluation, particularly the usefulness of a bladder He stated that many new modalities for the minimally EAU and the ICS, along with the various EAU Sections diary, is a major challenge in the management of LUTS. It is imperative to look beyond the terms, for invasive treatment of LUTS due to benign prostatic dealing with aspects of functional and reconstructive enlargement (BPE) need better assessment for the urology, and is an important cooperation between the example overactive bladder (OAB), benign prostatic establishment of usage algorithm. two societies,” stated Prof. Chapple and Prof. Mourad. hyperplasia (BPH), and erectile dysfunction, to identify underlying causative problems and issues that are important to patients. It is essential to In addition, he said “A clear cut-off between the Prof. Chapple added, “This will allow a forum for a consider the expectations of patients and their goals medical and surgical treatment of BPH is a true multidisciplinary approach to this important area of to provide the best outcome for them,” stated Prof. challenge nowadays. With regard to female urology. We will examine the latest developments in Chapple. incontinence, we need to look at the restriction of functional urology, urogenital reconstruction and using meshes +/- slings in treating SUI and POP. Do andrology in this specialist multidisciplinary meeting. Prof. Chapple mentioned that there is a plethora of we give bulking agents injections more chances? Do Our objective is to provide an overview of what we pharmacotherapeutic agents currently available. In we go back to the traditional surgeries? This, too, is a know, what we don't know, and what we need to know to improve the quality of care for our patients.” combination therapy, one can augment the benefits of challenge as well.” any particular therapeutic agent at a lower dose and combining it with another active agent, as this could Prof. Chapple expressed that a critical review of What to expect at ELUTS19 existing knowledge will equip ELUTS19 participants Participants will congregate in Prague, Czech Republic improve efficacy and minimise side effects. to receive the best practices in LUTS management from myriad subspecialties. “The ELUTS19 scientific programme is comprised of carefully-selected topics that are relevant and interesting to urologists, 31 October - 2 November 2019 urogynaecologists, physiotherapists, and nurses,” Prague, Czech Republic said Prof. Mourad. European Lower Urinary

ELUTS19

Tract Symptoms meeting

By

with the latest treatments for their patients, and motivate them to help further boost research in the field. Possible future breakthroughs Prof. Chapple foresees a deeper understanding of the mechanisms in how therapeutic agents work. He anticipates a standardised approach in assessing patients with voiding or storage lower urinary tract symptoms. Another forecast is the ratification by the EAU Guidelines with regard to the importance of combination therapy and the most appropriate progression from oral therapy to third-line therapies. Prof. Chapple also predicts the recognition of the true role of urodynamics. Prof. Mourad foresees further advancement in robotic surgery with a reduction in costs involved; and more innovations with regard to stem cells in the field of tissue engineering and sphincteric deficiency. He predicts introduction of pharmaceutical agents for the treatment of underactive bladder, OAB, BPH, and painful bladder syndrome, with safer biodegradable meshes or slings for the treatment of SUI. “I anticipate more efficient and easier forms of minimally invasive techniques for BPE. In the coming years, there will be less invasive urodynamic machines and techniques, as well as, neuromodulation techniques,” stated Prof. Mourad. To know more about ELUTS19 and how to join this comprehensive, multidisciplinary meeting, visit www.eluts19.org. We hope to see you there!

www.eluts19.org

In collaboration with

The meeting is enriched with contributions from the EAU Sections of Female and Functional Urology (ESFFU), Genito-Urinary Reconstructive Surgeons

EULIS19 to present stone management essentials in Milan Meeting offers first-rate strategies and best practices in the field Exciting new developments in stone treatment await you in Milan, Italy at the 5th Meeting of the EAU Section of Urolithiasis (EULIS19). Receive scientific updates and clinical applications in the pathophysiology, diagnosis, metabolic evaluation, medical and surgical treatment of stone disease from the best in the field. Prof. Dr. Kemal Sarica, From 3 to 5 October 2019, you can expect EULIS Chairman contemporary medical management and evaluation of stones, essential training in endourological treatment, and handling of residual stones after endourology. We will deliberate on challenges such as treatment EULIS19 will also focus on patient perspective and quality of life; and emphasise integral collaborations. costs; availability of new minimally invasive management systems at clinics and hospitals; and lack of standardised training of residents. We will Live Surgery address the need for more reliable randomised You will examine the frontline techniques and clinical trials and relevant evidence-based data on practices in stone treatment first-hand as experts in management alternatives. the field will demonstrate these during the live surgery sessions.

Live surgery will be spread over two half-day sessions, one on the Thursday and one on Friday. The procedures will be live-moderated and also feature "provokers", asking challenging and hopefully enlightening questions to stimulate discussion as the case unfolds. A large variety of procedures will be demonstrated both live and pre-recorded. At EULIS19, you will familiarise yourself with laser systems for stone management especially the latest available systems which could enhance your daily practice. You will also learn how to prevent unwanted and unfortunate clinical situations as renowned specialists will impart insights and strategies on how to deal with complications that may arise in stone surgery. Addressing current major challenges As healthcare professionals, our main objectives are to continually improve care for our patients and ensure they have quality of life. We have challenges in stone management that we need to address together; and EULIS19 provides the quintessential platform to do so. 16

European Urology Today

Submit your abstract now! Deadline: 5 June 2019 At EULIS19, we also aim to further strengthen the collaboration between urologists and nephrologists to prevent stone recurrence; and collaboration between national societies and office sections for the standardisation of stone-related management alternatives and nomenclature for publications. The meeting therefore features collaboration with the Italian Lithiasis Club (CLU), the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA), the Progress in Endourology, Technology and Research Association (PETRA) and the South-Eastern Group for Urolithiasis Research (SEGUR).

Notable sessions Are you a urology nurse aiming to enrich your knowledge and refine your skills in stone management? A dedicated session is organised with these core objectives in mind. This new session for nurses will offer the best methods of maintenance and sterilization of the endoscopic instruments, as well as, the positioning and dressing of the patients in the operating room. The session "Stones course for nurses" is held on 5 October and will be in Italian only. EULIS19 will also tackle paediatric stone management in its first Thematic Session. The third Thematic Session is a special workshop on the clinical and metabolical evaluation of stone-forming patients. Experts will give some advice on hypercalcemic diseases, diet, metabolic syndrome and active monitoring of renal stone prophylaxis in an interactive setting. Another special session at EULIS19 is the PETRA Group's Resident Corner. On Thursday afternoon the scientific programme will focus specifically on young

Register now for the early fee! Deadline: 3 July 2019 urologists' needs, with input and speakers from the aforementioned PETRA Group. This is a not-to-bemissed opportunity for those at the beginning of their career to get a head start. Ah, Milano! Expand your know-how in the mornings and afternoons at EULIS19, then soak in the culture by exploring the majestic Italian city in the evenings. Whether you plan to admire the Gothic architecture of Duomo di Milano; enjoy opera at the Teatro alla Scala; examine Leonardo da Vinci’s “The Last Supper” at the church of Santa Maria delle Grazie; or relish aperitivo and huge spreads of food, Milan provides the setting for that balance between work and leisure. We look forward to welcoming you in Milan and brainstorming with you at EULIS19. For more information about the meeting, please visit www.eulis19.org.

www.eulis19.org

EULIS19 5th Meeting of the EAU Section of Urolithiasis 3-5 October 2019, Milan, Italy An application has been made to the EACCME® for CME accreditation of this event

The above-mentioned topics and challenges will be discussed in detail through state-of-the-art presentations, roundtable discussions and plenary sessions. March/May 2019


Report

ESU unveils urolithiasis updates at Pan-Hellenic congress Insights and course experience shared by the local faculty Assoc. Prof. Andreas Skolarikos Sismanoglio General Hospital Dept. of Urology Athens (GR)

andskol@yahoo.com

Dr. Athanasios Dellis Medical School, University of Athens Dept. of Surgery Maroussi (GR)

aedellis@gmail.com

Dr. Panagiotis Kallidonis University of Patras University Hospital Alonnisou 97a Patras (GR) pkallidonis@ yahoo.com

On 13 October 2018, the course “Recent developments and broadening indications in treatment of urolithiasis” took place during the 24th Pan-Hellenic Urology Congress in Athens, Greece. Dr. Bhaskar Somani (GB) and Dr. Guido Kamphuis (NL) shared their expertise on the modern management of urinary lithiasis.

most interesting topics of the course which were lectures on the tips and tricks on ureteroscopy and percutaneous nephrolithotomy. These presentations provided “food for thought” even for the experienced endourologists as insights gained could be beneficial in refining their clinical practice.

The course was organised by the European School of Urology (ESU) and it was well attended; the participants filled one of the largest auditoriums of the congress venue. The participants included experienced and novice endourologists who were a little hesitant to follow the course and to provide their input to the topics presented by the experts of the ESU.

The presentation “Broadening indications in treatment of urolithiasis” and the management of complicated urinary infections was further discussed by Dr. Somani. This was followed by Dr. Kamphuis who presented an array of different endourological complications, and proposed methods of prevention and management. Complications are always an interesting topic and several questions were addressed by the faculty.

Dr. Somani began with a presentation marking the high educational value of the ESU, which creates forward-looking solutions for continuous improvement, professional growth and knowledge sharing. It is one of the goals of the ESU to provide engaging training and educational activities for doctors at any stage of their urological career. The success of all the ESU is based on the support of its faculty, comprising of 150 experts in various urological fields, several of whom have a Greek background. It was the intention of the organisers to focus more on fruitful discussions and interaction with the participants rather than a series of presentations.

“...there are different ways to achieve the clearance of stones but safety for the patient is of utmost importance.”

As the local faculty, we presented non-index cases of urolithiasis by showing a number of cases including large, complex stone burdens; uncommon anatomical configurations; intraoperative mishaps that led to change of treatment strategy; and In his presentation “EAU Guidelines recommendations” complications. All these cases allowed the on stone disease, Dr. Kamphuis made a clear depiction productive exchange of ideas and experiences as of the current recommendations of the EAU said cases could not be managed by one approach Guidelines on stone disease by giving a highly alone. The ESU experts guided the discussion and expected update. This was followed by two of the provided valuable input.

A complex case of lithiasis involving the left pelvicalyceal system and the ureter

The take-home message was that there are different ways to achieve the clearance of stones but safety for the patient is of utmost importance. Thus, safety rules should be always followed despite the experience of the performing surgeon. When the ESU course was over, there was a gratifying feeling on time spent for participating in it. It was well worth it.

Report

ESU offers UTI & ED fundamentals at RSU congress Updates, lively debates, and knowledge-exchange at Yekaterinburg Prof. Igor Korneyev Saint Petersburg State Pavlov Medical University Dept. of Urology St. Petersburg (RU) iakorneyev@ yandex.ru

the daily work of urologists in both hospital and outpatient settings, the ORENUC classification of risk factors and new sepsis definitions were emphasised. The Acute Cystitis Symptom Score (ACSS) has been presented as a valuable tool to estimate and get a clearer picture of the disease. Prof. Wagenlehner stressed that growing bacterial antibiotic resistance is the trendsetter of continuous change in the medical approach to patients with UTI.

The European School of Urology (ESU) held its course “Urinary tract infections and erectile dysfunction” during the Annual Congress of Russian Society of Urology (RSU) in 10 November 2018 in Yekaterinburg, Russia. This is the second time that an ESU course was integrated into the RSU congress programme.

In the 2018 version of the EAU Guidelines, fluoroquinolones remain as first-line therapy for pyelonephritis. However, these drugs have been removed from the list of recommended medications for treatment of acute uncomplicated cystitis. Non-steroidal anti-inflammatory drugs (NSAIDs) and non-antibiotic herbal therapy look promising as alternatives for patients with cystitis in randomised trials.

The ESU course attracted a high attendance of more than 350 urologists from the European and Siberian parts of Russia, and also from neighbouring countries. It consisted of two main topics: urinary tract infection and andrology which were presented by Prof. Florian Wagenlehner (DE) and Mr. Suks Sukhbinder Minhas (GB), respectively.

Another presentation of Prof. Wagenlehner was devoted to the review of current opinion in assessing and treating recurrent UTI in women. There is no proof that extensive routine workup has high diagnostic yield for diagnosis of recurrent UTI, while several treatment modalities may bring the desirable effect.

Coverage on UTI Prof. Wagenlehner started with an overview of the EAU Guidelines recommendations for urinary tract infections (UTIs). Since UTIs account for a majority of

The EAU Guidelines strongly recommend diagnosis of recurrent UTI by urine culture. Urologists may rely on randomised controlled studies demonstrating efficacy of vaginal oestrogen replacement in post-menopausal women with recurrent UTI prophylaxis.

No empty seat left at the ESU Course

March/May 2019

Mr. Minhas discussed testosterone replacement therapy in men after PCa treatment based on EAUGuidelines recommended, evidence-based opinion. The treatment is to be offered with care as a testosterone substitution to symptomatic hypogonadal men one year after successful treated for local PCa with low risk for recurrence (i.e. Gleason score < 8; pathological stage pT1-2; pre-operative PSA < 10 ng/mL) and no evidence of active disease. Concluding the ESU course The ESU Faculty reports were Prof. Wagenlehner discusses acute and chronic prostatic infection followed by interactive case discussions prepared by the RSU faculty, and questions from the Another important topic covered by Prof. audience. At the end of the day, RSU Executive Wagenlehner was acute and chronic prostatic Director and local organiser, Prof. Magomed Gazimiev infection with a specific emphasis on the current (RU), gave his closing remark: “We thank our EAU/ opinion on antibiotic prophylaxis related to prostate ESU guests. We shall exert our best efforts in inviting biopsy, and the EAU Guidelines recommendation for colleagues from all over Russia, young urologists in treatment of bacterial prostatitis. Many questions in particular, to participate in future ESU courses; and to relation to the current clinical practice of UTI in Russia further develop the RSU-EAU cooperation.” were answered based on the local data of microorganisms incidence and antibiotic resistance.

Andrology matters Mr. Minhas presented two topics in andrology: Modern options for treating erectile dysfunction (ED) and the practical approach to male Additionally, the OM-89 vaccine has proven more hypogonadism management. Both effective than the placebo topics are related to men’s general for immunoprophylaxis in health and metabolic disturbances that should be checked and female patients with controlled accordingly. Recently recurrent UTI in several performed studies do not support the randomised trials. In hypotheses that testosterone selected patients with treatment results in changes in good compliance, prostatic histology, and that it does self-administered short-term antimicrobial not increase the risk of prostate therapy is a reliable tool. cancer (PCa).

Mr. Minhas shares insights on identifying reduced testosterone levels

European Urology Today

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Report

Participants review NMIBC Masterclass A brief report, testimonials and lessons learned By Erika De Groot Why did young and experienced urologists choose to partake in the 2nd ESU-ESOU Masterclass on Non-muscle-invasive bladder cancer? What beneficial insights did they bring back with them? In this article, participants give an insider’s look on what it was like to have the non-muscle-invasive bladder cancer (NMIBC) masterclass experience. About the masterclass Through the collaborative efforts of the European School of Urology (ESU) and the EAU Section of Oncological Urology (ESOU), the two-day masterclass was designed to cover all aspects of NMIBC management. The comprehensive curriculum included modern techniques of transurethral surgery: en-bloc resection, new imaging technologies, and new generation equipment. From 21 to 22 February 2019 in Prague, Czech Republic, the participants partook in stimulating discussions coupled with educational live and semi-live surgeries. Under the tutelage and guidance of leading experts such as Course Directors Prof. Marek Babjuk (CZ) and ESU Chairman Dr. Joan Palou (ES), participants learned about current perspectives on tumour classification; the benefits gained from the cooperation between urologists and pathologists; the stratification of patients; various diagnostic and therapeutic strategies. Personal highlights “For me, the highlights of the masterclass included the quality and content of the lectures; the dynamism and high-level interaction during discussions among the participants; and the live surgery which featured different techniques of transurethral resection of bladder tumour (TURB),” shared Dr. Skander Zouari (TN).

“It was a very good masterclass,” expressed Dr. Rik De Jongh (NL). “We received the latest updates in the field of NMIBC and the opportunity to observe practical techniques during the live surgeries. The interaction between the faculty and the participants was friendly and productive during the lectures, operations and case presentations.” According to Dr. Alexei Plesacov (MD), all of the topics covered by the masterclass were necessary. He added, “In my opinion, the masterclass highlights included the presentation of Prof. Babjuk “Endoscopic diagnosis of bladder cancer, strategy and technique of TURB (separate resection, en-bloc)”; the management of TURB complications; complications of intravesical treatment and their management. For Dr. Miguel Ángel Rodríguez Cabello (ES), his masterclass highlights were the quality of the lecture contents, the faculty, and the venue. “It was an excellent masterclass,” said Dr. Rodríguez. Reasons for joining “One of the most common urological diseases in Spain is bladder cancer. So I decided to apply to this masterclass to gather more information that will

enhance my clinical practice, which in turn, will improve my patient care,” disclosed Dr. Rodríguez. Dr. De Jongh joined the masterclass because he wanted to receive the latest NMIBC developments, and to know more about different imaging techniques used to visualise bladder tumours. These techniques were demonstrated during the live surgeries. Dr. Zouari shared, “For me, NMIBC is an attractive and very interesting subject. The coverage of the scientific programme was exhaustive. I signed up for the masterclass because I did not want to miss such an opportunity to improve my knowledge about bladder cancer.” The faculty was as enthusiastic as the participants Dr. Plesacov was interested in all topics offered at the masterclass. “I decided to apply for this masterclass because of the live surgeries. I found it interesting including the simultaneous discussions that followed, which provided necessary tips and tricks,” said Mr. Plesacov. Skills to enhance Aside from increasing their knowledge on bladder cancer, participants joined the NMIBC masterclass to develop specific skills. Dr. Rodríguez’s objective was to boost what he knows about en-bloc laser resection. “Thulium laser is an excellent tool to improve a lot of endourological procedures and with bladder cancer, this tool can obtain good results with less risks and a faster recovery period.”

The intimate setting was conducive to learning

“I wanted to learn more about en-bloc resection of bladder tumours and the various techniques such as incision electrode, loop and laser. The tips and tricks given during the procedures were very useful,” said Dr. De Jongh.

According to Dr. Zouari, the masterclass met his expectations. “I wanted to know about en-bloc resection using photodynamic diagnosis, narrowband imaging, and IMAGE S1 and the lectures and live surgeries covered these. For me, the experience was a blast,” said Dr. Zouari. “The en-bloc resection of the urinary bladder is the most contemporary technique at the moment, and the en-bloc laser resection is the technique I am currently interested in. I look forward to being able to apply the technique soon,” concluded Dr. Plesacov. Join us for the 3rd edition Interested in taking part in the third edition of the NMIBC Masterclass? Join us from 21 to 22 February 2020 in Prague. Would you like to participate in other must-attend ESU masterclasses? Check out the overview via www.esu-masterclasses.org and sign up for your masterclass(es) of choice.

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EAU Education Online introduces 2 new courses:

Guidelines on Muscleinvasive Bladder Cancer Guidelines on Primary Urethral Carcinoma Get a complete view on clinical aspects, diagnoses and treatments of Muscle-invasive Bladder Cancer and Primary Urethral Carcinoma:

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• Understand the diverse natures of MIBC and PUC • Arrive at the right diagnoses • Make risk assessment of cases • Decide on a treatment and follow-up strategy Prof. Dr. Henk Van Der Poel Dr. Nikolaos Grivas

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European Urology Today

March/May 2019


Report

FT masterclass presents disruptive technologies Reaching new paradigms in prostate cancer management Dr. Juan Gómez Rivas Member ESUT Ablative Group Hospital Universitario la Paz Urology Madrid (ES) @JGomezRivas

Dr. Eric Barret Chairman ESUT Ablative Group Institut Mutualiste Montsouris Dept. of Urology Paris (FR)

On PCa management Prostate cancer (PCa) is the most common cancer in men. Although many patients are diagnosed at an early stage, the only treatment options validated within the EAU Guidelines are either radical therapy, such as surgery and radiotherapy, or active surveillance. Since the inclusion criteria in an active surveillance programme are limited to a low-volume, low-risk disease, most of the patients will undergo radical therapy which causes serious side effects. Therefore focal therapy was developed to better personalise PCa management with the purpose of combining effective cancer control with minimal morbidity. The success of focal therapy depends on the correct identification and targeting of the lesion.

Lesions hold the clues Precise identification of the PCa lesion is key to focal therapy success and involves two crucial processes: the imaging and the biopsy. Multiparametric MRI (mpMRI) of the prostate is the leading imaging eric.barret@imm.fr modality in providing accurate information on the localisation and characteristics of the tumour. The The European School of Urology (ESU), the EAU Section combination of mpMRI with targeted fusion biopsy of Uro-Technology (ESUT) and the EAU Section of sampling allows urologists to better localise the index Urological Imaging (ESUI) organised the well-attended lesion and significantly increase the cancer detection 3rd edition of the ESU-ESUT-ESUI masterclass on focal rates relative to a standard biopsy. therapy (FT) for localised prostate cancer which took place in Paris, France last December 2018. New imaging techniques have emerged to improve the diagnosis and more specifically the accuracy of the The edition provided an extensive review of the localisation, staging and the assessment of tumour rationale for focal therapy and the modalities of aggressiveness. Anatomical and molecular data can be patient selection. It also ensured that the participants provided by the positron emission tomography (PET) will gain further knowledge and benefit from new imaging in combination with computer tomography or focal therapy techniques, modalities of treatment, MRI. Along with these, several PET radiotracers tools, and development of new energies. Together directed especially to prostate-specific membrane with the faculty, they discussed pre-recorded videos antigen (PSMA) have been developed. This showed and demonstrations, and participated in hands-on promising results for a comprehensive analysis of PCa training sessions to combine theory with practical and for providing an adequate tissue contrast, know-how. information that would be useful during diagnosis.

These findings must be taken into consideration in the planning and performing of procedures. The capsular delineation should be respected to guarantee better functional outcomes. Due to a greater accuracy of targeting the prostate lesion, focal treatment can be limited to the tumour area for a personalised treatment, while adding a safety margin in order to be confident of full tumour ablation relative to the larger histologic volume.

Prof. Eva Compérat presents "Quality of prostate biopsy"

Potential of focal therapy The definition of how to perform focal therapy itself is not well established. Several options have been reported in literature which included lesion-targeted ablation, hemiablation or subtotal gland ablation, sparing at least one neurovascular bundle. More or less extensive ablations have been proposed to limit the risk of failure.

Focal therapy is a new option in the armamentarium of PCa management. Many advances have already led to a better diagnosis and targeting of prostatic tissue. Technological improvements and the development of novel energy sources should make it possible to treat lesions even more precisely, while limiting the risks of side effects.

Nowadays, as previously demonstrated, mpMRI could assist in the appropriate selection, planning and management of patients for focal therapy. Then, the targeted lesion can be perfectly identified on mpMRI and so the energy application could be theoretically limited to the targeted area because the Prof. Georg Salomon presents on FT improvement and more tissue we will preserve, the better the functional management results will be. However, several studies have shown an underestimation of the MRI in determining the accurate volume of the tumour. Thus, it is recommended to ablate a much larger area of the prostatic parenchyma with a difference in boundary that are necessarily most significant on the non– capsular side of the lesion.

In the future, there is potential to effectively expand the indications of this technique to include in the treatment of more aggressive tumours. If the promising results of this technique are confirmed, there is no doubt that this technology will be incorporated into the EAU Guidelines in the near future.

www.esuerectile19.org

www.esufocal19.org

ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie’s disease

ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer

3-4 October 2019, Leuven, Belgium

28-29 November 2019, Paris, France An application has been made to the EACCME® for CME accreditation of this event

March/May 2019

An application has been made to the EACCME® for CME accreditation of this event

European Urology Today

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1st UROBESTT features fresh innovations and talent Contenders share experiences, aspirations and meeting highlights By Erika De Groot Young promising urologists took centre stage as Challengers at the first URO Berlin Skills Teaching and Training (UROBESTT), a novel programme of the European School of Urology (ESU). During the Challenger sessions, these contenders defend their research and perspectives on selected clinical cases through riveting debates and deliberations. Here are their testimonials.

saw that the patients don’t receive quality medical treatment, advice and optimal options for their diseases. I decided to make the presentation for the Challenger sessions because I wanted to find more colleagues who also care about patients in those kind of circumstances; to get new experiences; to receive advice from faculty whom I admire a lot; and to show what I know and what I can do.

Chernylovskyi: My clinical and research topics of interest are prostate cancer and adrenal gland Why did you apply to be a participant tumours. I am aware that adrenal gland is not a centre of interest of urologists, but at the EAU Annual at UROBESTT? Congress there was coverage on retroperitoneal and Winner of the Challenger sessions, Dr. Nikolaos Liakos adrenal tumours. So I thought my topics could be (GR), said: While browsing the EAU website late in one interesting to the UROBESTT audience. And to be able autumn evening, I saw an announcement about to discuss patient cases about complications after UROBESTT. I said to myself “Well, why not? Give it a cytoreductive prostatectomy with experts was chance. Attending the meeting would be a good challenging. Thank God I survived! opportunity to meet experts and colleagues from other countries.” So, I applied. A few weeks later, I received Hameed: I thought of presenting two unique topics of an email that I’ve been selected! stone disease at UROBESTT as they emphasise on newer technique and methodology. In my presentations, I Volodymyr Chernylovskyi (UA): After being a wanted to stress the results in depth using the charts. I participant of the EUREP programme and ESU-Weill also used the latest indexed articles from reputed Cornell Masterclass in General urology, I know that journals. EAU-ESU meetings are never boring. The experts who make up the UROBESTT faculty are amazing and to Liakos: I decided to present a topic deriving from the learn from them is a privilege. All the presented topics very heart of the EAU educational programmes. Training were in the field of my interest, and the possibility is to in robotic-assisted surgery has been a major part of my present my research is a plus. residency and of my scientific activities. My main targets were to present the positive effects of modular training Dr. Marius Markevicius (LT): Several months ago, I saw on daily clinical practice and an aspect of the structured an ad about UROBESTT in European Urology Today and training in my institution. I was instantly enthusiastic just looking at it. I checked every week to see if I could apply already. Something was pulling me to this exciting event; I felt that I needed to go there.

UROBESTT faculty members and the Challengers

Dr. Zoltán Kiss (HU): I came across UROBESTT while browsing the EAU website and instantly thought the meeting was interesting due to the wide variety of sessions such as the lectures, case reports, hands-ontrainings and of course, the Challenger sessions.

Sener: As I can’t give up on clinic work and quality time with family, I had to sacrifice hours intended for sleeping. Sacrifice is an inevitable part of life and sometimes it’s necessary. The sleepless nights and thorough research combined with meticulous PowerPoint skills resulted in two 15-minute comprehensive presentations.

Dr. Emre Sener (TR): The chance to be a part of this meeting was an opportunity that I couldn’t miss as the EAU-ESU always provides the highest quality of standards when it comes to meetings.

Tursunkulov: Based on my past experiences on presenting and addressing questions about my research, I can somewhat gauge what to expect at the Challenger sessions.

Dr. Azimdjon Tursunkulov (UZ): I thought it was a great opportunity to improve my knowledge and skills, and learn from world-renowned experts as mentors.

Kiss: The meeting was an unmissable opportunity to advance my debating skills and to acquire new knowledge at the same time. I made sure that my presentation was on point by knowing the ins and outs of my research and anticipating possible questions from the panel.

How did you prepare for the Challenger sessions? Markevicius: At first I thought of just attending UROBESTT but the opportunity to be a Challenger came up and I felt that I have something to say and something to share. I used to work at the only Chronic Pelvic Pain Syndrome (CPPS) treatment centre in Lithuania. It was there that I

Liakos: Well, the truth is that every minute on the podium felt like an hour (at a minimum!). It was a wonderful experience that can’t be compared to any other EAU meetings and congresses. To have four experts evaluating your work is a challenge in itself; it equips you with courage and determination to do your best. Yuri: Even though I often speak at various podiums, presenting at UROBESTT was very different. I had to argue and discuss with the best young urologists from around the world, great professors and mentors who are experts in their fields. The faculty has taught us a lot in a friendly accommodating manner. They also provided important lessons on how we can use available facilities in our countries with a simple effort that yields excellent benefits for our patients. Prof. Alken underlined that the mission of UROBESTT is to set the highest standards in urological care, promote efficiency and compassion in health services. Markevicius: Before my presentation, I was very nervous. What they will say? What they will ask? What will be the audience’s reaction? But when I entered the podium, I felt liberated because I had 15 minutes of free expression to present my research and highlight issues that need addressing. I received invaluable questions and comments which helped me understand more what I have to do in the future. Kiss: I have to admit, I was a bit nervous before my presentations and having to respond to many questions. I felt somewhat out of my comfort zone. Tursunkulov: As a Challenger I came to understand to keep striving for excellence. It was a great experience where I received valuable advice.

Dr. Prahara Yuri (ID): The first time I read about UROBESTT, I thought to myself that this meeting is the kind of meeting that encourages us to think differently, to think beyond the conventional. So I registered and I was pleasantly surprised that I was accepted. Dr. Zeeshan Hameed (IN): Of all the conferences I’ve attended and known, UROBESTT intrigued me. I’ve never heard of the Challenger sessions so I decided to join to show them what I’m made of (as the UROBESTT tagline says). Another important reason for my application was the faculty line-up. I wanted to listen to their insights and to have the opportunity to interact with them.

What was it like on the podium and deliberating with the faculty?

Yuri: I have great interest in research from the time I was still in the residency programme up until now. For the Challenger sessions, I made sure to prepare interesting presentations for the audience and for myself. I included both my published and unpublished results, then compared these with other studies to see if the results would be same or not.

Hameed: Frankly, I was nervous; I faced highlyexperienced urologists from around the globe. But once I presented a couple of slides, I delivered the rest without problems. Looking at the encouraging participants and the faculty, the whole process was comforting. The panel bombarded us with questions which led to productive discussions. They also gave their opinions and advice regarding slides and delivery to improve future presentations. Chernylovskyi: It’s very important to keep calm and to just continue during one’s presentation. For young urologists like me, it’s an absolutely new experience to discuss my topics with experts such as Dr. Joan Palou, Prof. Olivier Traxer, Prof. Peter Alken and many others on stage. To be there is like playing in an amateur football team against giants such as FC Barcelona or Real Madrid. It was unforgettable!

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European Urology Today

“The new kid in the scene” There is a stage in the professional life of urologists where challenges and new information, skills, and techniques grow exponentially and this is possibly those first years after you have finished your residency and practise as a certified urologist in your service. In this period you are 100% responsible for the procedures, clinical decision that you perform and the outcomes and you could use an educational programme to guide you. Since in this period just after the residency has finished there are still many skills to explore and to be trained in and to improve.

Unfilled space The European School of Urology (ESU) has detected this unfilled space and have created a new programme to fill the void with a ‘new kid in the scene’ “URO Berlin Skills Teaching and Training”, a programme designed for young and promising urologists coming from all over Europe and beyond.

Exceptional experience I had the honour to be selected as one of the participants of this first edition and it was an exceptional experience in which the reality surpassed the expectations. The three-day programme focused on improving the knowledge and to update on the most important “hot topics” in current urology, improving your clinical decision making and also improving presentation and surgical skills. A complete guide for young urologists how to become better in every aspect of this profession.

Expert faculty The faculty was lead by Dr. Joan Palou (ESU chair) from Barcelona and Dr. Oliver Traxer (France) and also included a wide variety of experts in the field of education training such as (Michiel Sedelaar, Juan Gomez, Esteban Emiliani, Domenico Veneziano) amongst others. The three day programme was developed in Berlin at an amazing location with a friendly atmosphere for 70 young urologists. In addition to the teaching programme, the trainees were also evaluated through their presentation about their research or interesting topics of their choice and received feedback from the faculty on every aspect (presentations skills, presentation quality, topic selection, the content of the presentation). This integrative evaluation from the professors allowed the attendees to realise what are the areas they should work on to improve.

Interactive format Challenger sessions winner Dr. Liakos on the podium

Sener: Being on the podium is always exciting, especially when the panel includes legendary urologists such as Prof. Alken. I knew that I’d have a hard time against the panel but I think it went well. All the comments made by each panel member were truly valuable and educative. I think everyone in the room profited from the comments as well.

What are your UROBESTT highlights?

Dr. Sener presents, deliberates with the panel

UROBESTT19 in Berlin

Liakos: For me, it was the motivation to participate on behalf of the colleagues and their willingness to discuss, set in the meeting’s easy-going atmosphere. The variety of the lectures was something I’ve never seen before. The Challenger sessions gave young scientists the opportunity to present their work to experts. How can this session not be a unique opportunity for us?

This interactive format course is a new trend in education where the participants become involved in the process of learning and break down the barriers of education. Therefore UROBESTT is a meeting that will be very attractive to young urologists and to become a new highlight for ESU (European School of Urology). The faculty will be looking forward to the next edition and to train new candidates who will select the best topics. I am sure it will be a great success.

By Dr. Leonardo Tortolero Blanco Alicante (ES)

March/May 2019


The first UROBESTT was well-attended Yuri: The three highlights for me were the meeting itself as a whole; the venue was a great place for training (excellent facilities, friendly employees and delicious food); and the faculty who were patient and engaging. They delivered their insights in a clear and concise manner. Hameed: Without a doubt, the Challenger sessions was the meeting’s “cream of the crop”. The clinical case discussions were interesting as there were a variety of cases to discuss. The lectures by the faculty were amazing, giving us a lot of insight on the advances in uro-oncology, laparoscopy and endourology. And the historical KARL STORZ building as the meeting venue was notable. Sener: The highlights for me were the fantastic venue; the faculty made up of key opinion leaders from all subspecialties; and the opportunity to meet and befriend many talented urologists from around the world who are committed to scientific activities and who want to do their best for their patients. Chernylovskyi: I liked the open discussion of nonstandard cases from all over the world. I also found the

Enthusiastic participants and faculty together with the ESU

tips and tricks session very interesting; to learn about laparoscopic and endoscopic complications from Prof. Liatsikos is what young urologists need. Tursunkulov: There were more than three highlights for me. Excellent organisation; participate as a challenger; active debates with faculty; hands-on trainings; lectures from top mentors; and clinical case report series. Markevicius: In my opinion, the highlights were the possibility to participate in the Challenger sessions; the opportunity to talk to the experts, get new experience and share my own findings. I think that if such a meeting takes place two or three times a year, more young urologists will experience UROBESTT.

What is your message to future UROBESTT participants? Hameed: Since UROBESTT gives budding urologists the platform to showcase what they know, I would encourage them to apply for this meeting. To me, UROBESTT is one of the best programmes out there that will keep raising the bar of top-notch clinical practice.

And if I may add, it would be great to make use of the experience of the 2019 Challengers to mentor the future challengers of UROBESTT. The mentoring can be divided per field of interest such as endourology, stone disease, uro-oncology, etc. or per geographical region. Markevicius: UROBESTT gave me the possibility to gain new experience, boost my skills and get helpful advice. At that time, I remember feeling that the faculty helped us to be better doctors in all aspects: from patient care, our practice, and our overall skillset. To future participants, grab the chance to be at the meeting, show your best and learn.

Yuri: UROBESTT is the best programme for young urologists as it helps develop their knowledge; encourages the sharing of experiences; and it teaches them how to give excellent presentations. For the next UROBESTT, don't hesitate to take this good opportunity. In addition, I would like to express my gratitude to the faculty and meeting organisers. Sener: It is a privilege to participate and to present at UROBESTT. I really wish to attend it again and meet new friends. So my advice is: Apply for the meeting!

Liakos: Participate in this new meeting, register for the Challenger sessions and enjoy every single moment at UROBESTT. It is worth your time and the effort to prepare yourself as a Challenger. You will broaden your network and exchange knowledge at the meeting.

Chernylovskyi: This new programme is a great chance to learn from the best and to have the podium to share your knowledge. Here in Ukraine, I’ll be the “recruiter” for UROBESTT. Next year, the meeting will receive a huge number of applications! I hope to see the EAU-ESU team very soon in another programme. My special thanks goes to Mrs. Mariëlle Van De Wiel of the ESU who helped facilitate my participation in Berlin.

Kiss: I have had an invaluable experience and I encourage fellow young urologists to take part in the next UROBESTT.

Tursunkulov: UROBESTT is an "all-in-one" event for young urologists. Take the opportunity to join when you can!

www.urobestt.org

www.esunmibc20.org

ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer 20-21 February 2020 Prague, Czech Republic 16-18 April 2020, Berlin, Germany An application has been made to the EACCME® for CME accreditation of this event

March/May 2019

Application deadline: 1 November 2019

European Urology Today

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ESU Event Calendar Date

Event name

Location

MAY 2019 16 16-17 17-18 25

ESU course on Prostate and testis cancer during the national congress of the Dutch Urological Society 4th ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction 2nd EAU Update on Bladder cancer (BCa19) ESU course on New perspectives in the management of upper tract tumours during the 6th Baltic Meeting in conjunction with the EAU

Rotterdam (NL) Heilbronn (DE) Turin (IT) Tallinn (EE)

ESTs1 and E-BLUS during the 5th MISUR: Unbound MIS - Urology ESU course on Management of non-muscle invasive bladder cancer during the national congress of the Slovak Urological Society E-BLUS during the Summer Urologic School in Astana ESU course on Kidney laparoscopic approach and Non muscle invasive bladder tumours during the national congress of the Romanian Association of Urology 1st EAU Update on Renal Cell Cancer (RCC19) ESU course on Update guidelines prostate, kidney and muscle-invasive bladder cancer during the national congress of the Spanish Urological Association ESU course on Update in prostate cancer during the national congress of the Polish Urological Association ESU course on Urinary tract infection during the national congress of the Ukrainian Urological Association 3rd ESU-ESUT Masterclass on Urolithiasis ESU course on Endo update during the national congress of the Urology Society from Republic of Moldova ESU - Weill Cornell Masterclass in General urology

15-17

ART in Flexible - Step 1

6-11 11-13 21 Tbd

17th European Urology Residents Education Programme (EUREP) ESU-ERUS courses during the 17th Meeting of the EAU Robotic Urology Section (ERUS) ESU course on Modern BPH surgery and Endourology (PCNL and RIRS) during the national congress of the Russian Society of Urology ESU course on Urolithiasis during the national congress of the Iraqi Urological Association

PCa, kidney cancer, reconstructive surgery, endourology & stones updates By Erika De Groot

JUNE 2019 3-7 6 6-7 7 7-8 12 14 14 14-15 21 23-29

CAUREP unveils urology essentials in Punta Cana

Bangkok (TH) Martin (SK) Astana (KH) Bucharest (RO) Prague (CZ) Bilbao (ES) Katowice (PL) Kyiv (UA) Patras (GR) Chisinau (MD) Salzburg (AT)

JULY 2019 Berlin (DE)

SEPTEMBER 2019 Prague (CZ) Lisbon (PT) Rostov-on-Don (RU)

Providing learning opportunities and relevant updates for the Hispanic urological community is the core aim of the Confederación Americana de Urología Residents Education Programme (CAUREP). The programme is a joint initiative of the European Association of Urology (EAU) and the Confederación Americana de Urología (CAU), and modelled after the European Urology Residents Education Programme (EUREP), a flagship programme of the European School of Urology (ESU) offered to urological residents who are in their final year. The concept was adapted Dr. N. Bernardo: “We should learn both about prone & supine by the CAU to also encourage knowledge-sharing of in percutaneous surgery.” insights, research and emerging technologies between the region and Europe. Renowned experts representing the CAU such as Prof. The programme’s fifth successful edition concluded in Norberto Bernardo (AR), Prof. Rafael Coelho (BR), Dr. October of last year. Although CAUREP was set in a Rubén Olivares (CL), and Dr. Ramón Virasoro (US) multicultural environment, language was never a shared their valuable insights on partial nephrectomy, barrier. Sessions were presented in English with treatment alternatives to urethral trauma, and simultaneous Spanish translations. The participants updates percutaneous nephrolithotripsy among many received state-of-the-art updates from the speakers other topics. and had plenty of opportunities for deliberations and addressing controversies openly and comprehensively. In his lecture "Optimising patient selections: Prostate biopsy and focal therapy”, Dr. Olivares stated that high-intensity focused ultrasound (HIFU) and cryotherapy has developed and has shown promising results (highly efficacious with low side effects) over the past two decades. He said that the technology is still evolving and improving. The role of focal therapy will remain debatable until the long-term results become available.

Baghdad (IQ)

OCTOBER 2019 2 2-5 3-4 4 10 11 11-12 10-11 12 17 24-25 31- 1/11

ESTs1 during the 5th Meeting of the EAU Section of Urolithiasis (EULIS) 6th Confederación Americana de Urologia Residents Education Programme (CAUREP) ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie's disease ESU course on The treatment of muscle-invasive bladder and metastatic bladder cancer during the Caucasus Central Asia meeting ESU course on New challenges and unmet needs in basic science and histopathology to address the clinical management of renal malignancies during the 26th Meeting of the EAU Section of Urological Research (ESUR) ESU course on Update on prostate and bladder cancer during the national congress of the Turkish Urological Association 3rd EAU Update on Prostate cancer (PCa19) ESTs2 during SET-UP Programme ESU course on Prostate cancer during the national congress of the Hungarian Urologic Association ESU course on Controversies on the treatment of urological tumours during the national congress of the Czech Urological Society 2nd ESU-ESTU Masterclass on Kidney transplant ESU-ESFFU Masterclass on Functional urology at the European Lower Urinary Tract Symptoms meeting (ELUTS19)

Milan (IT) Buenos Aires (AR) Leuven (BE) Tbilisi (GE) Porto (PT)

Antalya (TR) Prague (CZ) Bangkok (TH) Eger (HU) Prague (CZ) Madrid (ES) Prague (CZ)

NOVEMBER 2019 11 ESU course on Prostate and bladder cancer; Insight into research and lecturing during the national congress of the Scientific Society of Urologists of Uzbekistan 14-17 ESU courses on Oligometastases in Genito urinary cancers and Immunotherapy for urological tumours during the 11th European Multidisciplinary Meeting in Urological Cancers (EMUC) 21-22 6th ESU-ESUT Masterclass on Lasers in urology 23 ESU course on Prostate cancer imaging during the national meeting of the Lithuanian Association of Urology 28-29 4th ESU-ESUT Masterclass on Focal therapy for localised prostate cancer 28-2/12 E-BLUS during the Philippine Urological Association (PUA) 60th Annual Convention

Tashkent (UZ)

Prof. O. Traxer shares URS tip and tricks

Esteemed internationally-known experts represented the EAU and the CAU from 30 to 31 October 2018 in Punta Cana, Dominican Republic. The programme was overseen by Dr. Joan Palou (ES), Chair of the ESU; and Dr. Jorge Rodriguez (US), Secretary General of the CAU. On behalf of the EAU, Dr. Alberto Breda (ES), Dr. Richard Inman (GB), Dr. Palou, and Prof. Olivier Traxer (FR) presented lectures on urethral strictures, bulbar urethroplasty, and robotic-assisted laparoscopic prostatectomy to name a few.

Join the 6th edition of CAUREP Since its commencement in 2014, CAUREP attendance has increased year after year. The calibre of the speakers, the dedication of the faculty, the quality and relevance of the urological updates shared contribute to its growing success. From 2 to 5 October 2019, residents can look forward to the sixth edition of the CAUREP will take place in Buenos Aires, Argentina. Its Scientific Programme will focus on topics such as functional urology, laparoscopy, prostate cancer and urinary tract infections, to name a few. Stay tuned for more updates on the next CAUREP. More developments will unfold and posted on the CAUREP website www.caunet.org/en/.

In his lecture “Lymphadenectomy in prostate cancer”, Dr. Palou concluded that an extended pelvic lymph node dissection (PLND) still represents the gold standard for nodal staging in PCa patients. He added that the integration of surgery with postoperative therapies such as androgen-deprivation therapy (ADT) and radiotherapy in a multimodal setting substantially improves oncologic outcomes. Dr. Inman stated in his lecture “Current management of urethral stenosis” that no single repair is suitable for all strictures. He also advised to have a repertoire of techniques and to make sure that patients have realistic expectations especially regarding complex penile strictures.

CAU & EAU together at EAU19. (L to R) Drs. M. Torrico, J. Palou, J. Gutierrez, C. Chapple, A. Rodriguez, R. Rodriguez Lay

Vienna (AT)

Barcelona (ES) Vilnius (LT) Paris (FR) Manila (PH)

DECEMBER 2019 3-5 4 6

ART in Flexible - Step 2 Berlin (DE) ESU course on Functional reconstructive urology during Cairo (EG) the national congress of the Egyptian Association of Urology ESU course during the national congress of the Algiers (DZ) Algerian Association of Urology A panel member's perspective

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Pre- and post-pubertal fertility preservation in males Discussion about future opportunities for paediatric cancer patients to have children Dr. Christian Fuglesang Skjødt Jensen Dept. of Urology Herlev and Gentofte Hospital University of Copenhagen (DK)

step forward and the birth of healthy babies after round spermatid injection has been reported5, there still seems to be a long way to go for clinical application of in vitro maturation of SSCs for fertility preservation. This includes methods to achieve spermatid elongation and ways to establish genetic and epigenetic normality of the matured haploid cells.

Transplantation of SSCs is still a future prospect in humans but it has been reported in several animal models including Rhesus Macaque monkeys. After Thanks to modern radiation and chemotherapy, the autologous and allogenic transplantation of SSCs overall survival rate from childhood cancer has into the testes of both adult and pre-pubertal increased significantly. In developed European Rhesus Macaque monkeys it was demonstrated countries the overall five-year survival rate from that spermatogenesis was restored6. No studies on 1 childhood cancer exceeds 80% , giving rise to a large transplantation of human SSCs are registered in cohort of patients with an expected long life after clinicaltrials.gov. Just as in vitro maturation of SSCs, it may take some time before transplantation of cancer. human SSCs is available in clinical practice. The This highlights the need to focus more extensively on future success of SSC transplantation depends on technical development and thorough ethical quality of life after cancer treatment. Unfortunately, cancer therapy often has a negative effect on fertility considerations. One particularly important rendering the long-term cancer survivors infertile. Not challenge is to purify SSCs to ensure that no being able to have children as a consequence of malignant cells are re-introduced during cancer and cancer treatment is a serious psychological transplantation. It does however seem reasonable to assume that the progress being made will allow burden. Couples undergoing fertility treatment an opportunity for biological fatherhood when describe it as the most upsetting event they have today’s pre-pubertal boys with cancer reach experienced2. Therefore, a discussion of methods to preserve and/or restore fertility is an essential part of adulthood. This should be communicated to the cancer survivorship care. parents facing difficult decisions during their child’s cancer treatment. Fertility preservation in males is the process of saving spermatozoa or testis tissue with the aim of providing “Preserving or restoring fertility a future opportunity to father biological children. The standard fertility preservation technique is is an essential part of cancer cryopreservation of ejaculated semen. This is not survivorship care” always possible in paediatric patients making preand post-pubertal fertility preservation a challenging but nevertheless highly important task. Difficult and sensitive topic In post-pubertal boys, masturbation and Pre-pubertal fertility preservation cryopreservation of the ejaculated sample is the In boys facing cancer, a conversation to assess the absolute first choice. This can be a difficult and reproductive and sexual maturity should be sensitive topic to discuss with a pre-pubertal boy initiated as this might determine the strategy for and his parents and it is vital to ensure sufficient fertility preservation. Sometimes the boy is time for the consultation. In some cases, the boys unwilling to discuss experiences with ejaculation feel so uncomfortable that obtaining an ejaculate is and nocturnal emissions. It is important to know not possible. The next step is penile vibratory that large variations in maturity exist. The median stimulation (PVS). This involves the placement of a age of spermarche is approximately 13-14 years medical vibrator on the glans penis to initiate a with a range of 11-17 years3. Pre-pubertal boys do reflex ejaculation (Fig. 2). Typically, a peak-to-peak not have haploid spermatozoa and spermatids in amplitude of 1.5 mm and a frequency of 100 Hz is their testes. However, the presence of used7. An approach that is sometimes successful is spermatogonial stem cells (SSCs) makes to give the boy the vibrator and instruct him how to cryopreservation of pre-pubertal testis tissue for use it himself. When the boy returns with the fertility preservation purposes a promising ejaculate it might even turn out that the vibrator possibility. So far, this method is considered was not used after all, but it gave the boy experimental and should only be carried out as incitement to masturbate when his surroundings part of an approved study protocol. thought the vibrator was used. fullejensen@gmail.com

The procedure involves a testicular biopsy followed by in vitro expansion and cryopreservation of SSCs with the aim of performing future SSC autotransplantation to restore spermatogenesis or in vitro maturation of SSCs to spermatozoa. Testicular biopsy cryopreservation protocols are well-established. The procedure has been conducted for more than 10 years in some fertility centres around Europe. In Denmark 35 pre-pubertal boys have had their testis tissue cryopreserved while this number is around 100 in the Netherlands and Belgium. Post-thaw survival of SSCs from frozen pre-pubertal testis tissue is good (Fig. 1), but methods for transplantation and in vitro maturation of human SSCs are not established. Clinical application: a long way to go A recent study reported the in vitro generation of round spermatids (haploid germ cells) from pre-pubertal testis tissue from boys with cancer (age 2-12 years)4. Although this is an important

Fig. 2A: Illustration of penile vibratory stimulation (PVS) and the components of the initiated ejaculatory reflex. 2B: Illustration of the placement of the probe for electroejaculation (EEJ).

Conclusions Cancer survivorship care is increasingly important with the growing cohort of long-term childhood cancer survivors. Multi-modal cancer therapy often causes impaired fertility and parents and children should be counselled on these negative long-term sequelae and on options for fertility preservation. In pre-pubertal boys, testicular biopsy cryopreservation with the aim of autotransplantation or in vitro maturation of SSCs is a promising technique but is still considered experimental. In post-pubertal boys attempts to obtain an ejaculate through masturbation could be offered as a first choice followed by assisted ejaculation with PVS or EEJ. If these attempts fail, surgical sperm retrieval can be offered after careful counselling and discussion with the patient and his parents.

3.

4.

5.

6.

References 1. Winther JF, Kenborg L, Byrne J, Hjorth L, Kaatsch P, Kremer LC, et al. Childhood cancer survivor cohorts in Europe. Acta oncologica (Stockholm, Sweden). 2015;54(5):655-68. 2. Holley SR, Pasch LA, Bleil ME, Gregorich S, Katz PK, Adler NE. Prevalence and predictors of major depressive

7.

disorder for fertility treatment patients and their partners. Fertility and sterility. 2015;103(5):1332-9. Jorgensen M, Keiding N, Skakkebaek NE. Estimation of spermarche from longitudinal spermaturia data. Biometrics. 1991;47(1):177-93. de Michele F, Poels J, Vermeulen M, Ambroise J, Gruson D, Guiot Y, et al. Haploid Germ Cells Generated in Organotypic Culture of Testicular Tissue From Prepubertal Boys. Frontiers in physiology. 2018;9:1413. Tanaka A, Nagayoshi M, Takemoto Y, Tanaka I, Kusunoki H, Watanabe S, et al. Fourteen babies born after round spermatid injection into human oocytes. Proceedings of the National Academy of Sciences of the United States of America. 2015;112(47):14629-34. Hermann BP, Sukhwani M, Winkler F, Pascarella JN, Peters KA, Sheng Y, et al. Spermatogonial stem cell transplantation into rhesus testes regenerates spermatogenesis producing functional sperm. Cell stem cell. 2012;11(5):715-26. Schmiegelow ML, Sommer P, Carlsen E, Sonksen JO, Schmiegelow K, Muller JR. Penile vibratory stimulation and electroejaculation before anticancer therapy in two pubertal boys. Journal of pediatric hematology/oncology. 1998;20(5):429-30.

Methods of fertility preservation In cases of unsuccessful PVS, electroejaculation (EEJ) has proven an important method of post-pubertal fertility preservation. Under general anaesthesia, a rectal probe is placed with the electrodes in contact with the rectal mucosa in the area of the prostate and seminal vesicles (Fig. 2). Administration of a pulsatile pattern of stimulations will often produce an ejaculation. It is important to keep in mind that part of the ejaculate might be retrograde and subsequent catheterisation of the bladder should be performed. Several reports have demonstrated the feasibility of both PVS and EEJ. Unpublished data from a series of 21 Danish boys aged 10-13 years demonstrated successful PVS in five cases and successful EEJ in the remaining 16 cases (courtesy of Professor Jens Sønksen). The total number of spermatozoa ranged between 1-44 x 106 with 4-45 % motility. In cases of failed assisted ejaculation, surgical sperm retrieval is an option. This can be performed as a testicular sperm aspiration or testicular sperm extraction. Of note, these procedures might also be relevant for adult childhood cancer survivors having suffered gonadotoxic treatment without prior fertility preservation. In such cases, a microdissection testicular sperm extraction is also an option.

Fig. 1: Histological image of surviving spermatogonia after testis tissue cryopreservation (courtesy Prof. C. Yding Andersen)

March/May 2019

In summary, there are several options for postpubertal fertility preservation. It is vital that proper counselling of patients and their parents is performed whenever there is a risk of gonadal damage and fertility loss. Patients and their parents should preferably be referred to a reproduction specialist before initiating treatment to ensure optimal counselling. European Urology Today

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Treatment of simple urinary tract infections in Europe Different views share the same message: Avoid the use of fluoroquinolones, follow guidelines Dr. Aleko Khelaia Member, EAU Section of Urologists in Office National Center of Urology Dept. of Urology Tbilisi (GE) alekoxelaia@ gmail.com

nitrofurantoin and fosfomycin-trometamol. In some cases, only symptomatic relief of symptoms by nonsteroidal anti-inflammatory drugs (NSAIDs) and water intake increase are sufficient. We need to remember that UTI tends to recur, exclude all provocations and be familiar with non-antibiotic prophylaxis. We need to stop overtreatment of uncomplicated UTI and asymptomatic bacteriuria – we are very close to reaching the end of the era of antibiotics, if we aren’t already there.

A Georgian view Almost half of all women suffer from at least one episode of urinary tract infection (UTI) in their lives. Also specific subpopulations are at increased risk of UTI - infants, pregnant women, the elderly, patients with spinal cord injuries and/or catheters, patients with diabetes or multiple sclerosis, patients with acquired immunodeficiency disease syndrome/human immunodeficiency virus, and patients with underlying urological abnormalities. I would like to share some ideas about the management of uncomplicated UTI by urologists in office practice and emphasise that up to 20% of our patients suffer from this condition. The high frequency of uncomplicated UTI in adults and their overtreatment with antibiotics causes massive antibiotic-resistant bacteria in the population and collateral damage. Resilience of the dominant human faecal microbiotics takes several months after antibiotic treatment. In Georgia, as in many places in world, the most commonly prescribed antibiotics seem to be fluoroquinolones. According to my research in the database of one of the laboratories in Tbilisi, 35% of E. coli is resistant to all fluoroquinolones. During empirical treatment of UTI, the growing resistance to cotrimoxazole and ampicillin should be taken into consideration. And I have not even mentioned extended spectrum beta-lactamase producing (ESBLs) and carbapenemresistant Enterobacteriaceae (CRE). In 2015, we started implementing the EAU recommendations for uncomplicated UTI management in clinical practice of urologists in office, gynaecologists and primary-care physicians. We met more than one thousand doctors all around Georgia. The central goal of our mission was to switch prescriptions of broad-spectrum antibiotics to EAU Section for Urologists in Office (ESUO)

Dr. Athanasios Zachariou Board, EAU Section of Urologists in Office Dept. of Urology University of Ioannina Ioannina (GR) zahariou@otenet.gr A Hellenic view Uncomplicated UTI are among the most common bacterial infections seen in everyday practice. Greek urologists in office take care of a broad spectrum of patients, ranging from low-risk groups such as young adults to vulnerable populations such as elderly patients, spinal cord injury patients as well as patients requiring permanent or intermittent bladder catheterisation. Within a relatively short period of time, a substantial increase in the non-susceptibility rates of Gramnegative community-acquired uropathogens to most antibiotics, but especially to fluoroquinolones, was noted in Greece (figure 1). Local resistance patterns to antibiotics in Greece are a significant factor in the choice of management of UTI. The vicious circle of further resistance perpetuates and effective options are exhausted. Having that in mind, the antibiotic choice should be considered not only on efficacy and safety but also on the concept that broad-spectrum antibiotics should be used sparsely to safeguard their future effectiveness. Greece has high antibiotic consumption rates compared to other European countries, both in total and in outpatient clinics. In 2015, 1,242 Daily Defined Doses (DDD) were recorded per 1000 individuals in fluoroquinolones and 3,450 DDD/1,000 individuals for cephalosporins according to The Center for Disease

Figure 1

Figure 3: Index of total antibiotic prescriptions in the Netherlands

Dynamics Economics & Policy in our country. Reasons for increased antimicrobial resistance are manifold. Population mobility (immigration and tourism, because of the country’s geographic position) can introduce resistant strains. Moreover, the ease of procuring antibiotics without a prescription in Greek pharmacies results in excessive and unreasonable use. Even though the Greek Drug Administration (EOF) requires culture-directed selection of fluoroquinolones for UTIs to prevent their widespread use, some clinicians do not comply with the best practice recommendations and inappropriately circumvent these restrictions.

In recent years, however, two issues have changed our view on prescribing FQs: the growing drug resistance and the knowledge about possible side effects. The European Centre for Disease Prevention and Control publishes the palette of antibiotic resistance for different European countries annually. More information and education for urologists as well In Figure 2, the FQ resistance for E. coli in the different as general practitioners are a key measure to promote countries is depicted. There are geographical the rational prescription of antibiotics and should differences, and note that the general trend is rising help tackle the rise of antibiotic resistance in Greece. resistance.

Dr. Stefan Haensel Board, EAU Section of Urologists in Office Franciscus Hospital Dept. of Urology Rotterdam (NL) s.haensel@ franciscus.nl A Dutch view After the introduction and popularisation of the use of oral fluoroquinolones (FQs) in the treatment of UTI, well over half a million prescriptions were written annually in The Netherlands. That was almost 10% of

Figure 2

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

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European Urology Today

The relatively rare, but severe side effects of the FQs, such as tendonitis (including spontaneous Achilles tendon rupture), neuropathies, depression, impaired function of smell, taste and vision, have caused the European Medicines Agency to advise against the use of FQs in simple or recurrent lower UTI. In recent years, the prescription of FQs has reduced impressively (figure 3) in The Netherlands. Apart from avoiding these side effects, we could argue that this is one of the reasons why FQ resistance of E. coli remained relatively stable in recent years. In the guidelines of the Dutch general practitioners and urologists, the antibiotic treatment of UTI is nitrofurantoine (first choice), fosfomycin (second) or trimetoprim. In prevention, the focus is on improvement of fluid intake, treatment of obstipation, the use of cranberry derivates in recurrent E. coli infections and local treatment with estriol in postmenopausal women. The role of probiotics and other non-antibiotic regimens are frequently debated but failed to get a fixed place in the armamentarium of the office urologists in our country. Conclusion In the 2019 edition of the EAU Guidelines on Urological Infections, the recommendation of the management of uncomplicated cystitis is to use antimicrobial therapy that is guided by the spectrum and susceptibility patterns of the aetiological pathogens, efficacy, tolerability, adverse ecological effects, costs and availability. The use of fluoroquinolones is not considered to be first choice and should be kept on the shelf for special occasions, such as treatment of complicated UTI, rare resistance patterns or pyelonephritis. The Guidelines Committee recommends fosfomycin, pivmecillinam and nitrofurantoin as drugs of first choice. With the increasing resistance patterns of different bacteria and the increasing knowledge of the side effects and ecological burden of the antibiotics all over Europe, these guidelines should be followed accurately.

ResistanceMap: Antibiotic resistance. https://resistancemap.cddep.org/AntibioticUse. php. Date accessed: March 21, 2019.

Help urologists collect CME credits and register your activity today!

all antibiotic prescriptions in our country. This generally well-tolerated group of drugs with apparently little side effects was commonly used in the daily offices of general practitioners and urologists.

Have you moved? Changed name? New employer? Alter your personal data on-line: fast and easy - www.eu.acme.org March/May 2019


Tips & tricks to avoid complications, optimise management Neuro-urology connects both neurological and urological aspects of diagnosis and management Prof. Thomas M. Kessler Dept. of NeuroUrology Balgrist University Hospital University of Zürich (CH) tkessler@gmx.ch Due to the complex, still not fully understood multilevel control of the lower urinary tract, many neurological disorders such as multiple sclerosis, Parkinson’s disease, stroke, spinal cord injury, spina bifida, diabetic neuropathy, Alzheimer’s disease, etc. frequently result in neurogenic lower urinary tract dysfunction. The site and nature of the lesion in the neurological axis determine the type of lower urinary tract dysfunction (Figure 1) which is reflected in the patient’s symptoms1,2. Aims of neuro-urological management The aims of the neuro-urological management are to preserve upper urinary tract function, to control urinary tract infection, to improve quality of life, and to maintain a low-pressure bladder that is both continent and capable of emptying completely1,2. These goals are ideally achieved without an indwelling catheter or a stoma, and in a manner that is socially and vocationally acceptable to the patient, whilst avoiding complications such as recurrent urinary tract infections, urethral strictures, calculus disease, hydronephrosis, and renal failure. Basic assessments The cornerstone of neurogenic lower urinary tract assessment is history taking. It is necessary to gather information on congenital and neurological abnormalities, prior urogenital complications and treatments, medication, urinary tract, sexual, bowel, neurological and gynaecological function. Evaluation of lifestyle factors, such as smoking, alcohol, or addictive drugs, and quality of life are also important, and attention should be paid to physical and mental handicaps. Keeping a bladder diary is a highly useful tool in clinical practice since it provides an objective measure of lower urinary tract symptoms mirroring day-to-day reality. The patients’ symptoms often cannot be reproduced by clinical examination and urodynamics because of the extraordinary situation and the time limits of medical consultation. Physical examination includes the abdomen, flanks and external genital organs, as well as sensation and reflexes in the urogenital area (Figure 2). Anal sphincter and pelvic floor functions must be tested extensively. Urinalysis and urinary culture, blood chemistry (in case it is not already performed by the referring physician), free uroflowmetry and measurement of post-void residual volume (either by ultrasound or catheterisation) are part of the basic neuro-urological assessment. Specialized assessments Video-urodynamic investigation (i.e. urodynamic investigation with simultaneous fluoroscopic monitoring) is crucial to assess detrusor and bladder outlet function and it is essential for clinical decision making. Generally accepted risk factors jeopardising the upper urinary tract are high detrusor pressure during storage phase due to low compliance bladder and/or detrusor overactivity combined with detrusor sphincter dyssynergia. Importantly, urodynamic investigations are needed to identify these conditions. Urethro-cystoscopy (combined with bladder washing cytology if appropriate) is used if indicated to detect urethral and bladder pathologies, such as urethral stricture, urethral or bladder stones and bladder tumours, including carcinoma in situ. Estimation of renal function Serum creatinine, cystatin c and corresponding estimations yield a reasonable estimation of renal function with minimal cost and inconvenience. Creatinine clearance provides a more precise assessment but involves a 24-hour urine collection to measure creatinine excretion. This may result in underestimation of renal function if the urine collection is incomplete. The most accurate measurement is isotopic glomerular filtration rate, especially when renal function is poor or with alterations of muscle mass (this is common in patients with an underlying neurological disease). EAU Section of Female and Functional Urology

March/May 2019

Treatment of storage dysfunction In daily practice, it is straightforward to base the neuro-urological management on the clinical and urodynamic dysfunction pattern to determine the appropriate therapeutic strategy to preserve both upper and lower urinary tract function, and to achieve or maintain urinary continence. In patients with detrusor overactivity, the therapeutic concept is to convert the overactive into a normoactive or underactive detrusor. Although antimuscarinics are the pharmacological treatment of choice, they have limited effectiveness and many patients discontinue their use because of adverse events. The beta-3 adrenergic agonist mirabegron has recently been introduced as an alternative to antimuscarinics for treating the non-neurogenic overactive bladder, but research into its application in the neuro-urological patients is very limited. For refractory neurogenic detrusor overactivity, intradetrusor onabotulinumtoxinA injections are a highly effective, minimally invasive, and generally well-tolerated treatment that improves health-related quality of life. In the case of failed onabotulinumtoxinA treatment, augmentation cystoplasty is an established treatment option, but requires abdominal surgery with interposition of an intestinal segment (usually ileum) Figure 1: Patterns of lower urinary tract dysfunction following neurological disease (with permission from (1)) into the bladder and/or partial replacement of bladder by an intestinal substitute. In highly selected patients, cystectomy with continent or incontinent urinary diversion becomes necessary as a salvage procedure. In the case of stress urinary incontinence due to low bladder outlet resistance, electrical stimulation of the pelvic floor can help to restore urinary continence in patients with incomplete lesions. In some neurological patients, the implantation of a suburethral sling or an artificial urinary sphincter may become necessary. However, it needs to be considered that artificial urinary sphincters generally do not continue working indefinitely and the probability of revision surgery is high. Treatment of voiding dysfunction In patients with an underactive/acontractile detrusor and/or with detrusor sphincter dyssynergia, intermittent self-catheterisation is recommended to assist bladder emptying. Passive voiding by abdominal straining (Valsalva manoeuvre) or, particularly, by suprapubic downwards compression of the lower abdomen (Credé manoeuvre) is not recommended since it creates un-physiological and high intravesical pressure which puts the upper urinary tract at risk and causes compression of the urethra, i.e. a functional obstruction resulting in an inefficient emptying. Nevertheless, some patients are not able and/or not willing to perform intermittent self-catheterisation and therefore an indwelling transurethral or suprapubic catheter is potentially the only alternative. Regular follow-up In neuro-urology, regular follow-up is essential since neurogenic lower urinary tract dysfunction is often not stable and symptoms may vary considerably even within a relatively short period2. The EAU Guidelines on Neuro-Urology2 provide strong recommendations to perform urodynamic investigation as mandatory baseline diagnostic intervention, to instigate further, specialised, investigation in the case of any significant clinical changes, to perform a physical examination and laboratory urinalysis every year in high-risk patients. Also the upper urinary tract should be assessed at regular intervals in these patients.

Figure 2: Lumbosacral dermatomes, cutaneous nerves, and reflexes (with permission from (1))

from a young neuro-urology talent to the next International Neuro-Urology Society (INUS) Annual Congress, to be held in Istanbul, 23 to 25 January 2020 (www.neuro-uro.org). Please save the date and visit www.swisscontinencefoundation.ch for all information on the application and awarding criteria. Neuro-urology needs outstanding young researchers and clinicians – they are our speciality’s future! I am looking forward to receive your applications! References 1. Panicker JN, Fowler CJ, Kessler TM. Lower urinary tract dysfunction in the neurological patient: clinical

assessment and management. Lancet Neurol 2015; 14:720-32. 2. Groen J, Pannek J, Castro Diaz D, Del Popolo G, Gross T, Hamid R, Karsenty G, Kessler TM, Schneider M, t Hoen L, Blok B. Summary of European Association of Urology (EAU) Guidelines on Neuro-Urology. Eur Urol 2016; 69:324-33. 3. Mehnert U, Kessler TM. The Swiss Continence Foundation Award: promoting the next generation in neuro-urology and functional urology. BJU Int 2015; 115 Suppl 6:26-7.

However, taking into account the lack of studies with a high level of evidence, the follow-up of the neuro-urological patient is more eminence than evidence-based. There is no uniform follow-up and a rather individualised, patient-tailored approach aiming to achieve an optimum quality of life and to protect the upper and lower urinary tract is needed for this special patient population1,2. Swiss Continence Foundation Award Neuro-urology is a highly dynamic, rapidly developing and relevant speciality bridging both neurological and urological aspects of diagnosis and management. To be able to encounter the future challenges in neuro-urology, it is our responsibility to pave the way for further scientific and clinical developments and to support young talents in the field! Thus, I am delighted to announce the prestigious Swiss Continence Foundation Award (Figure 3) launched to promote the next generation in neuro-urology3. It comes with prize money in the amount of 10,000 Swiss francs and is awarded to the best contribution Figure 3: Swiss Continence Foundation Award European Urology Today

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

Oliver.Hakenberg@ med.uni-rostock.de

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

Case study No. 59

Case study No. 60 This 28-year-old man was referred with the incidental diagnosis of bilateral renal tumours. He was completely asymptomatic and there was no relevant personal or family history. Urine examination including urine cytology was negative, routine blood chemistry was also normal. According to the radiologists the tumours are not typical of renal cell carcinoma.

shown in fig.2, showing a rather small left paraaortic residual compared to the original mass, measuring 4x2 cm.

This 34-year-old man was treated for a testicular cancer und underwent left radical orchiectomy. The histopathology was pure seminoma, β-HCG was elevated around 400 and the CT scan at the time is shown below (fig.1).

Figure 1: Retroperitoneal mass before chemotherapy

The patient has a strong smoking history. He underwent four courses of PIE chemotherapy (cisplatinum, etoposide and ifosfamide) which were well tolerated. Tumour markers had normalised after the second course of chemotherapy. The post-chemotherapy CT scan is

Figure 2: Postchemotherapy CT showing relatively small residual mass

Discussion point: 1. What further treatment is advisable?

Case provided by Oliver Hakenberg, Dept. of Urology, Rostock University, Germany. Email: oliver. hakenberg@med.uni-rostock.de

RPLND because of ureteral compression Comments by Dr. Andreas Hiester Düsseldorf (DE)

First, the treatment of patients with metastatic seminoma should strictly follow the EAU guidelines. IGCCCG good risk patients are usually sufficiently treated with 3 x bleomycin, etoposide and cisplatin (BEP). In cases of a severe smoking history and pulmonary restrictions bleomycin should be avoided and the alternative of 4 x etoposide and cisplatin (PE) should have been given. Second, the current EAU guidelines recommend no primary resection of residual masses irrespective of size but it recommends to control tumour markers and to perform imaging1. In residual masses > 3 cm an FDG-PET is recommended to reveal vital tumour cells. However, the use of FDG-PET is controversial due to its relatively high false positive rate of 15%, in special occasions of up to 65%2. If patients with positive FDG-PET

undergo surgery to clarify the histology this may result in severe morbidity in up to 38%3, including nephrectomy, bowel resection and blood loss. Therefore, we recommend to use an algorithm to follow patients after chemotherapy for metastatic seminoma as published by Decoene et al.: If a FDG-PET is performed at all, it should be postponed at least 8 weeks after the end of chemotherapy. If a positive signal on FDG-PET is shown with a decreasing size as compared to the initial images, this should be followed by a second FDG-PET 6 weeks later. In cases of a still unclear signal, the EAU guidelines recommend a biopsy to ascertain the persistence of disease. Therefore, the indication for surgery is restricted to FDG-PET positive growing masses without tumour marker elevation and to patients with ureteral stents due to tumour compression during chemotherapy in order to perform a ureterolysis for stent removal. Reason for this is that a real seminoma persistence or recurrence should not be generally treated by surgery but by salvage chemotherapy (either 4 x TIP (paclitaxel, ifosfamide, cisplatinum) or high-dose chemotherapy).

This current patient presents with a residual mass of 4x2 cm paraaortic on the left side. The initial CT scan shows a large retroperitoneal mass with obvious compression of the left ureter. The residual mass still shows contact to the left ureter and the left ureter seems to be stented. The only reason to perform surgery is to avoid long term complication such as ureteral strictures or the permanent need of a ureteral stent. So, we would discuss a ureterolysis in cases of hydronephrosis after stent removal. A formal residual tumour resection is not necessary. References 1. Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, et al. Guidelines on Testicular Cancer: 2015 Update. European urology. 2015;68:1054-68. 2. Decoene J, Winter C, Albers P. False-positive fluorodeoxyglucose positron emission tomography results after chemotherapy in patients with metastatic seminoma. Urologic oncology. 2015;33:23 e15-23 e1. 3. Mosharafa AA, Foster RS, Leibovich BC, Bihrle R, Johnson C, Donohue JP. Is post-chemotherapy resection of seminomatous elements associated with higher acute morbidity? The Journal of urology. 2003;169:2126-8.

Follow-up with MRI or PET/CT Comments by Prof. Noel Clarke Manchester (UK)

This patient had Clinical Stage 2c Seminoma at first presentation. Although the size of the tumour looks as if the patients must have the highest risk, in fact the risk categorisation is “intermediate” i.e. the tumour is confined to the retroperitoneum, is above 5 cm and has elevation in LDH. The prognosis for a case of this type is for survival in excess of 90% at 2 years and 70% at 5 years1. Standard treatment is with systemic combination chemotherapy with 3 cycles of bleomycin, etoposide and cisplatinum (BEP) but in view of the heavy smoking habit and known pulmonary toxicity of bleomycin, many clinicians would use 4 cycles of EP, or would substitute ifosfamide for etoposide, as was used in this case. There has been significant shrinkage of the mass after treatment but there is a residual mass > 3cm in close approximation to the aorta and the left renal hilum. The likelihood is that this contains fibrous tissue after regression of the metastatic tumour. However, in postchemotherapy residual masses > 3 cm from

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European Urology Today

seminoma there is a risk of up to 20% that there is active tumour within the lesion. Notwithstanding this, the initial management of a case like this is for observation in the first instance, as excisional surgery is challenging because of post chemotherapy fibrosis, a particular feature of post-chemotherapy masses from Seminoma. Follow-up of this mass lesion should be with serial tumour marker measurement and interval cross-sectional scanning, initially every 3-4 months for the first 2 years. This has traditionally involved CT scanning but MR is also effective and this limits the patient’s exposure to ionising radiation. The scanning interval can be extended thereafter. FDG-PET scanning can be helpful; a negative scan is highly predictive for the absence of active malignancy. By contrast, a positive scan is much less reliable, as the inflammation associated with tumour regression can show activity leading to the erroneous conclusion that there is tumour present. If an FDG-PET is to be done, it should not be carried out less than 3 months after cessation of chemotherapy and a positive scan is not of itself an indication for surgical intervention. If the mass starts to re-grow it is highly likely that there is active disease present. Options for treatment in this scenario include 2nd line chemotherapy, retroperitoneal radiation or surgical excision. The latter two treatments are only appropriate if the disease remains confined to the retroperitoneum.

Figs. 1A and 1B: Abdominal CT scan and MRI of the right kidney

Decisions regarding treatment in this setting should be taken by a multi-disciplinary group in a testis cancer referral centre which treats this disease in high volume. In the event that surgery is required, provision should be made for the inevitable degree of complexity that would be involved. It is likely that the left kidney would need to be removed and there may be a necessity for en-bloc aortic excision and grafting as both of these structures are in immediate proximity to the tumour and are likely to be involved intimately with peri-tumoural fibrosis. Reference 1. ESMO Conference on Testicular Germ Cell Tumours: Diagnosis, treatment and follow up. Honecker F. et al. Annals of Oncology 2018.

Discussion points: 1. What is the diagnosis? 2. What treatment is advisable? 3. Is there a genetic background?

Case provided by Oliver Hakenberg, Dept. Of Urology, Rostock University, oliver.hakenberg@med.unirostock.de

Challenging clinical cases, comments and suggestions can be sent to: h.lurvink@uroweb.org We believe that a considerable number of EUT readers greatly appreciate this Clinical challenge section. In case you are interested to become involved as an expert reviewer, please let us know. We are most happy to have your input!

Case study No. 59 continued The patient underwent post-chemotherapy retroperitoneal lymphadenectomy because of ureteral compression by the residual mass. This mass completely enclosed the ureter and was removed together with ureterolysis. Histology showed avital tumour necrosis only. The double J-stent was removed 3 days after surgery.

Any comments or suggestions on articles in EUT are welcomed at: EUT@uroweb.org

March/May 2019


EAU RF launches PHOENIX registry Prospective registry for patients undergoing penile prosthesis implantation for erectile dysfunction Christien Caris, MSc Clinical Project Manager EAU Research Foundation Arnhem (NL)

Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL)

c.caris@uroweb.org

w.witjes@ uroweb.org

At the occasion of the Annual EAU Congress in Barcelona the first Phoenix investigator meeting took place. Phoenix is a recently initiated registry and short for ‘Prospective registry for patients undergoing penile prosthesis implantation for male erectile dysfunction’.

write a synopsis on patient and partner satisfaction as well as assess the mechanical reliability of the different PPIs on the market. The final goal is to demonstrate the effectiveness of this therapeutic option in patients with refractory Erectile Dysfunction (ED) who did not respond to previous treatments. Furthermore it should be possible to identify clinical The aim of the registry is to collect prospective data and surgical factors that correlate with patient from 1,000 patients with a penile prosthesis implant outcome, surgical complications and mechanical (PPI). The set-up includes collection of data on all PPIs reliability of the devices used in daily urological that are used in daily urological practice, and practice. It is expected that with the results, treatment therefore all surgeons who implant any of these recommendations and guidelines can be further prostheses are welcome to participate! This will improved, resulting in better care for this group of ED enable the EAU Research Foundation (EAU RF) to patients. During the well-attended investigator meeting the study protocol was presented and the attendees

EAU Research Foundation

participated in lively discussions. In this registry various patient questionnaires, related to sexual function, treatment satisfaction and quality of life, will be used. Since not all questionnaires are available in the required languages, the questionnaires will be professionally translated, using backward and forward translation, to ensure robust endpoint measurements. The EAU RF is keen to start this very interesting project. Once all translated documents are available, the aim is to submit the project for ethical approval and to start recruitment soon afterwards, hopefully during the third quarter of this year. Who can participate in collection of data and funding We aim at including all European centres who offer PPI to their patients with erectile dysfunction. High as well as low-volume centres can participate, in order to get a good representation of daily clinical practice. In the registry we will collect pre-defined parameters related to this kind of surgery. All registered penile implant devices used in daily urological practice should be included. No extra patient visits will be required to collect the data; patients are seen on a regular basis according to standard clinical practice. Patient inclusion should be consecutive.

Netherlands, France and the United Kingdom. Quite a few centres have also shown interest in setting up such a registry and are willing to participate by contributing their patient data after receipt of the patient’s consent. Additional participating centres are welcome! Companies producing PPIs will receive an invitation to assist in funding the registry - the first company has already agreed. Interested? Should you be interested in participating or funding this registry, please contact the EAU RF by sending an email to Ms. Christien Caris at C.Caris@uroweb.org. Principal Investigators: Dr. Koen Van Renterghem, Hasselt, Belgium Dr. Federico Deho, Milano, Italy Organisation: EAU Research Foundation

The initiative of this registry has been received with much interest from European urologists from e.g. Belgium, Italy, Germany, Denmark, Serbia, Spain, the

Berne Urological University Hospital EBU re-certified Department of Urology first in Switzerland to be EBU-certified in 2001 Prof. Fiona Burkhard University Hospital of Berne Dept. of Urology Anna Seiler-Haus Berne (CH) fiona.burkhard@ insel.ch

Prof. George Thalmann University Hospital of Berne Dept. of Urology Anna Seiler-Haus Berne (CH) george.thalmann@ insel.ch ˛ A wealthy childless widow, Anna Seiler, founded the Inselspital in Berne in 1354 to provide treatment for the poor. The Department of Urology at the University of Berne was established in 1943 and is located in the Anna Seiler Haus on the premises of the Inselspital (fig. 1). Prof. George N. Thalmann was nominated as chairman of the Department in 2010 after Prof. Urs E. Studer stepped down. The department has 37 beds in two wards with an intermediate care unit (4 beds) and a day-care clinic (6 beds). There is an outpatient clinic with a radiology unit with its own CT scanner where almost 12,000 patients are seen each year. In 2014, the Department of Urology in Berne was certified as the first uro-oncological centre in Switzerland by the German Cancer Society (DKG). The prostate cancer centre was certified at the same time.

clinic to the ward, OR, the intermediate care unit, urodynamic and stone centres. Significance EBU certification The EBU certification was an important step forward as it improved the training programme and introduced stringent quality control. The staff of the Department of Urology consists of 13 permanent staff members (2 full professors, 2 associate professors and 1 emeritus professor) and 17 residents in training. This ratio is important for the training programme as residents are regularly mentored, with one staff member mentoring up to 3 residents. Every staff member covers one day a week at the outpatient clinic, where he or she mainly consults patients requiring one of their specialities, assisted by a resident. Standard operating procedures are an important topic and are regularly reviewed according to guidelines and current literature. Surgical procedures are standardised as much as possible to allow for a clear and straightforward learning curve of the residents in training. Continuous education Another high priority of our institution is continuous education with postgraduate educational meetings for residents held once a week. Participation in the annual EBU In-Service Assessment is mandatory for all residents, as are the EBU Examinations in Urology. Furthermore, the Department of Urology in Berne is regularly present at all major national and international urological meetings, where the residents present their research results.

March/May 2019

Close collaboration The urological research laboratory works in close collaboration with the Department of Biomedical

Research (Prof. M. Rubin) of the University of Berne (CH) and is focused on urogenital cancers with a special focus on prostate and bladder cancer (Ass. Prof. M. de Julio Kruithof, Ass. Prof. R. Seiler, Prof. G. Thalmann), bladder function, bladder outlet obstruction and neurogenic bladder dysfunction (Prof. K. Monastyrskaya, Prof. F. Burkhard). Research is funded with national and international grants and supported by many national and international partnerships. Residents are thus exposed to and involved in research and participate actively in at least one project.

Get certification and become part of EBU’s training centre network At the European Board of Urology we envision that in the future urology training is of high quality, accessible and transparent in all European countries and that urology trainees and fellows have access to updated and comprehensive information about training opportunities in Europe. Contact us in case you are interested in: • •

Having your residency training programme evaluated by a professional body of experts and/or Attracting (inter)national fellows who are interested in high-quality training.

We certify Residency Training Programmes in Urology, as well as EBU-EAU Host Centres offering EUSP scholarships. Currently almost 100 European training centres are part of EBU’s network of certified centres. For more information visit our website www.ebu.com/certification-programmes/

European Urological Scholarship Programme (EUSP)

ESWL treatments The Department of Urology serves as a referral centre for approximately 1.5 million inhabitants. All aspects and subspecialties of urology are covered, with the exception of paediatric urology. Over 2,000 patients are treated each year on an inpatient basis leading to 10,000 hospitalisation days and 2,800 are seen on an outpatient basis. There are still 200 extracorporeal shock wave lithotripsy (ESWL) treatments performed per year and over 1,000 patients are treated in our day-care clinic. Residents in training rotate according to a predetermined schedule from the outpatient EBU Certified Centres

Important pillar Clinical and basic research remains an important pillar of our institution. For clinical research and quality control three full-time research nurses follow patients treated for oncological diseases or treated with novel treatment modalities, but they also work as data managers. Since certain clinically relevant questions can only be answered by large clinical studies, the Department of Urology is actively participating in European (EORTC, MRC) and national (Swiss Institute for Applied Cancer Research) cancer research organisations.

Do not forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme before 1 September. For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website www.uroweb.org/education/scholarship/ Urology University Clinic, Inselspital, Berne, Switzerland

European Urology Today

27


Young Urologists/Residents Corner Nightmare case: Rare gigantic emphysematous cystitis Symptomatology poor and nonspecific and early diagnosis is vital Dr. Rami Boulma FSI Hospital Dept. of Surgery TUNIS (TN)

rboulma@ hotmail.com Co-authors: Dr. Hassen Khouni and Bilel Saidani Emphysematous cystitis is a rare form of complicated infection of the urinary tract, characterised by the presence of gas within the bladder wall and the vesical lumen. It is a rapidly progressive disease that could be life-threatening. The prognosis depends on early diagnosis and rapid medical management. Nowadays, the place of non-surgical treatment is becoming more and more important. The aim of our work is to discuss diagnostic and therapeutic means of this potentially severe entity. Observations A 71-year-old man presented to the emergency department for weakness. He had a medical history of diabetes, rheumatoid arthritis, benign prostatic hypertrophy, and renal stones. He was taking corticosteroids and immunosuppressive medication. The physical examination showed an impaired general condition, a fever of 38.5 °C, a blood pressure of 80/50 mmHg, a pulse rate of 100 bpm, tenderness in the hypogastric abdominal area. The digital rectal examination showed a small prostate without any collection. The rest of the physical examination did not show any organ failure. Laboratory blood tests showed a hyperleukocytosis (19800/mm3), an elevated C-reactive protein (445 mg/L), hyperglycaemia (2.57 g/L), normal serum creatinine and liver enzymes. Urinalysis was positive for pyuria. Klebsiella pneumoniae was detected later in the urine culture. Abdominal ultrasonography showed bilateral renal stones with asymmetric hydronephrosis affecting mostly the left kidney. A computer tomodensitometry (CT) of the abdomen and the pelvis showed bilateral focal nephrite lesions without signs of abscess formation, bilateral small lower caliceal stones and many stones in the iliac and pelvic left ureter. The bladder was distended reaching the umbilical level, with gas inside both its lumen and wall (Fig 1, Fig 2). A hydroaeric level was noticed in the bladder with a dozen of punctiform stones above an increased prostate volume (Fig 3). The patient was transferred to the intensive care unit at the urology department. Intravenous broad-spectrum antibiotics were administered including imipenem and gentamycin. Fluids resuscitation and insulin for glucose control were administered. A bladder catheter was placed and drained urine with pneumaturia. Internal drainage of the left ureter was carried out by a ureteral double j stent. Strict clinical monitoring was undertaken. The clinical course showed apyrexia after 48 hours of antibiotics treatment, stabilisation of vital signs and regression of the inflammatory syndrome. The ultrasonography control of the bladder after ten

days attested disappearance of gas in the bladder lumen. After 14 days of hospitalisation the patient was dismissed with a negative urine culture. Antibiotic therapy was adapted, according to the antibiogram and oral amoxicillin + clavulanic acid was prescribed for 4 weeks. Discussion This case of gigantic emphysematous cystitis complicated by sepsis has been successfully resolved by nonsurgical treatment. Emphysematous cystitis is a rare and potentially serious disease that is part of the urinary tract infections7,12.It is characterised by the presence of gas in the bladder wall or in the lumen. The mechanism of gas formation is still unclear1,6,7,9.

Conclusion Emphysematous cystitis is a rare and potentially serious infection. The symptomatology is poor and nonspecific. Diagnosis is based on CT. Management of the infection tends to be conservative nowadays if it is diagnosed early. There is an interest in the development of biological infection markers which might make an important contribution to diagnosis in the future. Fig. 2: Sagittal view showing giant emphysematous cystitis at umbilicus level

Bacteria frequently found are aerobes like Escherichia coli (60%), Klebsiella pneumoniae (20%), Proteus spp., Clostridium perfringens, Enterobacter aerogenes and some types of streptococci4,9,12. In our patient, the urine culture showed a multisensitive Klebsiella pneumoniae causing this severe infection probably because of the immunosuppression. The presence of gas in the bladder can be explained by glycosuria used for bacterial fermentation, which leads to the formation of CO2 in the case of diabetes mellitus1,4,7. In non-diabetic patients, albumin and lactose present in the urine may serve as a substrate for pathogens. Another theory suggests that in the case of vascular disease, local inflammation or obstructive uropathology (conditions that increase local pressure or decrease tissue perfusion), there is a difficulty for gas elimination. This gas accumulates, increases pressure,reduces tissue perfusion, and induces ischemia of adjacent tissues. These tissues then provide a favourable environment for gas-producing bacteria4,7. The symptomatology of emphysematous cystitis varies and is nonspecific. Abdominal pain is found in 80% of cases, low urinary tract symptoms (dysuria, urinary burning pain) in 50% of cases; pneumaturia is reported in 10% of cases and sepsis is described in 4% of cases. The patient can be completely asymptomatic in 7% of cases. In our case, the patient only had fever and weakness2,6.

The biology exploration shows an inflammatory syndrome with elevated CRP and procalcitonin.

28

European Urology Today

The treatment is often medical and based on 3 pillars:

1) Antibiotic therapy Intravenous, broad-spectrum, synergistic and bactericidal as initial empirical therapy. Antibiotic therapy should be adapted based on the antibiogram followed by oral step-down therapy after obtaining apyrexia. The duration of antibiotic Epidemiologically, it occurs more frequently in diabetic therapy is poorly defined; literature data support women. The exact prevalence of the disease is not treatment between 3 and 6 weeks. known1. The other risk factors are lower urinary tract obstruction, chronic urinary tract infection, 2) Bladder drainage by an indwelling catheter neurological bladder dysfunction, immunodepression (malnutrition, alcohol, tumour disease, 3) Control of risk factors immunosuppressive treatment) and indwelling • Stabilisation of diabetes mellitus, and treatment of catheter1,4,9. Most of these risk factors (diabetes, immunodepression, prostatic hyperplasia) were the causal pathology should be planned after complete control of the infection2,3,7,13. identified in our case. • Surgery can be indicated in case of unfavourable evolution and occurrence of complications like bladder rupture and peritonitis1,5,6. • Finally, control CT should be systematically performed to monitor the progress.

Any delay in diagnosis may extend the infection to the ureters and the renal parenchyma and lead to serious complications, such as necrotising cystitis, emphysematous pyelonephritis, septicaemia, subcutaneous emphysema, bladder rupture and peritonitis1,2,3.

Fig. 1: Coronal view showing a 13 cm long giant bladder with gas inside and a protruding, median lobe

CT is sensitive and specific; it confirms the diagnosis, specifies the severity of the disease, identifies associated pyelonephritis and eliminates vesicodigestive fistula, which constitutes the main differential diagnosis. Pneumaturia can be present in case of instrumental iatrogenic, vesico-digestive fistula and emphysematous cystitis4,6,10.

KUB x-ray and Bladder ultrasound can show the gas in the lumen or the wall5,6. However, ultrasound is lacking sensitivity. The definitive diagnosis is based on abdominal CT scan.

References 1. Shimi A, Boumedian A, Elbakouri N, Derkaoui A, Khatouf M. Une cause rare du choc septique chez le diabétique: la cystite emphysémateuse compliquée d’une rupture vésicale. Pan African Medical Journal 2015:204.5. 2. Nejmeddine A, Atef B, Youssef D, Ramez B, Issam B M. Emphysematous cystitis of the diabetic patient: North American. Journal of Medical Sciences 2009;(1):114-6. 3. Barclay C J, Buchanan M Da, Steven C. Giant

Fig. 3: Transversal view showing an intra-vesical hydraulic level with presence of bladder stones

Emphysematous Cystitis. Visual Journal of Emergency Medicine 2016:47–48. 4. Gargouri M M, Abid K, Kallel Y , Ben Rhouma S, Chelif M , Nouira Y .Severe sepsis secondary to emphysematous Cystitis. African Journal of Urology.2015;(21): 41–3. 5. Gordona L, Gordond C. A rare x-ray image of emphysematous cystitis: Urolog. Case Reports 2019 ;(22):40–1. 6. Amano M, Shimizu T .Emphysematous Cystitis: A Review of the Literature. Intern Med 2014;(53):79-82. 7. Piraprez M, Ben Chehida M, Fillet M. La cystite emphysémateuse. Rev Med Liege 2017; 72(9): 384-7. 8. Santin A, Ovaska H, Mayer J, Renaud B. Emphysematous cystitis: Ann. Fr. Med. Urgence 2012 ;(2):111. 9. Li S X, Wang J, Hu J, He L, Wang C. Emphysematous pyelonephritis and cystitis: A case report and literature review. Journal of International Medical Research2018; 46(7):2954–60. 10. Dekeyzer S, Houthoofd B: emphysematous cystitis: Journal of the Belgian Society of Radiology 2018 ;( 66):1–2. 11. Coninck V, Michielsen D. Cystitis presenting as severe confusion and abdominal pain: two case reports. Journal of Medical Case Reports 2015 ;( 9):54. 12. Abusnina W, Shehata M, Nassri S, Zied F. Emphysematous cystitis Cleveland Clinic. Journal of Medicine2019 ;( 86):10-1. 13. Chen Y C, Chen H W, .Juan Y S, Wu W J,Tsai C C .Gaseous bladder tamponade secondary to emphysematous cystitis. Letter to the editor 2018; 44(3):653-4.

Apply for your EAU membership online!

Would you like to receive all the benefits of EAU membership, but have no time for tedious paperwork?

Becoming a member is now fast and easy! Go to www.uroweb.org and click EAU membership to apply online. It will only take you a couple of minutes to submit your application, the rest is for you to enjoy!

March/May 2019


Young Urologists/Residents Corner The BURST Collaborative: Progress and news Call for all residents to participate in the large prospective international multi-centre study IDENTIFY Dr. Sinan Khadhouri BURST Committee Urology Resident Aberdeen Royal Infirmary NHS Grampian Aberdeen (UK) sinan.khadhouri@ doctors.org.uk

Dr. Kevin Gallagher BURST Committee MRC Clinical Research Fellow & Urology Resident University of Edinburgh Edinburgh (UK) kevin.mjgallagher@ gmail.com

Dr. Veeru Kasivisvanathan BURST Chair Urology Resident Wexham Park Hospital and UCL London (UK) veeru.kasi@ucl.ac.uk The British Urology Researchers in Surgical Training (BURST), is an international group of urology residents, consultants and research methodologists (see column 4). We aim to deliver high quality international research and audit. What do we do? Collaborative research is a novel research model. Traditional research models have a risk of producing underpowered studies. Collaborative research has the ability to deliver large-scale multi-centre studies that can change clinical practice. The model implemented by BURST1, demonstrates how this works. We deliver fast, high quality research with definitive answers. This is embodied by the success of our recent studies MIMIC2 and IDENTIFY. A relatively small workload from each individual can scale up to a high-powered study in this model. BURST make it quick and simple to contribute to our user friendly online database RedCap®. We are passionate about recognising the input of our collaborators, with PubMed indexed collaborative authorship. Furthermore, opportunities to present the study are offered to collaborators outside of the study committee and the highest recruiting collaborators will be invited on to paper writing committees. Table 1: Recruitment numbers by country for the IDENTIFY study

How do I get involved with BURST? Following the “Dragon’s Den” project proposal competition in BAUS 2018 we are developing two new projects. The first aims to assess the use of ultrasound by urology residents in torsion diagnosis. The other aims to assess the optimal stent strategy post ureteroscopy. We will be recruiting sites and asking for your involvement within the next year. You are invited to attend the interactive BURST session at BAUS 2019 to discuss and develop these projects. BURST also has other projects to get involved in including an audit of androgen deprivation therapy, Fig. 3: IDENTIFY receiving 1st Prize Best Abstract by a resident and we welcome new ideas for projects. Email us at bursturology@gmail.com to join the mailing list and follow us on twitter @BURSTUrology for regular updates and to make sure you don’t miss out on any individualised diagnostic strategy, which will take into opportunities. account patient specific factors such as demographics, presentation and risk factors. The advantage of such a well-powered large-scale multi-centre study is two-fold: Firstly, the ability to investigate individualised diagnostic strategies in subgroups of patients and secondly, the ability to analyse the diagnosis of rarer urothelial cancers such as upper What is the IDENTIFY study? tract TCC. The Investigation and DEtection of Neoplasia in paTIents reFerred with suspected urinarY tract The study has now closed after recruiting 11000 cancer: a multi-center analysis (IDENTIFY) is the patients in 1 year from 27 countries (Table 1). This is current BURST collaborative study, which has just the largest ever prospective study on haematuria in finished data collection. IDENTIFY aims to personalise secondary care! haematuria investigation and reduce investigative burden. It aims to determine the prevalence of urinary IDENTIFY results are now being analysed by expert tract cancer in secondary care and to analyse the statisticians in conjunction with the BURST team. value of different diagnostic strategies in patients with Preliminary results were discussed and shared at EAU haematuria. This may help develop an optimal, 2019. IDENTIFY was successful enough to receive the Best Poster award in its session, as well as 1st Prize Best Abstract by a resident. We were also invited for an interview at EAU TV which should be available soon. The success of the study is down to the hard work and dedication of every one of our collaborators. The top recruiters were recognised and awarded Ranking Institute certificates at EAU 2019. (Table 2). Following EAU Vancouver General Hospital, 2019, IDENTIFY has been accepted for oral 1. Canada presentations at BAUS in Glasgow, AUA in Chicago, ASC in Bangkok, CUA in Quebec, ASiT in Belfast, RSM 2. Cattinara Hospital, Italy Urology in London and will be submitted to SIU in Athens. Many of our top recruiters (outside of the San Giovanni Battista 3. BURST committee) are presenting IDENTIFY at these Hospital, Italy conferences themselves. All collaborators will be recognised with PubMed indexed collaborator 4. University of Alberta, Canada authorship for any publications that result from this 5. Royal Derby Hospital, UK study. Key contributors will also be invited on the writing committee for publications. Western General Hospital, 6. UK The investigators and many others are excited to see Queen Alexandra Hospital, the anticipated results of IDENTIFY which is hoped to 7. UK change practice internationally in urinary tract cancer diagnosis. Salford Royal Foundation 8. Trust, UK More information about BURST and the IDENTIFY Fig. 1: Francesco Claps, GiancarloRoyal Marra and Matteo Boltri study is available on our website Doncaster Infirmary, 9. (clockwise) receiveUK awards for excellent recruitment in the (www.bursturology.com) Further questions and IDENTIFY study at the EAU investigators meeting queries can be sent to identifystudy@gmail.com. University of North Carolina, 10. USA Committee members Veeru Kasivisvanathan, Ben Lamb, Taimur Shah, Sinan Table 2: Top recruiters for the IDENTIFY study Khadhouri, Kevin Gallagher, Arjun Nambiar, Matthew Jefferies, Kenneth MacKenzie, Eleanor Zimmermann, Name Eric Edison, Chuanyu Gao, Sacha Moore Records

Ranking

Institute

1.

Vancouver General Hospital, Canada

Miles Mannas

436

Francesco Claps

356

2.

Cattinara Hospital, Italy

Mark Assmus

350

3.

San Giovanni Battista Hospital, Italy

Guiseppe La Montagna

296

4.

University of Alberta, Canada

Taeweon Lee

235

Tomas Austin

5.

Royal Derby Hospital, UK

230

Matteo Boltri

222

6.

Western General Hospital, UK

Alison Downey

212

7.

Queen Alexandra Hospital, UK

Nicholas Boxall

208

Nkwam Nkwam

205

8.

Salford Royal Foundation Trust, UK

Troy Sukhu

200

Antón Juanilla Marta

180

9.

Doncaster Royal Infirmary, UK

Sonpreet Rai

172

10.

University of North Carolina, USA

Yew Fung Chin

154

Madeline Moore

124

Country

Recruitment

1

UK

4857

2

Italy

1358

3

Canada

1021

4

Spain

707

5

USA

660

6

Ireland

268

7

Portugal

240

8

France

181

9

Turkey

180

10

Hong Kong

165

11

Slovenia

134

12

Argentina

113

13

Australia

105

14

Netherlands

104

15

Poland

102

16

Denmark

82

17

China

75

18

Hungary

56

19

Malaysia

51

20

Uruguay

51

21

Belgium

50

22

Croatia

50

23

Czech Republic

50

24

Greece

50

25

Iraq

50

26

Japan

50

27

Singapore

50

New members Nikita Bhat, Meghana Kulkarni, Luke Chan, Joseph Norris, Kieran Clement, Alexander Light, Chon Lam, William Cambridge, Keerthanaa Jayaraajan, Melissa Matthews Advisory board Hashim Ahmed, Ben Challacombe, Mark Emberton, Graeme MacLennan, Stephen Hughes In memory of: Prof. Robert Pickard References 1. Kasivisvanathan V, Ahmed H, Cashman S et al. The British Urology Researchers in Surgical Training (BURST) Research Collaborative: an alternative research model for carrying out large scale multi-centre urological studies. BJU Int 2017. doi:10.1111/bju.14040. 2. Shah T, O’Keefe A, Gao C et al. A multi-centre cohort study evaluating the role of inflammatory markers in patients presenting with acute ureteric colic (MIMIC) Eur Urol Suppl 2017; 16:e723-4.

Fig. 2: BURST members at EAU19

European Urology Today

March/May 2019 Name

Table 3: Top recruiting institutes

Records

29


USANZ Trainee Week ‘A long flight, rewarded by a fantastic learning experience’ Dr. Nishant Bedi Imperial NHS Trust Charing Cross Hospital Dept. of Urology London (UK) nishbedi@ hotmail.com

The direct flight from Heathrow to Perth is currently one of the longest commercial flights in the world with a duration of 17 hours 20 minutes. Coming from London’s dreary November to 30 degrees and sunshine softened the landing nicely. Meeting the USANZ organisers, who were friendly and had been meticulous in planning our trainee week made me forget the flight very quickly. Wide range of subjects The trainee week started on Sunday morning for the senior trainees, with practice viva exams to help prepare them for their oral examinations. The viva subjects were anatomy, pathology, ‘structured oral’ or short cases, and ‘CIM’ or imaging. The candidates were tested on a range of surgical

European Urological Scholarship Programme Office

anatomy and pathology subjects, from the renal hilum or the fascial planes involved in Fournier’s gangrene to the aetiology of a deep vein thrombosis (DVT). Other topics varied from history and outpatient management of overactive bladder to surgical approaches for a neobladder. The syllabus reflects a mixture between the two systems of European and American guidelines, which provided some interesting comparisons. For example prostate cancer diagnostics currently have very different pathways, with the Americans favouring initial transrectal biopsies and most UK / European centres moving towards pre-biopsy multiparametric MRI. Modern teaching format The week followed an excellent, modern teaching format with a variety of teaching styles. There was a mixture of presentations and teaching from consultants and micro-teaching from trainees. Breakaway sessions were planned to allow for small group discussion of cases and examination technique. Topics covered the breadth of urology, with multiple choice, viva and essay questions. As essay questions are not included in the European exam, this proved an unfamiliar challenge. Answering the essay questions required detailed knowledge of all treatment options along with a structured approach to communicate them to the patient. The final session of the week was a fantastic, fancy dress game-showstyle quiz named “Masters of the Uroverse”. All six regions were pitted against each other, with the home team eventually ending first.

The author and some of the other lucky international trainees at the Trainee Week

Great opportunity In total there were approximately 90 delegates with 30 faculty present at the USANZ trainee week. The group of international trainees included delegates from Canada, Nepal, China, Bangladesh, Indonesia and Portugal. There were also approximately 20 trade reps on the Wednesday and Thursday. The six USANZ regions New South Wales (NSW), Victoria (VIC), Southern Australia (SA), Queensland (QLD), Western Australia (WA) and New Zealand (N) were all represented. There were several social events with the opportunity to meet the trainees. We explored the local

area of Fremantle, visited the famous “Little Creatures” brewery and made a trip to Perth city, where our final dinner was held in the beautiful Kings Park. USANZ trainee week was a fantastic learning experience and the local trainees and faculty were all friendly and welcoming. I would highly recommend this week to any trainees should they get the opportunity to attend it in the future. For further information on participating in the next USANZ trainee week, please contact Ms. Angela Terberg at a.terberg@uroweb.org

Robotic flexible ureteroscopic stone management Higher success rates with better ergonomic conditions for the surgeon Kemal Sarica Chairman, EAU Section of Urolithiasis Dept. of Urology Kafkas University Medical School Kars (TR) saricakemal@ gmail.com Marked developments in medical technology enabled the clinical use of smaller diameter flexible endoscopes rather than flexible gastroscopes and colonoscopies. These endoscopes are called ‘flexible ureterorenoscopes’ and can be inserted into the ureter thanks to their diameter of less than 3 mm. Development and effective use of such fine and smaller flexible ureterorenoscopes (fURS) resulted in the clinical introduction of the ‘retrograde intrarenal surgery’ (RIRS) method. This allows reaching up to the renal collecting system in a very practical and minimally invasive manner through natural urinary channels, namely bladder and ureter, without puncturing or cutting the patient. Easy passage of ‘laser fibre’ through these endoscopes has further enabled pulverising the stones in the pelvis and calyx in the kidneys involved. Manipulation of flexible ureteroendoscopes Because of the accumulated experience over the last 10-15 years, minimally invasive management of kidney stones with flexible ureteroscopy became widely used. Endo-urologists also began treating relatively larger and/or multiple stones with this modality. However, it is well-known that the manipulation of such flexible ureterorenoscopes by hand is extremely difficult and tiresome particularly during long-lasting procedures. The surgeon should wear a lead apron and sterile surgical gowns during the RIRS for radiation protection. Once the stone is reached, the endo-urologist should keep this extremely difficult standing position during the fine dusting procedure of the stone(s) with Holmium YAG laser by making precise movements for a reasonable period of time. This is highly important when using this method to disintegrate larger stones and it can sometimes take as long as 2 hours. On the other hand, the learning curve of RIRS is very long. To gain enough experience in flexible EAU Section of Urolithiasis (EULIS)

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European Urology Today

ureteroscopic procedures, a surgeon may require 40-50 cases to obtain the aimed experience for successful and safe procedures. Additionally, the data published so far and the clinical experience observed clearly show that flexible ureteroscopes are highly precise and fragile instruments which may not be cost-effective because of misuse. It is possible to damage the endoscope even the first time. Studies show that the life of an endoscope is limited to 30-40 cases, even if they are used carefully.

reduce the risk of radiation exposure. This ergonomic, comfortable position highly simplifies orientation with the help of 3D-simulation of endoscope and kidney. Moreover and more importantly, the learning curve of the RIRS method will be shortened due the facts mentioned above.

Regarding the procedure-related factors, which may certainly effect the final outcome of the procedure, use of a robotic system for fURS will provide 24 times more precise manipulation than manual precision Use of robots and allows surgeons to perform more operations To overcome all these limitations, procedure-related without getting tired compared to manually problems and high cost issues, the use of robots is performed procedures. As a result of all these rapidly becoming widespread throughout the world in advantages this approach will provide easy, safe and all areas of surgery including endourology. Leading successful treatment of even larger as well as multiple calyceal systems of the urologists also say that 'robotic surgery is the future of stones located in different 1097 endourology'. Robotic flexible ureteroscopy offers kidneys. Finally, while being aware of all these Table 3 – Comparison of conventional and robot-assisted flexible ureteroscopy using a validated questionnaire concerning ergonomics of advantages which lead to high success and lower many advantages for the treated patients. It may endourology Surgeon surgeons to carry B.E. K.S treatment R.S. Z.T. J.J.R O.T.rates, robotic Mean complication treatments are also enable outA.Y.M the whole extremely attractive to patients looking for new without cutting the patient and/or puncturing the technologies. kidney and eliminate the related risks with regard to morphology as well as function of the affected kidney. Robot increases lifetime This enables the patients to return quickly to their Last but not least, extremely expensive and fragile daily lives, thanks to rapid healing, and obtain a endoscopes which are sometimes very costly for the higher quality-of-life status. This approach also increases the success of stone free rates after the first institutions to purchase and/or renew, are protected by the robot. This results in an increased lifetime, session of the procedure and enables shortening the duration of treatment which will eventually reduce the approximately 10 times longer compared to when procedures are done by hand, which is 20-30 cases exposure of radiation applied to patient. according to the literature. This will reduce the overall operational cost both for the institution and for the Advantage for surgeon patients. Due to its shorter learning curve, the The advantages for the operating surgeon include sitting on an ergonomic control console, which allows number of surgeons performing the RIRS procedure will increase and the procedure can be applied even him/her to work without fatigue or loss of in peripheral hospitals, which will reduce the gap concentration. Operating on a console in a relatively between the regions. distant position from the radiation source will again EUROPEAN UROLOGY 66 (2014) 1092–1100

Age, yr 51 FURS experience, yr 16 FURS workload, h/wk 10 Classic FURS, complaints (0–5) Musculoskeletal pain 3 Neck pain 3 Shoulder stiffness 5 Arm pain 5 Forearm pain 5 Elbow stiffness 5 Hand pain 3 Wrist stiffness 3 Finger numbness 1 Back pain 3 Leg pain 2 Eye strain 0 Total score 38 Robot-assisted FURS, complaints (0–5) Musculoskeletal pain 0 Neck pain 0 Shoulder stiffness 2 Arm pain 2 Forearm pain 2 Elbow stiffness 2 Hand pain 2 Wrist stiffness 0 Finger numbness 0 Back pain 0 Leg pain 0 Eye strain 0 Total score 10

52 7 12

50 10 15

67 5 7

40 5 10

59 16 6

46 15 18

52.14 10.57 11.14

3 2 3 3 3 2 3 4 2 1 2 2 30

3 2 3 3 3 2 3 4 2 1 2 2 30

3 2 4 4 3 2 3 3 1 2 2 2 31

3 2 2 3 3 2 4 3 3 3 3 3 34

3 3 3 3 4 4 4 4 3 3 4 2 40

1 1 1 1 1 2 2 1 2 1 2 1 16

2.71 2.14 3.00 3.14 3.14 2.71 3.14 3.14 2.00 2.00 2.43 1.71 31.3*

1 0 0 1 1 0 0 0 1 0 0 1 5

0 0 0 1 1 0 0 0 1 0 0 1 4

0 0 1 1 0 0 0 0 1 0 0 0 3

0 1 0 0 0 0 1 1 1 0 0 2 6

0 1 0 0 0 0 1 0 1 1 2 1 7

0 0 0 0 0 0 1 1 1 0 0 1 4

0.14 0.29 0.43 0.71 0.57 0.29 0.71 0.29 0.86 0.14 0.29 0.86 5.6*

FURS = flexible ureteroscopy. Classic FURS evaluated the last 10 cases performed at surgeon‘s institution; robot-assisted FURS evaluated all individually performed cases. p < 0.01.

*

Advantages of Flexible Ureteroscopy (fURS) Robot Avicenna Roboflex • provides better treatment • is able to rotate more than manual (3.5 times more) - manually 120o rotation - robotically 440o rotation (almost 1¼ turn) • gives more precise deflection - manually 10o deflects the tip 60o - robotically 10o deflects the tip up to 2.5o It means that Roboflex is 24 times more precise than manual. The surgeon can manipulate and control all parameters of the procedure from the ‘Control Console’ in a very comfortable sitting position, e.g. the precise in/out movement of the endoscope by selecting a speed between 0.5 mm and 20 mm/sec, the precise movement of the laser fibre and finally irrigation fluid activation and selection of flow speed on demand based on to the course of stone disintegration. Another very important advantage of this system is ‘the interchangeable flexible ureteroscope holder’ which enables using all brands and models of flexible URS available on the market. In summary, robotic flexible ureteroscopic stone management with the Avicenna Robotic fURS system will enable endourologists to treat large as well as multiple kidney stones in an effective manner by providing improved ergonomic conditions. Additionally the durability of the flexible scopes will improve and result in a cost-effective procedure for the institutions.

Table 4 – Summary of results of robot-assisted flexible ureteroscopy (n = 81) Criteria

Range

SD

Treatment time, min Time docking robot, s Time to visualize stone, min Fragmentation time, min Fragmentation speed, mm3/min Console time, min Complications

74 59.6 3.7 46 29.1 53 1

Value

40–182 35–124 2–8 18–115 18–46 23–135 –

31.8 45 1.4 21.7 6.1 23.2 –

Comparison of ergonomics, score Classic FURS

31.3

16–40

7.8

Robotic FURS Retreatment Nonfunctioning of robot Stone free at 3 mo

5.6 2 None 65 (80%)

3–10 – – –

2.4 – – –

Comment Inclusive access sheath and DJ stent 46 s after 42 cases Including complete inspection of collecting system Depending on stone size Increasing to 32.7 mm3/min after 42 cases Depending on stone size, learning curve Failure of endoscope (case 42), classic FURS not possible; placement of DJ stent Based on last 10 cases performed by each surgeon at own institution Based on immediate evaluation Classic FURS – 16 patients (20%) with clinically insignificant residual fragments

FURS = flexible ureteroscopy; SD = standard deviation.

Saglam R, Muslumanoglu AY, Tokatlı Z, Caşkurlu T, Sarica K, Taşçi Aİ, Erkurt B, Süer E, Kabakci AS, Preminger G, Traxer O, Rassweiler JJ. A new robot for flexible ureteroscopy: development and early clinical results (IDEAL stage 1-2b). Eur Urol. 2014 Dec;66(6):1092-100. doi: 10.1016/ j.eururo.2014.06.047. Epub 2014 Jul 21. PubMed PMID: 25059998.

The ergonomic position of the surgeon and the use of 3D-simulation improves orientation

March/May 2019


BCG biomarker research profits from NIMBUS trial Substudies enable validation of genetic and immune-related markers of BCG response Dr. Sita Vermeulen Assoc. Prof. of Genetic Epidemiology Dept. for Health Evidence Radboudumc Nijmegen (NL) Sita.Vermeulen@ radboudumc.nl

Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ uroweb.org

1) Induction cycle BCG-full dose; wks 1 through 6 plus maintenance cycles at months 3, 6 and 12 (wks 1,2,3); total 15 full doses. 2) Induction cycle BCG-full dose (reduced frequency); wks 1,2,6 plus maintenance cycles at months 3,6 and 12 (wks. 1,3); total 9 full doses. The NIMBUS trial is actively recruiting in Germany, the Netherlands, France, Belgium and Spain. Italy and Turkey are starting up and the first patients from these countries are expected beginning 2019. Until now, a total of number of 328 patients is recruited from Germany (145), the Netherlands (107), France (62), Belgium (13) and Spain (1) (cut-off date 19Apr19). Extensive evaluation of germline DNA variants for BCG response markers The BCG-induced immune response in a patient may be heavily affected by germline DNA variation. The study of germline DNA variants as BCG response markers can profit from some important advantages over other, e.g. urine-based immune-response, markers including pre-treatment availability, high measurement accuracy, the ease of studying many markers simultaneously, and marker stability over time. The majority of previous studies into DNA variants for BCG response are however limited in number and scope, measure just one or a few variants in selected candidate genes (inflammatory, DNA-repair, cell cycle-control), are strongly underpowered, and often lack replication3.

urine sample is collected from a subset of NIMBUS patients (in both the standard and reduced frequency arm) prior to each instillation and a one spot urine sample between 4 and 8 hours after each instillation, both during the induction and maintenance period. There is ample evidence that activation of a Th1 immune response is required for clinical efficacy of BCG1,2. The Th1 response results in the production of cytokines such as interferon (IFN)-γ, interleukin (IL)-2 and IL-12 which favour the development of cellular immune responses which may then generate tumour-specific immunity and bladder tumour–killing cells comparable to lymphokine-activated killer cells8,9. Development of the cytokine response might depend on the time interval during sensitisation and 2014;11(3):153-62. challenge. IL-2 production can be down-regulated by 2. Pettenati C, Ingersoll MA. Mechanisms of BCG immunotherapy and its outlook for bladder cancer. repeated instillations with a short interval, Nature reviews Urology. 2018;15(10):615-25. presumably as a result of expression of regulatory 3. Grotenhuis AJ, Dudek AM, Verhaegh GW, Aben KK, Witjes cytokines10. JA, Kiemeney LA, Vermeulen SH. Independent

Replication of Published Germline Polymorphisms IL-2 was detected after the first BCG instillation in Associated with Urinary Bladder Cancer Prognosis and NMIBC patients , however levels fell after the second Treatment Response. Bladder Cancer. 2016;2(1):77-89. and third instillations in both responders and 4. Hirschhorn JN, Gajdos ZKZ. Genome-Wide Association non-responders11. Comparison of urinary IL-2 Dr. Wim Witjes Studies: Results from the First Few Years and Potential induction patterns during a repeat course with the Scientific and Clinical Implications for Clinical Medicine. Annu Rev Med. initial BCG induction revealed that levels tended to be Research Director 2011;62:11-24. higher during the first and lower during the last EAU Research 5. Zuiverloon TC, Nieuweboer AJ, Vekony H, Kirkels WJ, weeks. These observations suggested an accelerated Foundation Bangma CH, Zwarthoff EC. Markers predicting response induction of urinary IL-2 during a subsequent Arnhem (NL) to bacillus Calmette-Guerin immunotherapy in high-risk instillation course of BCG10. However, there is also evidence in the literature that repeated instillations bladder cancer patients: a systematic review. European may down-regulate the response after a certain urology. 2012;61(1):128-45. w.witjes@ number12. Similar levels of IFN-γ, IL-2 and IL-12 (Th1) 6. Kamat AM, Briggman J, Urbauer DL, Svatek R, Nogueras Agnostic, systematic searches of germline DNA uroweb.org Gonzalez GM, Anderson R, Grossman HB, Prat F, Dinney mRNA induction after a schedule of only two BCG variation via genome-wide association studies CP. Cytokine Panel for Response to Intravesical Therapy instillations administered in week 1 and 6 (1+6 (GWAS) have proven their value over candidate gene (CyPRIT): Nomogram of Changes in Urinary Cytokine schedule), compared to 6 weekly instillations were studies4 and we and others are currently working Levels Predicts Patient Response to Bacillus Calmettetowards a first GWAS for BCG response. Collaboration demonstrated in an animal study8. Significantly lower levels of the Th2 cytokines of IL-10 and IL-4 mRNA in Guerin. European urology. 2016;69(2):197-200. Introduction is pivotal in such an initiative, as thousands of DNA Transurethral resection of the tumour followed by samples from well-defined patient series are required the 1+6 schedule were also observed. Since a reduced 7. Arts RJW, Carvalho A, La Rocca C, Palma C, Rodrigues F, number of instillations could provide equivalent Th1 Silvestre R, Kleinnijenhuis J, Lachmandas E, Goncalves intravesical Bacillus Calmette-Guérin (BCG) for a powerful discovery and replication analysis. In cytokine expression as the standard regimen and the LG, Belinha A, Cunha C, Oosting M, Joosten LAB, immunotherapy is currently considered standard addition to several existing NMIBC biorepositories in BCG-induced Th1/Th2 cytokine ratio was associated Matarese G, van Crevel R, Netea MG. Immunometabolic treatment for the 20% of bladder cancer patients with Europe and the US, the NIMBUS trial is one of the with effective anti-tumour activity13, a novel strategy, Pathways in BCG-Induced Trained Immunity. Cell reports. high-risk non-muscle-invasive bladder cancer (NMIBC), contributors within the GWAS consortium. 2016;17(10):2562-71. i.e. reduced number of instillations (as evaluated including lamina-propria-invasive (stage T1) tumours, 8. de Boer EC, Rooyakkers SJ, Schamhart DH, de Reijke TM, high-grade tumours, and carcinoma in situ. However, within NIMBUS), may provide an alternative way of NIMBUS DNA substudy: Validation of predictive Kurth KH. BCG dose reduction by decreasing the BCG dose reduction. 50% and 15% of BCG-treated patients experience genetic markers for BCG response instillation frequency: effects on local Th1/Th2 cytokine recurrence and progression, respectively. Unfortunately, Preliminary analyses of genome-wide association responses in a mouse model. European urology. The cytokine substudy investigation is thus based on even after decades of clinical experience with BCG study (GWAS) data of a subset of 250 high-risk 2005;48(2):333-8. the hypothesis that after an initial BCG instillation that therapy, urologists still do not have the tools to identify BCG-treated NMIBC patients within the BCG GWAS 9. Thalmann GN, Dewald B, Baggiolini M, Studer UE. BCG-non-responsive NMIBC patients for whom consortium revealed several interesting association provides sensitisation, the number of subsequent alternative treatment is preferred and to optimize BCG Interleukin-8 expression in the urine after bacillus signals in relation to BCG recurrence and progression. instillations can be reduced for a proper anamnestic Calmette-Guerin therapy: a potential prognostic factor of therapy in terms of dose and frequency. With novel Final analyses in the large patient sample will require immune response. This will then be reflected in a tumor recurrence and progression. The Journal of similar Th1 and a more favourable Th2 cytokine immunotherapies for high-risk NMIBC on the horizon, extensive validation to distinguish true from response at the end of the 6th week and 3rd week of urology. 1997;158(4):1340-4. the need for these tools becomes even more pressing. false-positive findings. This validation will greatly benefit from DNA collection in the context of maintenance in the reduced compared to the standard 10. de Reijke TM, de Boer EC, Kurth KH, Schamhart DHJ. randomised clinical trials, characterised by BCG treatment arm. Urinary interleukin-2 monitoring during prolonged Lack of effective immune response bacillus Calmette-Guerin treatment: Can it predict the It is generally accepted that BCG non-response is due standardised treatment schedules and prospective optimal number of instillations? J Urology. 1999;161(1):67to the inability of an individual to have a BCG-induced documentation of BCG response. The DNA substudy in Identification and validation of biomarkers that allow for selection of patients that profit from BCG the NIMBUS trial will provide valuable samples for 71. effective immune response against the (residual) treatment is relevant but challenging. There is great 11. Saint F, Kurth N, Maille P, Vordos D, Hoznek A, Soyeux P, tumour cells. What an effective BCG immune response validation of the most promising GWAS signals. benefit in collection of biospecimens in the context of Patard JJ, Abbou CC, Chopin DK. Urinary IL-2 assay for exactly entails is unclear. However it is recognised Validation of promising immune-related biomarkers randomised clinical trials, not only in terms of monitoring intravesical bacillus Calmette-Guerin that, subsequently, the attachment of BCG to potential numbers but also because of the for response response of superficial bladder cancer during induction urothelial cells, internalisation of BCG by bladder standardised treatment schedules and prospective Numerous clinical studies have built on mechanistic course and maintenance therapy. International Journal of cancer cells and stimulation of the immune system insights on the relevance of specific immune response documentation of BCG response. As the NIMBUS trial Cancer. 2003;107(3):434-40. are of relevance. For the latter, the importance of provides access to large, well-defined patient series, 12. Saint F, Patard JJ, Maille P, Soyeux P, Hoznek A, Salomon processes and have evaluated immune-related BCG secretion of cytokines, innate immune cell BCG biomarker research will highly profit from the response biomarkers in blood, urine and tumour L, De La Taille A, Abbou CC, Chopin DK. T helper 1/2 recruitment, recognition of the MHC-II BCG-antigen substudies within this trial. We encourage other lymphocyte urinary cytokine profiles in responding and tissue of BCG-treated patient series. These studies complex by CD4+ cells, a shift towards a type 1 have, however, been hampered by limited availability ongoing and future trials to facilitate biomarker nonresponding patients after 1 and 2 courses of bacillus T-helper cell response and tumour cell killing by of relevant biospecimens and analytical validity issues, studies as well. Calmette-Guerin for superficial bladder cancer. J Urology. CD8+ T-cells and NK-cells have been described, 2001;166(6):2142-7. leading to many small, single marker studies and mainly based on pre-clinical in vitro and animal 13. Riemensberger J, Bohle A, Brandau S. IFN-gamma and unreplicated findings that have had no clinical impact References studies1,2. This highlights the complexity of the BCG IL-12 but not IL-10 are required for local tumour response trait and the challenge for identification of so far5. However, the recently published CyPRIT 1. Redelman-Sidi G, Glickman MS, Bochner BH. The relevant response markers. nomogram holds promise6 and warrants replication. mechanism of action of BCG therapy for bladder surveillance in a syngeneic model of orthotopic bladder The nomogram is based on a score that reflects cancer--a current perspective. Nature reviews Urology. cancer. Clin Exp Immunol. 2002;127(1):20-6. Our research group aims to contribute to the changes in 9 urinary cytokines during BCG treatment identification of BCG response markers via a number and was constructed in a cohort consisting of 125 of approaches, including identification of germline patients that were treated according to regular clinical DNA variants for BCG response and validation of practice. We set out to validate CyPRIT in comparable, promising immune-related biomarkers. For both independent patient series as part of the Tribute study, approaches we have the necessary access to large, an observational Dutch multicentre study among well-defined patient series and can profit from high-risk NMIBC patients that is focused on evaluation substudies in the NIMBUS trial. of the role of ‘trained immunity’7 in BCG response in NMIBC, and the NIMBUS trial. For the latter, urine NIMBUS trial collection was initially initiated in light of a substudy The NIMBUS trial assesses whether a reduced number into the effect of BCG instillation frequencies on The SATURN Registry evaluates the cure rate of surgical procedures for treatment of Male Stress cytokine responses throughout treatment. The urine of BCG instillations is not inferior to standard number Urinary Incontinence. The study has started in 15 sites from Belgium, Czech Republic, Germany, collection, however, also offers excellent opportunity and dose intravesical BCG treatment in patients with for replication of the CyPRIT panel. high-grade NMIBC. The aim is to enrol 824 BCG-naive the Netherlands, Norway, Spain and the United Kingdom. New sites from Belgium, Finland, patients with HG Ta-T1 NMIBC with or without CIS. France, Germany, Italy, Norway, Spain, United Kingdom and Sweden will become active in near NIMBUS Cytokine substudy: Prospective evaluation NIMBUS is a multicentre, prospective, randomised, future. parallel group, not blinded trial to compare the efficacy of cytokines following BCG instillations Some selected NIMBUS centres participate in an and safety of two adjuvant treatment schedules: For more information, please visit the EAU RF website http://uroweb.org/research/projects/. immunological substudy that aims to evaluate the impact of the frequency of BCG instillations on EAU Research Foundation cytokine levels throughout therapy. Thus, a one spot

SATURN Registry enrols 300th patient

March/May 2019

European Urology Today

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ESOU19 sums up vital onco-urology updates Meeting examines developments in 2018 Dr. Jakub Hornák Charles University and University Hospital Motol Prague (CZ)

surveillance for treatment of GS 3+4”. Both stated that AS could be considered as a possible modality in selected cases of the intermediate risk group. In his lecture “Focal treatment for GS 3+4”, Assoc. Prof. Clement Orczyk (GB) presented impressive results of patients who underwent a high-intensity focused ultrasound treatment.

In the debate “What is high quality local treatment in high-risk localised prostate cancer?”, Prof. Steven Joniau (BE), who made the argument for pro-surgery, mentioned excellent cancer-specific survival results. He added that in around 50% of patient cases, radical The 16th meeting of the EAU Section of Oncological prostatectomy could be used in monotherapy. Urology (ESOU19) took place in the city of Prague in Alternatively, Prof. Paul Nguyen (US) from Harvard January this year. Overall, 966 participants Medical University, took a stance for radiotherapy. He representing 48 countries received updates in made it clear that in cases of high-risk disease, oncological urology from the previous year. high-quality radiation therapy needs long-term androgen deprivation therapy and a brachytherapy On Friday, 18 January, ESOU Chairman Prof. Maurizio Brausi (IT) and Meeting Chairman, Prof. Marek Babjuk boost. According to one recent retrospective study, patients provided with this type of treatment might (CZ) welcomed the participants to the meeting. The scientific programme was then divided into sessions have clinical advantage when compared to radical prostatectomy or radiotherapy. on prostate, renal and bladder cancers. Each section started with the hot topics in diagnosis, followed by After the break, the topic switched to renal cancer, treatment, and ended with a panel discussion of specifically to cystic renal tumours. During a case clinical cases. presentation with video demonstrations, participants On prostate cancer, the speakers provided updates on could see open laparoscopic and robotic approaches. Based on the reactions of the audience and panel active surveillance (AS). Prof. Nicolas Mottet (FR) members, the open approach of Prof. Hein Van presented “Risk stratification for active surveillance“ Poppel (BE) was considered impressive. However, and Prof. Monique Roobol (NL) presented “Active jakub.hornakk@ gmail.com

supporters of the other techniques considered this method outdated. During the debate “T2 renal tumours: best surgical tumours”, Prof. Charles Karim Bensalah (FR), who was defending partial nephrectomy, and Prof. Peter Mulders (NL), who took a stance for radical nephrectomy, both agreed that partial nephrectomy should be considered when feasible. Nevertheless, Prof. Mulders emphasised that the radical approach should remain the gold standard because according to him, current studies lack sufficient quality. The urothelial and bladder cancer session focused on new imaging methods. Dr. Valeria Panebianco (IT) presented the new mpMRI bladder cancer scoring system, VI-RADS. Then, Prof. Brausi presented the very futuristic method “Confocal laser endomicroscopy for diagnosis of CIS and dysplasia” which, if mastered, might lead to real-time diagnosis of CIS without the need of a pathologist. Throughout the day, participants observed discussions over the hot topics and in doing so, they often participated. This was especially demonstrated during this session, where the panel members discussed their differing opinions on the eternal question to re-TURB or not to re-TURB quite passionately at times. The second day started with the popular hands-on training course in prostate MRI, where instructors spent the entire morning sharing their experiences. Simultaneously, the Scientific Programme started with the problem of locally advanced prostate cancer. The three speakers, Prof. Alberto Briganti (IT), Prof. Thomas Wiegel (DE), and Prof. Maria De Santis (DE) deliberated on surgery, radio hormonal therapy and systemic treatment, respectively. Even though they all presented promising results, there was no consensus whether one method is superior to the others.

ESOU’s popularity increases every year

www.esou19.org

Riveting presentations and discussions at ESOU19

In the following session on penile and testicular cancers, Ass. Prof. Jan Philipp Radtke (DE) presented “Molecular markers for testis cancer” during which he stated that classic serum markers are not always elevated. He then discussed superior biomarkers: the embryonic miRNA. The last session was dedicated to urothelial cancer. This time the speakers presented rather rare methods of prostate and nerve sparing possibilities of radical cystectomies, proving that in selected cases the indications might exist. The meeting was completed on the third day. The morning sessions focused on locally advanced diseases. In his lecture “Cytoreductive nephrectomy (CN): current recommendations”, Prof. Arnaud Mejean (FR) explained that according to current knowledge, biological therapy alone is not inferior to the combination of CN and biological therapy. However, CN is still indicated in selected cases (e.g. the oligometastatic disease, etc.). Thank you to those who joined ESOU19. The participants received a great deal of new information to keep pushing forward for new onco-urological discoveries.

www.esou20.org

www.esut20.org

ESOU20

ESUT20

17th Meeting of the EAU Section of Oncological Urology

7th Meeting of the EAU Section of Uro-Technology in conjunction with the German Working Groups of Endourology, Laparoscopy and Robotic Assisted Surgery

17-19 January 2020, Dublin, Ireland An application has been made to the EACCME® for CME accreditation of this event

Incl. Live Surgery

23-24 January 2020, Leipzig, Germany An application has been made to the EACCME® for CME accreditation of this event

Arbeitskreis Endourologie

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European Urology Today

March/May 2019


ERUS19: New indications, new technology, new training As robotic surgery matures and diversifies, training and certification need to catch up “Over the past few years, the robotic community has evolved: centres are becoming high-volume, surgeons more experienced,” says Prof. Alex Mottrie, Chairman of the EAU Robotic Urology Section ERUS. “Accordingly, our annual meeting reflects these changes, offering more complex (live) cases, and new indications for a robotic approach.” ERUS19 is coming to Lisbon, Portugal for its 16th Annual Meeting on 11-13 September, 2019. The regular scientific programme starts on September 12th, but delegates are encouraged to take part in the Technology Forum on the 11th. Other activities on the 11th include the Junior ERUS-YAU meeting for young urologists. Courses by the European School of Urology are integrated into the regular scientific programme. Prof. Mottrie: “We invite manufacturers and delegates both to join the Forum for New Technologies before the regular scientific programme starts on September 12th. The Forum will take place before the regular congress because we feel all these new developments deserve enough time to be thoroughly presented.”

Register now for the early fee! Deadline: 10 June 2019 Mottrie expect these systems to come to market in the coming two years and wants to offer manufacturers a very specific setting that allows them to update the audience and demonstrate their new technology. New technology, new procedures In addition to prostate and kidney surgery, other urological procedures are becoming increasingly ripe for robotic assistance, Mottrie sees. “The Elmed Avicenna robot for endo-urological indications, the Aquablation (robotic waterjet) for prostate adenoma. We’re not sure if all these new systems will stand the cost-benefit analysis, but it’s up to us as the EAU’s robotic section to assess these systems and examine their potential.”

Take part in the Technology Forum: Wednesday 11 September at 16.30 hrs

Prof. Alex Mottrie, Chairman ERUS

While a variety of robot-assisted instruments is coming to market to supplement the surgeon’s armamentarium, some direct competitors for Intuitive’s widely-used DaVinci system, like Medtronic, Verb and CMR are also on the horizon. Prof. Mottrie sees a challenge not only to the current surgical systems, but also the currently established training and certification programmes. “I think we can solve this problem. The ORSI academy, which is set to become the EAU’s robotic training centre, will offer training on all available systems. The trainee will be taught on the machine that his or her centre uses. We are working with the manufacturers so that we can effectively train surgeons to use their equipment.”

Fields like endo-urology or adenoma treatment that are currently performed manually with TURP or HOLEP could potentially become robot-assisted. In future, certain procedures could become automated completely, if the robot uses 3D scan-based models that work as navigation, autonomous recognition of organs. Prof. Mottrie also shared an informal three-point manifesto for ERUS and the future of robotic surgery in general. “First of all, we need to convince colleagues to stop working ‘with knife and fork.’ Advanced technology exists and it will allow us to perform the same procedure in a less-invasive fashion,

with less effort and more safety for the patients.” “Secondly, training has to improve. At the moment, I feel medical training is too dependent on random things: where the resident ends up being stationed, and how much of a trainee’s success depends on the relationship with superiors. We want to move beyond the Halsted model of ‘see one, do one, teach one’, towards quality-assured training and proficiency-based progression. By rationalizing and improving training, we should be able to reduce complications, lower costs and better treat patients.” “Finally, by specializing and performing enough robotic procedures, the high costs of new tech will pay for themselves in lower complication rate and shorter hospitalisation.” For more information and registration please visit: www.erus19.org

Robotic Live Surgery

16th Meeting of the EAU Robotic Urology Section

Looking ahead ERUS19 will naturally and prominently feature live robotic surgery, state-of-the-art lectures and case discussions. Prof. Mottrie shares a look at the future of the field, and his goals for ERUS and robotic surgeons in general: “We’re seeing more smart technologies in and around the house, why should the OR be any different? Procedures that are currently being performed manually can be done more precisely, effectively and safely when automated or robotassisted.

ERUS19 Creating consensus in robotic urology

11-13 September 2019, Lisbon, Portugal

In conjunction with: • Junior ERUS-YAU Meeting • European School of Urology (ESU) Courses • ESU/ERUS Hands-on Training in Robotic Surgery

www.erus19.org

Introducing RCC19: The EAU’s first dedicated RCC meeting The Czech capital is set to host the EAU’s first Update on Renal Cell Cancer. RCC19 is the second of the “Update” meetings that the EAU is holding this year, following BCA19 and ahead of PCA19. The goal of this meeting is to offer the practicing urologist a comprehensive overview of the latest developments in renal cell cancer.

EAU Update on Renal Cell Cancer 7-8 June 2019 Prague, Czech Republic

We spoke to Prof. Axel Bex (London, GB), co-chairman of the RCC19 Scientific Committee and one of the speakers in Prague on 7-8 June.

www.rcc19.org

Prof. Bex is Consultant Clinical Lead at the Specialist Centre for Kidney Cancer at the Royal Free London NHS Foundation Trust. Bex is also affiliated with the UCL Division of Surgery and Interventional Science (London) and the Netherlands Cancer Institute (Amsterdam).

Prof. A. Bex, Co-chairman of the RCC19 Scientific Committee

In Prague, Prof. Bex will co-chair the immunotherapy update on locally advanced and metastatic RCC, speak on case discussions on choosing and prescribing first-line systemic agents in metastatic RCC, and he is one of the panelists on the interdisciplinary management of metastatic RCC.

in a multidisciplinary setting. Urologists might not be actively involved with the delivery of the drugs, but they can learn to identify suitable patients and they should also be aware of the drugs’ impact on their patients’ quality of life.

Starting a new meeting “Kidney cancer management is going through a period of great and rapid changes,” Prof. Bex explains. “There are some exciting new developments, especially in the field of systemic therapy which not only led to new treatment paradigms but several adjuvant and neoadjuvant trials in which urologists are involved.” Some of the hotter RCC-related topics that will be addressed in Prague are, according to Prof. Bex: “Small renal masses are increasingly being diagnosed, so we will be talking about their management. Particular attention will be given to the introduction of immunotherapy and combination therapies into RCC management.” The EAU feels it is important for urologists to familiarise themselves with the latest generation of immunooncologic agents to be able to make informed decisions March/May 2019

EAU onco-urology series

Register now for the late fee! Deadline: 30 May 2019

Target audience As one of the onco-urology update meetings, RCC19 has a programme that is slanted towards evidencebased education, rather than cutting-edge new developments. Still, as the first edition of the meeting, much of the scientific programme is brand new and based on this rapidly-developing field. Bex: “RCC19 will be an educational meeting, but with a strong focus on new developments in the management of localised, locally-advanced and metastatic RCC.” “In a nutshell, we want this meeting to be of interest for a multidisciplinary audience. We want to attract urologists, oncologists, radiologists and radiation oncologists who have a special interest in kidney cancer. We are offering a condensed update within the framework of a single meeting.” For more information please visit www.rcc19.org European Urology Today

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European Tour 2019 Academic Exchange Programme Wonderful experience for Taiwanese and Japanese urologists in Spain Ass. Prof. Po-Fan Hsieh Taichung (TW)

d17341@ mail.cmuh.org.tw

Ass. Prof. Yu-Hua Fan National Yang-ming University Dept. of Urology Taipei (TW)

yhfan2@gmail.com

Urethral reconstruction Furthermore, we not only observed urethral reconstruction using buccal mucosal graft in a patient who had urethral stricture or fistula due to post-hypospadias surgery, but also listened to a detailed lecture. In addition, we were given a lecture on the best BCG dose which was derived from the CUETO (Club Urológico Español de Tratamientos Oncológicos) trials. After observation of other endourological surgeries, we had lunch with members of the La Paz University Hospital. La Paz University Hospital On Tuesday 12th March, Prof. J. Gómez Rivas kindly picked us up early and took us to La Paz University Hospital. After the impressive lecture about ICG for the detection of sentinel lymph nodes in prostate cancer by Prof. L. Martínez-Piñeiro, we actually observed its excellent technique (Figure 1). Further, Prof. D. M. Carrion gave us a lecture about PCNL. He presented his interesting technique of PCNL and showed it in the OR. We promised the La Paz urology members to meet again at EAU Annual Congress in Barcelona.

Dr. Po-Ming Chow National Taiwan University Hospital Dept. of Urology Taipei (TW)

Royal Palace The day after arrival, the Japanese and Taiwanese groups went out for sightseeing at the Royal Palace and historic Madrid city centre, blessed with fine weather. It is always a good start to know the people by knowing their history. At night, we had a dinner with Prof. L. Martínez-Piñeiro and his colleagues. The staff was very easy-going and we got to know each other during dinner. On Monday 11 March, Prof. M. Alvarez Maestro kindly picked us up and took us to the Department of Urology of La Paz University Hospital, which was located in the most modern area of Madrid. During these two days, we observed two urethroplasties and a laparoscopic radical prostatectomy nicely performed by Professor Martinez-Piñeiro, a PCNL by Dr. Cansino in a heavily-operated kidney, and a rapid HoLEP for a 250g prostate by Dr. Peret-Carral. The latter procedure can also be seen on YouTube. The urethroplasties were performed in two stages for Lichen sclerosis, which is quite rare in Asian countries.

Hospital de Sant Pau tour At the end of the visit, we participated in the Hospital de Sant Pau guided tour which was really a wonderful experience. We were overwhelmed, not only by the symmetry and beauty of the modern design but also by the truly progressive health care principles. This complex demonstrates the best of the "form follows function" design principle in terms of patient care. We walked around in the city of Barcelona, and visited the Sagrada Familia, Park Guell and Casa Vicense. Interesting lectures On Thursday 14 March, we walked to the Fundacio Puigvert. We heard many interesting lectures: Endourology in UTUC by Prof. A. Breda; Analysing data of T1G3 bladder cancer by Prof. F. Pisano; Clinical cases in partial nephrectomy by Prof. A. Breda; Penis: sentinel node and reconstructive surgery by Prof. J.M. Gaya; Complications in radical cystectomy: diagnose and solve! by Prof. O. Rodriguez; Medical treatment in metastatic kidney cancer: where are we? by Prof. P. Maroto; Active surveillance: concept, indications and results by Prof. F. Sanguedolce. EAU Annual Congress On Friday 15 March, the EAU Annual Congress opened and urologists from all over the world gathered in Barcelona. Until Monday 19 March, we learned many things we have not learnt in Taiwan or Japan, for example how to speak in presentation; how to answer questions; how to communicate with foreign doctors.

meow1812@ gmail.com

We were selected as members of the EAU-JUA/TUA International Academic Exchanged Programme and the time we spent in Spain from 9 to 19 March 2019 was like a dream come true. Below you will find an overview of our exciting trip.

thoughts on our clinical practice by discussing with the speakers.

Fellows meeting with Dr. Palou at the Fundació Puigvert

Barcelona’s Sagrada Familia We were so excited to find that the accommodation was located in a fantastic place next to the Sagrada Família and close to Fundació Puigvert! On Wednesday 13 March, Ms. Lluïsa Ponsa took us to the Fundació Puigvert next to the Hospital de Sant Pau, which is included in the World Heritage List. Dr. Joan Palou and Dr. Alberto Breda gave us an overview about Fundació Puigvert which is a historical hospital specialised in urology and nephrology. Then we took some photos together (Figure 2). We moved to the operating room, where we observed many kinds of operations; robotic prostatectomy with lymph node dissection; endourological surgery for ureteroileal anastomostic stricture; open cystectomy for advance bladder cancer; deceased-donor renal transplantation. After lunch with the professors and young urologists, the professors gave us very practical lectures. The most impressive lectures were “Tips and Tricks in Prostate Cancer Surgery” by Prof. J. Palou, and “Cryotherapy in Prostate Cancer” by Prof. Breda. We got some new

In various sessions we could see the cutting-edge knowledge and techniques, advances in clinical and basic research, as well as fantastic innovations in surgical skills. Because there were so many different interesting topics held at the same time, we had a lot on our plate. Fortunately, we could use webcast on Uroweb to catch every important message from the Annual Congress. These precious experiences inspired us not only in better clinical practice but also in research. International Friendship Dinner On Sunday 17 March, the International Friendship Dinner was held at a traditional restaurant in Barcelona. Then the chairman presented us with awards of the Exchange Programme. There, we met Prof. L. Martínez-Piñeiro, Prof. M. Alvarez Maestro, Prof. J. Gómez Rivas and Prof. J. Palou again, and we

Dr. Jose QuesadaOlarte University Hospital La Paz Dept. of Urology Madrid (ES)

The La Paz University Hospital, Urology Department in Madrid (ES) had the opportunity to welcome the participants of the 2019 Japanese and Taiwanese Urological Association - EAU Exchange Programme, which consisted of a 2-day educational experience. The programme started at the urology department with a warm welcome from Dr. Martinez-Piñeiro, staff members and residents.

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European Urology Today

ryu-matsumoto@ amber.plala.or.jp

Assoc. Prof. Koichiro Wada Okayama University Dept. of Urology Okayama (JP)

gmd17055@ s.okadai.jp expressed our thanks to them. Also, we met the president of JUA, Prof. M. Fujisawa and talked about the fantastic activities of the EAU (Figure 3). Tuesday 19 March was the day we had to leave and go back home. We said goodbye to each other at the hotel and promised to stay in touch. We would like to thank the EAU, TUA and JUA, which set up such a fantastic and perfect programme. And we especially appreciate the efforts made by Prof. L. Martínez-Piñeiro in La Paz University Hospital, Prof. J. Palou in Fundació Puigvert, their colleagues and secretaries. Through this programme in Spain we learned so much that will absolutely be useful in our basic/clinical skills.

Prof. M. Fujisawa, JUA President, with Drs. Wada and Matsumoto at the International Friendship Dinner

Unique networking opportunity for European and Asian urologists

Jose.quesada@ salud.madrid.org

Watching the excellent sentinel lymph node detection technique in PCa of Prof. Martínez Piñeiro

Ass. Prof. Ryuji Matsumoto Hokkaido University Hospital Dept. of Urology Sapporo (JP)

RIRS and hOLEP, performed by Dr. Martinez-Piñeiro, Dr. Cansino and Dr. Perez-Carral. They had lunch with some residents and staff members, after which they visited the main city attractions and the Bernabeu museum stadium. They had dinner with Dr. Martinez-Piñeiro, Dr. Cansino, Dr. Perez Carral, other staff members and residents. The visitors explained how the Japanese and Taiwanese medical systems work. It was a wonderful occasion for us to learn about the main energy sources used in endourology, urological techniques and facilities available in prestigious Asian hospitals. I think this was a unique opportunity for our European residents and young urologists to network with their Japanese and Taiwanese colleagues. For further information on applying for the 2020 Japanese Tour please visit: www.uroweb.org/exchange-japan

We had the opportunity of meeting with Dr. Po-Fan Hsieh, Dr. Yu-Hua Fan, Dr. Po-Ming Chow, Dr. Ryuji Matsumoto and Dr. Koichiro Wada. They could listen to lectures about urethral reconstruction surgical techniques and PCNL techniques given by Dr. Martinez-Piñeiro and Dr. Cansino, respectively. They observed several urological surgeries, including a laparoscopic radical prostatectomy, urethroplasties, March/May 2019


www.esur19.org

ESUR19 26th Meeting of the EAU Section of Urological Research 10-12 October 2019, Porto, Portugal

EAU Update on Prostate Cancer

11-12 October 2019 Prague, Czech Republic

EAU onco-urology series

www.pca19.org

In collaboration with the Society for Basic Urologic Research (SBUR) and the EAU Section of Uropathology (ESUP)

Call for Abstracts

Early Fee Registration

Deadline 8 July 2019

Deadline 12 July 2019

www.esui19.org Call for Abstracts Deadline 1 July 2019

ESUI19 8th Meeting of the EAU Section of Urological Imaging 14 November 2019 Vienna, Austria In conjunction with the 11th European Multidisciplinary Congress on Urological Cancers

14-17 November 2019, Vienna, Austria

An application has been made to the EACCME® for CME accreditation of this event

Less is more: What’s really needed in imaging

Implementing multidisciplinary strategies in genito-urinary cancers 11th European Multidisciplinary Congress on Urological Cancers In conjunction with the • 8th Meeting of the EAU Section of Urological Imaging (ESUI) • European School of Urology (ESU) • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP)

Call for Abstracts Deadline 1 July 2019

www.emuc19.org March/May 2019

European Urology Today

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European Tour 2019 Academic Exchange Programme A collective account from the Canadian delegation Prof. Joseph Chin University of Western Ontario Dept. of Urology London-Ontario (CA)

joseph.chin@ lhsc.on.ca

Dr. Mélise Keays Children’s Hospital of Eastern Ontario University of Ottawa Ottawa (CA)

melise.keays@ mac.com

Dr. Paul Toren Université Laval Dept. of Surgery Québec (CA)

paul.toren@ crchudequebec. ulaval.ca

Walz and his team. Their impressive automated data capture system coordinated through integrated forms and their electronic health record was used as a prospective database and as a means to monitor quality improvement initiatives. The multidisciplinary approach to care and shared academic oncological vision was very evident in Marseille, with surgeons, radiologists, medical oncologists and radiation oncologists working together to ensure coordinated care and research productivity along the patient care continuum, supported by comprehensive patient data templates. Next we visited Valencia (ES) with Dr. Jose RubioBriones at the Instituto Valenciano de Oncologia. As a comprehensive cancer centre, the group has a commitment to prospective data capture by performing careful data abstraction for oncological, andrological and functional variables and outcomes. Additionally, we were introduced to novel diagnostic and therapeutic techniques, such as confocal microscopy of tissue biopsies and prostate focal therapies, and the group at IVO are actively studying these modalities. Adapting new approaches and studying the impact of surgical and technological innovations on patient care is strongly emphasised in the clinical and research vision at IVO. Finally, our journey ended in Barcelona (ES) with Professor Antonio Alcaraz’s team who showed us their extensive data gathering approach to answer innovative questions in renal transplant, surgical technologies and endourology at Hospital Clinic de Barcelona. As a pioneering centre in oncology and renal transplantation, the commitment to education, research and surgical innovation was very evident.

A collage of the 4 European sites toured by the Canadian team

Innovations in surgery We were all very impressed with the level of innovation and early adoption of surgical technology in the European centres we visited. Robotic technologies were very prevalent, with application in prostate, bladder (including salvage cases), extensive nodal and renal surgery. Advanced diagnostic and minimally invasive approaches to prostate cancer were commonplace in the centres we visited. MRI-fusion biopsy technologies, focal therapies and the use of PMSA-PET scans are extensively used, more so than in Canada. We also got to witness lymphoscintigraphy for nodal dissection for penile cancer, ESWL treatments for erectile dysfunction, and learned about robotic approaches to renal transplant and even natural orifice surgery.

aimed at improving the ability of trainees to perform robotic surgery through simulation, case observations and modular console training at the learner’s host institution. This model appears to be very useful, especially if the private system limits the ability of the trainee to participate in certain operative cases.

Women in urology Our exchange programme occurred during the time of the International Women’s Day and included the Dr. Trustin Domes Exchange of research ideas and opportunities for first Canadian female to participate in the University of collaboration exchange, Dr. Mélise Keays. We were impressed to Saskatchewan To encourage collaboration, we participated in a rich have met so many women who were leading College of Medicine exchange of ideas by sharing our research projects programmes in their institutions and crafted Dept. of Surgery and interests with our host institutions. Through these successful practices while maintaining balanced Saskatoon (CA) well-organised research symposia, we presented our personal lives. At each centre, we met projects at the sites we visited: Dr. Trustin Domes accomplished female faculty and researchers on presented on approaches to small renal masses, trustin.domes@ “...strong academic vision, support staff, including faculty who had completed training including a prospective trial on irreversible in Canada (Dr. Mireia Musquera from Barcelona usask.ca and commitment to infrastructure...” (ES)), prior participants in the CUA-EAU exchange electroporation for small renal cancers; Dr. Mélise Keays presented on information technologies and (Dr. Carmen Mir from Valencia (ES), CUA-EAU 2018 Three very energetic and accomplished young patient reported outcomes in surgery; Dr. Paul Toren Training, education and Canadian-European exchange) and saw one of our hosts being urologists from the Canadian Urological Association discussed his translational research projects on connections acknowledged as a female pioneer in urology (CUA), led by their senior advisor Prof. J. Chin, took predictive markers of response to abiraterone and One of the most interesting things we learned on our (Prof. Maria Ribal from Barcelona (ES)) at the EAU part in the ongoing academic exchange with the EAU. also on the role of sex hormones and innate immune exchange is the incredible differences between the International Friendship Banquet. As in Canada, They visited some top urology units in Europe just cells on cancer progression and Prof. Joseph Chin Canadian and European urology training models. European centres have an increasing number of prior to the EAU Congress in Barcelona. presented on salvage therapies after radiation failure Unlike Canada, where most medical students compete female urology trainees and we shared in and management of lymph nodes with prostate for medical school positions after an undergraduate meaningful dialogue of their unique contributions We gained academic knowledge and established cancer. Reciprocally, we learned about numerous degree, European medical students are selected into to the field and how to encourage more women to invaluable potential linkages with European research areas in the different centres and the power medical school upon completion of a competitive pursue leadership positions in urology. colleagues for research and academic collaboration. of multi-centred collaborative research which is written examination upon completion of high school. We experienced extremely generous hospitality from commonplace in Europe. One particular highlight was In Europe, selection into urology residency does not Highlights of European cultural experiences our gracious hosts at every stop for which we are to learn more about the impressive EAU’s Young involve reference letters, portfolios or multiple With a packed agenda, we took advantage of most grateful. Academic Urologists (YAU) network, which includes interviews but is based on one’s ranking in a experiencing the local cities and sites during the free talented up-and-coming European academic standardised national examination, where the highest hours we could to experience the richness of An academic vision and a robust prospective data urologists under 40 years of age. The YAU network scoring applicants select their preferred residency European culture. In Milan, we were treated to capture system demonstrates the power of research collaboration and programme. Many of the residents and fellows we fantastic Italian cuisine and great company In every centre we visited, there was a mature mentorship, and allows young urologists to encountered were among the highest ranked in their culminating in an evening stroll by the Castello systematic approach to standardised prospective data meaningfully participate in EAU guideline cohorts. Instead of staying in one centre during Sforzesco with Prof. Montorsi and the Duomo di collection which has helped to drive the research development and educational curricula. residency, we found it fascinating to learn that many Milano with Prof. Salonia. In Marseille, we enjoyed a portfolio of these institutions. A strong academic urology residents participate in out of country city tour with a fantastic view from Notre-Dame de la vision, support and commitment to infrastructure mini-fellowships, which includes a strong Canadian- Garde with Dr. Thomas Maubon, a guided tour of the were evident, leading to a positive research culture, European connection between Milan and the Centre Provence region and we ended our time in Marseille productivity and a collective belief that research is Hospitalier de l’Université de Montreal. We also with a run through the breath-taking le Parc des complementary to providing excellent clinical care. learned that resources exist to encourage graduating Calanques with Prof. Walz. In Valencia, we were urology residents to pursue additional advanced fortunate to witness the spectacular Las Fallas We started our visit in Milan (IT) at San Rafaelle education. For example, graduating Spanish urology festivities with Dr. Rubio-Briones and colleagues, Hospital, which is internationally recognised as a residents have the opportunity to pursue further including “feeling” the explosive mascleta display. urology research powerhouse. Professor Francesco supported studies (such as a PhD) through a Montorsi introduced us to his research team, comprised competitive nationally sponsored programme. Final thoughts on the CUA-EAU exchange of clinicians, basic scientists and data managers. The We are all incredibly grateful to our gracious hosts for data managers are responsible for maintaining The model of health care delivery is integral to planning a very engaging, interactive and truly prospective comprehensive databases in a wide range training and we discussed the potential impact of the meaningful academic exchange despite their busy of urological conditions, including oncology, andrology European mixed public-private model health care clinical schedules and personal lives. Finally, we are and functional outcomes. In addition, basic scientists delivery and education. Although there were some all incredibly thankful to our local departments, work alongside clinicians, in the impressive urologic parallels to Canada’s completely publicly funded clinical partners, spouses and families who covered research institute at San Rafaelle focusing on hospital health care model in every country we our clinical and personal responsibilities that allowed andrology, infertility and oncology. The well-structured visited, many cities had combined public and private us to participate in this once in a lifetime experience. integration of clinicians and basic scientists focused on clinics and related differences in wait times and We returned home with new insights, ideas and urological research is uncommon, and this greatly access to various diagnostic and therapeutic friendships that will surely lead to exciting new supports collaboration and translational research. procedures. To ensure adequate exposure and collaborations! training, certain aspects of surgical training have Marseille and Valencia been centralised in Europe, with the creation of the For further information on applying for the In Marseille (FR), we had the pleasure to visit the Dr. Trustin Domes scrubbing in on a case in Hospital Clínic of European Robotic Curriculum. This well-studied 2020 Canadian Tour please visit: Institut Paoli-Calmettes and were hosted by Dr. Jochen Barcelona, Spain model uses structured and validated modular training www.uroweb.org/exchange-canada 36

European Urology Today

March/May 2019


Highlights and impressions of EAUN19 in Barcelona Hospital visits, inspiring lectures, training and discussions add up to valuable learning experience Twenty years have passed since the European Association of Urology Nurses (EAUN) held its first conference in Brussels. The number of participating nurses has increased and cooperation with national urology societies has intensified. Over 300 nurses from over 30 countries attended the meeting in Barcelona. The meeting started with a warm welcome from the chairs of the EAU, EAUN and the Spanish Association of Urology Nurses Enfuro. This was followed by presentations from all chairs of the EAUN through the years who showed the development of the EAUN and the annual meeting in the past 20 years, and concluded with a view on the future by the current Chair, Ms. Susanne Vahr Lauridsen. The highlight of the session was the announcement of the winner of the first Ronny Pieters Award: Mr. Ronny Pieters from Ghent, Belgium himself. Unfortunately, he could not be there to receive the award himself. In Barcelona several important meetings took place. Chairs of nine different associations of Urology Nurses met with the EAUN Board to discuss cooperation in the fields of education and guidelines, amongst others. The ongoing development of a Urological Nursing Curriculum was topic of another meeting, attended by the Chairs, Presidents and representatives of ANZUNS, BAUN and EAUN.

2. The penis: The stubborn myths To promote sexual health in urological patients, a Clinical Nurse Specialist needs to have broad knowledge of possible physical causes. Diseases such as penile curvature can make penetration more difficult. Likewise, premature or delayed ejaculation can have an influence on the common sexual life of partners.

well as, individual healthcare professionals representing their own country (Ireland amongst them) were present. While their aim is to create a strong global voice for bladder cancer patients, they also have a very ambitious goal of establishing national chapters in countries which do not yet have dedicated bladder cancer support networks.

3. The challenges of hypersexuality in men and women We discussed what it means when a too strong need for sex dominates the lives of patients. The combination of physical and psychological causes makes it clear that hypersexuality requires psychotherapeutic therapy, including pharmacological.

The enthusiasm at this meeting was palpable, and with collaborators present lending support and advice such as the International Kidney Cancer Coalition, this initiative is sure to be a success which will bring tangible benefits to bladder cancer patients. (By Mr. Robert McConkey, Galway, IE)

In summary, all three experts made it clear that there is a need for interprofessional cooperation in the promotion of sexual health. It was well demonstrated how professions can learn from each other and how the exchange of experiences across cultural boundaries is beneficial to promote sexual health. (By Mrs. Franziska Geese, Berne, CH)

Presentation of the first Ronny Pieters Award

Three different aspects The session highlighted three different aspects of bladder cancer from three countries. The first session by Mr. Rajesh Nair, Consultant Urologist from Guys Hospital London (UK), examined BCG treatment. Looking at it from “Top 10 facts” was an engaging approach - exploring how BCG works, when and how to use it, as well as issues and myths surrounding BCG.

The second session, by Ms. Elke Rammant, PhD Inspiring first time congress experience Researcher at Ghent University (BE), explored exercise I would like to thank the EAUN for the opportunity to and psychological care in bladder cancer by outlining a participate at various sessions. I brought home a great study which has led to a digital programme to deal of inspiration to share with my co-workers in stimulate exercise at home. It will be exciting to follow Denmark. My most inspiring experience was the visit to the progress of this research once it has been piloted. the Hospital Clinic of Barcelona on Sunday 17 March. Nine nurses from different countries such as Greece, The third session by Ms. Anna Munk Nielsen, RN and Trials Coordinator at Aarhus (DE), considered Germany, Australia, Ukraine, and Switzerland joined. Two nurses guided us through the urology department; biobanking in bladder cancer care. It discussed the first the ambulatory and the day section, then the part PAGER study and the aim of instituting individualised where the admitted patients were staying. care through ctDNA testing and optimising a personal biomarker that can detect recurrence in non-muscleinvasive bladder cancer. Prejudices I think I had a few prejudices beforehand because Value of attending although our hospital in Denmark is quite new but These sessions have been of immense value to me we lack space. The Hospital Clinic in Barcelona is located in an older building but it has many spacious clinically and professionally. They have increased my understanding of BCG, its use in management of The posters in the Expert-guided poster session attracted much rooms. I realised space is quite important, because in urology we use a lot of equipment. Moreover, every bladder cancer and issues surrounding it. This will attention room in the ambulatory has its own toilet for the help improve my care of inpatients. patients to do flows etc. That is something I wish for in my hospital. The role of the patient in bladder cancer care and the Supporting each other and sharing knowledge has importance of their engagement and empowerment been EAUNs philosophy since its inception. The 3-day were highlighted. I work in an inpatient setting and EAUN Meeting provides a forum for presenting original In Barcelona, they are very focused on preventing infections especially in recently operated patients and generally only have fleeting contact with patients unpublished data and sharing ideas for urological nursing innovation as well as disseminating (evidence- patients who have had an indwelling catheter for short during their cancer journey. This has given me the or long time. In contrast to Denmark, they follow up on impetus to explore how patients are (or are not) based) knowledge of primary clinical importance and the patient after he/she has gone home, because he/ empowered and supported locally and to then of particular relevance to the role of the nurse. The she is still at risk of developing an urinary tract consider strategies to encourage and support this. various poster, video and difficult case sessions are good examples, as well as the yearly organised visits to infection (UTI). I hope to introduce this practice in Denmark, in order to decrease the number of UTIs. The sessions have given me the opportunity, as a local (university) hospitals and the hands-on training practitioner working in a local hospital in the UK, to session, this year covering the ins and outs of flexible consider the management of bladder cancer in a global cystoscopy. Found below are reports from some of the Documentation Another difference between practices in Denmark and context. They emphasise the importance of networking travel grant winners and lecturers themselves. Spain is the manner of documentation. In Spain, and being part of an organisation such as the EAUN. nurses use smartphones as their journal and as a tool (By Ms. Vanessa McLean, Worthing, UK) to order blood tests for patients, for example. I think Interprofessional perspective on sexual health this is great because they will have more time Those who work as urology nurses are aware of the Focus on bladder cancer taboo topics in the care of patients. The aim of the Joint attending to their patients. (By Ms. Jeanette Christiansen Schulze, Vejle, DK) I was both grateful and honoured to have been Session of the EAUN and the Australia & New Zealand awarded an EAUN travel grant. Before leaving Ireland, Urological Nurses Society (ANZUNS) was to familiarise I had downloaded the EAUN conference app and nurses with different professional perspectives and to Travel Grant enables attendance marked my calendar with events I wanted to attend. expand their expert knowledge. The topic “Sexual Firstly, I would like to thank the EAUN for awarding me There were a number of sessions that I felt were Health Matters” focused on the existential needs of with an EAUN Travel Grant. Without it, I would not have essential for me. As my own role is focused on the patients with urological problems. been able to attend. I used the opportunity to attend a management of patients with bladder cancer, I was committed to attend Thematic Session 3 by the Bladder With the support of the experts Ms. Kathryn Schubach, variety of sessions. The session I found especially valuable was the “Bladder Special Interest Group: Cancer Special Interest Group (SIG) on Saturday, 16 Nurse Practitioner in Uro-Oncology & Chair of the March and the inaugural meeting of the World Bladder ANZUNS (AU), Ms. Jeanette Verkerk-Geelhoed, Clinical Bladder cancer – past, present and future perspectives” which was held on Saturday 16 March. Cancer Coalition on Monday, 18 March. Nurse Specialist Endourology (NL), and Ms. Belinda Winder, Prof. of Forensic Psychology (GB), three Inauguration World Bladder Cancer Patient Coalition different perspectives on the promotion of sexual I noticed that the bladder cancer SIG session appeared health were given: to have one of the highest attendance rates of delegates of all the EAUN19 sessions I attended. The 1. ANZUNS presentation: Sexual dysfunction - an World Bladder Cancer Patient Coalition (WBCPC) event Australian Nurse Practitioner`s perspective was also well attended. This highlights the fact that After an insight into the Australian health system and healthcare professionals are interested in increasing the scope of practice of a Nurse Practitioner in their knowledge about conditions; promoting Uro-Oncology, Ms. Schubach pointed out which awareness; influencing political policymakers; and approach she uses in the treatment of patients with advocating for patients and support groups with the sexual dysfunction in Australia. Using the bio-psychoultimate aim of improving patient outcomes. social model, the patient is viewed holistically and placed at the centre of treatment. The model not only The key players in the development of a Urology Nursing The WBCPC inaugural meeting was livestreamed on assesses physical problems, but also establishes Curriculum. Sitting l-r: K. Schubach (ANZUNS), J. Brocksom Twitter. Representatives from bladder cancer support connections between psychological and social (BAUN), S. Vahr (EAUN); standing l-r: J. Taylor (BAUN), and advocacy groups from countries such as the United influences in order to find the cause and treat it in a P. Allchorne (EAUN), J. Marley (EAUN) States, Canada, Australia, and the United Kingdom, as targeted way.

20th International EAUN Meeting March/May 2019

EAUN Guidelines panel It has been a great pleasure for me to be the candidate from Norway to participate in the EAUN Guidelines panel for the update of Transrectal Ultrasound (TRUS) Guided Prostate Biopsy. The Guidelines group has been working on the update for the last three years. I was very happy to be able to attend the session where the “Update of TRUS guided prostate biopsy guidelines” was presented by Ms. Corinne Tiller who did a great job. The Guidelines show that nurses can safely perform prostate biopsies with no increase in complications if they are adequately trained and supervised by a competent practitioner. They must, like other new practitioners, perform at least 50 biopsies with supervision before being signed off as competent to practice on their own. Nevertheless, it is essential to confer with an experienced urologist.

Group picture with all Chairs after the National Societies meeting

Patients should receive an up-to-date, evidence-based and easy to understand PIL (Patients Information Leaflet) prior to TRUS biopsy. And it is important to ensure that the information is well understood. The number of cores to detect cancer in the initial prostate biopsies is recommended to be 10 – 12. It is not recommended to only perform MRI-targeted biopsies initially. Additional to answering the above questions, the update of the TRUS prostate biopsy guidelines contains complications after TRUS biopsy and their frequency, and recommendations on the use of anticoagulants, amongst other topics. (By Mrs. Ingrid Iversen, Kristiansund, NO)

All in all EAUN19 exceeded the expectations of many participants and they are already looking forward to an even better meeting next year in Amsterdam. For this EAUN20 meeting travel grant, abstract, research plan and difficult case submission will open soon! Make sure to avail of the opportunities to receive a complimentary registration or a grant of 500 euro. Watch out for e-mailings and the new website from 1 July 2019: www.eaun20.org

Hands-on training offers valuable learning experience

16-18 March 2019, Barcelona

European Urology Today

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Animated narratives in a digital platform A new way of informing cancer patients pre- and post-operatively Dennis Michael Hansen Clinical Nurse Specialist Herlev and Gentofte Hospital Copenhagen (DK)

that they do not receive the information they need about their disease and treatment, or only receive part of it3. Another study of patients undergoing breast cancer surgery based on ERAS showed that only 18% of the patients had read the written information given to them and they were generally not satisfied with the level of information4.

Dennis.Michael. Hansen@regionh.dk

My Treatment platform As nurses we continually discuss how to improve care and stimulate new developments. In the beginning of 2018 My Treatment was presented to all clinical nurse specialists and the head of the department. The initiative was discussed and approved, and the department decided to continue the collaboration.

Heidi Andersen, RN Herlev and Gentofte Hospital Dept. of Urology Copenhagen (DK)

heidi.andersen@ regionh.dk The Department of Urology at Herlev and Gentofte University Hospital (HGH) is the largest in northern Europe. In 2017, 4,244 Danish men were diagnosed with prostate cancer and approximate 220 patients underwent radical prostatectomy at our Department of Urology.

My Treatment is a concept develop by Visikon, a research-based company specialising in audio-visual communication. My Treatment is a digital platform developed for patients facing a hospital treatment procedure. The platform is developed in close cooperation with the clinical experts at the hospital and is based on the hospital’s own written information5. By conducting studies Visikon has documented that animation video creates a high degree of identification that may work to reduce pre-surgical anxiety6. Several studies show that animated narratives can help reduce patient anxiety5,6.

In Denmark, patients receive their cancer treatment no more than 10 days after diagnosis1. The system must be efficient and productive and therefore our care is based on the concept of enhanced recovery after surgery (ERAS). ERAS is a multimodal approach to control postoperative pathophysiology and rehabilitation and one of the key components is preoperative information. A very important task for the nurses is to make sure that the patient and his relatives are well informed and can take part in the postoperative rehabilitation2. However, information to patients recently diagnosed with cancer continues to represent a major challenge. The 'My Treatment' digital platform

“...25% of patients claim that they do not receive the information they need about their disease and treatment...” The nurse often needs to prioritise the information given to the patients. In the outpatient clinic at the Department of Urology HGH 25% of patients claim

From written information to animated narratives The process began with a review and update of the written patient information done by the department’s own clinical experts, both nurses and doctors. It was a good opportunity to ensure that all the material was updated and the process was characterised by several good clinical discussions regarding evidence-based nursing.

16-18 March 2019, Barcelona Further investigation After introducing My Treatment, the nurses see better educated patients, both at the outpatient clinic and at the bed unit. This makes the nurses’ interaction with the patient much easier. The nurses use the animated narratives as a guide during day-to-day care in the pre- and postoperative programme and as a supplement during the talk about discharge. The feedback is also positive from the patients. They find My treatment easy to use and they feel well informed.

Animated narratives can help reduce patient anxiety

A nurse representative from Visikon came to our department and interviewed our clinical experts of both the inpatient and outpatient clinics. Then an illustrator observed a patient from the time of diagnosis until surgery. Based on the review of our patient information, the interviews and the observations, animated narratives were drafted, speech was added and everything was placed on a digital platform called My Treatment. The animated narratives were reviewed by our clinical experts and final corrections were done before they were presented to the rest of the department. My treatment was implemented and introduced to patients undergoing radical prostatectomy on 1 December 2018. The content of My Treatment The digital platform contains a sequence of 17 animated narratives which prepares the patient and his relatives by describing what happens before, during and after the operation. This includes the psychological reactions to the diagnosis, the importance of mobilisation and nutrition both before and after radical prostatectomy as well as managing pain and constipation after radical prostatectomy. The animated narratives introduce the patient to the care of the urinary catheter at home, when to contact the hospital with complications and the psychological and sexual rehabilitation. The animated narratives are supported by an interactive diary, symptom guides, frequently asked questions and our department’s own written information material.

While implementing My Treatment, the department has initiated a study to identify the effect of the digital platform, and a knowledge questionnaire was constructed in collaboration with Visikon. The questionnaires were handed out to patients 3 months before the implementation and 3 months after. Among other things we hope to clarify the quality of the preoperative information and the information about discharge. We expect the results to be ready by the end of 2019 after which they will be published.

Nurses use the animated narratives as a guide during day-to-day care

References 1. sst.dk 2. Sygeplejersken 2006; (17) 42-48. Sygeplejefaglige artikler) 3. https://patientoplevelser.dk/sites/patientoplevelser.dk/ files/_zip_/982/field_zipfiler_2/1/herlev%20og%20 gentofte%20hospital/Urologisk%20afdeling%20 (HEH)/2.%20AMB%20Tabelrapport%202018%20 (Urologisk%20afdeling%20(HEH)).pdf 4. Rud K, Egerod I, Brodersen J. Patient experiences of fast-track breast cancer surgery. Klinisk Sygepleje, [s. l.], v. 28, n. 1, p. 46–62, 2014. 5. https://www.visikon.com/ 6. Høybye M et al. Producing patient-avatar identification in animation video information on spinal anesthesia by different narrative strategies. Health Informatics Journal 23 dec. 2014. 1460-4582

16-18 March 2019 Barcelona, Spain

First Prize for the Best Practicedevelopment Poster Presentation Robert McConkey, Rogers E., Darcy F., Dowling C., Durkan G., Walsh K., Jaffry S., O' Malley P., Nusrat N., Aslam A., Hahessy S., University Hospital Galway (IE) With the poster: "Development of an advanced nurse practitioner led bladder cancer surveillance service in Ireland: Preliminary audit results"

First Prize for the Best Scientific Poster Presentation Mattia Boarin, Mannarini M., Della Giovanna G., Villa G., Marzo E., Manara D.F., Milan (IT)

With the poster: "Self-care in ostomy patients and their caregivers"

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Second Prize for the Best Practicedevelopment Poster Presentation Sajida Chagani, Sutria Z.S., Aziz W.A, Karachi (PK)

With the poster: "Simulation based workshop on urosepsis improves knowledge and skills of urology nurses"

Second Prize for the Best Scientific Poster Presentation Ralph Klauser, Uster (CH)

With the poster: "An investigation of the role of the Advanced Practice Nurse caring for urological patients in a regional hospital in Switzerland"

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

www.eaun.uroweb.org

EAUN Award Winners

Becoming a member is now fast and easy! Go to www.eaun.uroweb.org and click EAUN membership to apply online. It will only take you a couple of minutes to submit your application, the rest - is for you to enjoy! European Association of Urology European Nurses Association of Urology Nurses March/May 2019


4th EAUN workshop at EUSC 2018 in Dubai Board members educate urology nurses from the Philippines, China, the United Arab Emirates and beyond The first part of the workshop was rounded off by looking at intermittent selfcatheterisation and indwelling catheters. We were able to show the Before the workshop started, Stefano gave an participants different introduction to EAUN. In this short presentation the types of catheters, function and objectives of EAUN were addressed. In brief these are: developing urological nursing in all its provided by various j.alcorn@eaun.org aspects; fostering the highest standards of urological company representatives from the conference. nursing care; promoting the exchange of experience Stefano also presented and good practice; establishing standards for training Stefano Terzoni, RN, and discussed the EAUN and practice for urological nurses; and liaising and PhD guidelines on this topic. collaborating with other organisations in the field of San Paolo Hospital urology. An overview of the educational partnerships Bachelor School of After a short break, the EAUN Board members J. Alcorn and S. Terzoni at the EUSC Congress in Dubai for the EAUN and support were expressed. This short presentation Nursing second part of the workshop ended with an invitation to EAUN annual conference Milan (IT) workshop started. I in Barcelona. opened with a presentation on the safe and effective use of is a safe procedure and has many diagnostic and “... fluid balance, an oftentherapeutic uses. cystoscopes. This presentation was supplemented s.terzoni@eaun.org with a rigid and flexible cystoscope for participants overlooked part of the nurses’ The final part of the workshop concentrated on novel to look at and handle. During this presentation we practice, but vitally important to The 7th Emirates International Urological Conference looked at the history of the cystoscope of Philipp treatments for erectile dysfunction. This lively and fun & 15th Annual Arab Association of Urology Conference the well being of the patient...” Bozzini’s 1807 Lichtleiter. Originally developed for presentation engendered discussion from the was held in Dubai, November 2018. The conference viewing bullets within wounds. This presentation participants which was humorous at times. The was attended by participants from the Arab nations, also focussed on the handling of the cystoscope, presentation was thorough in looking at what is with the nurses’ workshop attracting 34 nurses from The workshop provided by my colleague, Stefano, erectile dysfunction and the potential causes. We then with video presentations of how to set up and use the Philippines, China and the United Arab Emirates the cystoscope. The participants were also informed discussed current treatment options ending with a commenced with reminding the participants about who practice locally. of how to limit the damage when using look at the novel treatment of penile low intensity the anatomy and physiology of the urinary tract. This cystoscopes. This was further highlighted in the shockwave treatment. interactive session set the tone for the following By the time Stefano Terzoni and I arrived in Dubai, the sessions. It is important to have a timely reminder next presentation from Cherry Banaynal, a locally conference was in full swing, having been officially The presentation ended with discussing patient based nurse. Cherry discussed how to disinfect about the system of the body where we practice opened by Highness Sheikh Hamdan Bin Rashid Al cystoscopes between patients and reinforced the concerns, awareness and how we, as nurses, may nursing. This was followed by an interesting session Maktoum, Deputy Ruler of Dubai, Minister of Finance on fluid balance, which is an often-overlooked part of handling of the items. This practical session was help with these. My session ended with a practical and President of the Dubai Health Authority. This was the nurses’ practice, but which is vitally important to demonstration of the penile low intensity well received and useful for the participants. The the fourth time that EAUN have been requested to shockwave treatment machines given by locally the well being of the patient. Stefano expertly guided take home messages from this workshop were that participate and provide a nursing workshop. based nurse, Abigail Rome. the participants through this area and onto the care of when handled safely and effectively, the cystoscope the patient with a nephrostomy tube. Utilising a wide The purpose of this workshop was to help with the range of video clips which supported the practical education and collaboration with our colleagues in care of the patient with a nephrostomy tube. The take the United Arab Emirates. On completion of the home messages were to be vigilant when looking workshop, the participants were able to describe the after our patients, especially when it comes to rationale of fluid balance, as well as the EAUN monitoring fluid balance and that nephrostomy tube recommendations for catheter management. They care is to be taken seriously. Jason Alcorn, FHEA, DN, MSc, BSc, Dip Urol Care, RN - Adult Mid Yorkshire NHS Trust Dept. of Urology Wakefield (UK)

will be able to describe the principles of treatment of erectile dysfunction and the nursing interventions in this field. Furthermore, they will be able to handle cystoscopes in a safe way and describe risk situations.

Annual Conference 2018 of Society of Urologic Nurses Best programme ever in San Diego last October Bente Thoft Jensen Senior Researcher Dept. of Urology Aarhus University Hospital Aarhus (DK) benjense@ skejby.rm.dk My gratitude goes to the Danish Urological Nursing Society, who supported both the present EAUN chair, Susanne Vahr, Copenhagen University Hospital (DK), and me, former EAUN Chair Bente Thoft Jensen, Aarhus University Hospital (DK), in participating in the Annual Conference for Urologic Nurses last October in San Diego (US) and also to the EAUN for making this trip possible.

significant number of sponsors and co-operators during the congress. When we asked a random number of sponsors why they chose to support the Annual Urologic Nurses Meeting they all pointed out that, despite they faced some economic challenges, they discovered that urological nurses have a unique position; not only because of their role as teachers and care-providers but as mediators and communicators of complex knowledge to the ‘end users’ and are thus pivotal and the perfect base for partnership. Pre-conference workshops As frequent attendee of the Annual SUNA Meeting, I believe that the San Diego meeting offered one of the best programmes ever at SUNA, with an emphasis on the professional nurse, who seems to be forgotten

Support from sponsors The meeting was a great success and was very well attended, with more than 600 nurses from around the world. They represented a broad range of clinical nurses and ward nurses working with, or affiliated with, urology nursing. Nurse leaders at different levels were present as well as primary care nurses and nurses working in the field of research and development.

“The pre-conference workshops were excellent with opportunities to sign up for 8-hour intensive courses in e.g. basic hands-on urodynamics.” When we visited the exhibition hall, we became aware Susanne Vahr Lauridsen and Bente Thoft Jensen at the Annual of the outstanding and unique support from a SUNA Meeting March/May 2019

over the last couple of years. Not only in the USA but in Europe as well, where a trend, for several reasons, convinced stakeholders of the benefits of having more generalist nurses than specialised nurses, which resulted in loss of competencies and reduced quality of care. The pre-conference workshops were excellent with opportunities to sign up for 8-hour intensive courses in e.g. basic hands-on urodynamics. You learned the basic dynamic of the bladder, SUNA President Gwendolyn Hooper with President Elect Margaret Amy Hull in the exhibition hall and learned how to carry out a simple urodynamic workshops, which addressed both general and investigation including describing and interpreting advanced clinical aspects in female sexual health curves. Moreover, at the end of the session the before and after cancer treatment. A third workshop participants were given a patient case and had to focused specifically on vulva /vaginal aspects come up with a plan for treatment and care. The including skin and tissue, vaginal infections, recommendations could include, for example, vestibular pain and clitoral damage. teaching the patients to perform clean intermittent catheterisation (CIC) or instillation of intravesical medicine or proceed to a nurse-led cystoscopy clinic. At the research symposium Susanne Vahr (Chair EAUN) presented the results from her PhD project If you had chosen the last option you could move on and participate in the advanced hands-on cystoscopy regarding the efficacy of an early smoking and alcohol workshop. In other words, following in the footstep of stop in relation to major bladder cancer surgery and the impact on complications. As usual Susanne Vahr the patients … delivered a fantastic talk. Female sexual health If you would like to visit SUNA, please visit the Another emerging clinical aspect is female sexual website below: www.suna.org health. A well-known sexual centre in San Diego led by Dr. Irwin Goldstein (former chair and initiator of the Sexual Medicine Society in North America) and his This year the SUNA conference is in Disneyland, Florida (US) in October 2019. team of sexual consultants carried out two European Urology Today

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Anniversary 20th EAUN Meeting in Barcelona Strong international bonds highlighted in Joint Sessions with AEEU, ECET and ANZUNS Corinne Tillier Chair EAUN Scientific Congress Office Amsterdam (NL)

c.tillier@eaun.org Some of the readers may remember the first urology nurses conference in Brussels, Belgium, where around 68 nurses joined in session room Cinedoc, April 2000. Despite some problems with the projectors on the second day, this first meeting was such a success that it was decided to continue this initiative in the next year and form a group of organisers.

Rita Willener presenting in Stockholm in 2009

At the request of Ronny Pieters, on 7 September 2000 a meeting was organised by the EAU to discuss the start of a nurses’ committee. Ronny Pieters (BE), Martin Beynon (UK), Maria Ascension Crespo Garcia (ES), Rita Willener (CH), Thea De Laat (NL) attended, as well as two professors from Switzerland, Prof. Fiona Burkhard (CH) and Prof. Hans-Jürg Leisinger (CH), and the Secretary General and founder of the EAU, Prof. Frans Debruyne, as well as EAU Executive Manager Operational Affairs Jacqueline Roelofswaard.

proposed a programme on Testicular and Prostate cancer, Cystoscopy and Nurses training in various countries. At the third meeting in February in Birmingham in 2002, nurse participants from all over Europe got to know each other better at the ‘Healthcare Professionals Dance Evening’ in Tiger Tiger, the same party destination that was unknowingly selected by the EAUN Board 15 years later in London! Ronny Pieters chaired the EAUN until 2004, when Aase Grundal (DK) took over (she chaired from 2004-2006). After a short co-chairmanship by Ronny Pieters and Jerome Marley until 2007, the following chairs were installed at the annual meeting: Bente Thoft Jensen (DK, 2007-2011), Kate Fitzpatrick (IE, 2011-2014), Lawrence Drudge-Coates (UK, 2014-2016) Stefano Terzoni (IT, 2016-2018). The current chair is Susanne Vahr Lauridsen (DK, 2018-2021), who will hand over the baton to Paula Allchorne (UK) to chair the EAUN from 2021 until 2024.

The committee that decided to initiate an annual meeting for urology nurses, Brussels, April 2000

At the conference in March 2005 the very first EAUN guidelines were introduced, entitled “Urethral Catheterization, Section 1: Male Catheterization”, of what now is a series of 11 guidelines. The first Nurses Panel consisted of Martin Beynon (UK), Thea De Laat (NL), Jessica Greenwood (UK), Toine Van Opstal (NL), Eva Lindblom (SE) and Eija Luotonen Emblem (NO). Many other important guidelines for urology nurses followed, continuously keeping up with the developments in the scientific process of developing guidelines. The series currently counts 7 topics which are regularly reviewed.

16-18 March 2019, Barcelona

In 2014 the EAUN Board decided that the important task of composing the Scientific Programme of the annual EAUN meeting should be left to a committee of experienced scientifically trained nurses, which would enable the board to increase their efforts to develop educational activities and accreditation specifically for the members and build on the international relations. Ronny Pieters handing over the award to A. Bäärnhielm in 2009

The first Scientific Congress Office (SCO) counted several members with a long and strong relation with the EAUN: Rita Willener (CH), Lisette Van De Bilt (NL), Bente Thoft Jensen (DK), Jerome Marley (IE) and was chaired by Stefano Terzoni (IT), EAUN Board Member, and they have set the tone for a more complete, and more attractive programme with a high scientific level.

Looking back it cannot be missed that there is one person who has been at the heart of all these developments. This, and the joyous occasion of celebrating the 20th annual meeting in Barcelona, is the reason the EAUN Board has established a lifetime achievement award to be awarded yearly to an exceptional EAUN member. The award is named after the initiator of the annual meeting for urology nurses: Mr. Ronny Pieters (BE). In Barcelona the first award was awarded to Mr. Ronny Pieters himself. From now on it will be possible to nominate European nurses who should, in your opinion, win this prize because they have provided an outstanding and enduring contribution to the development of urological nursing in Europe. The nomination form will soon be available on the EAUN website www.eaun.uroweb.org.

New EAUN Board Member Contributing to new challenges in nursing care Tiago Santos, RN, MScN, Rehab.Nurs. Champalimaud Foundation Prostate Unit Lisbon (PT)

and in 2016 I joined the panel for updating the EAUN guideline on TRUS biopsy which was presented this year at the Annual Meeting in Barcelona (ES). It has been a great experience to be part of this panel since it allows me to contribute to updating nursing knowledge about this topic.

Jerome Marley chairing in 2009

At the EAU Congress in Geneva in 2001 the first board of the EAUN was installed, of course with Ronny Pieters as the first Chair, and as first board members: Martin Beynon (UK), Fiona Burkhard (CH), Maria Ascension Crespo Garcia (ES), Thea De Laat (NL), Helén Marklund Bau (SE), Thomas Stöcker (DE), Rita Willener (CH). For the Geneva nurses’ meeting an abstract session and an excellent programme were composed, also thanks to a Swiss nurses and doctors group who

t.santos@eaun.org

Helén Marklund Bau receives a prize in Milan in 2008

The 3rd International EAUN Meeting took place in 2002 in Birmingham

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European Urology Today

My name is Tiago Santos, I am 28 years old and I graduated in 2012 at the Nursing School of Lisbon. I started my career as a registered nurse in a nursing home where I mainly worked in a rehabilitation ward. In 2014, I embraced a new career project and started to work in the Urology Department at Champalimaud Foundation in Lisbon, a reference cancer centre in Portugal, as the responsible nurse for the outpatient urology clinic.

In 2019, I joined a group of Portuguese nurses who started a scientific online nursing journal. The first edition was published in January and I am currently one of the reviewers. In my opinion, now is the right time to join the EAUN board because new challenges of nursing care are emerging due to the quick advance of technology in health systems. I am very motivated to contribute in order to maintain the connection between nursing practice and state-ofthe-art methods. Furthermore I hope to contribute with the perspective of a nurse working in a country where the urology nursing career is not as developed as in some European countries.

This was a huge challenge for me because I was the first nurse specifically dedicated to developing the urology outpatient department. I became increasingly motivated over the years, because I had the opportunity to implement a lot of projects and see the positive impact they had on patient recovery and quality of life.

EAUN Board

The main urological surgeries performed in our department are robot-assisted radical prostatectomies. My main work starts at the time of the diagnostic exams, then I prepare the patient for surgery, promoting an early start of the rehabilitation process and, after surgery, I continue the rehabilitation process with major emphasis on recovery of urinary continence and sexual function.

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

Therefore, and because of my special interest in urological patient rehabilitation, I finished my Master degree and specialisation in Rehabilitation Nursing in 2018. Since 2015 I have been a member of the EAUN

Susanne Vahr (DK) Paula Allchorne (UK) Jason Alcorn (UK) Jerome Marley (GB) Tiago Santos (PT) Corinne Tillier (NL) Jeannette Verkerk (NL) Giulia Villa (IT)

www.eaun.uroweb.org

March/May 2019

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European Urology Today March/May 2019  

European Urology Today (EUT) March/May 2019. EUT is the official newsletter of the EAU

European Urology Today March/May 2019  

European Urology Today (EUT) March/May 2019. EUT is the official newsletter of the EAU

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